Citation Nr: 22040127 Decision Date: 07/13/22 Archive Date: 07/13/22 DOCKET NO. 13-28 143A DATE: July 13, 2022 ORDER Entitlement to an initial disability rating of 20 percent, but no higher, for degenerative joint and disc disease of the lumbosacral spine with intermittent spasms, effective July 16, 2009, is granted. Entitlement to an initial disability rating of 30 percent, but no higher, for tinea pedis, claimed as severe athlete's foot, effective July 16, 2009, is granted. FINDINGS OF FACT 1. From the date of award of service connection, July 16, 2009, when resolving the benefit of the doubt in favor of the Veteran, his service-connected degenerative joint and disc disease of the lumbosacral spine with intermittent spasms has been manifested by pain with limitation of motion that more nearly approximates flexion limited to 60 degrees or less; but without forward flexion limited to 30 degrees or less, ankylosis, incapacitating episodes of at least four weeks over the past 12 months, or associated neurological abnormalities other than radiculopathy of both lower extremities. 2. From the date of award of service connection, July 16, 2009, when resolving the benefit of the doubt in favor of the Veteran, his tinea pedis required systemic therapy for a total duration of at least six weeks or more. CONCLUSIONS OF LAW 1. The criteria for an initial 20 percent rating, but no higher, for degenerative joint and disc disease of the lumbosacral spine with intermittent spasms have been met, effective July 16, 2009. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.7, 4.71a, Diagnostic Codes 5235-5243. 2. The criteria for an initial 30 percent rating, but no higher, for tinea pedis, have been met, effective July 16, 2009. 38 U.S.C. § §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Codes 7806 (in effect prior to August 13, 2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 2006 to November 2006. He also served in the U.S. Navy Reserves from November 1987 to April 2008 and had several periods of active duty for training (ACDUTRA) including from June 6, 1988, to June 19, 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which awarded service connection for the Veteran's low back disability and tinea pedis. The case was remanded by the Board in August 2017 for further development. In a July 2019 decision, the Board denied entitlement to service connection for traumatic brain injury, a chronic headache disorder, and right lower extremity radiculopathy, to include numbness and pain, and initial higher ratings for a lumbar spine disability and tinea pedis. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court) and in August 2020, the parties agreed to a Joint Motion for Remand (JMR) that vacated and remanded the Board's decision. The Court granted the JMR in an August 2020 Order. Subsequently, in a March 2021 rating decision, the Board again denied an initial higher rating for tinea pedis but remanded the remaining issues on appeal. The Veteran appealed the denial of the tinea pedis rating to the Court and in December 2021 the parties agreed to a Joint Motion for Partial Remand (JMPR) that vacated and remanded the Board's decision. The Court granted the JMPR in December 2021 Order. In March 2022, the Board remanded this issue to comply with the JMPR. The issue has now been returned to the Board. The Board finds that there has been substantial compliance with the prior Board remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Further, while on remand, in a March 2022 rating decision, the agency of original jurisdiction (AOJ) granted a 20 percent rating for the Veteran's low back disability, effective October 15, 2021. However, the Veteran is presumed to seek the maximum available benefit for a disability. As such, the claim is still considered to be on appeal. See AB v. Brown, 6 Vet. App. 35(1993). The Board also finds that there has been substantial compliance with the prior Board remand directives with respect to this issue. See Stegall, cited above. Moreover, service connection was awarded for radiculopathy of the right lower extremity, traumatic brain injury and post traumatic headaches; representing a full grant of the benefits sought on appeal. Increased Rating Entitlement to an initial higher disability rating for degenerative joint and disc disease of the lumbosacral spine with intermittent spasms The Veteran asserts that a higher rating is warranted for his service-connected low back disability. In this regard, the Veteran has contended that he experiences severe pain, difficulty going up and down stairs, and trouble bending over. Again, the Veteran's low back disability has been rated as 10 percent disabling prior to October 15, 2021, and 20 percent disabling thereafter. Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Under the General Rating formula for Diseases and Injuries of the Spine, ratings contemplate symptoms such as pain (whether or not it radiates), stiffness, or aching and are assigned as follows: a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; a 30 percent rating is warranted for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine; a 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine; a 50 percent rating is awarded for unfavorable ankylosis of the entire thoracolumbar spine; and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Note (1) to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that a 20 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Note (1) provides that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59 (2006); see also Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). The possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. §§ 4.40 ), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45 ). See Mitchell, supra. Further, the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). Further, a VA examination is inadequate when the VA clinician does not elicit relevant information as to the Veteran's flares or ask him to describe additional functional loss, if any, he suffered during flares and then does not "estimate the [Veteran's] functional loss due to flares based on all the evidence of record (including the [Veteran's] lay information) or explain why [he or she] could not do so." Sharp v. Shulkin, 29 Vet. App. 26, 35 (2017). The most recent VA examination done in October 2021 complies with both Correia and Sharp. During the pendency of the appeal, the rating criteria evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended, effective February 7, 2021. 85 Fed. Reg. 230 (November 30, 2020). However, the Veteran's lumbar spine disability is rated under the General Formula for Disease and Injuries of the Spine, which did not change. The Board observes that Diagnostic 5243 for intervertebral disc syndrome was revised to only apply when there is disc herniation with compression and/or irritation of the adjacent nerve root. Although the most recent October 2021 VA examiner did not find any disc herniation, the Board will still consider the criteria for Intervertebral disc syndrome as the previous criteria is more favorable to the Veteran. Based on the evidence of record, when resolving the benefit of the doubt in favor of the Veteran, the Board finds that a 20 percent rating is warranted from the date of claim of service connection, July 16, 2009. By way of background, the Board previously found that February 2010 and September 2010 VA examinations were inadequate as they did not comply with Correia. The Board also observes that neither of those examiners provided an estimate in degrees with respect to any additional loss during flare-ups or repeated use over time. Further, despite the Veteran's reports of flare-ups, the November 2017 VA examiner indicated that there was no further functional impairment during flare-ups or repeated use over time with no additional explanation. However, the examiner also found that the Veteran would not be able to do work that required prolonged standing, walking, bending, lifting or carrying over 50 pounds. Given this finding, the examiner's opinion that there is no additional functional impairment during flare-ups or repeated use over time appears inconsistent with the Veteran's documented limitations. Moreover, the August 2020 JMR found that the November 2017 VA examination was also inadequate as it did not estimate the missing range of motion findings in the prior examinations. Most recently, the Veteran was afforded a VA examination in October 2021, which found flexion to 60 degrees, which meets the criteria for a 20 percent rating. Although the examiner was not able to approximate flare-ups in the prior 2010 examinations without resorting to speculation, the examiner determined that the Veteran's flexion would be limited to 40 degrees during flare-ups. Given the inadequacies of the prior examinations, the Board finds that this examination is the most probative evidence addressing the severity of the Veteran's low back disability during the course of the appeal. Moreover, the Veteran has consistently reported that he experiences severe low back pain that affects his ability to bend, lift, kneel as well as climb up and down stairs. Accordingly, when resolving the benefit of the doubt in favor of the Veteran, a 20 percent rating is warranted from the date of award of service connection, July 16, 2009. However, based on the evidence of record, the Board finds that, when applying the General Rating Formula to the Veteran's low back disability, the evidence does not warrant a rating in excess of 20 percent at any point since the award of service connection. In this regard, the medical evidence does not show flexion limited to 30 degrees or less. Importantly, the most restrictive range of motion, which was documented at the October 2021 VA examination, showed flexion to 40 degrees during flare-ups. Further, under Correia, the most recent VA examiner found that passive range of motion testing could not be performed as it was medically contraindicated. The Veteran has reported chronic low back pain and thus, the Board recognizes the application of 38 C.F.R. §§ 4.40 and 4.45, and DeLuca, supra. However, a higher compensation is not warranted under these provisions because there is no persuasive evidence of additional functional loss due to pain, weakness, fatigue, or incoordination which would limit motion to such a degree so as to warrant a rating in excess of the 20 percent. The Board again notes that the earlier VA examinations did not adequately address whether there is additional functional impairment following repeated use or during flare-ups. At the most recent VA examination, the examiner clearly found that flexion was limited to 40 degrees during flare-ups, and to 50 degrees following repeated use over time, which is the criteria for a 20 percent rating. See Sharp v. Shulkin, 29 Vet. App. 26, 31 (2017). Again, the Board finds that this examination is probative on whether the Veteran suffers additional functional loss and to what extent. As such, the Veteran's functional impairment does not meet the criteria for a rating in excess of 20 percent. Again, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, does not itself constitute functional loss. Mitchell, 25 Vet. App. 32 (2011). Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 11; see 38 C.F.R. § 4.40. In this case, it does not. Therefore, a rating in excess of 20 percent is not warranted based on limitation of motion. Further, consideration has been given as to whether a higher disability evaluation could be assigned under Diagnostic Code 5243 for intervertebral disc syndrome. There has been no evidence showing that the Veteran has been prescribed bed rest due to incapacitating episodes having a total of at least four weeks during the past 12 months to warrant a higher rating for intervertebral disc syndrome. In this regard, the VA examinations and VA treatment records are silent with respect to any physician prescribed bedrest. Moreover, neither the Veteran nor his representative have described any periods of bedrest. Further, with respect to any associated neurological abnormalities, the Board observes that under Chavis, the Court has acknowledged that under certain circumstances, the Board has jurisdiction over separate neurological ratings awarded during the adjudication of an increased rating claim for the spine without the need of the claimant filing a specific notice of disagreement for the separately awarded neurological ratings. Chavis v. McDonough, 34 Vet. App. 1 (2021) (noting that an increased rating claim for the spine could include neurological ratings as part and parcel, but the Court declined finding that it "always" would). In this case, service connection was awarded in the May 2019 rating decision for radiculopathy of the left lower extremity as associated with the low back disability. Further, in the March 2022 rating decision, service connection was awarded for radiculopathy of the sciatic nerve and femoral nerve of the right lower extremity, and of the femoral nerve of the left lower extremity. The Veteran has not appealed these decisions. Here, the Board finds that the radiculopathy ratings are not part and parcel of the low back rating on appeal here. In this regard, neither the Veteran nor his representative have indicated a desire for the ratings to be reviewed in the context of this appeal or an expectation that the rating would be reviewed in the context of this appeal. Importantly, the AOJ issued a supplemental statement of the case (SSOC) in May 2019 and the Board remanded the low back disability claim in March 2021; and neither of these decisions indicated that the left lower extremity radiculopathy rating was on appeal. Further, in March 2022, the AOJ issued another SSOC, which showed that none of the ratings for radiculopathy were part of the appeal. Further in the June 2022, the Veteran's representative addressed the low back rating and gave no indication that the radiculopathy ratings should be considered on appeal. In sum, given the procedural context of this case, the Veteran has no reasonable expectation that the bilateral lower extremity radiculopathy ratings are procedurally part of this appeal. Further, the Veteran may still appeal the March 2022 rating decision. Accordingly, the Board will not address the separate ratings awarded for bilateral lower extremity radiculopathy as part of this decision. Additionally, with the exception of radiculopathy of the lower extremities, there has been no objective finding of neurological abnormalities associated with the Veteran's low back disability during this period. In this regard, upon examination, all of the VA examiners clearly found that the Veteran did not have any associated neurological abnormalities. Thus, the Board finds that a separate rating is not warranted for any other neurological symptoms and the Veteran's manifested symptoms associated with his low back disability are adequately contemplated in the current 20 percent rating. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. In this regard, he is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay evidence has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. The Board has considered the Veteran's lay statements in awarding a 20 percent rating from the date of award of service connection. The Board has considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected low back disability; however, the Board finds that his symptomatology has been stable throughout the course of the appeal. Therefore, assigning staged ratings for such disability during this period is not warranted. In conclusion, based on the analysis above, the Board finds that an initial 20 percent rating, but no higher, for the Veteran's low back disability is granted, effective July 16, 2009. However, the evidence persuasively weighs against a rating in excess of 20 percent during this period, benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107 (b). Entitlement to an initial higher disability rating for tinea pedis The Veteran generally contends that a higher rating for his tinea pedis is warranted. The Veteran's tinea pedis has been rated under Diagnostic Code 7813, which provides that tinea pedis should be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), or dermatitis (7806) depending on the predominant disability. VA amended the criteria for rating skin disabilities, effective 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. As in this case, 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.3d1327 (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. In this case, as the Veteran does not have disfigurement of the head, face or neck; or scars, the predominant disability is considered dermatitis and should be rated under Diagnostic Code 7806. Prior to August 13, 2018, under Diagnostic Code 7806, a 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; 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. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; 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. Or rate as disfigurement of the head, face, or neck (Diagnostic Code7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7806. For claims filed prior to August 13, 2018, 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 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). Moreover, effective August 13, 2018, a new General Rating Formula for the Skin applies to Diagnostic Code 7806. See 38 C.F.R. § 4.118. Under this formula, a 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent 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 over the past 12-month period. A 30 percent rating is assigned at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20to 40 percent of exposed areas affected; 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. Or rate as disfigurement of the head, face, or neck (Diagnostic Code7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating for the Skin for Diagnostic Codes 7806, 7809, 7813-7816, 7820-7822, and 7824. Based on the evidence of record and when resolving the benefit of the doubt in favor of the Veteran, the Board finds that a 30 percent rating under the prior rating criteria is warranted for tinea pedis from the date of award of service connection, July 16, 2009. In this regard, the Veteran was recently afforded a VA examination in May 2022 to address whether the Veteran has used treatment that was considered systemic therapy under the old criteria. The examiner noted that the Veteran had used a medication for six weeks or more, but the name was not remembered by the Veteran. The examiner observed that the Veteran used over the counter topical medication for the toenail condition; however, current specific medication name is not provided by the Veteran. Nevertheless, the Veteran's record indicated use of Triamcinolone, ketoconazole, and Lotrisone. The examiner observed that triamcinolone, ketoconazole, and Lotrisone are systemic therapy. Triamcinolone - Exhibits anti-inflammatory and immunosuppressant activity via inhibiting the phospholipase A2 enzyme on the cell membrane phospholipid layer, thereby hindering the breakdown of leukocyte lysosomal membranes and preventing the formation of arachidonic acid. Triamcinolone metabolism is primarily hepatic, and elimination is via both renal and fecal pathways. Ketoconazole - Inhibits the cytochrome P450 14-demethylase enzyme. This enzyme is responsible for inhibiting the biosynthesis of triglycerides and phospholipids by fungi. More specifically, ketoconazole inhibits the synthesis of lanosterol, a necessary precursor for ergosterol biosynthesis. Ergosterol is needed to maintain the integrity of the membrane of fungi. Ketoconazole has approval for use in the treatment of fungal infections of the skin and systemic fungal infections. Lotrisone - Contains two compounds - a synthetic corticosteroid (betamethasone dipropionate) and a synthetic antifungal agent (clotrimazole) - that target different aspects of fungal infection. Clotrimazole is a broad-spectrum, antifungal agent used for the treatment of superficial infections caused by species of pathogenic dermatophytes, yeasts, and Malassezia furfur. The mechanism of action involves inhibition of the synthesis of ergosterol, a major sterol in the fungal cell membrane. This leads to instability of the cell membrane and eventual death of the fungus. Lotrisone cream can cause reversible hypothalamic-pituitary-adrenal (HPA) axis suppression with the potential for glucocorticosteroid insufficiency. This may occur during treatment or after withdrawal of treatment. Cushing's syndrome and hyperglycemia may also occur due to the systemic effect of corticosteroids while on treatment. In sum, importantly, the most recent VA examiner clearly outlined that the Veteran had been on topical treatments at various times during the course of the appeal that were systemic in nature. Moreover, the February 2010 VA examiner noted that the Veteran's service-connected tinea pedis was treated with ketoconazole as needed for greater than six weeks. The examiner noted that the medication was topical and that it was neither a corticosteroid nor an immunosuppressive. However, the most recent examiner appeared to indicate that this medication was systemic. Further, significantly, the Veteran also used triamcinolone as needed for a period greater than six weeks in the prior 12 weeks. The examiner noted that this medication was a topical corticosteroid. The subsequent September 2010 VA examination also indicated that the Veteran had used ketoconazole for greater than six weeks. Accordingly, in light of the above, the Board finds that the medical evidence of record shows that the Veteran has used what was considered systemic therapy under the prior rating criteria for a total duration of six weeks or more warranting a 30 percent rating under the old criteria. However, the evidence persuasively weighs against finding that a higher rating is warranted. In this regard, the evidence does not show that the Veteran's tinea pedis affects at least 40 percent of the entire body affected; or at least 40 percent of exposed areas affected; or requires constant or near-constant systemic therapy. The VA examinations clearly showed that less than 5 percent of total body area was affected and less than 5 percent or none of the exposed area was affected. Moreover, the examinations that did discuss the Veteran's topical treatment both found that while use was more than six weeks, there was no finding of constant or near-constant systemic therapy. VA clinical records also do not show constant or near-constant use of such treatment. Thus, a 60 percent rating or higher is not warranted under either version of Diagnostic code 7806. The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his tinea pedis. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. The Board has considered the Veteran's lay statements in awarding a 30 percent rating from the date of award of service connection. The Board has considered whether staged ratings are appropriate for the Veteran's service-connected tinea pedis. See Fenderson, supra. However, the Board finds that his symptomatology has been stable since the award of service connection; therefore, assigning staged ratings for such disability is not warranted. Based on the analysis above, the Board finds that an initial 30 percent rating, but no higher, for the Veteran's tinea pedis is granted, effective July 16, 2009. However, the evidence persuasively weighs against a rating in excess of 30 percent during this period, benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107 (b). L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.N. Moats 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.