Citation Nr: 22013483 Decision Date: 03/09/22 Archive Date: 03/09/22 DOCKET NO. 15-33 135 DATE: March 9, 2022 ORDER Entitlement to a rating of 10 percent, but no more, for discoid lupus erythematosus is granted on and after September 21, 2012, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a compensable rating for scarring alopecia with unstable scar from September 21, 2012 to December 11, 2016 is denied. Entitlement to a rating of 10 percent, but no more, for scarring alopecia with unstable scar is granted on and after December 12, 2016, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a rating of 10 percent, but no more, for disfigurement associated with scarring alopecia with unstable scar is granted on and after December 12, 2016, subject to the laws and regulations governing the payment of monetary benefits. FINDINGS OF FACT 1. On and after September 21, 2012, the Veteran's discoid lupus erythematosus manifested as intermittent systemic therapy for a total duration of less than 6 weeks over a 12-month period, but not characteristic lesions affecting at least 20 percent of total body area, lesions affecting at least 20 percent of exposed areas, or systemic therapy for a total duration of at least 6 weeks over a 12-month period. 2. From September 21, 2012 to December 11, 2016, the Veteran's scarring alopecia did not manifest as disfigurement, unstable or painful scars, scarring affecting at least 77 square centimeters or at least 20 percent of the scalp, or other disabling effects. 3. On and after December 12, 2016, the Veteran's scarring alopecia manifested as an unstable scar with one characteristic of disfigurement, but not a painful scar, visible or palpable tissue loss, gross distortion or asymmetry of features, at least two characteristics of disfigurement, scarring affecting at least 77 square centimeters or at least 20 percent of the scalp, or other disabling effects. CONCLUSIONS OF LAW 1. With resolution of reasonable doubt in the Veteran's favor, on and after September 21, 2012, the criteria for a rating of 10 percent, but no more, for discoid lupus erythematosus have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.118, Diagnostic Codes 7809-7806 (2021). 2. From September 21, 2012 to December 11, 2016, the criteria for a compensable rating for scarring alopecia with unstable scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.118, Diagnostic Code 7804 (2021). 3. With resolution of reasonable doubt in the Veteran's favor, on and after December 12, 2016, the criteria for a rating of 10 percent, but no more, for scarring alopecia with unstable scar have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.118, Diagnostic Code 7804. 4. With resolution of reasonable doubt in the Veteran's favor, on and after December 12, 2016, the criteria for a rating of 10 percent, but no more, for disfigurement associated with scarring alopecia with unstable scar have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.118, Diagnostic Code 7800 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from February 1971 to April 1972, including service in the Vietnam War. These matters are on appeal from a May 2013 rating decision. In a November 2019 decision, the Board remanded the claims to attempt to obtain additional treatment records. The Agency of Original Jurisdiction (AOJ) has done so. In a December 2020 decision, the Board remanded the claims again to afford the Veteran an additional VA examination. The Veteran was afforded a VA examination of his skin in December 2020. In an August 2021 decision, the Board remanded the claims again to afford the Veteran an addendum opinion. The Veteran was afforded an addendum opinion in September 2021. With the addition of the addendum opinion, the December 2020 VA examination is adequate with regard to the claims being decided below because it was based upon consideration of the Veteran's pertinent medical history, his lay assertions and current complaints, and because it describes his skin symptoms in detail sufficient to allow the Board to make fully informed determinations. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). There was therefore substantial compliance with the remand directives with regard to the issues being decided below. See Stegall v. West, 11 Vet. App. 268 (1998). VA's duty to notify was satisfied by a November 2012 letter. 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2020); Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). With regard to the duty to assist, the Veteran's service medical treatment records and VA medical treatment records have been obtained. The Veteran most recently underwent a VA examination relating to the claims on appeal in December 2020. As stated above, with the addition of a September 2021 addendum opinion, that examination is adequate. Increased Ratings 1. Discoid Lupus Erythematosus 2. Scarring Alopecia with Unstable Scar 3. Disfigurement Associated with Scarring Alopecia with Unstable Scar The Veteran contends that his service-connected skin disabilities warrant higher ratings than those currently assigned. His discoid lupus erythematosus is currently rated under 38 C.F.R. § 4.118, Diagnostic Codes 7809-7806, with a noncompensable rating on and after September 21, 2012. His scarring alopecia with unstable scar was rated under 38 C.F.R. § 4.88b, Diagnostic Code 6350-38 C.F.R. § 4.118, Diagnostic Code 7830 with a noncompensable rating from September 21, 2012 to December 16, 2020, and is currently rated under 38 C.F.R. § 4.118, Diagnostic Code 7804 with a 10 percent rating on and after December 17, 2020. He also has a separate 10 percent rating under 38 C.F.R. § 4.118, Diagnostic Code 7800 for disfigurement associated with his scarring alopecia with unstable scar on and after December 17, 2020. The full periods of service connection are on appeal. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate Diagnostic Codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4 (2021). Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. "Staged" ratings are 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). Given the nature of the present claims for higher initial evaluations, the Board has considered all evidence of severity since the effective dates for the awards of service connection. Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Hyphenated Diagnostic Codes are used when a rating under one Diagnostic Code requires use of an additional Diagnostic Code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2021). Diagnostic Code 6350 pertains to disseminated systemic lupus erythematosus and Diagnostic Code 7830 pertains to scarring alopecia. Diagnostic Code 7809 pertains to discoid lupus erythematosus and Diagnostic Code 7806 pertains to dermatitis or eczema. The rating criteria for Diagnostic Code 6350 are based on the frequency of exacerbations of systemic lupus erythematosus. Because the Veteran has not been diagnosed with systemic lupus erythematosus during the period on appeal and a rating under Diagnostic Code 6350 is not to be combined with a rating under Diagnostic Code 7809, these criteria do not provide a basis for a compensable rating in the Veteran's case. 38 C.F.R. § 4.88b, Diagnostic Code 6350. VA amended the criteria for rating skin disabilities, effective August 13, 2018. Because this claim was pending prior to the effective date of the amendment, VA must consider the Veteran's claim under both sets of rating criteria and apply the criteria that are more favorable to the Veteran's claim. Under both sets of rating criteria, ratings are based on either the surface area of the body affected or the type and frequency of medication used. Diagnostic Code 7830 pertains to scarring alopecia and provides for rating as follows: 20 percent if more than 40 percent of the scalp is affected, 10 percent if 20 to 40 percent of the scalp is affected, and a noncompensable rating if less than 20 percent of the scalp is affected. 38 C.F.R. § 4.118, Diagnostic Code 7830. Diagnostic Code 7809 pertains to discoid lupus erythematosus or subacute cutaneous lupus erythematosus. Prior to August 13, 2018, Diagnostic Code 7809 provided for rating as disfigurement of the head, face or neck under Diagnostic Code 7800, scars under Diagnostic Codes 7801, 7802, 7803, 7804, or 7805, or dermatitis under Diagnostic Code 7806, depending upon the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7809 (2017). On and after August 13, 2018, Diagnostic Code 7809 provides for rating under the General Rating Formula for the Skin (General Formula). 38 C.F.R. § 4.118, Diagnostic Code 7809 (2021). Prior to August 13, 2018, with regard to surface area, Diagnostic Code 7806 provided for rating as follows: a 60 percent rating with more than 40 percent of the entire body or more than 40 percent of exposed areas affected, a 30 percent rating for 20 to 40 percent of the entire body or exposed areas affected, a 10 percent rating for at least 5 percent but less than 20 percent of the entire body or exposed areas affected, and a noncompensable rating for less than 5 percent of the entire body or exposed areas affected. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2017). On and after August 13, 2018, Diagnostic Code 7806 provides for rating under the General Formula. With regard to surface area, the rating criteria under the General Formula are the same as the pre-August 13, 2018 criteria for Diagnostic Code 7806. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2021). Therefore, with regard to surface area, the rating criteria before and after August 13, 2018 are functionally identical. The General Formula also provides for the option of rating as disfigurement of the head, face, or neck, or scars, depending upon the predominant disability. The rating criteria for disfigurement and scars did not change on August 13, 2018. With regard to medication, prior to August 13, 2018, Diagnostic Code 7806 provided for rating as follows: a 60 percent rating for constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during the past 12-month period, a 30 percent rating for 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 for 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, and a noncompensable rating for no more than topical therapy required during the past 12 months. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2017). For claims filed prior to August 13, 2018, the United States Court of Appeals for Veterans Claims (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. Effective August 31, 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). In addition, the General Formula further clarifies the definition of systemic therapy as "including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs." The rating criteria with regard to medication are otherwise the same. Given the vagueness of the definition of systemic therapy prior to August 13, 2018, in order to view the evidence in the light most favorable to the Veteran, the Board will consider any non-topical medication both before and after August 13, 2018 to be systemic therapy. Scars or disfigurement of the head, face, or neck are evaluated as follows: with visible or palpable tissue loss and other gross distortion or asymmetry of three or more features or paired sets of features or with six or more characteristics of disfigurement (80 percent); with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features or four or five characteristics of disfigurement (50 percent); with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features or two or three characteristics of disfigurement (30 percent); and with one characteristic of disfigurement (10 percent). 38 C.F.R. § 4.118, Diagnostic Code 7800. The "paired sets of features" are the nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, and lips. Id. Diagnostic Code 7800, Note (1) lists the eight characteristics of disfigurement as: scar 5 or more inches (13 or more cm.) in length; scar at least one-quarter inch (0.6 cm.) wide at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding six square inches (39 square cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 square cm.); underlying soft tissue missing in an area exceeding six square inches (39 square cm.); and skin indurated and inflexible in an area exceeding six square inches (39 square cm.). Id. Diagnostic Code 7800, Note (4) allows for separate rating of any disabling effects other than disfigurement, such as pain, instability, and residuals of associated muscle or nerve injury, under the appropriate diagnostic code(s). Id. 38 C.F.R. § 4.118, Diagnostic Code 7801 (2021) pertains to scars that are associated with underlying soft tissue damage and provides for rating as follows: 40 percent for an area of 144 square inches (929 square centimeters) or greater; 30 percent for areas of at least 72 square inches (465 square centimeters) but less than 144 square inches (929 square centimeters); 20 percent for areas of at least 12 square inches (77 square centimeters) but less than 72 square inches (465 square centimeters); and 10 percent for areas of at least 6 square inches (39 square centimeters) but less than 12 square inches (77 square centimeters). 38 C.F.R. § 4.118, Diagnostic Code 7802 (2020) pertains to scars that are not associated with underlying soft tissue damage and provides for a 10 percent rating for areas of 144 square inches (929 square centimeters) or greater. Unstable or painful scars are evaluated as follows: five or more scars that are unstable or painful (30 percent); three or four scars that are unstable or painful (20 percent); and one or two scars that are unstable or painful (10 percent). 38 C.F.R. § 4.118, Diagnostic Code 7804. Diagnostic Code 7804, Note (2) allows for an extra 10 percent rating if one or more of the scars are both unstable and painful. Diagnostic Code 7804, Note (1) defines an unstable scar as "one where, for any reason, there is frequent loss of covering of skin over the scar." The provisions of 38 C.F.R. § 4.118, Diagnostic Code 7805 (2021) apply to other scars, including linear scars, and "other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, and 7804." Diagnostic Code 7805 contains the instruction "Evaluate any disabling effect(s) not considered in a rating provided under diagnostic codes 7800-04 under an appropriate diagnostic code." The Veteran was afforded a VA examination for systemic lupus erythematosus and other autoimmune diseases in May 2013. The clinician diagnosed discoid lupus erythematosus. The Veteran denied systemic symptoms. The Veteran reported current constant or near-constant use of a topical corticosteroid, triamcinolone. On examination, cutaneous manifestations affected less than five percent of the exposed areas of the Veteran's body. Scarring alopecia affected less than 20 percent of the Veteran's scalp and did not cause scarring that was unstable, painful, disfiguring, or with a total surface area greater than 39 square centimeters. The clinician found that the Veteran's skin disabilities would have no effect on his ability to work. The Veteran was afforded an additional VA examination for systemic lupus erythematosus and other autoimmune diseases by the same VA clinician in June 2013. The clinician diagnosed discoid lupus erythematosus. The Veteran denied systemic symptoms. The Veteran reported current constant or near-constant use of a topical corticosteroid, triamcinolone. The clinician noted that the Veteran had no diagnosis of systemic lupus erythematosus. On examination, cutaneous manifestations affected less than five percent of the total and exposed areas of the Veteran's body. Scarring alopecia affected less than 20 percent of the Veteran's scalp and did not cause scarring that was unstable, painful, disfiguring, or with a total surface area greater than 39 square centimeters. The clinician found that the Veteran's skin disabilities would have no effect on his ability to work. An August 2013 VA treatment record notes an intralesional steroid injection and that the Veteran's lesions had decreased by half since the previous visit, after the injection. It is not clear from this record whether it reports a second injection or a follow up visit from the first. In order to afford the Veteran the benefit of the doubt, the Board will assume that this record refers to two separate injections. A September 2014 VA treatment record notes that the Veteran had no active lesions from his chronic discoid lupus erythematosus and that treatment with topical creams would continue. A VA treatment record from January 2015 noted the Veteran's report of an itchy rash since the beginning of a long-distance trip five days prior and that he had left his medications at home. The treatment provider diagnosed a pruritic eruption most consistent with eczematous process, likely exacerbated by cold weather/xerosis. During a February 2015 VA treatment appointment, the Veteran reported scaly exfoliating skin on both hands and dry skin and a rash on the internal aspect of the femoral area. A May 2015 VA treatment record again notes that the Veteran had no active lesions from his chronic discoid lupus erythematosus; he reported that his symptoms were well controlled. In a September 2015 statement, the Veteran referred to his service-connected skin conditions as "prolonged and severe." In October 2015, the Veteran went to a VA emergency room due to a body ache and itch that had begun that morning. He was treated with two injected medications. In order to afford the Veteran the benefit of the doubt, the Board will assume that these injections were to treat the Veteran's service-connected skin disabilities. An October 2015 VA treatment record notes a skin rash on the Veteran's scalp and one ear as well as hypopigmentation. The treatment provider noted that the Veteran's chronic discoid lupus erythematosus was stable. In November 2015, the Veteran again visited a VA emergency room due to a body rash and itch that was subsiding with the use of his usual topical creams. The treatment provider noted a mild rash of the left forearm, a tiny area of erythema that was improving, and instructed the Veteran to continue with his usual medication. The Veteran was afforded a VA examination for skin diseases in November 2015 by the same clinician who performed the May 2013 and June 2013 VA examinations. The clinician diagnosed discoid lupus erythematosus. The Veteran reported that his condition had become progressively worse. The clinician noted that the Veteran's skin conditions did not cause scarring or disfigurement of the head, face, or neck and that there were no systemic manifestations. The Veteran reported constant or near-constant use of two topical corticosteroids: desonide and betamethasone. There were no active lesions at the time of the examination, but the clinician noted chronic treatment for discoid lupus erythematosus with evidence of recurrence. The clinician found that the Veteran's skin disabilities would have no effect on his ability to work. The Veteran was afforded an additional VA examination for skin diseases in May 2016 by a different VA clinician. The clinician diagnosed discoid lupus erythematosus, eczema, and alopecia. The Veteran reported that his condition worsened in winter months and that the rash he reported during his January 2015 trip had resolved with treatment. He also reported that his condition worsened in sunlight and that his skin condition had affected his social life. He also reported that his skin condition was intermittent. The clinician noted that the Veteran's skin condition was not present at the time of examination. The clinician noted that the Veteran's skin conditions did not cause scarring or disfigurement of the head, face, or neck and that there were no systemic manifestations. The Veteran reported use of betamethasone valerate for six weeks or more but not constantly and of desonide cream for less than six weeks. This time, the clinician characterized the former as a topical corticosteroid and the latter as another topical medication. On examination, scarring alopecia affected less than 20 percent of the Veteran's scalp and there was no evidence of eczema or active discoid lupus skin lesions. The clinician found that the Veteran's skin disabilities would have an effect on his ability to work because sunlight exacerbated his condition. A VA treatment record dated three days after the examination noted erythematous patches on the scalp but no other active chronic discoid lupus erythematosus lesions. The Veteran was afforded an additional VA examination for skin diseases in September 2016. The clinician diagnosed discoid lupus erythematosus and scarring alopecia. The Veteran reported that his condition was intermittent and unchanged since the May 2016 examination. The clinician noted that the Veteran's skin conditions did not cause scarring or disfigurement of the head, face, or neck and that there were no systemic manifestations. The Veteran reported constant or near-constant use of betamethasone valerate, a topical corticosteroid. On examination, scarring alopecia affected less than 20 percent of the Veteran's scalp and there were three erythematous patches on the anterior neck area, measuring 3cm by 2cm, 4cm by 3cm, and 2cm by 2cm, affecting less than five percent of the Veteran's total or exposed body area. The clinician found that the Veteran's skin disabilities would have an effect on his ability to work because he needed to avoid prolonged periods of sun exposure and should use protective clothing and sun screen lotion if momentary sun exposure is required. A December 12, 2016 VA treatment record noted that the Veteran's chronic discoid lupus erythematosus had become inactive on his scalp and ears but that there was scarring and one alopecic plaque at the right side of his temporal scalp. During a VA treatment appointment two weeks later, the Veteran reported itching and redness, mostly at his neck. The treatment provider noted urticarial wheals. A May 2017 VA treatment record notes that the Veteran's discoid lupus was stable with no new lesions but scars at the scalp and ears. An October 2017 VA treatment record notes the Veteran's report of new lesions on his forearms, one of which on the right forearm was an active lupus lesion. During a March 2018 VA treatment appointment, there were no new lesions but the Veteran showed photographs of recent dermatitis on his forearms. His scarring alopecia was stable. During an August 2018 VA treatment appointment, the Veteran reported intermittent urticaria in cold temperatures and during recent periods when he had renal infections and foot trauma but his chronic discoid lupus erythematosus was without exacerbation and there was no evidence of urticaria on examination. A March 2019 VA treatment record noted inactive scar-like lesions on the Veteran's scalp and ears but no new active lesions. The Veteran was afforded an additional VA examination for skin diseases in April 2019 by the same clinician who performed the May 2016 VA examination. The clinician diagnosed discoid lupus erythematosus and scarring alopecia. The Veteran reported continued recurrent skin lesions, now appearing in other areas such as his arms, and that his condition was intermittent. The Veteran reported constant/near-constant use of betamethasone valerate and desonide cream. The clinician again characterized the former as a topical corticosteroid and the latter as another topical medication. On examination, there was no eczema and discoid lupus erythematosus affected less than 5 percent of the Veteran's total and exposed body area. The clinician noted that the Veteran's discoid lupus affected both forearms with several erythematous spots. Scarring alopecia affected less than 20 percent of the Veteran's scalp. The clinician noted that the Veteran's skin conditions did not cause scarring or disfigurement of the head, face, or neck but also noted an "irregular hypopigmented area in the middle upper scalp" measuring approximately 3cm. The clinician found that the Veteran's skin disabilities would have an effect on his ability to work because he reported inability to be exposed to sunlight for prolonged periods. An August 2019 punch biopsy was negative for active discoid lupus. During a January 2020 VA treatment appointment, the Veteran reported that he was well. His chronic discoid lupus erythematosus was inactive. During a November 2020 VA treatment appointment, the Veteran again reported that he was well. His chronic discoid lupus erythematosus was controlled. The Veteran was afforded an additional VA examination for skin diseases on December 17, 2020. The clinician diagnosed discoid lupus erythematosus and scarring alopecia. The Veteran reported intermittent lesions and that the last recurrence was some months ago. The lesions were coin-shaped red patches, which he treated with steroid cream. He also reported that, after a lesion on the right side of his scalp healed, he was left with a hypopigmented alopecia patch. The Veteran reported use of betamethasone dipro, which the clinician characterized as a topical corticosteroid, for less than six weeks, of betamethasone valerate, which the clinician characterized as another topical medication, for six weeks or more but not constantly, and of clobetasol solution, which the clinician also characterized as another topical medication, for less than six weeks. On examination, there were no active lesions of discoid lupus erythematosus. There was one alopecia patch with hypopigmentation and atrophy in the scalp on the right side of the top of the head, measuring 3.0cm by 1.5cm. Scarring alopecia affected less than 20 percent of the Veteran's scalp. The clinician found that the Veteran's skin disabilities would have no effect on his ability to work. On the same day, the Veteran was also afforded a VA examination for scars and disfigurement. Because the Veteran reported that his scar frequently itched and lost the covering of the skin, the clinician characterized it as unstable. The Veteran did not report that his scar was painful. As stated above, the scar measured 3.0cm by 1.5cm. There was no elevation, depression, adherence to underlying tissue, or missing underlying soft tissue. There was abnormal pigmentation in the form of hypopigmentation. There was abnormal texture in the form of atrophic skin. The scar was not tender to palpation or unstable upon inspection. The approximate total area affected was 4.5 square centimeters. There was no gross distortion or asymmetry of facial features or visible or palpable tissue loss. The scar did not result in any limitation of function and the clinician found that it would have no effect on the Veteran's ability to work. The Veteran was afforded an addendum opinion in September 2021 by the clinician who performed the December 2020 VA examinations. The clinician opined that the Veteran's topical medications did not constitute systemic therapy and provided a detailed rationale for this opinion, specifically that application was restricted to the affected sites, which were small and only intermittently present (with the exception of the scar, which was also small), and that the amount that could enter the bloodstream was negligible and clinically insignificant. Affording the Veteran the benefit of the doubt, the most persuasive evidence weighs in favor of finding that his discoid lupus erythematosus warrants a 10 percent rating on and after September 21, 2012. Although the Veteran's topical medication during the period on appeal was not systemic, there is evidence of treatment with injected medication on as many as three occasions. The use of systemic medication warrants at least a 10 percent rating. However, the most persuasive evidence weighs against finding that the Veteran's discoid lupus erythematosus warrants a rating in excess of 10 percent at any point during the period on appeal. Three occasions over the ten-year period on appeal does not constitute use of systemic therapy for six weeks or more over a 12-month period, which is required for a 30 percent rating under the prior or amended criteria. The affected area was also less than five percent of his total body area or exposed area; a 30 percent rating requires 20 to 40 percent of total or exposed areas to be affected. With regard to scarring, affording the Veteran the benefit of the doubt, the most persuasive evidence weighs in favor of finding that his scarring alopecia with unstable scar warrants a 10 percent rating under Diagnostic Code 7804 on and after December 12, 2016, which is the date of the first mention in the record of a scar on the right side of the Veteran's scalp. The most persuasive evidence also weighs in favor of finding that the Veteran's disfigurement associated with his scarring alopecia with unstable scar warrants a 10 percent rating under Diagnostic Code 7800 on and after December 12, 2016, for the same reason. However, the most persuasive evidence weighs against finding that the Veteran's scarring alopecia with unstable scar warrants a compensable rating prior to December 12, 2016. During that period, there was no scarring or disfigurement and the affected area was less than 20 percent of the Veteran's scalp. The most persuasive evidence also weighs against finding that the Veteran's scarring alopecia with unstable scar or associated disfigurement warrant ratings in excess of 10 percent on and after December 12, 2016. During that period, there was one unstable scar, that scar was not painful, there was only one characteristic of disfigurement (width greater than 0.6cm), the affected area was only 4.5 square centimeters, there were no other disabling effects, and the affected area was less than 20 percent of the Veteran's scalp. Although the December 2020 VA examination report noted hypopigmentation and atrophic skin texture, those only constitute characteristics of disfigurement if the area affected exceeds 39 square centimeters. The Board has considered the Veteran's lay statements. The Veteran is competent to report his own observations with regard to the symptoms of his service-connected skin disabilities. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Nothing in those statements is inconsistent with the ratings now assigned. Because the Board considered the applicable ratings under the prior criteria for the Veteran's skin disabilities, the General Formula, and every Diagnostic Code pertaining to the Veteran's service-connected skin disabilities, including scars and disfigurement, the Board finds that there are no other potentially applicable Diagnostic Codes by which higher ratings can be assigned. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Ryan Frank, 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.