Citation Nr: 21031779 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 12-24 641 DATE: May 24, 2021 REMANDED Entitlement to a rating in excess of 10 percent for recurrent ulcer and cellulitis of the right lower extremity is remanded. REASONS FOR REMAND The Veteran served pm active duty from April 1975 to September 1975. In July 2015, the Veteran testified at a Board hearing via videoconference before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In October 2015, the Board remanded the claim for a compensable rating for recurrent ulcer and cellulitis of the right lower extremity for additional evidentiary development. In October 2018, the Board issued a decision denying a compensable rating for recurrent ulcer and cellulitis of the right lower extremity. The Veteran appealed that decision to the U.S. Court of Appeals for Veterans Claims (Court). In March 2020, the Court issued an order that vacated the Board's October 2018 decision and remanded the matter on appeal for adjudication consistent with the March 2020 Joint Motion for Remand (JMR) by the parties. In August 2020 and January 2021, the Board again remanded the claim for additional evidentiary development. The matter has properly returned to the Board for appellate consideration. Entitlement to a rating in excess of 10 percent for recurrent ulcer and cellulitis of the right lower extremity is remanded. In compliance with the Board's August 2020 remand, the Veteran was afforded VA contract examinations in October 2020, to address evidence of pyoderma during the appeal period. The October 2020 VA examiner opined that the Veteran's pyoderma and right leg pain are manifestations of his service-connected recurrent ulcer and cellulitis. The October 2020 examiner also identified topical corticosteroid "Triamcinolone cream 1%" as medication used for recurrent ulcer with cellulitis. The Veteran's VA treatment records also reflect that he was prescribed topical medication (Mupirocin2%) for treatment of his "skin rash pyoderma". See VA treatment records dated December 2015. Thus, as noted in the Board's January 2021 remand, given the guidance in Johnson v. Shulkin, 862 F.3d 1351, 1354 (Fed. Cir. 2017), and Burton v. Wilkie, 30 Vet. App. 286, 291 (2018), for purposes of evaluating the Veteran's skin disability under Diagnostic Code7806, an addendum medical opinion was needed to clarify whether the identified topical corticosteroid medications (Triamcinolone cream 1% and Mupirocin 2%) may be considered systemic therapy. The Board directed that the examiner was to specifically address whether the Veteran's prescription medications of Triamcinolone cream 1% and Mupirocin 2% are considered topical therapy or systemic therapy. For each identified medication, if topical therapy, the examiner was to indicate whether it affects the body as a whole in treating skin symptoms, or if it is applied by direct contact with the skin, localized treatment of a dermatological condition. The examiner was also to address whether the Veteran's use of topical medications could be considered systemic therapy by explaining the method by which the topical treatment works. For example, a topical treatment may affect the body as a whole if it circulates through the bloodstream. See Burton v. Wilkie, 30 Vet. App. 286 (2018).c). For each identified medication, the examiner was to specifically address whether it is "like" a corticosteroid or other immunosuppressive drug to constitute systemic therapy in that it affects the body as a whole. Finally, the examiner was directed to estimate the percentage of the entire body and exposed areas that are affected by the skin disability during flare ups. In compliance with the Board's January 2021 remand, a VA medical opinion was submitted in March 2021. The examiner concluded that the Veteran's prescription medications, Triamcinolone cream 1% and Mupirocin 2% are considered topical therapy, and both are localized treatment, applied directly to skin. However, the examiner did not address whether the Veteran's use of the noted topical medications could be considered systemic therapy, by explaining the method by which the topical treatment works. Specifically, he did not discuss whether the topical medications circulate through the bloodstream, thereby affecting the entire body. In addition, although the examiner concluded that the Triamcinolone cream 1% is a corticosteroid and Mupirocin 2% is an antibiotic, he did not indicate that the Triamcinolone cream is used systemically or how long it has been required to be used. Finally, the examiner opined that 5% to less than 10% of the Veteran's body is affected by his skin disorder, but he did not specify what portion of the total body and what portion of the exposed areas are affected. For these reasons, the Board finds that the March 2021 VA medical opinion is incomplete and therefore, inadequate for evaluation purposes, and an addendum medical opinion is necessary to clarify whether the identified topical corticosteroid medications (Triamcinolone cream 1% and Mupirocin 2%) may be considered systemic therapy, and to help estimate the total body area and exposed area affected during flare ups. The matters are REMANDED for the following action: 1. Updated treatment records should be obtained and added to the claims file/e-folder. 2. Following completion of the above, arrange for the examiner who conducted the March 2021 VA skin/scar examinations to provide an addendum opinion. If the examiner is not available, the request may be referred to another, equally qualified medical professional, who should independently review the electronic claims folder. The claims folder should be made available to the examiner for review in connection with the examination and the examiner should acknowledge such review in the examination report or in an addendum. Any indicated studies should be performed. If the reviewer determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. The examiner is to provide an addendum on the following: a) Identify any medication used to treat the Veteran's service-connected recurrent ulcer with cellulitis, including manifestations such as pyoderma. The examiner should specifically address whether the Veteran's prescription medications of Triamcinolone cream 1% and Mupirocin 2% are considered topical therapy or systemic therapy? The term "systemic therapy" means treatment pertaining to or affecting the body as a whole; and "topical therapy" means "treatment pertaining to particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied." See Johnson v. Shulkin, 862 F.3d 1351, 1354 (Fed. Cir. 2017). b) For each identified medication, if topical therapy, does it affect the body as a whole in treating skin symptoms? Or is it applied by direct contact with the skin, localized treatment of a dermatological condition? The examiner should also address whether the Veteran's use of topical medications could be considered systemic therapy by explaining the method by which the topical treatment works. For example, a topical treatment may affect the body as a whole if it circulates through the bloodstream. See Burton v. Wilkie, 30 Vet. App. 286 (2018). c) For each identified medication, specifically address whether it is "like" a corticosteroid or other immunosuppressive drug to constitute systemic therapy in that it affects the body as a whole, and indicate how long such treatment has been required during the past 12-month period, i.e. six weeks or more, but not constantly, during the past 12-month period. d) Please estimate the percentage of the entire body and exposed areas that are affected by the skin disability during flare ups. In rendering the requested opinion, the VA examiner should consider all relevant medical and lay evidence of record, to include photographs, if any, and additional lay statements submitted by the Veteran in December 2020 describing his skin disability in its active state. See 38 C.F.R. § 4.118, Diagnostic Code 7806. 3. After completion of the above and any other development deemed necessary, review the expanded record, and readjudicate the claim for an increased rating. If the claim remains denied, the Veteran and his representative should be furnished an appropriate supplemental statement of the case, afforded an opportunity to respond, and the case should thereafter be returned to the Board for further appellate review, if in order. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board F. Yankey, 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.