Citation Nr: 21040898 Decision Date: 07/07/21 Archive Date: 07/07/21 DOCKET NO. 15-03 929A DATE: July 7, 2021 ORDER 1. Entitlement to service connection for a sleep disorder, to include as secondary to inoculations or exposure to burn pits, is denied. 2. Entitlement to a disability rating in excess of 10 percent for service-connected papular dermatitis with pruritis of the right forearm is denied. REMAND 3. Entitlement to service connection for erectile dysfunction, to include as secondary to inoculations or exposure to burn pits and to include as secondary to his unspecified trauma and stressor-related disorder, is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran's sleep disorder began during active service or is otherwise related to an in-service injury or disease, to include inoculations or exposure to burn pits 2. The Veteran's papular dermatitis with pruritis of the right forearm manifests with exposure of at least 5 percent but less than 20 percent of his entire body, or at least 5 percent but less than 20 percent, of exposed areas affected, and intermittent systemic therapy such as corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over a 12-month period. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a sleep disorder have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 2. The criteria for entitlement to a disability rating in excess of 10 percent for service-connected papular dermatitis with pruritis of the right forearm have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.14, 4.118, Diagnostic Code (DC) 7806. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from November 1968 to December 1969 and in the Air Force Reserves from April 2005 to April 2006. He had additional periods of service in the Air National Guard and Air Force Reserves from April 1991 to August 2011. These matters before the Board of Veterans' Appeals (Board) are on appeal from a July 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania (Agency of Original Jurisdiction (AOJ)). The Board remanded these matters in January 2019 for additional development. In consideration of the appeal, the Board is satisfied there was substantial compliance with the remand directives and will proceed with review. Stegall v. West, 11 Vet. App. 268 (1998). As an initial matter, the Board notes that at the time these issues were appealed, the issue of entitlement to service connection for a lumbar spine disability was also included. However, while these matters were pending on appeal, the AOJ granted entitlement to service connection for a lumbar spine condition in a March 2021 rating decision. This award is effective April 3, 2012, which is the date the Veteran first filed his claim. As this represents a complete grant of the Veteran's claim, this issue is no longer on appeal before the Board. See Grantham v. Brown, 114 F.3d 116 (Fed. Cir. 1997); Barrera v. Gober, 122 F.3d 1030 (Fed. Cir. 1997). Service Connection Service connection may be granted for a current disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110; 38 C.F.R. §§ 3.303. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. §§ 3.303(d). The requirement that a current disability exist is satisfied if the claimant had a disability at the time the claim for VA disability compensation was filed or during the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). For those who served in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may also be established under 38 C.F.R. § 3.317. Under that section, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C. § 1117, 38 C.F.R. § 3.317, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez, 19 Vet. App. at 8-9. Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. 38 C.F.R. § 3.317(a)(5); see Stankevich v. Nicholson, 19 Vet. App. 470 (2006). A medically unexplained chronic multisymptom illnesses is one defined by a cluster of signs or symptoms and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness. A "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). Lay evidence is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition is capable of lay observation and may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature." Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). A veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. See Fagan v. Shinseki, 573 F.3d 1282, 1287-88 (2009). In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. See Fagan, 573 F.3d at 1287 (quoting 38 U.S.C. §§ 5107(b)). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. 38 U.S.C. §§ 1154(a); Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). 1. Entitlement to service connection for a sleep disorder, to include as secondary to inoculations or exposure to burn pits The Veteran contends that he has a sleep disorder that is etiologically related to his active duty service. Specifically, he believes that the Anthrax inoculations he received as a condition of his service resulted in his sleep condition. Alternatively, he asserts that his exposure to burn pits during service resulted in his sleep disorder. He explained that when he first returned from Southwest Asia after receiving the beginning of the series of shots, he slept for 20 hours straight, waking up only to use the restroom and eat; he said that this continued for three and a half months. Though his condition has improved somewhat, he still feels fatigued even after sleeping 10 to 12 hours a night. In connection with his claim, the Veteran submitted a series of articles documenting the sleep disturbances Gulf War veterans may have as a result of their service. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for a sleep disorder. The reasons follow. The record corroborates that the Veteran has a current diagnosis of a sleep disorder. VA treatment records include chronic fatigue syndrome as part of his medical history, though it is unclear if this was self-diagnosed or diagnosed by a medical professional. These records also note that in July 2015, following a sleep study, the Veteran was diagnosed with obstructive sleep apnea. An October 2020 VA examination also provided a diagnosis of obstructive sleep apnea. Therefore, the facts establish that the first element of a service connection claim is met. The Veteran's service treatment records (STRs) are generally silent for complaints, diagnoses, or treatment for sleep problems. The available Reports of Medical History and Reports of Medical Examinations do not reference complaints regarding sleep. Rather, the Veteran specifically and repeatedly denied having or having had frequent trouble sleeping on Reports of Medical History contained in the claims file. However, on a post-deployment health assessment (PHA) dated January 2006, the Veteran marked "yes" when asked if he still felt tired after sleeping. The STRs also document that he received a number of inoculations, including multiple anthrax vaccines from 1998 through at least 2005. The Veteran's contentions that he was exposed to burn pits during his active duty service is consistent with his deployment to Southwest Asia. Thus, the Board accepts the Veteran's inoculations and exposure to burn pits as well as his contention of still feeling tired upon waking as in-service events. However, as to evidence of a nexus between the current disability and service, the Board finds that this element of a service-connection claim is not met. The Veteran was provided a VA examination in October 2020 to assess the nature and etiology of any diagnosed sleep disorder. The VA examiner, after noting a diagnosis of obstructive sleep apnea, noted that obstructive sleep apnea is classified as a disease with a clear and specific etiology and diagnosis, and therefore opined that obstructive sleep apnea is less likely than not related to a specific exposure event experienced by the Veteran during his service in Southwest Asia, to include in-service inoculations or exposure to burn pits. The examiner rationalized, "[The] causes of sleep apnea include excess weight, neck circumference, a narrowed airway, being male, being older, family history, use of alcohol...smok[ing], [and a variety of] medical conditions. On exam, the Veteran is noted to be obese, a cigarette smoker, and male. While a neck circumference was not measured, it did appear outside of normal limits. These are all known causes of sleep apnea." In November 2020, an addendum opinion was submitted by the same examiner who provided the October 2020 VA examination. The examiner was asked to consider the Veteran's report of still feeling tired after sleeping on a PHA from November 2006. The examiner stated that, "Although there was fatigue/tiredness noted after service, the [Veteran] was diagnosed with several conditions that could be a potential cause, including hepatitis C and chronic fatigue syndrome. As there was no diagnosis related to the report of the PHA in 2006, the etiology cannot be determined without resorting to speculation. Given this, along with the fact that the sleep apnea wasn't diagnosed until 2015, the other conditions with overlapping symptoms, and the aforementioned causes of [sleep apnea] that the Veteran has . . . it is less likely than not caused by the in-service condition/exposures." The same VA examiner provided a third opinion in March 2021. The examiner was asked to assume the Veteran's onset of sleep problems began during active duty service (i.e. within one year of discharge, based on the Veteran's PHA). Nonetheless, she determined, "Reports of 'still feeling tired after sleep' does not substantiate a diagnosis of sleep apnea as there are several causes for this symptom, including poor sleep hygiene, mental health conditions, malnourishment/not enough caloric intake, anemia, endocrine disorders, too much caffeine, diabetes, dehydration, heart conditions, etc. As such, the sleep apnea is less likely than not due to the complaints of feeling tired after sleep." Based on the aggregate evidence of record, the Board must deny the claim for entitlement to service connection for a sleep disorder. As an initial matter, the evidence is against finding that the Veteran's sleep disorder was caused by his anthrax inoculations. Though he submitted safety reviews of the anthrax vaccine in connection with his claim, these reports determined "there are no known long-term patterns of side effects from the anthrax vaccine." Moreover, the VA examiner stated that obstructive sleep apnea is more likely caused by other factors, including the Veteran's obesity, status as a smoker, and sex which predisposed him to develop sleep apnea. As it relates to his exposure to burn pits, the Veteran submitted additional literature in support of his claim. The Board acknowledges that Gulf War Syndrome encompasses a multitude of illnesses, including chronic fatigue syndrome. Notably, though, the Veteran's obstructive sleep apnea is a specifically diagnosed disease with a clear and specific etiology. Though VA treatment records include reports of chronic fatigue syndrome, it is unknown if this was determined by a medical professional or if the Veteran self-diagnosed. Given that VA examinations and the vast majority of the Veteran's claims file does not document a diagnosis of chronic fatigue syndrome, the Board finds it is not at least as likely as not that the Veteran has a diagnosis of chronic fatigue syndrome. Regardless, his sleep disability is not a qualifying chronic disability based on his service in Southwest Asia. Finally, the Board finds that the Veteran is not entitled to service connection on a direct basis for his diagnosed obstructive sleep apnea. With the exception of the 2006 PHA, his records are silent for complaints of sleep symptomatology, and, as noted above, the Veteran repeatedly denied having or having had recurrent trouble sleeping on Reports of Medical History. Even when considering the PHA, the VA examiner provided a reasonable rationale, stating that reports of 'still feeling tired after sleep' does not substantiate a diagnosis of obstructive sleep apnea, especially given that the Veteran was not diagnosed with obstructive sleep apnea until April 2016, which is nearly a decade after the Veteran initially reported feeling tired after sleeping.. The Board acknowledges that an October 2020 VA psychiatric examination opinion was provided contemporaneously by a different physician, specifically a psychologist. This opinion noted that the Veteran's sleep issues were related to his unspecified trauma and stressor related disorder. The Board notes that this opinion appears to relate primarily to the Veteran's nightmares and "emotional responses," and not his separately diagnosed obstructive sleep apnea, and the Board finds that the sleep symptomatology referenced by the examiner is considered and compensated for in in the Veteran's 50 percent rating for unspecified trauma and stressor-related disorder. Given the aforementioned, the Board finds that the preponderance of the evidence of record is against finding that the Veteran is entitled to service connection for a sleep disorder, to include as secondary to inoculations or exposure to burn pits. For these reasons, the Veteran's claim is denied. In reaching the above conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Thus, the claim for service connection for a sleep disorder is denied. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability is resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. In determining the propriety of the initial rating assigned after a grant of service connection, the evidence since the effective date of the grant of service connection must be evaluated and staged ratings must be considered. Staged ratings are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the course of the appeal. Fenderson v. Brown, 12 Vet. App. 119, 12627 (1999). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. 38 U.S.C. § 1154(a); Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). 2. Entitlement to a disability rating in excess of 10 percent for service-connected papular dermatitis with pruritis of the right forearm The Veteran is currently in receipt of a 10 percent rating under Diagnostic Code 7806. The Veteran contends that a higher rating is warranted. During the pendency of this appeal, the applicable rating criteria for skin disorders, found at 38 C.F.R. § 4.118 and including Diagnostic Code 7806, were substantively amended. When regulations are revised during the course of an appeal, the Board is generally required to consider the claim in light of both the former and revised schedular criteria and to apply the regulation more favorable to the Veteran. The new rating criteria, however, may be applied only prospectively from the effective date of the change forward, unless the regulatory change specifically permits retroactive application. VAOPGCPREC 3-2000 (Apr. 10, 2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (emphasis added). The Board has an independent obligation to consider all potentially applicable provisions of law and regulation and to apply the diagnostic criteria in a manner that maximizes benefits. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); Bradley v. Peake, 22 Vet. App. 280 (2008). Thus, the Board has considered all applicable criteria in evaluating the Veteran's claims. The former version of Diagnostic Code 7806, effective August 30, 2002, provided a noncompensable rating when there was less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period. A 10 percent disability rating was warranted when at least 5 percent but less than 20 percent of the entire body or at least 5 percent but less than 20 percent of exposed areas affected, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating was assigned for 20 to 40 percent of the entire body or 20 to 40 percent of 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 60 percent rating was assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran's skin condition; and (2) whether the given treatment is "like" a corticosteroid or other immunosuppressive drug." Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. VA amended the criteria for rating skin disabilities, effective from August 13, 2018. 83 Fed. Reg. 32592 (July 13, 2018) as corrected at 83 Fed. Reg. 38663 (Aug. 7, 2018). These new regulations apply to all applications for benefits received by VA or that are pending before the AOJ on or after August 13, 2018. Effective August 13, 2018, a new General Rating Formula for the Skin applies to DCs 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. See 38 C.F.R. § 4.118. Under this formula, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent 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 for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating is assigned when at least one of the following are present: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. Or rate as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating for the Skin for Diagnostic Codes 7806, 7809, 7813-7816, 7820-7822, and 7824. Also effective August 13, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). The Board notes that the United States Court of Appeals for Veterans Claims (Court) held that topical use of corticosteroids constitutes systemic therapy under Diagnostic Code 7806. Johnson v. McDonald, 27 Vet. App. 497 (2016). The United States Court of Appeals for the Federal Circuit (Federal Circuit), however, reversed the decision by the Court. Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). In reversing, the Federal Circuit agreed with the VA Secretary that the Court erred when it "read Diagnostic Code 7806 as unambiguously elevating any form of corticosteroid treatment, including any degree of topical corticosteroid treatment, to the level of systemic therapy." The Federal Circuit noted that Diagnostic Code 7806 "draws a clear distinction between 'systemic therapy' and 'topical therapy' as the operative terms of the diagnostic code." The Federal Circuit went on to explain that systemic therapy means 'treatment pertaining to or affecting the body as a whole,' "whereas topical therapy means "treatment pertaining to a 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." Although a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, this possibility does not mean that all applications of topical corticosteroids amount to systemic therapy. A review of the relevant evidence of record as it pertains to the Veteran's papular dermatitis with pruritis of the right forearm reveals the following. At the outset of his claim filed in April 2012, the Veteran received a VA examination in July 2012. At that time, the examiner documented his diagnosis of papular dermatitis. The examiner further observed he had dermatitis of his right forearm with pruritis, but there was no scarring or disfigurement of the head, face, or neck. The examiner noted the Veteran had not been treated with oral or topical medications in the last 12 months and estimated his dermatitis covered approximately 5 to 20 percent of his total body area and less than 5 percent of his exposed areas. VA treatment records dated January 2013 include references to topical treatment solutions for the Veteran's skin disability. In September 2014, the Veteran presented to his physician complaining of a rash on his face that itched and burned and was a little painful. He endorsed experiencing it in the past and being given a steroid cream. At that time, he was prescribed a steroid cream and lidocaine cream, and told to use hydroxyzine as needed for itching. The Veteran also noted that this rash "comes and goes" on his arms, face, and neck. Similar findings were documented in February 2015. In May 2016, the Veteran received another VA examination for his skin disability. His diagnosis of papular dermatitis was again recorded. The examiner documented that the Veteran utilized topical corticosteroids, specifically cortisone, for six weeks or more, but not constantly. When assessing the total body area affected by dermatitis, the examiner documented that between 5 percent and 20 percent of his total body area was affected and less than 5 percent of his exposed area was affected. Describing the appearance, the examiner said, "areas scattered over neck, trunk, and arms of dermatitis with reports pruritis." There is a gap in VA treatment records between February 2015 and December 2017, as the Veteran did not receive treatment within the VA system during this period. His skin condition was briefly referenced, but it does not appear he was given a prescription or further treatment for it at that time. Similar remarks were made in January 2019. The Veteran received another VA examination in October 2019. The examiner recorded that the Veteran's condition "started in [the Veteran's] first deployment 1998 to desert and [his] arms turn[ed] different colors...no cream works on it and it itches terribl[y]. [He] was...given medications for it which have not worked. It [is] worse when it [is] hot and it starts on [his] neck then [his] arms." He had redness in his elbows and under his beard, but no itching at the time. The Veteran reported that it only starts to get itchy when is it really warm outside. The examiner documented that the Veteran had not been treated for any skin condition in the past 12 months with medications or procedures. When assessing the total body area affected by dermatitis, the examiner documented that less than 5 percent of his total body area was affected and none of his exposed area was affected. The examiner classified the severity of the skin disability as mild and noted the following: "After examining the [Veteran], interviewing him, and reviewing the medical records to include the remand..., the [Veteran's] treatment for papular dermatitis with pruritis of the right forearm having been cortisone cream is more categorized [as] systemic therapy. If you google cortisone cream on Epocrates, it is registered as a systemic therapy. I am not able to find records in the chart about the creams that [the Veteran] has been given, but he has been off it for quite some time because he does not believe they are helpful at all." Throughout the period on appeal, VA treatment records, with the exception of when the Veteran was seen specifically for treatment for a rash, document that the Veteran denied having rashes or lesions and the skin was documented to be "well-appearing" and "warm and dry" by treatment providers, further supporting the Veteran's contention to the September 2014 VA examiner that his rash would come and go. In January 2019, the Veteran specifically denied having a persistent skin rash. The Board finds that a 10 percent disability rating is the appropriate rating for the Veteran's papular dermatitis with pruritis of the right forearm. The Board acknowledges that skin conditions are known to fluctuate with active and inactive stages. See generally Ardison v. Brown, 6 Vet. App. 405 (1994). Under the old criteria, a 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of 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. The new criteria mandates that a 30 percent rating is assigned for at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. At no point during the pendency of this appeal has the evidence suggested that the Veteran's dermatitis covered 20 to 40 percent of his entire body or 20 to 40 percent of the exposed areas. Additionally, while the May 2016 examiner documented that he utilized topical corticosteroids for six weeks or more but not constantly, the frequency and duration of this treatment does not warrant a 30 percent rating. Indeed, the Veteran fluctuates between using topical corticosteroids and not using them at all. The Board acknowledges that the VA examiner who performed the Veteran's VA examination in October 2019 determined that the Veteran's use of cortisone cream should be classified as a systemic therapy. However, the Board notes that given the findings of the Federal Circuit in Johnson, it seems unlikely that the treatment used by the Veteran, which was described a topical cream to be applied to the affected area rather than a treatment for the body as a whole, meets the Federal Circuits definition of the systemic therapy under the old rating criteria. Nonetheless, with the exception of the single reference to the Veteran's use of topical corticosteroids for six weeks or more but not constantly at the May 2016 VA examination, the preponderance of the evidence of record does not support the finding that a disability rating in excess of 10 percent is warranted for the period on appeal. Specifically, VA examinations prior to and after the May 2016 VA examination specifically documented that the Veteran did not treat his disability for six weeks or more in the past 12 months. Furthermore, VA treatment records, to the extent the Veteran was treated by VA during the period on appeal, repeatedly document that other than during a flare-up requiring treatment, the Veteran's skin was documented to be normal and the Veteran denied having a continuous and persistent rash. In conclusion, the Board finds that the Veteran's service-connected papular dermatitis with pruritis of the right forearm is most closely contemplated by a 10 percent disability rating. As such, his claim is denied. REASONS FOR REMAND 1. Entitlement to service connection for erectile dysfunction, to include as secondary to inoculations or exposure to burn pits and to include as secondary to his unspecified trauma and stressor-related disorder. The Veteran contends that he has erectile dysfunction that is etiologically related to his active duty service. Specifically, he believes that the Anthrax inoculations he received as a condition of his service resulted in his inability to achieve and maintain an erection. Alternatively, he speculates that his exposure to burn pits during service resulted in his erectile dysfunction. He explained that after receiving the shots, he continued to notice a marked lack of sexual sensitivity and a "losing battle to obtain an erection." In a September 2012 correspondence, the Veteran cited to a conversation he had with his provider regarding his service-connected unspecified trauma and stressor related disorder as it related to erectile dysfunction. However, the record does not contain an etiology opinion related to this contention, and such an opinion is necessary given that the record raises a reasonable possibility that the Veteran's erectile dysfunction is caused or aggravated by his service-connected unspecified trauma and stressor-related disorder. The matters are REMANDED for the following action: Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the diagnosed erectile dysfunction. The examiner is asked to opine: (a) Is the Veteran's erectile dysfunction at least as likely as not (50 percent probability or greater) caused by the Veteran's service-connected unspecified trauma and stressor-related disorder? (c) If the answer to (b) is negative, is it at least as likely as not (50 percent probability or greater) that the erectile dysfunction is aggravated by the Veteran's service-connected unspecified trauma and stressor-related disorder? Aggravation is different from causation in that it did not cause the disability but that it caused an increase in severity that is not due ot the natural progress of the disability. (d) If the examiner finds that unspecified trauma and stressor-related disorder aggravates the Veteran's erectile dysfunction, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the erectile dysfunction prior to aggravation. If the examiner is unable to establish a baseline for the erectile dysfunction prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. In providing the aforementioned opinions, the examiner should consider the following: the Veteran's correspondence dated September 2012, January 2013, April 2013, and February 2014; private treatment records dated June 2013 and December 2014; the VA examinations and opinions provided in October 2019, October 2020, and April 2021. The examiner is asked to provide a rationale for each opinion given, including providing the medical principles and evidence relied upon for each opinion. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. A. Keninger Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Victoria A. Banis, 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.