Citation Nr: 21031470 Decision Date: 05/22/21 Archive Date: 05/22/21 DOCKET NO. 14-36 280 DATE: May 22, 2021 ORDER Entitlement to a compensable disability rating for pseudofolliculitis barbae (PFB) under Diagnostic Code (DC) 7899-7813, prior to May 31, 2017, is denied. Entitlement to a disability rating in excess of 30 percent for chin scarring due to PFB under DC 7813-7800, effective May 31, 2017, is denied. Entitlement to a 10 percent disability rating for painful scars due to PFB under DC 7804, effective May 31, 2017, is granted. REMANDED Entitlement to service connection for a lumbar spine disability is remanded. FINDINGS OF FACT 1. Prior to May 31, 2017, the Veteran's PFB resulted in no characteristics of disfigurement and affected less than five percent of the entire body and exposed areas. 2. Effective May 31, 2017, the Veteran's chin scarring due to PFB resulted in two characteristics of disfigurement. 3. Effective May 31, 2017, the Veteran's painful scars due to PFB resulted in two painful scars. CONCLUSIONS OF LAW 1. Prior to May 31, 2017, the criteria for a compensable disability rating for PFB under DC 7899-7813 have not been met. See 38 U.S.C. § 1155; 38 C.F.R. § 4.118, DCs 7800, 7806, 7813. 2. Effective May 31, 2017, the criteria for a disability rating in excess of 30 percent for chin scarring due to PFB under DC 7813-7800 have not been met. See 38 U.S.C. § 1155; 38 C.F.R. § 4.118, DCs 7800, 7813. 3. Effective May 31, 2017, the criteria for a 10 percent disability rating for painful scars due to PFB under DC 7804 have been met. See 38 U.S.C. § 1155; 38 C.F.R. § 4.118, DC 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1983 to July 1987. This matter comes to the Board of Veterans' Appeals (Board) from a November 2013 rating decision which continued to deny a compensable disability rating for PFB and found that no new and material evidence had been submitted to reopen a previously denied claim of service connection for a lumbar spine disability. In June 2017, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In April 2018, the Board found that new and material evidence had been submitted to reopen a previously denied claim of service connection for a lumbar spine disability. The Board then remanded both claims for further development. A March 2020 rating decision assigned a 30 percent disability rating for PFB, effective November 27, 2019. In July 2020, the Board remanded these claims for further development. The Board finds substantial compliance with regard to the increased rating claim. Following remand, the Veteran attended a new VA examination for PFB. A December 2020 rating decision assigned a 30 percent disability rating for PFB, effective May 31, 2017. Increased rating, generally Disability ratings are determined by applying the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity, and individual disabilities are assigned separate DCs. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if the veteran's disability picture more nearly approximates the criteria for the higher evaluation. See 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. The Veteran's PFB is evaluated under the Schedule of Ratings for Skin Disabilities. See 38 C.F.R. § 4.118. Based on the evidence of record, the manifestations of the Veteran's PFB warrants consideration under DC 7800 for scars of the head, face, or neck due to other causes; DC 7804 for scars, unstable or painful; and DC 7813 for dermatophytosis. On July 13, 2018, the rating criteria was amended for DC 7813, with an effective date of August 13, 2018. See 83 Fed. Reg. 32592, 32596 (July 13, 2018). For claims pending prior to the effective date, VA will consider the claim under the old and new rating criteria and apply the more favorable rating criteria. See 83 Fed. Reg. at 32593. As the Veteran filed his claim before the effective date, the Board will apply the more favorable rating criteria to the Veteran's claim. The Board notes that no regulatory changes were made to DCs 7800 or 7804. For the entire period, the rating criteria for DC 7800 provides the following relevant ratings: a 50 percent rating for visible or palpable tissue loss and either gross distortion of asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with four or five characteristics of disfigurement; a 30 percent rating for visible or palpable tissue loss and either gross distortion of asymmetry of one feature or paired set of features, or with two or three characteristics of disfigurement; and a 10 percent rating for one characteristic of disfigurement. See 38 C.F.R. § 4.118, DC 7800. The eight characteristics of disfigurement are: (1) scar 5 or more inches (13 or more cm.) in length; (2) scar at least one-quarter inch (0.6 cm.) wide at widest part; (3) surface contour of scar elevated or depressed on palpation; (4) scar adherent to underlying tissue; (5) skin hypo- or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); (6) skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); (7) underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); and (8) skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). See 38 C.F.R. § 4.118, DC 7800, Note (1). For the entire period, the rating criteria for DC 7804 provides the following relevant ratings: a 20 percent rating for three or four scars that are unstable or painful, and a 10 percent rating for one or two scars that are unstable or painful. See 38 C.F.R. § 4.118, DC 7804. Prior to August 13, 2018, the rating criteria for DC 7813 evaluated the skin disability under DC 7800, 7801, 7802, 7803, 7804, 7805, or 7806, depending upon the predominant disability. See 38 C.F.R. § 4.118(a), DC 7813 (2017). Here, the applicable rating criteria are DCs 7800, 7804, and 7806. The Board has already noted that the requirements for DCs 7800 and 7804 did not change. Prior to August 13, 2018, the rating criteria for DC 7806 provides the following ratings: a 60 percent rating for more than 40 percent of the entire body or more than 40 percent of the exposed areas affected, or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period; a 30 percent rating for 20 to 40 percent of the entire body or 20 to 40 percent of the exposed areas affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period; a 10 percent rating for at least five percent, but less than 20 percent, of the entire body or at least five percent, but less than 20 percent, of the exposed areas affected, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period; and a noncompensable rating for less than five percent of the entire body or less than five percent of the exposed areas affected and no more than topical therapy required during the past 12-month period. See 38 C.F.R. § 4.118, DC 7806 (2017). The rating criteria cautions to alternatively rate as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. See id. Effective August 13, 2018, the rating criteria for DC 7813 evaluates the skin disability under the General Rating Formula for Skin, which provides the following ratings: a 60 percent rating for characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of the exposed areas affected, or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period; a 30 percent rating for characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of the exposed areas affected, or systemic therapy required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period; a 10 percent rating for characteristic lesions involving at least five percent, but less than 20 percent, of the entire body or at least five percent, but less than 20 percent, of the exposed areas affected, or intermittent systemic therapy required for a total duration of less than 6 weeks over the past 12-month period; and a noncompensable rating for no more than topical therapy required over the past 12-month period and either characteristic lesions involving less than five percent of the entire body or less than five percent of the exposed areas affected. See 38 C.F.R. § 4.118, DC 7813 (2021). The rating criteria cautions to alternatively rate as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. See id. The 2018 regulatory changes defined the terms "systemic" and "topical" therapy. Systemic therapy is "treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin" and topical therapy is "treatment that is administered through the skin." See 38 C.F.R. § 4.118(a) (2021). Prior to the regulatory change, however, topical therapy could fit within the definition of "systemic" therapy if the topical therapy was administered on a large enough scale to affect the body as a whole, see Johnson v. Shulkin, 862 F.3d 1351, 1355 (Fed. Cir. 2017), or if it affected the body more broadly, such as circulating through the bloodstream. See Burton v. Wilkie, 30 Vet. App. 286, 292 (2018). Pyramiding, that is the evaluation of the same disability or the same manifestation of a disability, under different DCs, is to be avoided when evaluating a veteran's service-connected disability. See 38 C.F.R. § 4.14. A veteran can be awarded separate ratings under DC 7804 and DC 7800, 7801, 7802, or 7805. See 38 C.F.R. § 4.118, DC 7804, Note (3). Determination of predominant disability The Veteran is currently assessed a noncompensable disability rating under DC 7899-7813, effective November 15, 2010, and a 30 percent disability rating under DC 7813-7800, effective May 31, 2017. See 38 C.F.R. § 4.27 (stating that a DC ending in "99" is provided when a veteran has a disability that is unlisted in the rating schedule); see also 38 C.F.R. § 4.20 (stating that an unlisted disability will be rated under a closely-related disability). The December 2020 rating decision stated that May 31, 2017, is the first record where the Veteran was diagnosed with scar as violaceous scar-distributed on the right cheek and right lip. At a November 2012 VA session, the Veteran reported PFB. The provider observed papular lesions in beard region, but no pustules or signs of abscess. The Veteran was referred to dermatology and prescribed Doxycycline, an antibiotic, and a cream. At a February 2013 VA dermatology consultation, the Veteran reported an area on his right lateral chin that seemed to be more thickened and hyperpigmented. The dermatologist observed some post inflammatory hyperpigmentation in the area of the right chin. The dermatologist discontinued both medications. In an April 2013 VA Form 9, the Veteran reported PFB for the past 30 years. He reported very painful ingrown hairs and that these hair bumps turned into scarring on his face. At a May 2013 VA examination, the examiner observed chronic folliculitis on areas of the chin and anterior upper neck that affected .3 percent of total skin surface and .69 percent of exposed skin surface. The examiner observed no scarring or disfigurement of the head, face, or neck. The examiner stated that this disability did not affect the Veteran's ability to work. At a February 2014 private session, the Veteran reported PFB. The provider noted that the Veteran's last visit was in 2005. The provider diagnosed PFB based on rare papules in the bearded area and prescribed Fluocinolone, a topical cream, to be applied to the affected areas. The provider also diagnosed eczema, benign nevi, and acne. In a February 2014 Notice of Disagreement, the Veteran stated that he was being treated for skin lesions (papules) and eczema, and was using Fluocinolone. At an October 2014 private session, the Veteran asked if his current medication was considered a corticosteroid and was considered systemic. The provider stated that the Veteran's PFB and eczema were well-controlled and continued to prescribe Fluocinolone to be applied to the affected areas. In an October 2014 VA Form 9, the Veteran stated that he was prescribed Fluocinolone, a corticosteroid. At a December 2016 private session, the Veteran requested a prescription refill because he had been out for a few weeks. The provider performed an examination of the head (including face) and observed a few follicular-based papules over beard area and dry eczematous scaling on lateral cheeks, central cheeks, and chin. The provider prescribed Desonate, a topical steroid, to be applied to the affected areas. At a May 31, 2017, private session, the Veteran reported scarring in beard area. The provider observed scattered hyperpigmented papules on right mandible and lower cheeks; the left side was not affected. The provider also observed a violaceous scar distributed on the right check to the right lip and mild eczematous scaling of skin on cheeks. The provider prescribed Differin, a topical gel, to be applied to face for PFB and injected the right cheek and right lip with Kenalog for scar. At a June 2017 hearing, the Veteran stated that his private provider prescribed a new medication, which was not as strong as Fluocinolone, but he could not see the difference. He reported scarring up over the area where he would pull hair out. The Veteran reported that his private provider called them scars and gave him Kenalog, which he described as systemic treatment. He stated that his symptoms affected the chin line and his face and stated that the scars were painful. At a May 2019 private session, the Veteran reported that Differin was not working as well for him. The provider observed fine follicular papules clustered throughout beard area and focal eczematous patches on cheeks. The provider prescribed Adapalene, a topical gel, to be applied to the face. At an October 2019 VA examination, the examiner reviewed the Veteran's claims file and performed an in-person examination of the Veteran. The examiner stated that the Veteran's visible characteristic lesions were less than five percent of total body size and less than five percent of exposed area. The examiner stated that this disability resulted in scarring and that the Veteran was injected with Kenalog in May 2017 to reduce the size of his scar. The examiner noted that the May 2019 treatment record did not mention that Kenalog was administered and that no additional treatment for Kenalog was noted in the plan for future treatment. The examiner stated that the Veteran's disability did not affect his ability to work. At a November 2019 VA examination, the examiner reviewed the Veteran's claims file and performed an in-person examination of the Veteran. The examiner diagnosed scarring secondary to PFB. The Veteran reported a long-standing history of "shave bumps" that were painful with regular shaving and for which he had been treated with injections. The examiner observed no gross distortion or asymmetry of facial features or visible or palpable tissue loss. The examiner observed one scar on the right lower chin area with six hyperpigmented, elevated, anular lesions of .2 mm. in diameter. The examiner stated that the scar length and width was 1.2 cm. squared. The examiner noted that the scar was not painful or unstable. The examiner stated that the scar did not affect the Veteran's ability to work. At an October 2020 VA examination, the examiner reviewed the Veteran's claims file and performed an in-person examination of the Veteran. The examiner stated that the Veteran's visible characteristic lesions were less than five percent of total body size and less than five percent of exposed area. The examiner observed two scars that were not painful or unstable. The scar on the left side of mouth was 1 cm. long and .5 cm. wide. The scar on the right side of mouth was 3 cm. long and .5 cm. wide. The examiner stated that PFB and scars did not affect the Veteran's ability to work. In November 2020, the VA examiner reviewed the Veteran's claims file and provided an addendum opinion. The examiner noted that there were no indications of scarring until the May 2017 session and that the only Kenalog injection was at the May 2017 session. After evaluating the evidence of record, the Board finds that the Veteran's predominant disability was PFB, prior to May 31, 2017, and chin scarring due to PFB, effective May 31, 2017. The medical evidence of record, to include the private treatment records, VA treatment records, and VA examinations, did not identify any scars until the May 31, 2017, private treatment session. The November 2020 VA examiner comprehensively reviewed the evidence of record and opined that the evidence did not show any scarring until May 31, 2017. The Board has considered the Veteran's lay statements of scarring, to include the April 2013 VA Form 9 and at the June 2017 hearing. While the Veteran is competent to report his symptoms, it is not clear that his use of the term "scarring" is in the same fashion as under DCs 7800 and 7804. The Board instead assigns probative weight to the medical evidence of record, to include the February 2013 VA dermatology consultation, May 2013 VA examination, February 2014 private session, October 2014 private session, and December 2016 private session, that mentioned no scarring. The May 2013 VA examination is particularly important because it was only one month after the April 2013 VA Form 9, and the VA examiner, who would have been familiar with the regulatory requirements of scarring, observed no scarring. The Board also assigns probative weight to the November 2020 VA examiner who comprehensively reviewed the evidence of record and opined that the evidence did not show any scarring until May 31, 2017. The Board has also considered the representative's assertions, to include the March 2021 letter stating that we do not believe the Veteran's disability changed on the same day as the VA examination. The Board notes that the May 31, 2017, effective date was the date of the private treatment session, not a VA examination. Moreover, the effective date for an increased rating is predicated on when the increase in the disability can be factually ascertained. See Swain v. McDonald, 27 Vet. App. 219, 224 (2015). The evidence of record, to include the November 2020 addendum opinion, first noted scarring at the May 31, 2017, session, and there is no competent and credible evidence suggesting an earlier factually ascertainable effective date. Given this initial finding, the Board can now assess the appropriate disability ratings. As explained below, the Board finds that a compensable disability rating for PFB is not warranted, prior to May 31, 2017; a disability rating in excess of 30 percent for chin scarring due to PFB is not warranted, effective May 31, 2017; and a 10 percent disability rating for painful scars due to PFB is warranted, effective May 31, 2017. PFB, prior to May 31, 2017 At a November 2012 VA session, the Veteran reported PFB. The provider observed papular lesions in beard region, but no pustules or signs of abscess. The Veteran was referred to dermatology and prescribed Doxycycline, an antibiotic, and a cream. At a February 2013 VA dermatology consultation, the Veteran reported an area on his right lateral chin that seemed to be more thickened and hyperpigmented. The dermatologist observed some post inflammatory hyperpigmentation in the area of the right chin. The dermatologist discontinued both medications. In an April 2013 VA Form 9, the Veteran reported PFB for the past 30 years. He reported very painful ingrown hairs and that these hair bumps turned into scarring on his face. At a May 2013 VA examination, the examiner observed chronic folliculitis on areas of the chin and anterior upper neck that affected .3 percent of total skin surface and .69 percent of exposed skin surface. The examiner observed no scarring or disfigurement of the head, face, or neck. The examiner stated that this disability did not affect the Veteran's ability to work. At a February 2014 private session, the Veteran reported PFB. The provider noted that the Veteran's last visit was in 2005. The provider diagnosed PFB based on rare papules in the bearded area and prescribed Fluocinolone, a topical cream, to be applied to the affected areas. The provider also diagnosed eczema, benign nevi, and acne. In a February 2014 Notice of Disagreement, the Veteran stated that he was being treated for skin lesions (papules) and eczema, and was using Fluocinolone. At an October 2014 private session, the Veteran asked if his current medication was considered a corticosteroid and was considered systemic. The provider stated that the Veteran's PFB and eczema were well-controlled and continued to prescribe Fluocinolone to be applied to the affected areas. In an October 2014 VA Form 9, the Veteran stated that he was prescribed Fluocinolone, a corticosteroid. At a December 2016 private session, the Veteran requested a prescription refill because he had been out for a few weeks. The provider performed an examination of the head (including face) and observed a few follicular-based papules over beard area and dry eczematous scaling on lateral cheeks, central cheeks, and chin. The provider prescribed Desonate, a topical steroid, to be applied to the affected areas. At a May 31, 2017, private session, the Veteran was prescribed Differin, a topical gel, to be applied to face for PFB and injected the right cheek and right lip with Kenalog for scar. At a June 2017 hearing, the Veteran stated that his private provider prescribed a new medication, which was not as strong as Fluocinolone, but he could not see the difference. The Veteran reported that his private provider called them scars and gave him Kenalog, which he described as systemic treatment. At an October 2019 VA examination, the examiner stated that the Veteran was injected with Kenalog in May 2017 to reduce the size of his scar. The examiner noted that the May 2019 treatment record did not mention that Kenalog was administered and that no additional treatment for Kenalog was noted in the plan for future treatment. In November 2020, the VA examiner noted that there were no indications of scarring until the May 2017 session and that the only Kenalog injection was at the May 2017 session. Whether using the prior rating criteria under DC 7806 or the current rating criteria in the General Rating Formula for Skin, the Board finds that a compensable disability rating for PFB, prior to May 31, 2017, is not warranted. The evidence of record, to include the VA examinations, showed that the Veteran's PFB affected less than five percent of the entire body and less than five percent of the exposed areas affected. See 38 C.F.R. § 4.118, DC 7806 (2017); 38 C.F.R. § 4.118, DC 7813 (2021). Similarly, during this period, the Veteran was generally prescribed a topical cream to be applied to the area affected. See id. Accordingly, these topical creams were not "systemic" therapy because they were not administered on a large enough scale to affect the body as a whole, see Johnson, 862 F.3d at 1355, or affecting the body more broadly, see Burton, 30 Vet. App. at 292. A 10 percent disability rating is not warranted using the prior rating criteria under DC 7806 or the current rating criteria in the General Rating Formula for Skin because the Veteran's PFB did not affect at least five percent of the entire body or the exposed areas affected, and he did not receive intermittent systemic therapy. See 38 C.F.R. § 4.118, DC 7806 (2017); 38 C.F.R. § 4.118, DC 7813 (2021). A 10 percent disability rating is also not warranted under DC 7800 because the evidence of record showed no characteristics of disfigurement. See 38 C.F.R. § 4.118, DC 7800, Note (1). The Board has considered the Veteran's lay statements and the representative's assertions. While the Veteran has stated that his medication is a corticosteroid or inquired whether his treatment is systemic, the Board finds that the topical creams prescribed prior to May 31, 2017, do not rise to the level of systemic therapy. The Board further finds that the Veteran was first injected with Kenalog on May 31, 2017. To the extent that the Veteran asserts any symptoms not contemplated by the rating criteria, the Board notes that there is no evidence of marked interference with employment or frequent hospitalization. Indeed, the May 2013 VA examiner stated that this disability did not affect the Veteran's ability to work. Because the preponderance of the evidence is against the Veteran's claim for an increased rating, there is no reasonable doubt to be resolved, and the claim for a compensable disability rating for PFB under DC 7899-7813, prior to May 31, 2017, must be denied. Chin scarring due to PFB, as of May 31, 2017 At a May 31, 2017, private session, the Veteran reported scarring in beard area. The provider observed scattered hyperpigmented papules on right mandible and lower cheeks; the left side was not affected. The provider also observed a violaceous scar distributed on the right check to the right lip and mild eczematous scaling of skin on cheeks. The provider prescribed Differin, a topical gel, to be applied to face for PFB and injected the right cheek and right lip with Kenalog for scar. At a June 2017 hearing, the Veteran stated that his private provider prescribed a new medication, which was not as strong as Fluocinolone, but he could not see the difference. He reported scarring up over the area where he would pull hair out. The Veteran reported that his private provider called them scars and gave him Kenalog, which he described as systemic treatment. He stated that his symptoms affected the chin line and his face and stated that the scars were painful. At a May 2019 private session, the Veteran reported that Differin was not working as well for him. The provider observed fine follicular papules clustered throughout beard area and focal eczematous patches on cheeks. The provider prescribed Adapalene, a topical gel, to be applied to the face. At an October 2019 VA examination, the examiner reviewed the Veteran's claims file and performed an in-person examination of the Veteran. The examiner stated that the Veteran's visible characteristic lesions were less than five percent of total body size and less than five percent of exposed area. The examiner stated that this disability resulted in scarring and that the Veteran was injected with Kenalog in May 2017 to reduce the size of his scar. The examiner noted that the May 2019 treatment record did not mention that Kenalog was administered and that no additional treatment for Kenalog was noted in the plan for future treatment. The examiner stated that the Veteran's disability did not affect his ability to work. At a November 2019 VA examination, the examiner reviewed the Veteran's claims file and performed an in-person examination of the Veteran. The examiner diagnosed scarring secondary to PFB. The Veteran reported a long-standing history of "shave bumps" that were painful with regular shaving and for which he had been treated with injections. The examiner observed no gross distortion or asymmetry of facial features or visible or palpable tissue loss. The examiner observed one scar on the right lower chin area with six hyperpigmented, elevated, anular lesions of .2 mm. in diameter. The examiner stated that the scar length and width was 1.2 cm. squared. The examiner noted that the scar was not painful or unstable. The examiner stated that the scar did not affect the Veteran's ability to work. At an October 2020 VA examination, the examiner reviewed the Veteran's claims file and performed an in-person examination of the Veteran. The examiner stated that the Veteran's visible characteristic lesions were less than five percent of total body size and less than five percent of exposed area. The examiner observed two scars that were not painful or unstable. The scar on the left side of mouth was 1 cm. long and .5 cm. wide. The scar on the right side of mouth was 3 cm. long and .5 cm. wide. The examiner stated that PFB and scars did not affect the Veteran's ability to work. In November 2020, the VA examiner reviewed the Veteran's claims file and provided an addendum opinion. The examiner noted that there were no indications of scarring until the May 2017 session and that the only Kenalog injection was at the May 2017 session. The Board finds that a disability rating in excess of 30 percent for chin scarring due to PFB, effective May 31, 2017, is not warranted. The evidence of record, to include the October 2020 VA examination, showed two characteristics of disfigurement, which is consistent with a 30 percent rating. See 38 C.F.R. § 4.118, DC 7800. A 50 percent rating is not warranted because the evidence of record, to include the VA examinations, did not show visible or palpable tissue loss and either gross distortion of asymmetry of two features or paired sets of features, or with four or five characteristics of disfigurement. See id. Due to pyramiding, the Veteran cannot receive separate ratings under DCs 7800 and 7813. See 38 C.F.R. § 4.14; see also 38 C.F.R. § 4.118, DC 7806 (2017); 38 C.F.R. § 4.118, DC 7813 (2021). While the Board has considered using the prior rating criteria under DC 7806 or the current rating criteria in the General Rating Formula for Skin, the Board notes that the Veteran is currently receiving the higher disability rating under DC 7800. Using either criteria, a 10 percent rating would be warranted because the evidence of record showed only one Kenalog injection, which is consistent with intermittent systemic therapy required for a total duration of less than six weeks during the past 12-month period. See 38 C.F.R. § 4.118, DC 7806 (2017); 38 C.F.R. § 4.118, DC 7813 (2021). For the same reasons stated in the prior section, the topical creams prescribed would not be classified as systemic therapy. A 30 percent disability rating would not be warranted using either criteria because the Veteran's PFB did not affect 20 to 40 percent of the entire body or exposed areas affected, or result in systemic therapy required for a total duration of six weeks or more, but not constantly, during the past 12-month period. See id. The Board has considered the Veteran's lay statements and the representative's assertions. To the extent that the Veteran's lay statements suggest Kenalog injections on multiple occasions, the Board assigns probative weight to the medical evidence of record, to include the private treatment records, the October 2019 VA examination, and the November 2020 VA addendum opinion, showing only one Kenalog injection. To the extent that the Veteran asserts any symptoms not contemplated by the rating criteria, the Board notes that there is no evidence of marked interference with employment or frequent hospitalization. Indeed, the October 2019, the November 2019, and the October 2020 VA examiners stated that this disability did not affect the Veteran's ability to work. Because the preponderance of the evidence is against the Veteran's claim for an increased rating, there is no reasonable doubt to be resolved, and the claim for a disability rating in excess of 30 percent for chin scarring due to PFB under DC 7813-7800, effective May 31, 2017, must be denied. Painful scars due to PFB, as of May 31, 2017 At a May 31, 2017, private session, the provider observed a violaceous scar distributed on the right check to the right lip and mild eczematous scaling of skin on cheeks. The provider injected the right cheek and right lip with Kenalog for scar. At a June 2017 hearing, the Veteran reported scarring up over the area where he would pull hair out and stated that the scars were painful. At an October 2019 VA examination, the examiner stated that the Veteran's PFB resulted in scarring and that the Veteran was injected with Kenalog in May 2017 to reduce the size of his scar. At a November 2019 VA examination, the examiner diagnosed scarring secondary to PFB. The Veteran reported a long-standing history of "shave bumps" that were painful with regular shaving and for which he had been treated with injections. The examiner noted that the scar was not painful or unstable. At an October 2020 VA examination, the examiner observed two scars that were not painful or unstable. The Board finds that a 10 percent disability rating for painful scars due to PFB under DC 7804, effective May 31, 2017, is warranted. See 38 C.F.R. § 4.118, DC 7804. The evidence of record, to include the October 2020 VA examination, showed two scars. The Board notes that the November 2019 and October 2020 VA examinations showed that the scars were not unstable or painful. While the Board has previously stated that it is unclear whether the Veteran used the term "scarring" in the same fashion as under DCs 7800 and 7804, the Board gives the Veteran the benefit of the doubt and finds that the scars identified at the VA examinations were painful. Indeed, the Board notes that the Veteran's scar was treated on one occasion with a Kenalog injection. The evidence of record, therefore, shows two painful scars, consistent with a 10 percent disability rating. See id. A 20 percent disability rating is not warranted because there is no competent evidence of three or four scars. See id. To the extent that the Veteran's lay statements could be interpreted to suggest more than two scars, to include the general reference to "scarring" in the April 2013 VA Form 9, the Board assigns probative weight to the medical evidence of record finding no more than two scars. There is no competent evidence that any scars are unstable. Accordingly, the Board finds that a 10 percent disability rating for painful scars due to PFB under DC 7804, effective May 31, 2017, is warranted. REASONS FOR REMAND The Board cannot make a fully-informed decision at this time on the claim of service connection for a lumbar spine disability because the September 2020 VA addendum opinion is inadequate. While the examiner notes a February 1987 service treatment record identifying mild back strain, possible motor vehicle collision, as well as the Veteran's reports of ongoing back pain since service, the examiner's sole rationale is that the Veteran is not qualified to ascribe a diagnosis to his symptoms. An examiner, however, cannot disregard a Veteran's lay statements solely because the Veteran is not qualified to ascribe a diagnosis to his symptoms. On remand, the examiner must consider the Veteran's lay evidence in opining whether the Veteran's lumbar spine disability is at least as likely as not related to service. The matter is REMANDED for the following action: Obtain an addendum opinion regarding the etiology of the Veteran's lumbar spine disability. If the examiner believes a new examination is warranted, schedule a new examination. The examiner must opine whether any of the Veteran's current lumbar spine conditions are at least as likely as not related to service, to include the injury when lifting a heavy crate of M16s and/or the injury following a motor vehicle accident. In rending this opinion, the examiner must consider and discuss the Veteran's testimony at a June 2017 Board hearing that he still had pain in his low back after service; that he continued to have "pounding" pain in the area, with sharp pain down his right leg; and that the same problems are occurring now. (Continued on the next page.) An opinion that the Veteran is unable to ascribe a diagnosis to his symptoms or that there are no objective clinical records to show a connection to service will not be adequate. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Ormson, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.