Citation Nr: 21044101 Decision Date: 07/20/21 Archive Date: 07/20/21 DOCKET NO. 09-14 557 DATE: July 20, 2021 ORDER Entitlement to service connection for psoriasis secondary to posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to service connection for skin conditions other than psoriasis to include seborrheic keratosis, basal cell carcinoma, and dermatitis as due to exposure to herbicides, and/or as secondary to ischemic heart disease (IHD) or PTSD is remanded. FINDING OF FACT The probative and competent evidence of record shows that the Veteran's psoriasis is aggravated by the Veteran's PTSD. CONCLUSION OF LAW The criteria for service connection for psoriasis secondary to PTSD have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from July 1968 to July 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before a Veterans Law Judge (VLJ), other than the undersigned, in March 2012. A transcript of the hearing is associated with the claims file. In March 2021, the Veteran was notified that the VLJ who had heard his hearing was no longer employed at the Board and he was offered the opportunity for a new hearing, which he declined. In September 2012, February 2016, April 2017, April 2018, and most recently in February 2020 for an addendum opinion, the Board remanded this claim for additional development. The United States Court of Appeals' Claim (Court) has consistently held that the Board can bifurcate a claim and address different theories or arguments in separate decisions. See Roebuck v. Nicholson, 20 Vet. App. 307, 315 (2006). In the present case, the Board concludes that bifurcating the psoriasis claim from the other skin conditions claim, into two separate issues is the most proper way of handling these appeals. See also Locklear v. Shinseki, 24 Vet. App. 311 (2011) (bifurcation of a claim generally is within VA's discretion); Tyrues v. Shinseki, 23 Vet. App. 166, 178-79 (2009), aff'd, 631 F.3d 1380 (Fed. Cir. 2011) (VA is free to dismember a claim and adjudicate it in separate pieces). SERVICE CONNECTION Service connection may be established on a direct basis for a disability resulting from disease or injury incurred in, or aggravated by, active military, naval, or air service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection also may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. See 38 C.F.R. § 3.303 (d). In general, service connection requires (1) evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310 (a). Aggravation of a non-service-connected disease or injury by a service-connected disability may also be service-connected. See 38 C.F.R. § 3.310 (b). The United States Court of Appeals for Veterans Claims (Court) held in the case of Ward v. Wilkie, No. 16-2157, 2019 U.S. App. Vet. Claims LEXIS 994 (June 14, 2019), that aggravation pursuant to 38 C.F.R. § 3.310 does not require a permanent worsening of the condition. Rather, the Court explained that "aggravation" is any incremental increase in disability attributable to the service-connected disability, i.e., any additional impairment of earning capacity that is above the degree of disability existing before the increase, regardless of its permanence. Id. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. The record establishes that the Veteran has a current diagnosis of psoriasis. He is also in receipt of service connection for PTSD. Therefore, the first and second element of secondary service connection are met. Regarding the third element of secondary service connection, a March 2020 medical opinion was provided. The VA examiner determined that the Veteran's psoriasis was not aggravated by his service-connected PTSD as permanent worsening had not been shown. However, under Ward, permanent worsening is not necessary to show aggravation i.e. aggravation may include temporary worsening of a disability. The VA examiner acknowledge that psychosocial stress associated with depression and anxiety have been shown to cause short term flare-ups of psoriasis and the Veteran has documented flare-ups of psoriasis. Thus, a temporary worsening of the Veteran's psoriasis has been shown. In light of the foregoing, the Board finds that service connection for psoriasis is warranted on a secondary theory of entitlement. REASONS FOR REMAND Entitlement to service connection for skin conditions other than psoriasis to include seborrheic keratosis, basal cell carcinoma, and dermatitis as due to exposure to herbicides, and/or as secondary to IHD or PTSD is denied. A March 2020 medical opinion determined that the Veteran's basal cell carcinoma was not proximately due to or the result of PTSD. However, no aggravation opinion has been provided with regard to basal cell carcinoma. Aggravation must be discussed to resolve secondary service connection. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (a medical opinion is inadequate when fails to adequately address the question of aggravation). Thus, a medical opinion is needed. In addition, a September 2017 medical opinion determined that the Veteran's basal cell carcinoma was less likely than not proximately due to or the result of the Veteran's PTSD medications. However, no aggravation opinion was provided. Further, the medical opinion failed to address whether the Veteran's seborrheic keratosis or dermatitis was caused or aggravated by the Veteran's PTSD medications. Thus, another remand is necessary. The matters are REMANDED for the following action: Obtain a VA opinion by an appropriate clinician to determine the nature and etiology of his skin conditions. An examination should be scheduled if such is deemed necessary. Copies of all pertinent records including this REMAND must be made available to and reviewed by the examiner. The VA examiner should provide an opinion as to: a. Whether it is at least as likely as not that the Veteran's basal cell carcinoma underwent any incremental increase in disability, regardless of its permanence, due to a service-connected PTSD or medications used to treat PTSD. b. Whether it is at least as likely as not that the Veteran's seborrheic keratosis or dermatitis is proximately due to or the result of the medications used to treat PTSD or underwent any incremental increase in disability due to the medications used to treat PTSD. The Veteran has tried a number of mediations included but not limited to Mirtazapine, Zoloft, Seroquel, Trazodone, Temazepam, Bupropion, Duloxetine, Lorazepam, and Xanax. Please review the Veteran's medication list. The term "incremental increase in disability" means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any "incremental increase in disability" need not be permanent. If the examiner concludes that an opinion cannot be offered without resort to mere speculation, the examiner must address whether research in the medical literature might assist him/her in providing the medical opinion requested in this matter, and if so, such research in the medical literature must be conducted. The examiner must also indicate whether any use of the phrase "without resorting to mere speculation" reflects the limitations of knowledge in the medical community at large as opposed to the limits of his/her knowledge and expertise in particular. Saudiee Brown Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Smith, 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.