Citation Nr: 22014208 Decision Date: 03/11/22 Archive Date: 03/11/22 DOCKET NO. 17-63 521 DATE: March 11, 2022 ORDER Entitlement to an initial rating in excess of 30 percent for hidradenitis suppurativa is denied. Effective June 23, 2014, entitlement to a separate 20 percent rating for voiding disfunction associated with hidradenitis suppurativa under Diagnostic Code (DC) 7599-7819 is granted subject to controlling regulations applicable to the payment of monetary benefits. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's hidradenitis suppurativa, at worst, affected 20 to 40 percent of his entire body area and did not require constant or near-constant systemic therapy such as corticosteroids or other immunosuppressant drugs. 2. The Veteran's hidradenitis suppurativa, at worst, required the wearing of absorbent materials, which had to be changed one to two times per day, throughout the period on appeal. 3. The Veteran's service-connected disabilities do not meet the schedular criteria for assignment of a TDIU, and the evidence of record does not reflect that the Veteran was unable to engage in substantially gainful employment as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for hidradenitis suppurativa have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.118, DC 7820-7806. 2. From June 23, 2014, the criteria for a separate 20 percent rating, but no higher, for hidradenitis suppurativa under DC 7599-7819 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.7, 4.115a, DC 7599-7819. 3. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1981 to June 1985. He died in March 2021. Thereafter, in July 2021, the Veteran's surviving spouse was substituted as the appellant. See July 2021 Correspondence. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In December 2019, the Veteran and the appellant testified at a Board hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. By way of background, this matter was previously before the Board in December 2019, when it was remanded for additional development. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more nearly approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. 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. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to an initial rating in excess of 30 percent for hidradenitis suppurativa is denied. 2. Effective June 23, 2014, entitlement to a separate 20 percent rating for hidradenitis suppurativa under DC 7599-7819 is granted subject to controlling regulations applicable to the payment of monetary benefits. As an initial matter, the Veteran filed his claim for entitlement to service connection for hidradenitis suppurativa on June 23, 2014. See June 2014 VA Form 21-526EZ, Fully Developed Claim (Compensation). The RO granted the Veteran's claim in a June 2015 rating decision and assigned a 10 percent rating, effective June 23, 2014. See June 2015 Rating Decision Narrative. During the pendency of the appeal, a November 2017 rating decision granted an increased 30 percent rating for hidradenitis suppurativa, effective June 23, 2014. See November 2017 Rating Decision Narrative. The Veteran's hidradenitis suppurativa has been evaluated under DC 7820-7806. 38 C.F.R. § 4.118. In this case, the hyphenated diagnostic code indicates that an infection of the skin, not listed elsewhere, is the Veteran's service-connected disorder under DC 7820, and DC 7806 identifies the basis for the evaluation assigned. 38 C.F.R. § 4.27. The Board notes that the rating criteria for evaluating skin disabilities were amended effective August 13, 2018. Prior to August 13, 2018, the Board will consider both the old and amended versions of the diagnostic code and rate based on whichever is most favorable to the Veteran; however, for the period beginning August 13, 2018, the Board will consider the amended version of the diagnostic code only. Prior to August 13, 2018, a 30 percent disability rating was assigned for skin conditions that covered 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or when systemic therapy, such as corticosteroids or other immunosuppressive drugs, was required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A higher 60 percent evaluation was warranted for skin conditions that covered 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. 38 C.F.R. § 4.118, DC 7806. For claims filed prior to August 13, 2018, the Court has 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. As noted above, VA published a final rule amending its regulations on skin disabilities, effective August 13, 2018. The amendment, in pertinent part, added a "General Rating Formula for the Skin" for DCs 7806, 7809, 7813-7816, 7820-7822, and 7824, and amended DCs 7801, 7802, 7817, 7819, 7825-7827, 7829. See 83 Fed. Reg. 32,592 (July 13, 2018). Under the new General Rating Formula for the Skin, a 30 percent rating is assigned if the disability meets 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; 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. Under the General Rating Formula, a maximum 60 percent rating is warranted when the disability meets one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks or more, but not constantly, over the past 12-month period. 38 C.F.R. § 4.118, DC 7806. The Board notes that, under the new General Rating Formula for the Skin, the rating criteria states that systemic therapy is treatment that is administered through any route other than through the skin, to include medications administered orally, injection, suppository, and intranasally. Conversely, topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Turning to the evidence of record, the Veteran endorsed pain and stated that he was experiencing a flare-up of his service-connected hidradenitis suppurativa in July 2014. On examination, the examiner identified a large tender mass on the Veteran's medal right gluteal area, which was approximately 11 centimeters by 6.5 centimeters. The assessment included right gluteal area abscess and hidradenitis suppurativa. A subsequent November 2014 plastic surgery outpatient note shows that the Veteran's hidradenitis suppurativa was mild following a two week course of antibiotics. In January 2015, the Veteran endorsed chronic pain and intermittent drainage in his perineal and gluteal areas. The examiner noted that the Veteran took Augmentin, a penicillin antibiotic, intermittently and that he had been evaluated by general and plastic surgery in the past. On examination, the examiner found multiple comedones in the Veteran's bilateral axillas, a fluctuant scarred nodule and scarred tracts in his left axilla, multiple punctate scars on his lower back, hips and buttocks, and a large area of induration and drainage tracts with active draining on his buttocks, gluteal cleft, inguinal crease and scrotum. The assessment included hidradenitis suppurativa, and the examiner prescribed doxycycline, an antibiotic, and Hibiclens rinses. He was also noted to have prescriptions for non-sterilized gauze pads and lamino pads. A May 2015 primary care note shows that the Veteran had been experiencing hidradenitis suppurativa, which mainly effected his gluteal areas, for approximately five years. He indicated that it limited his interaction with people as he had to change the gauze frequently and believed he "smell[ed.]" See November 2017 CAPRI. The Veteran underwent a VA examination for skin diseases in June 2015. The examiner noted that the Veteran had been diagnosed with hidradenitis suppurativa, tinea pedis, and pseudofolliculitis barbae. In this regard, the examiner indicated that the Veteran's service-connected hidradenitis suppurativa did not cause scarring of the head, neck, or face, but noted a bump on each side of the Veteran's beard, which may have been from pseudofolliculitis barbae or hidradenitis suppurativa. The examiner also noted several healed lesions in the Veteran's bilateral axillae, but no lesions were found on his chest, abdominal front, or back. The examiner further indicated that the Veteran used cefalexin, a cephalosporin antibiotic, on a constant or near-constant basis during the preceding 12-month period, but found that his hidradenitis suppurativa affected less than five percent of exposed areas and of his body as a whole. However, although the Veteran indicated that hidradenitis suppurativa also affected his bilateral groin and buttocks, the examiner stated that those areas were not examined during the examination. See June 2015 C&P examination. In his August 2015 notice of disagreement (NOD), the Veteran indicated that sore boils periodically appeared on his skin for two to three weeks. In this regard, he also stated that he occasionally developed boils between his legs, which prevented him from walking for days at a time. The Veteran also stated that the June 2015 VA examiner did not examine his buttocks during the examination, and as such, argued that it should be considered inadequate. See August 2015 NOD. An October 2015 primary care note shows that the Veteran had a hidradenitis flare-up in his gluteal area, which busted and drained a significant amount of pus. The assessment included hidradenitis suppurativa. A primary care note dated one month later indicates that a culture of the Veteran's hidradenitis suppurativa grew alpha and beta hemolytic streptococcus; he was treated with antibiotics. In January 2016, the Veteran endorsed four painful bumps on his buttocks that drained pus. He indicated that the bumps had been there for multiple years and stated that they covered the whole area of his buttocks. In addition, the Veteran indicated that he experienced pain when he tried to sit or lie down. In April 2016, the Veteran underwent a gluteal hidradenitis excision with local flap closure for his service-connected perineal hidradenitis suppurativa. Following the procedure, the Veteran was prescribed medication for pain. See November 2017 CAPRI. The Veteran underwent a VA examination for skin diseases in September 2016. The examiner noted that the Veteran had been diagnosed with hidradenitis suppurativa. During the examination, the Veteran reported that his hidradenitis suppurativa was most severe in his perineal and gluteal areas and endorsed ongoing draining abscesses. To this end, he indicated that he continued to get 1.3 centimeter diameter abscesses in the axilla, perineum, and buttocks, which drained, scarred, and recurred. The examiner noted that the area had healed following surgery but stated that he continued to have active draining abscesses for which he constantly wore a pad and that made sitting or pressing legs together painful. The examiner determined that the Veteran's service-connected hidradenitis suppurativa caused scarring of the axilla, buttocks, and groin. The examiner further indicated that the Veteran used oral or topical medications in the preceding 12 months for a duration of less than six weeks during the preceding 12-month period and noted that he had a surgery to remove a patch of hidradenitis with a flap in April 2016, also for a duration of less than six weeks during the preceding 12-indicated month period. On examination, the examiner noted that the Veteran's underarms, perineum, and bilateral buttocks had scattered abscesses in varying stages of draining or healing and that he required a pad around his anus and buttock. To this end, the examiner determined that the Veteran's hidradenitis suppurativa affected 20 percent to 40 percent of his total body area. Following the examination, the examiner indicated that the Veteran's service-connected hidradenitis suppurativa impaired his ability to work. Specifically, the examiner stated that it would be very painful for the Veteran to sit with active abscesses between his buttocks and on his bottom. See September 2016 C&P examination. The Veteran also underwent a VA examination for scars and disfigurement in September 2016. The examiner noted that the Veteran had surgical scars on his bilateral buttocks, as well as scars from abscesses of hidradenitis suppurativa. The examiner noted that the Veteran underwent two surgical procedures on his buttocks to removed scarred and infected tissue from hidradenitis suppurativa and to place a flap and that he had multiple 0.2 to 2 centimeter scars on his bilateral axilla, whole perineum, and bilateral buttocks. On examination, the examiner noted that the Veteran had too many scars to count in his bilateral axillas, which measured between 0.5 and 2 centimeters. The examiner noted that the scars in both of the Veteran's axillas were superficial and non-linear and described them as one scar, measuring 10 centimeters in length and 8 centimeters in width, bilaterally. The examiner further noted that the Veteran had five scars on his posterior trunk, including scars measuring 12 centimeters by 0.3 centimeters, 11 by 0.3 centimeters, and two scars that measured 8 centimeters by 0.3 centimeters. The examiner also indicated that the Veteran had too many scars to count on his bilateral buttocks, which were each between 0.5 and 2 centimeters and cover a total area of 30 centimeters in length by 24 centimeters in width with very tender areas of active drainage or swelling due to hidradenitis suppurativa. In sum, the examiner determined that the Veteran's superficial non-linear scars covered a total area of 80 square centimeters on his right and left upper extremities, 100 square centimeters on his anterior trunk, and 720 centimeters on his posterior trunk. However, the examiner also indicated that the Veteran's scars did not result in limitation of function or impact his ability to work. See September 2016 C&P examination. In his November 2017 substantive appeal, the Veteran alleged that his previous VA examination should be considered inadequate because the examiner did not examine the Veteran's entire body, to include his bottom, and determined that he had eczema, rather than hidradenitis suppurativa. To this end, the Veteran reported that he had undergone four surgeries on his bottom and indicated that his symptoms there did not respond to treatment with topical ointments. See November 2017 VA Form 9. In January 2018, the Veteran reported that his service-connected hidradenitis suppurativa covered more than 30 percent of his body and indicated that it caused lumps to appear on his face, axillas, groin, buttocks, and anus. He also stated that his hidradenitis suppurativa occasionally caused lumps to form between his legs, which prevented him from walking. See January 2018 NOD. In August 2018, the Veteran was admitted to the hospital for four days during a hidradenitis flare-up. The Veteran was noted to have an abscess on his left buttock in the setting of prior hidradenitis suppurativa, and a computed tomography (CT) scan revealed fluid collections in the Veteran's gluteal area. He subsequently underwent an incision and drainage procedure and was treated with intravenous drugs. See August 2018 Correspondence; September 2019 CAPRI. The Veteran underwent a plastic surgery consultation in December 2018. The examiner noted that the Veteran had been admitted to the hospital with an abscess involving his left buttock and underwent a bedside incision and drainage by plastics. The examiner noted that the Veteran changed his dressing every day. To this end, the examiner reported that there was a small amount of yellow drainage on the dressing but indicated that he was unable to express drainage. An April 2019 dermatology clinic note shows that the Veteran reported that his hidradenitis suppurativa was worsening but indicated that he was not undergoing any treatment. Specifically, the Veteran stated that his spots were tender and draining and that his hidradenitis suppurativa worsened after each of his surgeries and incisions and drainage. The examiner noted that the Veteran was not receptive to the idea of biologics and that he believed that antibiotics "messed his kidneys up" and caused him to throw up and to lose a significant amount of weight. The assessment included severe hidradenitis suppurativa, Hurley grade II. At that time, the Veteran indicted he planned to continue with wound care, bleach baths, and benzoyl peroxide cleanser daily. A May 2019 primary care note shows that the Veteran had hidradenitis suppurativa and that he was prescribed Humira, an immunosuppressive drug. However, the Veteran's wife stated that the Veteran was not sure whether he wanted to start the medication due to concerns about ongoing infection. On examination, the examiner noted that there were multiple areas in the Veteran's bilateral gluteal regions with drainage. The assessment was hidradenitis suppurativa. See September 2019 CAPRI. During his December 2019 Board hearing, the Veteran testified that his service-connected hidradenitis suppurativa caused him to develop painful, itchy skin on his waistline, buttocks, and back. He further reported that he had undergone three surgeries and had three or four pockets that left a bad odor on his clothing and occasionally became clogged with blood and pus. To this end, the Veteran reported that he had to wear pads on his buttock to absorb the drainage. He further indicated that he was no longer able to sit for long periods of time. In addition, the Veteran testified that he experienced sharp, shooting pains and stated that medication he took for his service-connected hidradenitis suppurativa resulted in weight loss. See December 2019 Hearing Transcript, pages 2-6. The Veteran underwent a VA examination for skin diseases in January 2020. The examiner noted that the Veteran had been diagnosed with hidradenitis suppurativa. During the examination, the Veteran reported that he had lesions on his buttocks and groin and indicated that he had to wear a pad over that area. To this end, the examiner noted that the Veteran's treatment routine included daily cleaning and applying a bandage. As such, the examiner found that the Veteran had not been treated with medication or undergone any other treatments or procedures for any skin condition in the preceding 12 months. On physical examination, the examiner found that the Veteran's hidradenitis suppurativa covered 5 percent to 20 percent of the Veteran's total body area but indicated that it did not cover any of his exposed areas. To this end, the examiner reported that the Veteran had open lesions with yellow drainage on his buttocks and genital region, which covered 5 percent of his total body area. Following the examination, the examiner found that the Veteran's service-connected hidradenitis suppurativa impacted his ability to work. Specifically, the examiner noted that the Veteran had difficulty sitting for more than 30 minutes at a time due to hidradenitis suppurativa lesions on his genital region and buttocks. In addition, the examiner indicated that the Veteran denied taking any medications, to include any medications that could cause weight loss during the examination. See February 2020 C&P examination. In September 2020, the Veteran was prescribed topical clindamycin, an antibiotic used to treat acne and to decrease the number of acne lesions, and oral doxycycline, a medication used to treat bacterial infections. See September 2020 Medical Treatment Record Non-Government Facility. Lastly, the Veteran underwent a wound care consultation in October 2020. The examiner noted that the skin on the Veteran's lower abdomen, pubic, groin, scrotum, and buttock was scarred with areas of minimal drainage. To this end, although the Veteran indicated that the affected areas were constantly draining, the examiner found some spots of drainage on the pad but did not locate any visible draining areas. See October 2020 CAPRI. Following a review of the evidence of record, the Board finds that a rating in excess of 30 percent for the Veteran's service-connected hidradenitis suppurativa is not warranted. As an initial matter, the Board has considered the Veteran's argument that the June 2015 VA examination should be considered inadequate because the examiner failed to examine his entire body, to include his buttocks. See, e.g., August 2015 NOD; November 2017 VA Form 9. In this regard, the Board notes that the June 2015 VA examiner indicated that he did not examine the Veteran's groin or buttocks, despite his reports that his service-connected hidradenitis suppurativa also affected those areas. See June 2015 C&P examination. Thus, the Board finds the Veteran's reports regarding that examination to be credible and the June 2015 VA examination to be inadequate for rating purposes. The Board further notes that the Veteran has not argued, and the evidence does not reflect, that the September 2016 or January 2020 VA examinations were inadequate. To the contrary, the September 2016 and January 2020 examination reports show that the examiners performed physical examinations, discussed the relevant evidence, considered the contentions of the Veteran, and provided adequate supporting rationales for the conclusions reached. To this end, the examinations reflect that the Veteran's service-connected hidradenitis suppurativa affected, at most, 20 to 40 percent of his total body area. See September 2016 C&P examination; February 2020 C&P examination. In addition, the Board recognizes that the Veteran underwent a gluteal hidradenitis excision with local flap closure in April 2017, was admitted to the hospital for four days during a flare-up in August 2018, and intermittently took medications for his hidradenitis suppurativa during the relevant period. However, the evidence of record shows that the Veteran primarily used wound care, bleach baths, and benzoyl peroxide cleanser to treat his hidradenitis suppurativa. See, e.g., September 2019 CAPRI. In this regard, although the September 2016 VA examiner indicated that the Veteran used oral or topical medications during the preceding 12 months and that he underwent surgery to remove a patch of hidradenitis with a flap in April 2016, she also reported that such treatments spanned a duration of less than six weeks during the preceding 12-month period. See September 2016 C&P examination. In addition, the January 2020 VA examiner noted that the Veteran's treatment routine included daily cleaning and applying a bandage but found that he had not taken any medications or undergone any treatments or procedures for any of his skin conditions in the preceding 12 months. See February 2020 C&P examination. Thus, to the extent that the Veteran's hidradenitis suppurativa treatments included medication, the Board finds that such were most consistent with topical, rather than with systemic, therapy as contemplated under the pre-August 2018 and amended rating criteria. In this regard, the Board finds that the Veteran's primary treatments, to include wound care, bleach baths, and benzoyl peroxide cleanser, were administered through the skin, did not affect his body as a whole, and were not "like" corticosteroids or immunosuppressant drugs. In reaching this conclusion, the Board has considered that the Veteran took antibiotics to treat flare-ups and infections multiple times during the period on appeal and that he was prescribed Humira, an immunosuppressive drug, in May 2019. However, the Board finds that the evidence of record does not show that the Veteran took antibiotics on a constant or near-constant basis or for a total duration of less than 6 weeks or more over any 12-month span during the relevant period. Moreover, the evidence of record indicates that the Veteran never took his prescribed Humira. To the contrary, the Veteran and his wife repeatedly expressed concerns about ongoing infection and stated that the Veteran did not plan to take the medication. See September 2019 CAPRI. Accordingly, an increased disability rating under DC 7806 based upon treatment is not warranted under either the pre-August 2018 or amended rating criteria. The Board has also considered whether the Veteran would be entitled to a higher disability rating under any other diagnostic code available under 38 C.F.R. § 4.118. However, there are no medical findings of disfigurement of the head, face, or neck in the evidence of record, and the disability ratings assignable under other potentially relevant diagnostic codes do not exceed 30 percent. Thus, diagnostic codes for rating these manifestations are not for application. See 38 C.F.R. § 4.118 DCs 7800, 7801, 7802, 7803, 7804, 7805, 7819. However, the Board does find that a separate 20 percent rating is warranted for voiding disfunction associated with hidradenitis suppurativa under DC 7599-7819. In this regard, the evidence of record shows that the Veteran endorsed chronic pain and intermittent drainage in his perineal and gluteal areas in January 2015. A physical examination conducted at that time revealed a large area of induration and drainage tracts with active draining on his buttocks, gluteal cleft, inguinal crease and scrotum, and the examiner noted that the Veteran's active prescriptions included non-sterilized and lamino gauze pads. See November 2017 CAPRI. Thereafter, the September 2016 VA examiner noted that the Veteran was required to wear a pad around his anus and buttock for abscesses in varying stages of draining or healing on his perineum and bilateral buttocks. In addition, a December 2018 plastic surgery consultation shows that the Veteran changed his dressing every day, and during the January 2020 skin diseases examination, the Veteran reported that he had to wear a pad over his buttocks and groin because he had lesions and indicated that his treatment routine included daily cleaning and applying a bandage. See September 2019 CAPRI; February 2020 C&P examination. Thus, the evidence of record shows that the Veteran's service-connected hidradenitis suppurativa was manifested by a voiding dysfunction requiring the use of absorbent materials that had to be changed less than two times per day throughout the period on appeal. As such, the Board finds that a separate 20 percent rating is warranted pursuant to DC 7599-7819, from June 23, 2014, the date of the Veteran's claim of entitlement to service connection for hidradenitis suppurativa. The Board further finds that a rating in excess of 20 percent is not warranted under DC 7599-7819 because the evidence does not show that the Veteran's service-connected hidradenitis suppurativa required the use of an appliance or the wearing of absorbent materials which must be changed two to four times per day. See 38 C.F.R. § 4.115a. The Board further acknowledges, and has considered, the Veteran's description of the problems caused by hidradenitis suppurativa, to include pain and occasional lumps, which formed between his legs and prevented him from walking. Martinak v. Nicholson, 21 Vet. App. 447 (2007). However, with the exception of the abovementioned voiding dysfunction, the Board finds that the Veteran's hidradenitis suppurativa has not been shown to affect him in a way not contemplated by the rating criteria. Thus, to the extent that the Veteran may argue or suggest that the clinical data supports an increased disability rating or that the rating criteria should not be employed, he is not competent to make that assertion. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The Board further acknowledges the Veteran's lay statements that his service-connected hidradenitis suppurativa and the medications he used to treat the disorder resulted in weight loss. See December 2019 Hearing Transcript, page 5. In this regard, the Board notes that the Veteran is competent to report purported symptoms, such as pain, itchiness, and weight loss. Layno v. Brown, 6 Vet. App. 465 (1994). These statements, however, must be viewed in conjunction with the probative medical evidence. Here, although the evidence of record shows that the Veteran intermittently took medications for his hidradenitis suppurativa, he primarily treated the disability with wound care, bleach baths, and benzoyl peroxide cleanser, and as stated above. See, e.g., September 2019 CAPRI. The Board further notes that the January 2020 VA examiner noted that the Veteran denied taking any medications, to include any medications that could cause weight loss. See February 2020 C&P examination. Thus, the Board finds that the medical evidence of record weighs against a finding that the Veteran's weight loss was caused by his service-connected hidradenitis suppurativa or by any medications he took to treat the disorder during the period on appeal. Accordingly, the Board finds that the evidence is persuasively against the assignment of an initial rating in excess of 30 percent for hidradenitis suppurativa under the either the pre-August 13, 2018 or revised Rating Criteria, and the claim must be denied. However, the Board finds that a separate 20 percent rating is warranted for a voiding dysfunction associated with hidradenitis suppurativa under DC 7599-7819 from June 23, 2014. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.115a; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to a TDIU is remanded. At the outset, the Board notes that the Veteran filed his claim for entitlement to a TDIU in November 2014. To this end, the Veteran reported that his service-connected hidradenitis suppurativa, bilateral knee disabilities, and shoulder disability prevented him from obtaining and maintaining substantially gainful employment. See November 2014 VA Form 21-8940 Veterans Application for Increased Compensation Based on Unemployability. A TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). TDIU will be granted when the evidence shows that the veteran, due to their service-connected disabilities, is precluded from obtaining or maintaining any gainful employment consistent with their education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. It is the established policy of the Department of Veterans Affairs that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Therefore, rating boards should submit to the Director, Compensation Service, for extra-schedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in paragraph (a) above. Pursuant to this decision, a separate 20 percent rating has been assigned for voiding dysfunction associated with hidradenitis suppurativa, effective June 23, 2014. The Veteran has also been service connected for the following disabilities: hidradenitis suppurativa rated as 30 percent disabling from June 23, 2014; right shoulder degenerative arthritis rated as 10 percent disabling from June 23, 2014; right knee arthritis rated as 10 percent disabling from June 23, 2014; left knee strain rated as non-compensable from June 23, 2014; tinea pedis rated as non-compensable from June 23, 2014; and pseudofolliculitis barbae rated as non-compensable from June 23, 2014. See November 2017 Rating Decision Codesheet. Thus, pursuant to the combined rating table in 38 C.F.R. § 4.25, the Veteran's combined disability rating is 60 percent throughout the period on appeal, which does not meet the schedular criteria for assignment of a TDIU. See 38 C.F.R. § 4.16(a). However, the Board must still consider whether referral for extraschedular consideration is warranted. Turning to the evidence of record, the Veteran reported that his service-connected hidradenitis suppurativa, bilateral knee disabilities, and right shoulder disability prevented him from securing or following any substantially gainful employment in November 2014. In this regard, the Veteran reported that he last worked for an automobile manufacturer from February 2007 to October 2010. However, he reported that he became too disabled to work in October 2010 and left his job due to his disabilities. He further indicated that he received or expected to receive disability retirement benefits. See November 2014 VA Form 21-8940 Veterans Application for Increased Compensation Based on Unemployability. A November 2014 disability determination and transmittal form shows that the Social Security Administration (SSA) found the Veteran to be disabled from October 1, 2010, and reported his primary diagnosis as hidradenitis suppurativa. SSA records show that the Veteran graduated from high school but did not complete any type or specialized job training, trade, or vocational school and that he previously worked as a slasher/operator at a textile mill from February 1992 to June 2006 and in engine assembly at an automobile factory from April 2007 to October 2010. See January 2015 Medical Treatment Records Furnished by SSA. A January 2015 VA Form 21-4192 shows that the Veteran was employed as a manufacturing associate from October 2009 to January 2011. The Veteran's employer noted that the Veteran worked 8 hours per day, of a total of 40 hours per week, until he took leave under the Family Medical Leave Act (FMLA) in October 2010. To this end, the employer explained that the Veteran did not return after his FMLA leave expired and that he was subsequently terminated for lack of attendance. See January 2015 VA Form 21-4192 Request for Employment Information in Connection with Claim for Disability. The Veteran underwent a VA examination for shoulder and arm conditions in June 2015. During the examination, the Veteran denied any functional loss or impairment associated with his service-connected right shoulder disabilities, and the examiner found that the Veteran's diagnosed right shoulder strain and right shoulder degenerative arthritis did not impact his ability to perform any type of occupational tasks. The Veteran was also afforded a VA examination for knee and lower leg conditions in June 2015. Following the examination, the examiner found that the Veteran's diagnosed bilateral knee strain impacted his ability to perform occupational tasks, to include limiting his ability to walk. In addition, the Veteran underwent a VA examination for skin diseases in June 2015. During the examination, the Veteran denied functional impairment associated with his service-connected tinea pedis and pseudofolliculitis barbae. However, the examiner found that the Veteran's service-connected skin disorders did not impact his ability to work. Notably, the June 2015 VA examiners further opined that the Veteran's service-connected right shoulder and bilateral knee disabilities did not render him unemployable. To the contrary, the examiner specifically determined that the Veteran was employable and fit for a desk job or for employment requiring mild physical activity that did not require him to lift more than 20 pounds. See June 2015 C&P examination. The Veteran reported that he was not able to walk for several days when he experienced hidradenitis suppurativa flare-ups on has August 2015 NOD. See August 2015 NOD. The Veteran was afforded a VA examination for skin diseases in September 2016. After performing an examination, the examiner determined that the Veteran's service-connected hidradenitis suppurativa impacted his ability to work. Specifically, the examiner indicated that it was very painful for the Veteran to sit with active abscesses between and on his buttocks. The Veteran also underwent a VA examination for scars and disfigurement in September 2016. The examiner noted that the Veteran had surgical scars on his bilateral buttocks and scars from abscesses of hidradenitis suppurativa but found that they did not result in limitation of motion or impact his ability to work. See September 2016 C&P examination. During the December 2019 Board hearing, the Veteran testified that he previously worked in the spinning room at a textile mill for 14 years and then as an assembly line worker for an automobile manufacturer from 2006 to 2010. To this end, he reported that he spent long periods of time on his feet in both positions and indicated that he was released from employment with the automobile manufacturer because his doctors did not clear him to return to work during the specified period of time. The Veteran further testified that his service-connected disabilities caused his feet to swell, his knees to give way and indicated that his shoulders felt "played out[.]" He also stated that he was no longer able to perform yard work or sit or stand for long periods of time. See December 2019 Hearing Transcript, pages 6-11. Lastly, the Veteran underwent a VA examination for skin diseases in January 2020. Following the examination, the examiner found that the Veteran's service-connected hidradenitis suppurativa impacted his ability to work. Specifically, the examiner noted that the Veteran had difficulty sitting for more than 30 minutes at a time due to hidradenitis suppurativa lesions on his genital region and buttocks. See February 2020 C&P examination. After a review of the evidence of record, the Board finds that the weight of the evidence indicates that the Veteran's service-connected disabilities did not preclude him from securing and maintaining substantially gainful employment. To this end, while it is clear that the Veteran has some occupational and functional impairment as a result of his service-connected disabilities, the evidence does not support that the Veteran's service-connected disabilities alone preclude him from securing and following substantial gainful employment. To this end, the Board acknowledges that the Veteran's service-connected bilateral knee disabilities and right shoulder disability impacted his ability to perform occupational tasks by, at worst, limiting his ability to walk and to lift more than 20 pounds. See, e.g., June 2015 C&P examination; December 2019 Hearing Testimony, pages 6-11. Nevertheless, the Board finds that the Veteran's service-connected bilateral knee disabilities and right shoulder disability did not impose restrictions, which when considered collectively and independently, precluded the Veteran from obtaining or maintaining employment that allowed him to stand as needed and that did not require heavy lifting. See June 2015 C&P examination. The Board further recognizes that the Veteran's service-connected hidradenitis suppurativa prevented him from walking or sitting for long periods of time. See June 2015 C&P examination; December 2019 Hearing Testimony, pages 6-11; February 2020 C&P examination. However, the Board finds that the Veteran's service-connected disabilities have not been shown to preclude substantial gainful employment that involves fewer physical demands. In this regard, the Board notes that the June 2015 VA examiner specifically found that the Veteran's service-connected bilateral knee disabilities and right shoulder disability did not render him unemployable. To the contrary, the examiner determined that the Veteran was employable and fit for a desk job and for employment requiring mild physical activity. See June 2015 C&P examination. Moreover, while the January 2020 VA examiner found that hidradenitis suppurativa lesions on the Veteran's genital region and buttocks would make it difficult for him to sit for more than 30 minutes, the examiner did not find that the disorder rendered the Veteran unemployable. See February 2020 C&P examination. Thus, while it is clear that the Veteran experienced some occupational and functional impairment as a result of his service-connected disabilities, the evidence does not support that the Veteran's service-connected disabilities alone precluded him from securing and maintaining substantially gainful employment. Specifically, the Board finds that the evidence of record shows the Veteran service-connected disabilities did not preclude him from performing work that allowed him to stand as needed or from employment that required only mild physical activity. In this regard, the Board acknowledges that the Veteran was deemed disabled by SSA due to hidradenitis suppurativa. However, the Board is not bound by any determination of SSA, and for the reasons stated above, the Board finds that the Veteran's service-connected disabilities, to include hidradenitis suppurativa, do not render him unemployable. To the contrary, the Board finds that the Veteran's symptoms, taken together, do not indicate that he would be unable to obtain and maintain employment. In sum, the Board finds that the evidence is persuasively against finding that the Veteran meets the requirements for entitlement to a referral of his TDIU claim for consideration on an extraschedular basis. 38 C.F.R. § 4.16(a-b). Accordingly, the Board declines to refer the claim to the Director of VA Compensation Service for consideration of TDIU on an extraschedular basis. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Justis, 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.