Citation Nr: 21041313 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 16-59 684 DATE: July 8, 2021 ORDER Entitlement to an initial increased rating for pseudofolliculitis barbae, rated as noncompensable prior to November 20, 2019 and 10 percent thereafter is denied. FINDING OF FACT 1. Prior to November 20, 2019, the Veteran's pseudofolliculitis barbae was manifested by involvement of less than 5 percent of the total body area and less than 5 percent of the exposed areas affected, and no more than topical therapy required during the last 12-month period. 2. From November 20, 2019 onward, the Veteran's pseudofolliculitis barbae was manifested by involvement of at least 5 percent but less than 20 percent of exposed areas affected without systemic therapy such as corticosteroids or other immunosuppressive drugs. CONCLUSIONS OF LAW 1. Prior to November 20, 2019, the criteria for a compensable disability rating in excess of 0 percent for pseudofolliculitis barbae have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7806. 2. From November 20, 2019 to present, the criteria for a compensable disability rating in excess of 0 percent for pseudofolliculitis barbae have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7806. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1980 to September 1992. This matter comes before the Board of Veterans' Appeals (Board) from a June 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The matter was before the Board in December 2018 and August 2020. The matter now returns to the Board for further appellate review. The Board finds substantial compliance with its prior remand directives and therefore issues this decision based on the merits. See Stegall v. West, 11 Vet. App. 270-71 (1998) (holding that a remand by the Board imposes upon the Secretary of VA a concomitant duty to ensure compliance with the terms of the remand). Increased Rating Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). In cases in which a claim for a higher initial evaluation stems from an initial grant of service connection for the disability at issue, multiple (staged) ratings may be assigned for different periods of time during the pendency of the appeal. See generally Fenderson v. West, 12 Vet. App. 119 (1999). Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2. Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In general, all disabilities, including those arising from a single disease, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, pyramiding, or evaluating the same manifestation of a disability under different diagnostic codes, is to be avoided. See 38 C.F.R. § 4.14. Thus, separate ratings under different diagnostic codes are only permitted if, for example, those separate ratings are assigned based on manifestations of the veteran's disability that are separate and apart from manifestations for which the veteran has already been rated. Esteban v. Brown, 6 Vet. App. 259, 261 (1994). When after careful consideration of all procurable and assembled date, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 1. Entitlement to an initial increased rating for pseudofolliculitis barbae, rated as noncompensable prior to November 20, 2019 and 10 percent thereafter The Veteran contends that he is due a 20 percent rating for his pseudofolliculitis barbae due to long term issues partly handled by over the counter measures and the feelings of embarrassment caused by people's reactions to his skin condition. See June 2016 Notice of Disagreement. The Board notes that pseudofolliculitis barbae is manifested as a skin disorder. The RO assigned the Veteran's pseudofolliculitis barbae a rating under Diagnostic Code 7813-7806. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. Here, the hyphenated diagnostic code indicates that the Veteran's pseudofolliculitis barbae is rated, by analogy, under the criteria for dermatitis or eczema under the General Rating Formula for the Skin in listed in 38 C.F.R. § 4.118 - Schedule of Ratings Skin. Notably, during the appeal period, changes were made to 38 C.F.R. § 4.118, Diagnostic Code 7816. Effective August 13, 2018, VA amended its regulations governing skin disabilities. VA's intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. 83 Fed. Reg. 32592 (July 13, 2018). The General Rating Formula for the Skin provides ratings at 60, 30, 10, and non-compensable (zero percent) ratings. The General Rating provides a 60 percent rating is warranted where 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. A 30 percent rating is warranted where 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 10 percent rating is warranted where 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 required for a total duration of less than six weeks during the past 12-month period. A zero percent, non-compensable, rating, is warranted where 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. Notably, the August 2018 changes to 38 C.F.R. § 4.118 added section a, a definition for systemic use which states: "For the purposes of this section, 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." The Board notes that an addendum medical opinion regarding systemic treatment was obtained from a clinician independent of the new definition added in August 2018. Turning to the evidence of record, higher ratings are not warranted either prior to or after November 20, 2019 based on the area affected (coverage) by the Veteran's skin disability or its treatment. There are two measurements of percentage of coverage of total body area and exposed body areas of record. The first is a May 2016 VA examination finding that the Veteran's skin condition was manifested by multiple papules and post inflammatory hyperpigmentation to bilateral chin and neck with total body area less than 5 percent and exposed area less than 5 percent. The next coverage measurement is found in a November 20, 2019 VA examination report, the examiner identifying that the Veteran's pseudofolliculitis barbae covered at least 5 percent but less than 20 percent of exposed areas and less than 5 percent of total body area. The Board found no other measurements of body area coverage of record. Based on body area coverage elements, the Veteran is not entitled to higher ratings for either claims periods on appeal. As noted above, the evidence dated prior to November 20, 2019, does not show that his pseudofolliculitis barbae involved 5 percent or more of his total body area or greater than 5 percent of exposed body areas as required for a compensable rating. Here, as the VA examination is the only competent medical evidence of record that provides an objective measure of the area affected by the Veteran's condition, the Board finds that such determination is higher probative and dispositive for the earlier period. Here, there is no evidence to the contrary in the treatment record or even lay assertions to the contrary. Similarly, an increased rating is also not warranted based on body coverage area for the period from November 20, 2019, onward, as the evidence does not show that the disability involves more than 20 percent of the entire body area or more than 20 percent of exposed body areas. Here, again, the only competent medical evidence that objectively quantifies the Veteran's condition is the November 2019 VA examination, which explicitly found that the Veteran's condition only affect less than 5 percent of total body surfaces, and between, 5-20 percent of exposed surfaces. As such, with regards to the later period, the Board must also find that the finding of the VA examination to be higher probative with regards to affected surface area. Regarding whether higher ratings may be assigned based on treatment of the disability, the medical evidence shows that the veteran has been treated with topical steroids for the entire period on appeal as well as topical antibiotics for some of the time. See e.g., September VA 2020 VA Addendum Opinion (Examiner stated that desonide and hydrocortisone are corticosteroid drugs and clindamycin is not a corticosteroid or other immunosuppressive drug); September 2020 VA Treatment Record (active prescription medication listing denoside and clindamycin); November 2019 VA Examination (identifying denoside for treatment); May 2016 VA Examination (identifying hydrocortisone for treatment for). Both examiners noted that the Veteran has not received any treatments other than systemic or topical medications. VA treatment records also note treatment with the antibiotic clindamycin, denoside, and hydrocortisone throughout the period on appeal. See September 2020 VA Treatment Record See e.g., October 2020 Treatment Note (Listing active medication listing desonide with instructions to apply twice a day for 2 4 weeks and then only as needed); September 2017 Treatment Note (Same as October 2020 Treatment Note). All treatment for the Veteran's pseudofolliculitis barbae for the entire claims period on appeal has been topical. The post August 2018 version of 38 C.F.R. § 4.118(a) defines systemic and topical treatment as "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" for the General Rating criteria. As such, the Veteran does not qualify for a higher rating than under the treatment prong. Prior to August 2018 update to 38 C.F.R. § 4.118, the Court of Appeals for the Federal Circuit held that topical treatment with corticosteroids may be considered systemic depending on the specific facts of the Veteran's case and medication. See Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). A September 2020 and October 2020 VA addendum opinions address systemic use with regards to the Veteran's recorded treatments for his service-connected condition. In both opinions, the VA examiners concluded that in the Veteran's case, the treatments were not considered systemic and that it is less likely than not that the Veteran exhibited any symptoms which can be in any way supported as a result of topical application of steroids to a portion of the face and/or adjacent skin. The Board finds the September 2020 addendum opinion probative regarding systemic effects of topical treatment based on the application of sound medical principles and knowledge to the facts specific to the Veteran's case. The September 2020 examiner explained that FDA prescribing information cautions that systemic absorption of topical corticosteroids can produce reversible hypothalamic-pituitary-adrenal (HPA) axis suppression with the potential for glucocorticosteroid insufficiency after withdrawal of treatment. The examiner stated that manifestation of Cushing's syndrome, hyperglycemia, and glucosuria can also be produced in some patients by systemic absorption of topical corticosteroids while on treatment. Further, the opinion noted that patients applying a topical steroid to a large surface area or to areas under occlusion should be evaluated periodically for evidence of HPA axis suppression. The examiner stated that the Veteran applied topicals to a portion of his face and therefore does not meet the definition of one who applied topical steroids to a "large surface area" or under an occlusive dressing. The September 2020 examiner continued to identify the specific side effects and their likelihood of occurrence for the corticosteroid drugs, first desonide and then hydrocortisone. The opinion noted that FDA prescribing information indicates desonide clinical research has determined that the total incidence of adverse reactions associated with the use of desonide ointment was approximately 6%. The examiner identified that adverse reactions were erythema, induration, pruritus, irritation, oiliness, and peripheral edema. He further stated that there is no consensus in the medical literature to support systemic side effects from the topical application of desonide, and identified that FDA prescribing information indicates hydrocortisone clinical research has determined: local adverse reactions are reported infrequently with topical corticosteroids, but may occur more frequently with the use of occlusive dressings. The September 2020 examiner noted that the Veteran used no topical steroid under occlusive dressings. The September 2020 examiner also stated that the identified local reactions, listed in an approximate decreasing order of occurrence, are: burning, itching, irritation, dryness, folliculitis, hypertrichosis, acneiform eruptions, hypopigmentation, perioral dermatitis, allergic contact dermatitis, maceration of the skin, secondary infection, skin atrophy, striae, and miliaria. The Board notes The September 2020 examiner also stated that there is no consensus in the medical literature to support systemic side effects from the topical application of desonide. The September 2020 examiner explained that the Veteran used these drugs intermittently with topical application to a small area of skin. The September 2020 examiner stated that the FDA prescribing information relies not only upon clinical research but also represents a consensus from a well respective group of subject matter expects. The September 2020 examiner identified that the manner, schedule, duration, volume, and area of application for the topical steroids used in the Veteran's case fall far short of that expected accumulated dosage which would raise a suspicion, or support the presence of any systemic effects. The Board finds, based on the September 2020 examiner's opinion, that the topical treatment of the Veteran's pseudofolliculitis barbae with corticosteroids is not systemic in nature. Therefore, the Veteran is not entitled to a higher rating under the treatment prong because it is only topical in nature, which warrants at the highest a non-compensable rating. (Continued on the next page) Based on the foregoing reasons, the Board find the preponderance of the evidence is against the Veteran's claim for a compensable rating in excess of 0 percent prior to November 20, 2019 and is against a rating in excess of 10 percent rating thereafter. The benefit of the doubt rule has been considered, and does not support a higher ratings in this case. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107(b). Zi-Heng Zhu Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Boushehri, Darjush M. 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.