Citation Nr: 21041899 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 16-57 129 DATE: July 10, 2021 ORDER Entitlement to service connection for tinea corporis (claimed as rash all over the body), to include as due to Gulf War illness, is denied. FINDING OF FACT The preponderance of the evidence is against finding that tinea corporis began during active service, or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for entitlement to service connection for tinea corporis, to include as due to Gulf War Illness, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.317. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1983 to March 1984, and from September 1990 to July 1991, to include service in Southwest Asia. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the claim in November 2018 for additional development to include an addendum opinion. A January 2019 VA examination and addendum opinion were obtained. The matter was most recently before the Board in March 2020, at which time it was remanded for further development, to include obtaining outstanding treatment records and scheduling the Veteran for an examination for tinea corporis. The RO complied with these instructions, and a VA examination was conducted in October 2020. The Board is satisfied that the prior remand directives have been complied with. See Stegall v. West, 11 Vet. App. 268 (1998). Service connection laws and regulations Entitlement to service connection on a direct basis requires (1) evidence of current nonservice-connected disability; (2) evidence of in-service incurrence or aggravation of disease or injury; and (3) evidence of a nexus between the in-service disease or injury and the current nonservice-connected disability. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Saunders v. Wilkie, 886 F.3d 1356 (2018). A Persian Gulf veteran is defined as a veteran who served on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(d)(1). The Veteran in this case served in the Persian Gulf during the Gulf War. Under 38 U.S.C. § 1117(a)(1), compensation is warranted for a Persian Gulf veteran who exhibits objective indications of a "qualifying chronic disability" that became manifest during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent during the presumptive period prescribed by the Secretary. To constitute a "qualifying" chronic disability, the chronic disability must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). The term "objective indications of chronic disability" includes 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 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(3). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to: Fatigue, signs or symptoms involving skin, headache, muscle pain, joint pain, neurologic signs and symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, menstrual disorders. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(b). A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): An undiagnosed illness; the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: Chronic fatigue syndrome; Fibromyalgia; Functional gastrointestinal disorders (excluding structural gastrointestinal diseases); Any diagnosed illness that the Secretary determines warrants a presumption of service-connection; or Any other illness that the Secretary determines meets the following criteria for a medically unexplained chronic multisymptom illness. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(2). The term 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 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(2). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A chronic disability resulting from an undiagnosed illness shall be rated using evaluation criteria from part 4 of this chapter for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. A disability shall be considered service connected for purposes of all laws of the United States. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(4). Generally, lay evidence is competent with regard to identification of a disease with unique and readily identifiable features which are capable of lay observation. See Barr v. Shinseki, 21 Vet. App. 303, 308 (2007). A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir 2007). Lay persons may also provide competent evidence regarding a contemporaneous medical diagnosis or a description of symptoms in service which supports a later diagnosis by a medical professional. However, a lay person is not competent to provide evidence as to more complex medical questions, i.e., those which are not capable of lay observation. Lay statements are not competent evidence regarding diagnosis or etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); Jandreau, at 1377, n. 4 ('sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer'); 38 C.F.R. § 3.159(a)(2). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. A VA claimant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), Gilbert at 54. Entitlement to service connection for tinea corporis The Veteran contends that his tinea corporis is related to his active duty service, specifically the conditions of his Gulf War service. See April 2011 Statement in Support of claim. Turning to the evidence, service treatment records (STRs) reveal no complaints, treatments, or diagnoses pertinent to tinea corporis. Reports of medical examinations performed in July 1983 (enlistment examination), October 1987 (quad examination), and April 1991 (redeployment examination) show that findings for the skin were normal. Post-service, VA treatment records from June 2010 include complaints of an itchy rash on the Veteran's back and chest. A December 2011 VA Gulf War examination noted a diagnosis of tinea corporis with a reported onset in 1990. The Veteran reported the condition started "with a skin rash" while in Kuwait. However, the examiner was unable to find corroborating documentation of onset in his STRs. During the examination, the examiner found that the Veteran had hyperpigmented, dry scaly skin from the deltoids to the mid-forearms of both arms which he diagnosed as tinea corporis. The examiner stated such diagnosis had a clear and specific etiology and was not related to any specific Southwest Asia exposure event during service. The examiner opined that the tinea corporis was less likely than not incurred in or caused by the claimed in-service injury, event, or illness because in reviewing the claims file, he was unable to find any documented skin conditions while the Veteran was on active duty in the military. A June 2015 VA examination noted a diagnosis of tinea corporis. Neither an opinion nor rationale were provided. VA treatment records from November 2016 include complaints of a rash mostly on the Veteran's back, to include patchy scaly skin consistent with tinea versicolor. The Veteran underwent a VA examination in January 2019. The examination report noted review of the claims file and medical records, recounted the Veteran's complaints and history, and included a physical examination of the Veteran. The Veteran stated that his tinea corporis was diagnosed in 2010 and he currently uses a topical ointment for treatment. The examiner opined that the tinea corporis was less likely than not incurred in or caused by the claimed in-service injury, event, or illness because there is no documentation that the Veteran was diagnosed, treated, or reported tinea corporis while he was on active duty in the military. In providing a rationale, the examiner considered the Veteran's statements, date of service, and STRs, specially the April 1991 report of medical examination in which the examiner noted the Veteran's skin was normal. An October 2020 VA examination report noted review of the claims file and medical records, recounted the Veteran's complaints and history, considered statements made by the Veteran dated April 2011 and April 2012, reviewed the March 2020 remand, and included a physical examination of the Veteran. The examiner opined that the tinea corporis is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The rationale provided was that in spite of the Veteran's lay statements regarding onset of a rash in service, the examiner found no basis that the rash in service was actually tinea corporis. The examiner could not find documented evidence about the claimed rash until June 2010, about 20 years after the Veteran was discharged from service. Moreover, the examiner noted there is a question about what kind of rash the Veteran actually has as there have been numerous diagnoses over the years, to include tinea corporis in June 2010 and December 2011, folliculitis in October 2012, tinea versicolor in January 2014, eczema in September 2014, tinea versicolor in April 2016, and tinea corporis in January 2019. Further, the examiner stated that tinea corporis is due to a fungus and "is not specific to [Southwest] Asia and can be acquired anywhere." After a review of all of the evidence, the Board finds that the criteria for entitlement to service connection for tinea corporis are not met. Here, the December 2011 examiner determined that the Veteran's tinea corporis had a clear and specific etiology and was not related to any specific Southwest Asia exposure event during service. Thus, his tinea corporis is not a "qualifying chronic disability" in which presumptive service connection can be granted. Additionally, tinea corporis is not a medically unexplained chronic multi-symptom illness (MUCMI) (such as chronic fatigue syndrome (CFS), fibromyalgia, or irritable bowel syndrome) that is defined by a cluster of signs or symptoms which may involve unexplained dermatological symptoms; or a diagnosed illness that warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B)(1). In addition, the Board has also considered the Veteran's claim under direct service connection. The Board recognizes that the Veteran currently is diagnosed with tinea corporis. Thus, the first element of service connection is established. See Shedden, 381 F.3d at 1167. Regarding the in-service element, the Board notes that the Veteran's STRs are silent for any complaints, treatment, or diagnosis of a chronic skin condition. However, the Veteran is competent to report skin disorder symptoms, to include experiencing a rash in service. See McCartt v. West, 12 Vet. App. 164, 167-68 (1999) (a veteran is competent to observe skin conditions such as boils, blotches, and rashes). While the Veteran is competent to describe a rash, he is not competent, as a layperson, without known medical training, to determine an etiologic relationship between a skin rash in service and the current tinea corporis. See Jandreau, 492 F.3d at 1376-77 (noting general competence to testify as to symptoms but not to provide medical diagnosis). As the Veteran has no known or reported medical expertise, he is not legally competent to establish a nexus between tinea corporis and service; thus, his opinion as to causation lacks probative value, and an opinion by a qualified medical professional is required to decide the claim. The Board finds that the October 2020 VA opinion, which was provided after the VA examiner reviewed the claims file, considered the Veterans statements, and examined the Veteran, is highly probative as it reflects consideration of all relevant facts and the examiner provided a detailed rationale for the conclusion reached. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion...must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). After considering the Veteran's statements regarding onset of a rash in service, the VA examiner was unable to make a connection between the rash in service and the current tinea corporis. The VA examiner determined tinea corporis was not related to active duty service because there was no diagnosis of tinea corporis in service, no documented evidence about tinea corporis until 20 years after service, no concrete diagnosis of the kind of rash the Veteran actually has, and no specific link between the fungus from tinea corporis and Southwest Asia. Thus, the Board finds the opinions of the VA examiner to be significantly more probative than the Veteran's lay assertions. Importantly, there are no medical opinions of record to the contrary. The Board finds that the Veteran's tinea corporis has not shown to be causally or etiologically related to any disease, injury, or incident during service. Based on the foregoing, service connection for such disability is not warranted. As the preponderance of the evidence is against the Veteran's claims, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55-57. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.M. Edwards, 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.