Citation Nr: 23020005 Decision Date: 03/31/23 Archive Date: 03/31/23 DOCKET NO. 18-49 838A DATE: March 31, 2023 ORDER New and material evidence having been received, reopening of the claim of service connection for a left wrist disorder is granted. Service connection for left foot plantar fasciitis is granted. Service connection for a right shoulder disorder is denied. An initial evaluation in excess of 10 percent for a C-section scar is denied. A compensable initial evaluation prior to January 10, 2021, and an evaluation in excess of 10 percent thereafter, for dermatitis is denied. REMANDED Entitlement to service connection for a left wrist disorder is remanded. Entitlement to service connection for a right foot disorder, to include hallux valgus, pes planus, and plantar fasciitis, is remanded. Entitlement to service connection for a left foot disorder other than plantar fasciitis, to include hallux valgus and pes planus, is remanded. Entitlement to service connection for a left shoulder disorder is remanded. Entitlement to service connection for a cervical spine disorder is remanded. Entitlement to service connection for a bilateral knee disorder is remanded. FINDINGS OF FACT 1. In a January 2004 rating decision, a Department of Veterans Affairs (VA) Regional Office (RO) denied in part a service connection claim for a left wrist disorder; this rating decision is final. 2. Evidence received since the final January 2004 rating decision relates to prior unestablished facts regarding the service connection claim for a left wrist disorder. 3. Resolving any reasonable doubt in her favor, the evidence supports that the Veteran's left foot plantar fasciitis was incurred in or caused by service. 4. The evidence does not show that the Veteran has a current right shoulder disability during the appeal period. 5. Throughout the appeal period, the Veteran has one C-section scar that is painful but not associated with underlying soft tissue damage and does not affect a total area equal to or greater than 144 square (sq.) inches (929 sq. centimeters (cm)). 6. Prior to January 10, 2021, the Veteran's dermatitis covered less than 5 percent of the total body area and none of the exposed area; no systemic therapy such as corticosteroids or other immunosuppressives drugs were used to treat her dermatitis. 7. As of January 10, 2021, the Veteran's dermatitis covered 5 percent to less than 20 percent of the total body area and none of the exposed area; no systemic therapy such as corticosteroids or other immunosuppressives drugs were used to treat her dermatitis. CONCLUSIONS OF LAW 1. The January 2004 rating decision is final; new and material evidence has been received to reopen the claim of entitlement to service connection for a left wrist disorder. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104, 3.156, 20.1103. 2. The criteria for service connection for left foot plantar fasciitis are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a right shoulder disorder are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for an initial evaluation in excess of 10 percent for a C-section scar are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.118, Diagnostic Code (DC) 7804. 5. The criteria for a compensable initial evaluation prior to January 10, 2021, and in excess of 10 percent thereafter, for dermatitis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.6, 4.7, 4.10, 4.118, DC 7806. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1993 to March 2003. This matter comes on appeal before the Board of Veterans' Appeals (Board) from September 2016 rating decisions of a VA RO. The Veteran did not request a Board hearing on this appeal. See November 2018 VA Form 9. This appeal was previously before the Board in July 2020, which reopened claims of service connection for bilateral foot disorders and remanded those reopened claims, as well as claims to reopen service connection for bilateral wrists, and service connection claims for bilateral knees, bilateral shoulders, alopecia, and cervical spine disabilities, and increased evaluation claims for her C-section scar and dermatitis. During the pendency of the appeal, the RO awarded service connection for a right wrist and alopecia disabilities in a February 2021 rating decision. As these issues were resolved by a full grant of benefits, the Board finds that these issues are no longer part of the current appeal. See 38 C.F.R. § 19.26(d); Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Accordingly, the issues on appeal, following issuance of the February 2021 Supplemental Statement of the Case, are those issues list above. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Reopening Left Wrist Claim The Board finds that new and material evidence has been received to reopen the previously denied service connection claim for a left wrist disorder. Accordingly, to this extent, the Board grants the Veteran's appeal. In support of this determination, the Board first notes that if a claim for service connection has been previously denied and the prior decision is final, the claim can be reopened only if new and material evidence is presented. 38 U.S.C. § 5108. The preliminary question of whether a previously denied claim should be reopened is a jurisdictional matter that must be addressed before the Board may consider the underlying claim on its merits. Turning to the instant case, in a January 2004 rating decision, the RO denied a service connection claim for a bilateral wrist disorder. In this decision, the RO concluded that there was no in-service incurrence or nexus linking military service to the Veteran's wrist disorder. She neither appealed this decision nor submitted any evidence within one year of notification. Accordingly, the January 2004 rating decision became final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 20.302, 20.1103; see also Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); see also Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). Generally, to reopen a previously denied, final claim, a claimant must present new and material evidence. See 38 U.S.C. § 5108. Evidence is "new" if it was not previously submitted to agency decision makers. Evidence is "material" if, when viewed by itself or with other evidence previously of record, it relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). After reviewing the evidence of record, the Board finds that new and material evidence has been received such that the application to reopen the previously denied service connection claim for a left wrist disorder must be granted. Specifically, since the last final January 2004 decision, VA obtained a January 2021 VA examination of the left wrist, which noted the Veteran's contention that her wrist strain was related to wear-and-tear from her military occupational specialty (MOS) as a transportation truck driver during service. Accordingly, the claim must be reopened at this time. See 38 C.F.R. § 3.156; Shade v. Shinseki, 24 Vet. App. 110, 117 (2010) (medical evidence which indicates that a medical opinion is warranted is sufficient to reopen a claim). Service Connection Claims Service connection will be granted for a disability resulting from a disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires: (1) the existence of a present disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). The United States Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Court recently held disability for VA purposes includes any condition that results in functional impairment of earning capacity. Martinez-Bodon v. Wilkie, 38 Vet. App. 393 (2020). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). A lay person is competent to report on the onset and reoccurrence of current symptomatology. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board must determine on a case-by-case basis whether a veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a claimant prevailing in either event. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The claimant is entitled to the benefit of the doubt when there is an "approximate" (meaning nearly equal) balance of positive and negative evidence regarding any material determination. See Lynch v. McDonough, 999 F.3d 1391 (2021); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Left Foot Plantar Fasciitis An April 2003 claims application reflects the Veteran's report that her left foot disorder began and that she was treated in 2002. In a November 2018 VA Form 9, she reported struggling with plantar fasciitis since service. Turning to the evidence in this case, a December 2002 service treatment record (STR) reflects a complaint of pain in the arch of the left foot from a road march two days prior, and an assessment of mild plantar fasciitis. February 2003 separation examination reports reflect a normal clinical evaluation of the feet and the Veteran's denial of foot trouble. An October 2018 private treatment record reflects a complaint of pain in both heels, which she had been having for over three years. She was assessed with bilateral plantar fasciitis, bilateral pes valgo planus deformities, right mild hallux abducto valgus deformity, and bilateral pain in the heels. A January 2021 VA examination report reflects review of the Veteran's claims file and diagnoses of bilateral pes planus, bilateral plantar fasciitis, and bilateral hallux valgus. The Veteran reported that her feet began hurting during service after wearing boots and marching. She was an athlete in school and never had issues with her feet. She reported complaining in service and being diagnosed with plantar fasciitis. Current symptoms included pain, numbness, and tingling in the morning after waking up, and pain with activity and walking and standing for a long time. The examiner opined that the Veteran's left foot plantar fasciitis was at least as likely as not incurred in or caused by service. After review of all of the evidence of record, lay and medical, the Board finds that the evidence demonstrates that the Veteran's left foot plantar fasciitis is related to service. As an initial matter, the Board finds that the Veteran has a current diagnosis of left foot plantar fasciitis. See January 2021 VA examination report. Next, as noted above, the Veteran's STRs reflect a complaint of left foot pain due to a road march and an assessment of mild plantar fasciitis during service. Additionally, the Veteran reported that her feet began to hurt during service after wearing boots and marching. Accordingly, the first two elements of service connection have been met in this case. Turning to the nexus element, the January 2021 VA examiner opined that the Veteran's left foot plantar fasciitis was at least as likely as not incurred in or caused by service. The Board acknowledges that there was very little rationale provided for this positive opinion. However, there is no evidence conflicting with this positive opinion. As the sole nexus evidence in this case weighs in favor of awarding service connection, service connection for left foot plantar fasciitis must be granted at this time based on the evidence of record. See 38 C.F.R. § 3.303; Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (it is not permissible to undertake further development if the sole purpose is to obtain evidence against an appellant's claim). In so reaching the above conclusions, the Board has appropriately applied the benefit of the doubt doctrine in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Right Shoulder Disorder In her September 2017 Notice of Disagreement (NOD), the Veteran contended that this issue occurred during service. As an initial matter, the evidence does not reflect a current right shoulder disability. The Board acknowledges private treatment records in April 2013 and May 2013 referring to shoulder pain, specifically that the Veteran went to the Emergency Room for shoulder and neck pain in April 2013, which was improved by the end of May 2013. Additionally, in her 2016 claim, the Veteran indicated that she was filing a claim for "bilateral shoulder pain." Based on the private records from 2013-demonstrating a possible right shoulder disability prior to the period on appeal-and the Veteran's sympathetically-read lay statements indicating bilateral shoulder pain, the Board remand the case for a VA examination. The Veteran underwent a VA examination of her shoulders in January 2021. At that time, the Veteran was diagnosed with left shoulder strain and tendonitis. During the examination, the Veteran's right shoulder had full, normal range of motion on initial testing, as well as after repetitive/repeated use testing. Muscle strength, reflex and neurological testing of the right shoulder were all normal, and the Veteran specifically denied any right shoulder symptoms, including pain, weakness, instability/dislocation, etc., as well as any episodes of flare-ups. The Board reflects that although asked for additional treatment records, the Veteran has not indicated any right shoulder treatment either at VA or with a private provider. Based on the evidence of record, the Board finds that a current disability of the right shoulder is not shown at any time during the appeal period. Initially, the Board reflects that the January 2021 examination does not disclose any diagnosed disability of the right shoulder, nor is there any contention or allegations of symptomatology that results in a functional impairment in earning capacity on that examination. Moreover, the evidence taken together during the appeal period appears to contemplate that the Veteran may have had right shoulder pain and issues during military service and that such occurred during service, but that although those symptoms may have been present during service there is no evidence of any chronic disability or residual functional impairment from that pain that may have been present during service. Or, in other words, although there may have been right shoulder pain during service, such appears to have resolved and there is no present, chronic disability as a result of such pain experienced during service. To this end, the Board acknowledges that the Veteran's statements in her 2016 claim regarding bilateral shoulder pain, as well as the April 2013 private treatment record referring to shoulder and neck pain, which could be interpreted as bilateral shoulder pain. Nevertheless, in assessing whether a current disability exists at this time, the Board does not find any evidence of any complaints of right shoulder symptoms at VA or with a private provider at any time during the appeal period-to include any symptomatology that may not rise to the level of a diagnosed medical disorder but nevertheless result in a functional impairment of earning capacity-or any diagnosed right shoulder disorder. Specifically, any potential evidence during the appeal period regarding any right shoulder pain appears to indicate that such pain was not suffered at any time during the appeal period but existed in the past and had resolved. The Veteran has not provided any evidence during the appeal period that she currently suffers from a right shoulder disorder or any symptomatology of the right shoulder that results in a functional impairment in earning capacity. Insofar as the 2016 claim can be construed as evidence of right shoulder pain, the Board finds those statements to be not credible with regards to the presence of any right shoulder pain or functional impairment at that time, as noted by her statements in the Notice of Disagreement, the lack of any submission of medical evidence or complaints or treatment for any right shoulder problems, as well as her denial of any right shoulder issues or problems during the January 2021 VA examination. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care); Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the Veteran). In short, the evidence of record at this time-when read as sympathetically as possible-does not demonstrate any currently-diagnosed right shoulder disorder or any complaints of symptomatology of the right shoulder that cause a functional impairment in earning capacity at any time during the appeal period. Consequently, the Board is compelled at this time to find that the record does not demonstrate a current right shoulder disability exists and her claim for service connection for a right shoulder disorder must be denied at this time. See 38 C.F.R. § 3.303; McClain v. Nicholson, 21 Vet. App. 319 (2007) (the requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim . . . even though the disability resolves prior to the Secretary's adjudication of the claim."); Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018); Brammer v. Derwinski, 3 Vet. App. 223 (1995) (Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability). Because the Board does not find that a current disability is shown, the Board does not otherwise need to reach a decision on or otherwise discuss any element of the Veteran's service connection claim. The Board does not otherwise intimate any opinion regarding either the in-service or nexus elements of the right shoulder claim herein. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the evidence is against the Veteran's claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Increased Evaluation Claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations 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. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under various diagnoses, and the evaluation of the same manifestation under different diagnoses, are to be avoided. 38 C.F.R. § 4.14. Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119 (1999). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Where a veteran is diagnosed with multiple disabilities of the same body part/system, and it is unclear from the record which symptoms are attributable to each distinct disability, the Board is precluded from differentiating between the symptomatology and the disabilities. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). C-Section Scar In her September 2017 NOD, the Veteran disagreed with the rating assigned for her C-section scar. The Veteran is in receipt of an initial 10 percent evaluation for a C-section scar under DC 7804 as of June 9, 2016. DC 7800 evaluates burn scars of the head, face, and neck; scars of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. As such, DC 7800 is not applicable. Likewise, DC 7801 evaluates burn scars or scars due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage. The evidence as discussed below does not reflect underlying soft tissue damage. Therefore, DC 7801 is not applicable. DC 7802 evaluates burn scars or scars due to other causes not of the head, face, or neck that are not associated with underlying soft tissue damage. A 10 percent rating is assigned if the scar(s) covers an area or areas of 144 sq. inches (929 sq. cm). See 38 C.F.R. § 4.118, DC 7802. DC 7804 allows for compensable ratings for unstable or painful scars. 38 C.F.R. § 4.118. A 10 percent rating is warranted for one or two scars that are unstable or painful. A 20 percent rating is warranted for three or four scars that are unstable or painful, with a maximum 30 percent rating warranted for five or more scars that are unstable or painful. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. See 38 C.F.R. § 4.118, DC 7804, Note (1). If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. See 38 C.F.R. § 4.118, DC 7804, Note (2). Based on review of the evidence, lay and medical, the Board finds that an initial evaluation in excess of 10 percent is not warranted for the Veteran's C-section scar. Turning to the evidence in this case, a September 2016 VA examination report reflects review of the Veteran's claims file and a diagnosis of a C-section scar. The Veteran reported pain to the left side of the scar with movement like trying to get up. She had one painful scar. She did not have any scars that were unstable with frequent loss of covering of skin over the scar. She did not have any scars that were both painful and unstable. The scar was on the lower abdomen and was superficial and nonlinear, measuring 17 cm x 0.5 cm with an approximate total area of 8.5 sq. cm. A September 2016 VA treatment record reflects that the Veteran reported pain when the left side of the C-section scar was pressed. A January 2021 VA examination report reflects that the Veteran had a C-section in May 2002, and that the resulting scar was painful with discomfort. The course of the scar had stayed the same since onset with pain and discomfort at the scar site. She had one scar that was tender to touch and numb. She did not have any scar with frequent loss of covering of skin over the scar, or due to burns. She had a horizontal scar in the lower abdomen area that measured 8.2 cm x 0.3 cm. It was tender to palpation. It had no underlying tissue damage and measured approximately a total area of 2.46 sq. cm. The evidence reflects that the Veteran has one painful scar that measured 8.5 sq. cm in September 2016, but at 2.46 sq. cm most recently in January 2021. There is also no evidence demonstrating that it was associated with underlying soft tissue damage. As such, a 10 percent evaluation is appropriate as she has one painful scar that does not cover an area of 929 sq. cm or greater. Accordingly, an initial evaluation in excess of 10 percent for a C-section scar is denied. See 38 C.F.R. §§ 4.7, 4.118, DC 7804. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Dermatitis In her September 2017 NOD, the Veteran disagreed with the rating assigned for her dermatitis. The Veteran is in receipt of a noncompensable initial evaluation for dermatitis prior to January 10, 2021, and an evaluation of 10 percent thereafter under DC 7806. Effective August 13, 2018, VA's Schedule, 38 C.F.R. Part 4, was amended with regard to rating skin disorders. Fed. Reg. 32664 (July 13, 2018) (codified at 38 C.F.R. § 4.118). When a law or regulation changes during the course of a claim or an appeal, the version more favorable to the veteran will apply, to the extent permitted by any stated effective date in the amendment in question. VAOPGCPREC 3- 2000; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The recently revised skin regulations do not provide for retroactive application; thus, the amendments may be applied as of, but not prior to, August 13, 2018. Hence, VA has made clear that its intent is that the 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. For applications filed on or after the effective date, only the new criteria will be applied. As the Veteran's claim was pending prior to August 13, 2018, the Board will consider entitlement under the prior regulations as well as the updated regulations for the period beginning August 13, 2018, applying the most favorable criteria for the Veteran. Prior to August 13, 2018, under 38 C.F.R. § 4.118, DC 7806, for dermatitis or eczema, a maximum 60 percent rating is warranted where the skin disability covers 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 is required during the past 12-month period. A 30percent rating is warranted where the skin disability covers 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 is required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 10 percent rating is warranted where the skin disability covers at least 5 percent, but less than 20 percent, of the entire body, at least 5 percent, but less than 20 percent, of the exposed areas affected; or intermittent systematic 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 noncompensable rating is warranted where the skin disability covers less than 5 percent of the entire body or exposed areas affected; and no more than topical therapy is required during the past 12-month period. Under the schedular criteria in effect beginning August 13, 2018, 38 C.F.R. § 4.118, DC 7806 states that dermatitis or eczema should be evaluated under the General Rating Formula for the Skin. The General Rating Formula for the Skin for DCs 7806, 7809, 7813-7816, 7820-7822, and 7824 provides that a maximum 60 percent rating is warranted where there are at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy involving, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. A 30 percent rating is warranted where there are at least one of the following: characteristic lesions involving 20 to 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. A 10 percent rating is warranted for at least one of the following: characteristic lesions involving at least 5 percent but less than 20 percent, of the entire body affected; at least 5 percent, but less than 20 percent, of the exposed areas affected; or intermittent systematic 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 noncompensable rating is warranted where there is no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected, or characteristic lesions involving less than 5 percent of the exposed areas affected. A determination of which criteria are more beneficial to the Veteran may depend upon how the terms "topical therapy" and "systemic therapy" are defined. Under the criteria effective from August 13, 2018, for the purposes of 38 C.F.R. § 4.118, systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin. Two or more skin conditions may be combined in accordance with § 4.25 only if separate areas of the skin are involved. If two or more skin conditions involve the same area of skin, then only the highest evaluation shall be used. Pre-2018 regulations do not define these terms and applicable cases indicate that this determination must be made on a case-by-case basis with the examiner providing a complete rationale for the therapy classification. Warren v. McDonald, 28 Vet. App. 194 (2016); Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). The Federal Circuit also held that a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, and the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. In Burton v. Wilkie, 30 Vet. App. 286 (2018), the Court held that there are at least two other potential ways of showing that a topical corticosteroid is systemic: the method by which the treatment works and its side effects. The Board must thus consider two questions, in any order, when determining whether topical treatment for a skin disorder constitutes "systemic therapy such as corticosteroids or other immunosuppressive drugs" under the pre-August 13, 2018, version of DC 7806: a) whether the topical treatment operates by affecting the body as a whole in treating a veteran's skin condition; and b) whether the given treatment is "like" a corticosteroid or other immunosuppressive drug. Only the second question needs to be considered if the treatment is clearly systemic. Turning to the evidence in this case, a September 2016 VA examination report reflects review of the Veteran's claims file and a diagnosis of dermatitis since the entrance examination. Although she reported having dermatitis under the breasts and being treated for dermatitis on the face, scalp, and under the breasts during service, she reported that she no longer had problems with dermatitis on the face and scalp, but continued to have constant dermatitis under the breasts, for which she used 2 percent over-the-counter hydrocortisone. The Veteran used topical over-the-counter hydrocortisone for six weeks or more, but not constantly, in the past 12 months. On examination, she had dermatitis on less than 5 percent of the total body area and on none of the exposed area. A January 10, 2021, VA examination report reflects review of the Veteran's claims file and a diagnosis of dermatitis since 1993, which had progressed or worsened. The Veteran reported only an unnamed topical treatment for alopecia; no corticosteroids or other immunosuppressive medications were reported or noted for her dermatitis. Her dermatitis covered 5 percent to less than 20 percent of the total body area, and none of the exposed area. She had dermatitis on the upper and lower extremities, which appeared as dry and flaky skin. Based on the lay and medical evidence of record the Board finds that the Veteran's dermatitis does not more nearly approximate the level of severity contemplated by a 10 percent rating prior to January 10, 2021, or a 30 percent rating thereafter. Prior to January 10, 2021, the Veteran's dermatitis covered less than 5 percent of her total body area and none of the exposed area. However, she used a topical over-the-counter hydrocortisone for six weeks or more, but not constantly, in the past 12 months. See September 2016 VA examination report. Given that less than 5 percent of the Veteran's total body area was involved in the topical treatment, the Board does not find that the topical treatment operated by affecting the body as a whole. Thus, the Board finds the Veteran's topical treatment was not systemic. As such, under both versions of DC 7806, a noncompensable initial evaluation is appropriate prior to January 10, 2021, as the dermatitis covers less than 5 percent of the entire body or exposed areas affected, and no more than topical therapy is required during the past 12-month period. As of January 10, 2021, the Veteran's dermatitis covered 5 percent to less than 20 percent of the total body area and none of the exposed area. She did not use any corticosteroids or other immunosuppressive medication for dermatitis at that time. Therefore, the evidence does not reflect that the dermatitis covered enough of the total body or exposed areas, or that systemic therapy was required for a total duration of six weeks or more, but not constantly, over the past 12-month period. Accordingly, an evaluation in excess of 10 percent is not warranted under either version of the DC as of January 10, 2021. The Board acknowledges that the Veteran's dermatitis did not worsen to warrant a 10 percent rating exactly on January 10, 2021. However, this is the first evidence demonstrating that her dermatitis covered 5 percent to less than 20 percent of the total body area. Therefore, it is the first evidence supporting an increase in severity that warrants an increased evaluation. Given the evidence summarized above, the Board does not find entitlement to a compensable initial evaluation prior to January 10, 2021, or an evaluation in excess of 10 percent thereafter for dermatitis is warranted under DC 7806. Accordingly, the claim for higher ratings for dermatitis must be denied. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, supra. REASONS FOR REMAND The evidence reflects current diagnoses of a left wrist strain; right foot pes planus, plantar fasciitis, and hallux valgus; left foot pes planus and hallux valgus; left shoulder strain and tendinitis; cervical strain; and bilateral knee strain. See January 2021 VA examination reports. At that time of the examinations, the Veteran contended that her wrist disorder was due to wear-and-tear from her job during service. Specifically, she was a transportation truck driver, which required constant use of the wrists when driving, which reportedly caused weakness. Her DD 214 confirms an MOS of a motor transportation operator. Additionally, she reported that her feet began hurting during service after wearing boots and marching. In fact, a December 2002 STR reflects a complaint of pain in the left foot due to a road march and an assessment of plantar fasciitis for the left foot only; there was no reference to the right foot at that time. She also reported an onset of cervical symptoms during service in 1995 to 1996, and contended that both her cervical spine and bilateral knee disorders were due to wear-and-tear over time from carrying a ruck sack and doing physical training marches. Moreover, she stated that she noticed issues with her shoulder after receiving anthrax injections in 1997 or 1998, and contended wear-and-tear of the shoulder over time. The January 2021 VA examiner opined that the Veteran's left wrist strain and bilateral knee strain were less likely than not caused by service as the record was silent for any left wrist and bilateral knee complaints or injury. She also opined that the Veteran's right foot disorder; left foot diagnoses other than plantar fasciitis, specifically hallux valgus and pes planus; and left shoulder disorder were less likely than not incurred in or caused by service as there were no complaints during or following separation from service. Additionally, she opined that the Veteran's cervical spine disorder was less likely than not incurred in or caused by service despite an October 1999 complaint of neck pain as there was no evidence of continuation of treatment or complaints. This rationale is deficient because it is based solely on the absence of documentation in the record and does not take into account the Veteran's reports of symptoms and history (even if recorded in the course of the examination). See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (examination was inadequate where the examiner did not comment on the appellant's report of in-service injury and instead relied on the absence of evidence in the service medical records to provide a negative opinion). In other words, the absence of treatment or symptoms in service is not necessarily fatal to the claims for service connection. Additionally, the examiner did not address the Veteran's contentions regarding the impact of her MOS on her left wrist, the effects of wearing boots and marching on her feet, the effects of anthrax injections and wear-and-tear on her left shoulder over time, and the result of carrying a ruck sack and doing physical training marches over time on her cervical spine and knees. Accordingly, a new VA medical opinion should be obtained in order to more adequately evaluate the nature and etiology of the Veteran's left wrist, right foot, left foot (other than plantar fasciitis), left shoulder, cervical spine, and bilateral knee disorders. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005) (a VA examination must be based on an accurate factual premise). The matters are REMANDED for the following action: 1. Obtain a VA addendum opinion from an appropriate qualified examiner in order to evaluate the nature and etiology of the Veteran's claimed left wrist disorder. The need for any additional examinations or telephonic interviews is left to the discretion of the examiner. If any examination is scheduled and the Veteran fails to report, however, the examiner must still render an opinion as requested below based on review of the claims file. Based upon review of all pertinent documents in the Veteran's claims file, including medical treatment and examination records, lay statements, and examination results, the examiner must opine whether the Veteran's left wrist disorder, to include a left wrist strain, began during, was caused by, or is otherwise related to military service. In so addressing, the examiner must address the Veteran's contentions that her left wrist disorder was caused by or related to her MOS as a transportation truck driver, which required constant use of her wrists when driving. The examiner should additionally address any lay statements of record regarding onset of symptomatology as well as any statements regarding continuity of symptomatology since onset and/or since discharge from service. A complete rationale should be provided for each opinion provided. 2. Obtain a VA addendum opinion from an appropriate qualified examiner in order to evaluate the nature and etiology of the Veteran's claimed right foot and left foot disorders (other than plantar fasciitis). The need for any additional examinations or telephonic interviews is left to the discretion of the examiner. If any examination is scheduled and the Veteran fails to report, however, the examiner must still render an opinion as requested below based on review of the claims file. Based upon review of all pertinent documents in the Veteran's claims file, including medical treatment and examination records, lay statements, and examination results, the examiner must opine whether any right foot disorders (pes planus, plantar fasciitis, and hallux valgus) and whether any left foot disorders other than plantar fasciitis (pes planus and hallux valgus) began during service or are otherwise the result of military service. In so addressing, the examiner must address the Veteran's contentions that her feet began hurting during service after wearing boots and marching and had continued since. Moreover, the examiner should additionally address any lay statements of record regarding onset of symptomatology as well as any statements regarding continuity of symptomatology since onset and/or since discharge from service. For any of those disorders that the examiner finds are not directly related to military service, the examiner must then opine whether such disorders of the bilateral feet are (a) caused by, or (b) aggravated (i.e., worsened) by the Veteran's service-connected left foot plantar fasciitis, to include any functional impairment due to pain, abnormal weightbearing, or altered gait as a result of that disability. The examiner is reminded that both prongs (a) and (b) must be addressed and that separate and distinct opinions with supporting rationales must be provided for each prong. A complete rationale should be provided for each opinion provided. 3. Obtain a VA addendum opinion from an appropriate qualified examiner in order to evaluate the nature and etiology of the Veteran's claimed left shoulder disorder. The need for any additional examinations or telephonic interviews is left to the discretion of the examiner. If any examination is scheduled and the Veteran fails to report, however, the examiner must still render an opinion as requested below based on review of the claims file. Based upon review of all pertinent documents in the Veteran's claims file, including medical treatment and examination records, lay statements, and examination results, the examiner must opine whether the Veteran's left shoulder disorder, to include a left shoulder strain and tendinitis, began during service, or is otherwise related to military service. In so addressing, the examiner must address the Veteran's report that she noticed her "shoulder issues" after receiving anthrax injections in 1997 or 1998, and contentions that her left shoulder disorder was a result of wear-and-tear over time. She also noted at her VA wrist examination that her MOS was a transportation truck driver which she contended affected her upper extremities, specifically her wrists; the examiner should also discuss the Veteran's MOS as to her left shoulder as well. The examiner should additionally address any lay statements of record regarding onset of symptomatology as well as any statements regarding continuity of symptomatology since onset and/or since discharge from service. A complete rationale should be provided for each opinion provided. 4. Obtain a VA addendum opinion from an appropriate qualified examiner in order to evaluate the nature and etiology of the Veteran's claimed cervical spine disorder. The need for any additional examinations or telephonic interviews is left to the discretion of the examiner. If any examination is scheduled and the Veteran fails to report, however, the examiner must still render an opinion as requested below based on review of the claims file. Based upon review of all pertinent documents in the Veteran's claims file, including medical treatment and examination records, lay statements, and examination results, the examiner must opine whether the Veteran's cervical spine disorder, to include a cervical strain, began during service, or is otherwise related to military service. In so addressing, the examiner must address the Veteran's contentions that her cervical spine disorder was due to wear-and-tear over time from carrying the ruck sack and doing physical training marches. The examiner should additionally address any lay statements of record regarding onset of symptomatology as well as any statements regarding continuity of symptomatology since onset and/or since discharge from service. A complete rationale should be provided for each opinion provided. 5. Obtain a VA addendum opinion from an appropriate qualified examiner in order to evaluate the nature and etiology of the Veteran's claimed bilateral knee disorder. The need for any additional examinations or telephonic interviews is left to the discretion of the examiner. If any examination is scheduled and the Veteran fails to report, however, the examiner must still render an opinion as requested below based on review of the claims file. Based upon review of all pertinent documents in the Veteran's claims file, including medical treatment and examination records, lay statements, and examination results, the examiner must opine whether the Veteran's bilateral knee disorder, to include bilateral knee strain, began during service, or is otherwise related to military service. In so addressing, the examiner must address the Veteran's contentions that her bilateral knee disorder was due to wear-and-tear over time from carrying the ruck sack and doing physical training marches. The examiner should additionally address any lay statements of record regarding onset of symptomatology as well as any statements regarding continuity of symptomatology since onset and/or since discharge from service. A complete rationale should be provided for each opinion provided. MARTIN B. PETERS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Lee, Jane R. 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.