Citation Nr: 22015595 Decision Date: 03/18/22 Archive Date: 03/18/22 DOCKET NO. 16-00 739 DATE: March 18, 2022 ORDER Entitlement to service connection for a low back disability is denied. Entitlement to a compensable rating for acne vulgaris is denied. REMANDED The appeal of entitlement to a compensable rating for eczema is remanded. FINDINGS OF FACT 1. Arthritis of the low back was not shown during service or for many years thereafter, and the weight of the competent and probative evidence is against finding that the Veteran's current back condition was incurred in or is otherwise related to service. 2. During the pendency of the appeal, the service-connected acne has not been manifested by deep acne; disfigurement of the head, face or neck; scars; or impaired function. CONCLUSIONS OF LAW 1. The criteria to establish entitlement to service connection for a low back disability have not been met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for a compensable rating for acne vulgaris have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Codes 7828, 7819. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1990 to March 1998. These matters come before the Board of Veterans' Appeals (Board) from a June 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In February 2019, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The claims were last before the Board in July 2021, when they were remanded for evidentiary development. 1. Service connection for a low back disability Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Moreover, service connection for certain chronic diseases, to include arthritis, may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from active service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309(a). The Veteran contends that her current back condition is related to service, to include being on jump status for over two years with multiple static line jumps. She described an incident in which her parachute deflated, and she was left swinging from a tree branch, after which she fell about 15 feet to the ground with resulting stiff and sore back; an injury when another jumper landed on her during a rope training exercise; and an incident while stationed in Italy when her back locked up and she fell down the stairs while holding her baby. See July 2013 and June 2018 statements, and February 2019 Board hearing transcript. She additionally testified that medics were on site during the line jumps, who dispensed ibuprofen; she did not go to sick call for her back during service; she sought VA treatment for her back after service and was told nothing was wrong; and her back pain continued to worsen, after which she sought private medical treatment. The medical evidence shows the Veteran is currently diagnosed with a back disability, namely, degenerative arthritis of the lumbar spine, as shown on March 2013 VA x-ray. Thus, the question becomes whether the current lumbar spine arthritis is related to service. After reviewing the evidence, the Board finds that the weight of the competent and probative evidence is against the claim. The Veteran's service treatment records do not show any complaints, treatment or findings related to her back. While service treatment records document treatment on multiple occasions for other complaints, to include hand laceration, scalp, earache, sore throat, abdominal pain, rash, acne, conjunctivitis and right ankle pain, none reflect complaints or findings related to the back. Notably, a January 1994 dental health questionnaire record shows the Veteran denied any health changes in the past 2 years and did not check the box for arthritis; and service treatment records in 1995 document complaints and treatment for a right ankle injury incurred while walking down stairs but do not mention her back. The Veteran's treatment for other conditions, including musculoskeletal symptoms, suggests that she raised concerns when she was not feeling well. Thus, although the Veteran asserted that medics treated them on-site during static line jumps, such that her back symptoms would not be documented in her service treatment records, the Board finds it is nonetheless likely the Veteran would have sought sick call treatment for those symptoms had those complaints been chronic or unresolved and those complaints would have been documented in her service treatment records. See AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present). Further, the medical evidence prior to the filing of the Veteran's 2012 claim does not mention the low back, including reports from a July 1998 general medical examination, an August 2003 VA examination that contained neurological evaluation of the extremities, and a November 2006 private examination report that provided a general overview of the musculo-skeletal system. Notably, the low back is not mentioned by the Veteran in these reports, including when she described a fall down stairs, nor did her compensation claims prior to 2012 mention the low back. Id. The earliest indication of treatment or complaints related to the low back is in 2012, which is contemporaneous to the Veteran's August 2012 service connection claim. At that time, she noted she had recently begun experiencing back spasms. Specifically, a November 2012 VA treatment record reflects reported acute symptoms of right low back pain radiating to the right calf after stepping off a train and landing on her right foot; the impression was low back pain. The first medical evidence of lumbar arthritis is in 2013, which is more than a decade after service and well beyond the one year presumptive period, as noted on March 2013 VA x-ray. To the extent the Veteran asserts that she had back problems during and ever since service, the Board finds these assertions are not consistent with the evidence of record and, thus, not credible. See Madden v. Gober, 125 F.3d at 1481 (Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336-1337 (2006) (the lack of contemporaneous medical records is a factor that the Board can consider and weigh against a veteran's lay evidence). Moreover, the Board finds the Veteran's statements made for purposes of seeking treatment to be significantly more credible and persuasive than statements made to VA for purposes of seeking compensation. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence). As the competent evidence of record does not establish arthritis of the low back during service or within one year following discharge, competent evidence linking the current back condition to service is needed to substantiate the claim. On this question, the weight of the competent and probative evidence is against the claim. The record includes nexus evidence both for and against the claim. Medical opinions from a private clinician, Dr. V.S.R., were provided in June 2018 and January 2019. Other than the phrasing of the nexus statement, which appears to have been changed in response to the June 2019 Board decision, these two statements are identical. In the June 2018 opinion, the clinician opined that the Veteran's lumbar disc disease could have been caused by her prior military job of being a parachutist. In the January 2019 opinion, the clinician stated the lumbar disc disease was more likely than not caused by the Veteran's prior military job of being a parachutist. No rationale was provided for either opinion. An April 2021 private medical statement from M.G., a nurse practitioner, states that the Veteran's service records show multiple episodes where she was treated for chronic low back pain while on active duty and that her duties as a paratrooper with more than 48 static line jumps contributed significantly to her lumbar arthritis as it caused her to develop significant weakness, along with chronic pain. The clinician did not provide an adequate rationale. An opinion from a private clinician, Dr. L.W., submitted in September 2021 and dated May 21, states that the Veteran's low back pain is as likely as not related to service. The clinician described the diagnosed osteoarthritis and indicated she reviewed the medical records and service records and studied the paratrooping landing training sequence. The clinician did not provide adequate rationale to support the statement. The Board notes that the Veteran did not respond to VA's September 2021 request to provide medical authorizations for Dr. L.W. and nurse practitioner M.G. so as to enable VA to obtain the medical records from these clinicians. She also did not otherwise submit the treatment records into evidence. As such, the Veteran did not assist in providing additional evidence to the VA that may have been relevant to her claim. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) ("The duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence."). Thus, the Board's analysis must be based on the opinions in the record. Conversely, a March 2013 VA examiner opined that the Veteran's lumbar spine arthritis was less likely than not related to service. She reasoned that the Veteran's degenerative disc disease and degenerative joint disease show very mild changes and most likely are a result of the normal aging process and not a result of the jumps she did while obtaining a parachutist badge fifteen years ago during service. She reasoned that the claims file does not show any complaints of back pain, which would have occurred had there been any damage to her back during the jumps required for her parachutist badge. She also cited medical literature to support her opinion, which discusses how any injury would manifest shortly after it occurs, not 15 years later and provided excerpts of the discussion paper, including how, with gradual aging, there is loss of water from the nucleus pulposus with resulting thinning of the disc space between the adjacent vertebrae, which can be seen on x-rays; that the narrowing of the disc space causes the annulus fibrosis to "bulge," which does not usually cause symptoms, but may compress the nerve roots if the bulging is excessive with resultant symptoms; and that the process of bulging is not the result of trauma. She described how aging may cause wear and tear changes and slipping of a vertebra, which are affected by heredity and race, but that a severe injury, such as a fall from a height (as opposed to a lifting strain) may result in the appearance (within a year) of narrowing of a single disc. She indicated that there is no evidence that the progression of x-ray changes is altered by a single injury (unless it is very severe) or by repetitive movement; that people with aging change might be more prone to develop back symptoms with repetitive strain although the evidence is tenuous; and that if an accident were to be the primary cause of a disc prolapse, features of the disc protrusion would be present within a few hours to a few days, or occasionally, two or three weeks, after the accident. A January 2020 VA examiner opined that the lumbar spine disability was less likely than not related to service. The examiner reasoned that the lumbar spine arthritis was diagnosed in 2013; that the disability is less likely a result of the Veteran's remote parachute incident in service, as there is no evidence of these findings in service records; that the service records do not document a chronic disabling back issue during service; and that there is insufficient medical evidence after service discharge until over a decade later to support a continuous chronic back issue after separation. In an October 2020 VA addendum opinion, the same examiner clarified the negative nexus option and specifically addressed the Veteran's contentions regarding in-service injuries and the June 2018 private medical opinion from Dr. V.S.R. Addressing the contentions of in-service injuries, to include due to jump status and incident while stationed in Italy when her back locked up and she fell down the stairs while holding her baby, the examiner reasoned that the first x-ray/magnetic resonance imaging (MRI) findings showing a lumbar spine diagnosis of degenerative disc disease and degenerative joint disease are from 2013, which is over 7 years after separation from service; that there is no evidence that the Veteran's jump status caused chronic back issues in service and, even if medics were on site during jumps, such that the Veteran did not have to go to sick call, this indicates that any treatment the Veteran may have received resolved the back pain, as there is no treatment for chronic back issues in service or within a year after separation; and that parachute injuries, such as swinging from a tree, do not cause back injuries as the parachute equipment supports the Veteran's upper torso and does not affect the lumbar spine. As to the alleged incident falling down the stairs, the examiner reasoned that the evidence does not show the Veteran sought medical attention for her back, thus any such injury did not result in any disabling back issue. Addressing the June 2018 private opinion from Dr V.S.R., the examiner reasoned that there is no evidence from service to support the clinician's conclusion that the current degenerative changes in the lumber spine are from the Veteran's duties as a parachutist, especially since there are no x-rays or in-service complaints of a chronic disabling back issue. Post-service VA and private treatment records do not suggest an association between or otherwise link the Veteran's low back arthritis to service. After reviewing the evidence, the Board finds the weight of the competent and probative evidence is against the claim for service connection for a low back disability. The Board finds the combined March 2013, January 2020 and October 2020 opinions the most probative and persuasive. Taken together, the opinions establish that the Veteran's current lumbar spine arthritis was not incurred in or is otherwise related to service, to include any injuries or incidents during service. The combined rationale is that the Veteran's service treatment records do not show any complaints of back pain or treatment, which would have been documented had she injured her back during the static line jumps or other alleged incidents; that the medical evidence does not show a chronic back disability in service or until over a decade after service, which indicates that any such in-service injury, had it occurred, resolved and was not chronic during service; that the diagnostic evidence does not support in-service trauma to the back; and that the current degenerative lumbar spine changes are more likely due to normal aging and hereditary. The Board finds the combined VA examiners' opinions highly probative and persuasive. The opinions were based on a thorough review of the medical evidence and physical examination of the Veteran; considered the Veteran's contentions and alleged injuries; and are supported by an articulated rationale for the conclusions reached that is consistent with the evidence. Additionally, the March 2013 VA examiner offered an alternative etiology, namely, aging and hereditary, and was based on literature research with detailed notations of the evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Accordingly, the combined VA opinions are afforded great probative weight. The Board does not afford the June 2018 opinion from private clinician, Dr. V.S.R., any probative weight as it is conclusory and speculative in nature. See Bloom v. West, 12 Vet. App. 185, 187(1999) (noting that the use of the term "could," without other rationale or supporting data, is speculative). The Board affords minimal probative weight to Dr. V.S.R.'s January 2019 opinion, as the opinion is not supported by any rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). As to the April 2021 statement from private clinician M.G., the Board finds that, to the extent this statement is intended to suggest the current back disability is related to service, the Board affords this statement no probative weight, as it is based on an inaccurate factual premise, specifically that the Veteran's service records show multiple episodes of treatment for chronic low back while on active duty, which the Board notes is not supported by the Veteran's service records. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise is not probative); see also Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("If the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely") (citing Reonal)). As to the September 2021 opinion from private clinician, Dr. L.W., the opinion is afforded minimal, if any, probative weight as it was not supported with any rationale. Thus, the Board finds the VA examinations in the record significantly more probative than the private opinions. See Owens v. Brown, 7 Vet. App. 429 (1995) (VA may favor the opinion of one competent medical expert over that of another when decisionmakers give an adequate statement of reasons and bases). Although the Veteran contends her current lumbar spine condition is related to service, as a lay person, she has not been shown to have the specialized training sufficient to render such an opinion because the diagnosis and etiology of degenerative arthritis are matters not capable of lay observation and require medical expertise to determine. See Jandreau v. Nicholson, 492 F.3d at 1376-77 (noting general competence to testify as to symptoms but not to provide medical diagnosis). Thus, the Veteran's own opinion regarding the etiology of her current back disability is not competent medical evidence. The Board finds the VA examiners' opinions, service records and post-medical treatment records to be significantly more probative than the lay assertions. In sum, the weight of the competent and probative evidence is against the claim for service connection for a low back disability, and the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Entitlement to a compensable rating for acne vulgaris Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. Service connection was originally established for acne vulgaris in an August 1998 rating decision and assigned a noncompensable rating under 38 C.F.R. § 4.118, Diagnostic Codes 7828-7819, effective March 25, 1998. The Veteran filed the present claim for a higher rating for acne in August 2012. The June 2013 rating decision that is the subject of this appeal continued a noncompensable rating. The Board notes that the Veteran is not service connected for lichen planus. Thus, the Board may not consider lichen planus in reaching its determination herein. See 38 C.F.R. § 4.14 (the use of manifestations not resulting from service-connected disability for evaluating the service-connected disability is to be avoided); see also Pratt v. Derwinski, 3 Vet. App. 269 (1992). Further, the Veteran has been separately rated throughout the appeal period for service connected residual scar, cyst removal of the rear side of the head and for eczema. Thus, symptomatology associated with these disabilities cannot be considered in evaluating the Veteran's acne as such would constitute pyramiding. See 38 C.F.R. § 4.14 (the evaluation of the same manifestation or disability under different diagnoses is to be avoided). The Veteran asserts that a compensable rating is warranted for acne. In a July 2013 notice of disagreement, she asserted that she has permanent scarring/disfigurement on the left side of her face. In October 2013, she asserted that she has facial scarring and acne marks on her buttocks, legs, neck and arms. In her December 2015 VA Form 9, she asserted she has superficial scarring on her limbs and face and multiple monthly acne flares that are puss-filled. In May 2018, she asserted her acne has worsened, to include acne breakouts, despite the use of prescribed Retin-A and other medications. She testified in February 2019 that she has dermatitis across her face, multiple breakouts per year, and scarring on the face and marks on the legs, feet, groin, buttocks, low back, neck and eyes. The Board notes that during the pendency of the appeal VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Those amendments do not directly change Diagnostic Code 7800, 7828 or 7819. The criteria for Diagnostic Code 7801, 7802, and 7805 pertaining to scars were revised. Diagnostic Code 7828 provides the rating criteria for acne. In pertinent part, a 10 percent rating is warranted for deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face and neck, or; deep acne other than on the face and neck; and the maximum 30 percent rating is warranted for deep acne (deep inflamed nodules and pus-filled cysts) affecting 40 percent or more of the face and neck. Acne may also be rated as disfigurement of the head, face or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801 through 7805), depending upon the predominant disability. 38 C.F.R. § 4.118. Diagnostic Code 7819 provides the rating for benign skin neoplasms, which are to be rated as disfigurement of the head, face, or neck under Diagnostic Code 7800; as scars under Diagnostic Codes 7801 through 7805; or as impairment of function. 38 C.F.R. § 4.118, Diagnostic Code 7819. Diagnostic Code 7800 pertains to burn scars of the head, face, or neck; scars of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. Diagnostic Codes 7801 through 7805 provide alternative rating approaches for scars. Diagnostic Code 7804 provides progressively higher ratings based on the number of unstable or painful scars. Diagnostic Code 7805 pertains to other scars and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7804, and provides that any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800 to 7804 should be evaluated under an appropriate diagnostic code. After reviewing the record, the Board finds that the weight of the competent and probative evidence is against assigning a compensable rating for the service-connected acne at any point during the pendency of the appeal pursuant to the relevant rating criteria in effect both prior to and since August 13, 2018. To merit the next highest (10 percent) rating under Diagnostic Code 7828, the Veteran's acne had to be manifested by deep acne affecting less than 40 percent of the face and neck, or deep acne other than on the face and neck. However, in this case, the medical evidence does not show deep acne at any point during the pendency of the appeal. Rather, physical examination during the November 2012, January 2020 and January 2021 VA examination showed only superficial acne (comedones, papules, pustules, superficial cysts), not deep acne; and the October 2018 VA examiner did not find the presence of any acne during the examination. Additionally, an April 2021 disability benefits questionnaire (DBQ) prepared by a private clinician and submitted by the Veteran is not fully completed and does not indicate whether the diagnosed acne is superficial acne or deep acne. VA treatment records during the appeal period do not reflect findings inconsistent with those on VA examinations. These include, for example, VA treatment in November 2014 showed a few pustules and comedones on the face and reported flare; VA treatment in July 2015 showing the Veteran reported an occasional acne bump around her chin/jaw area and VA treatment in January 2020 and January 2021 again showing the Veteran's acne is well-controlled with no flaring. The Board notes that the October 2020 VA examiner distinguished the symptomatology associated with the non-service connected lichen planus from the service-connected acne and eczema. He stated that lichen planus is clinically distinguishable from acne and eczema, as they are separate diagnoses. He described lichen planus as polygonal, flat-topped, violaceous papules and plaques with overlying, reticulated, fine what scale, commonly affecting dorsal hands, flexural wrists and forearms, trunk, anterior lower legs and oral mucosa; acne as a condition affecting the oil glands under the skin, such that, when the tunnels that connect the glands to the skin's surface (pores) get clogged, a pustule grows; and eczema as an autoimmune condition that causes erythema of the skin and difficulty of the skin to retain moisture. While the medical evidence in the record reflects symptoms associated with non-service connected lichen planus and other non-service connected conditions, including hyper-pigmented patches and macule and folliculitis, the Board may not consider these symptoms when evaluating the Veteran's acne. 38 C.F.R. § 4.14. The Board has considered whether a rating a higher rating is available for the Veteran's acne based on disfigurement of the head, face or neck under Diagnostic Code 7800; or scars under Diagnostic Codes 7801, 7802, 7804 or 7805, depending on the predominant disability, but finds that none provide for a higher rating under the criteria in effect both prior to and since August 13, 2018. In this regard, the November 2012, July 2018, October 2018, January 2020 and January 2021 VA examiners all indicated that physical examination showed no burn scars; scars of the head, face or neck due to other causes; or disfigurement of the head, face or neck. While VA examiners indicated the Veteran has one scar on the rear right side of the head, status-post lipoma removal, the Veteran is already separately service-connected for this scar; thus, the Board may not consider symptomatology associated with this scar when rating the Veteran's acne, and physical examination during all of the VA examinations showed no other scars and no disfigurement of the head face or neck due to scars, burns or other causes. The Board has also considered whether a higher rating is warranted under Diagnostic Code 7819, for benign skin neoplasm, which is rated as disfigurement of the head, face or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801 through 7805), or impairment of function. See 38 C.F.R. § 4.118, Diagnostic Code 7819. However, as already discussed, Diagnostic Codes 7800, and 7801 through 7805 do not apply in this case, as there is no evidence of disfigurement of the head, face or neck, or scarring due to acne. Further, the November 2012, October 2018, January 2020, and January 2021 VA examiners all indicated that the Veteran's acne did not functionally impair the ability to work, and the November 2012 and October 2018 VA examiners indicated there were no debilitating or non-debilitating episodes in the past 12 month period. Thus, a higher rating is not warranted based on impairment of function. The Board acknowledges the October 2021 DBQ prepared by a private clinician to support a higher rating. This DBQ notes a medical history of significant scarring due to a long history of infection and inflammation; four or more debilitating episodes in the past 12 months of inflammation/infected skin on more than 40 percent of her legs, ears, neck, inner arms and feet; flares of significant swelling and weeping on the Veteran's face; and functional impairment during flares, described as being unable to shave due to intense and severe weeping. The Board does not, however, find this DBQ probative and persuasive as to the nature and severity of the Veteran's acne, as the DBQ was not fully completed, did not include information in the section specific to acne, such as the type of, location and description of acne; and did not note whether the findings noted in the DBQ pertained to acne or other skin conditions. Further, there is no indication that the clinician reviewed the claims file or examined the Veteran. Finally, the findings in the DBQ are not consistent with other medical evidence in the record, including the numerous VA examinations discussed above and VA and private medical treatment records. Notably, the Veteran did not respond to VA's September 2021 request to return a medical authorization for the private clinician, M.G., or submit the clinician's medical treatment records. As such, the Veteran did not assist the Board in obtaining additional medical evidence that may have been relevant to the claim. See Wood v. Derwinski, 1 Vet. App. at 193 (1991). The Board finds the VA examinations and treatment records, which do not support a compensable rating, to be significantly more probative as to the nature and severity of the service-connected acne than the October 2021 DBQ. In reaching its decision, the Board reviewed and considered the Veteran's statements, including her assertions that she has permanent scarring/disfigurement on the left side of her face and other parts of her body and monthly acne flares. It also considered the photographs and medical receipts submitted in November 2012 and March 2019. However, the Board finds the medical evidence and VA examination reports identifying acne symptomatology versus other skin condition symptomatology to be more probative. The Board acknowledges the internet article submitted by the Veteran in May 2021, which discuss how tranexamic acid works on skin hyperpigmentation and dark spots. However, this article has not been specifically related to the Veteran's individual case by a medical professional and, thus, is assigned little probative value. See Sacks v. West, 11 Vet. App. 314, 317 (1998). In sum, the Board finds the weight of the probative evidence is against assigning a compensable rating at any point during the appeal period for the Veteran's acne under the rating criteria in effect prior to and since August 13, 2018, and the claim for a compensable rating for acne is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to a compensable rating for eczema The Veteran's eczema is assigned a noncompensable rating under 38 C.F.R. § 4.118, Diagnostic Code 7806, effective March 25, 1998. The Veteran filed the present claim for a higher rating for eczema in August 2012, which was denied in a the June 2013 rating decision that is the subject of this appeal. The Board notes that the rating criteria used to evaluate the skin were amended effective August 13, 2018, including those pertaining to Diagnostic Code 7806. Diagnostic Code 7806 provides ratings for dermatitis/eczema based, in part, on whether treatment involved no more than topical therapy or systemic therapy such as corticosteroids or other immunosuppressive drugs. 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). Effective August 13, 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). The Board finds that a remand is needed to obtain an addendum VA opinion, as the VA opinions and examinations reports provided in October 2020, January 2020 and January 2021 are not fully responsive to the Board's prior remands directives. Specifically, it is still unclear whether the VA examiners reviewed all of the medications prescribed by VA since 2012 to treat the Veteran's eczema and whether any such medication is a corticosteroid or other immunosuppressive drug. Further, an opinion that addresses whether any medication prescribed to treat the Veteran's eczema prior to August 13, 2018, is a topical treatment that affects the body as a whole and whether treatment is "like" a corticosteroid or other immunosuppressive drug is also needed. The matter is REMANDED for the following action: 1. Updated VA treatment records should also be obtained. 2. Provider the claims file to a VA examiner to obtain a clarifying opinion on the claimed eczema. If another examination is deemed necessary to respond the questions presented, one should be scheduled. After reviewing the claims file, the examiner should identify all medications prescribed to treat the Veteran's eczema since January 2012; and indicate whether such medication is a topical treatment that affects the body as a whole and whether treatment is "like" a corticosteroid or other immunosuppressive drug. In responding, the examiner is asked to specifically consider and address the specific medications documented in the record, including but not limited to, hydrocortisone, Retin-A, desonide, benzoyl peroxide, hydroquinone, tretinoin, triamcinolone acetonide, Eucrisa and clobetasol; and indicate whether the medication is/is not prescribed to treat eczema. 3. If the claim remains denied, issue a supplemental statement of the case, as appropriate. K. A. BANFIELD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. C. Birder 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.