Citation Nr: 25003392 Decision Date: 03/11/25 Archive Date: 03/11/25 DOCKET NO. 19-19 180 DATE: March 11, 2025 REMANDED Entitlement to service connection for a skin disorder, to include as due to a qualifying chronic disability under 38 C.F.R. § 3.317 and/or as secondary to service-connected other specified trauma or stressor-related disorder, is remanded. REASONS FOR REMAND The Veteran had active duty service in the United States Army from January 1989 to June 1991. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a November 2016 rating decision. In a September 2019 decision, the Board remanded the case to the agency of original jurisdiction (AOJ) for additional development and adjudication. In a subsequent April 2023 decision, the Board denied entitlement to service connection for a skin condition. The Veteran appealed that determination to the United States Court of Appeals for Veterans Claims (Court). In a January 2024 Order, the Court vacated the Board's decision and remanded the matter to the Board for development consistent with the parties' Joint Motion for Remand (Joint Motion). The Board later issued an April 2024 decision that remanded the case to the AOJ. The case has since been returned to the Board for appellate review. 1. Entitlement to service connection for a skin disorder, to include as due to a qualifying chronic disability under 38 C.F.R. § 3.317 and/or as secondary to service-connected other specified trauma or stressor-related disorder, is remanded. In response to the April 2024 Board remand, the AOJ obtained June 2024 VA medical opinions and a January 2025 VA addendum opinion that addressed whether the Veteran's diagnosed chronic urticaria is directly related to his active duty service, to include his participation in a toxic exposure risk activity (TERA) therein. Regarding the Board's directive to address the Veteran's reports that he has experienced itching skin since taking Pyridostigmine Bromide while stationed in Southwest Asia, the examiner stated in the January 2025 addendum opinion that it was less likely than not that the Veteran's current complaint of itching is due to a medication that was discontinued more than 20 years ago. The examiner explained that although itching was a common side effect of Pyridostigmine Bromide, the itching stopped at discontinuation and there were no studies to support that it would continue after discontinuing the medication. Although this opinion addressed the likelihood that the current urticaria is attributable to the in-service use of Pyridostigmine Bromide, the Board does not find that it adequately addressed whether the Veteran's current skin disorder manifested during service. The same examiner provided a negative nexus opinion addressing direct service connection in June 2024. However, the rationale only stated that the service treatment records (STRs) did not support urticaria in service. The Board finds that this explanation, without more, is inadequate. An additional VA medical opinion should therefore be obtained on remand. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board also notes that the previously obtained VA opinions related to the claimed skin disorder have not yet adequately addressed whether the Veteran's diagnosed chronic urticaria is a medically unexplained chronic multisymptom illness (MUCMI) associated with his Persian Gulf service. A January 2023 VA Memorandum stated that the Department of Defense had provided the Department of Veterans Affairs (VA) with authoritative data verifying that the Veteran met the definition of a "Persian Gulf Veteran" as specified by 38 U.S.C. § 1117. This conclusion is also consistent with the information in the Veteran's DD 214 documenting that the Veteran had service in Southwest Asia from September 1990 to April 1991. In January 2016, a VA examiner completed relevant Disability Benefits Questionnaires (DBQs) specific to a Gulf War General Medical Examination and Skin Diseases. In the Gulf War General Medical Examination, the examiner noted that from the conditions identified and for which Questionnaires were completed, there were not any diagnosed illnesses for which no etiology was established. The examiner did not include a rationale specific to the claimed skin disorder. Moreover, a MUCMI is a diagnosed illness without conclusive etiology OR pathophysiology. Stewart v. Wilkie, 30 Vet. App. 383, 389 (2018); 38 C.F.R. § 3.317. In the Skin Diseases DBQ, the examiner noted a diagnosis of itching of skin and stated under the remarks that it was not likely that the Veteran had any of the types of Gulf War pattern of disabling illness or conditions; adding that there are no known pathologic conditions of the skin, and the skin examination was normal. However, the examiner was unable to consider the diagnosis of chronic urticaria that was later documented in a December 2019 VA examination. The Board has also considered the June 2024 VA medical opinions in which the examiner answered "unknown" in response to a request to provide an opinion regarding the nature and etiology of the Veteran's skin condition. However, further clarification is needed regarding whether the Veteran's diagnosed skin disorder is a MUCMI as the examiner proceeded to state that the cause of chronic urticaria was often unknown while also identifying positive possible causes of the disorder. As 38 C.F.R. § 3.317(b) provides that signs or symptoms of a MUCMI may include signs or symptoms involving the skin, the opinion provided on remand should also address whether the chronic urticaria is a MUCMI where either the etiology or pathophysiology of the disorder is inconclusive. The Board also acknowledges that the January 2016 VA examiner stated under the remarks of the Skin Diseases DBQ that the Veteran reported having seasonal allergies since childhood, and skin itching can be associated with the body's allergy cascade mechanism. However, the examiner also noted under the medical history section of this report that the Veteran reported that onset of his skin itching was in September 1991. The Veteran's skin was also marked as normal in the October 1987 enlistment examination, and the Veteran was noted to be qualified during subsequent physical inspections conducted in December 1988 and January 1989 with no skin defects indicated. In addition, the Veteran denied having a history of skin diseases in the October 1987 Report of Medical History. Under these circumstances, the Board does not find that the record has raised the question of whether the Veteran's current skin disorder preexisted service such that it is necessary for the opinions obtained on remand to address the presumption of soundness. Lastly, the Board finds that the examiner's statements in the June 2024 VA medical opinions raised the theory that the Veteran's chronic urticaria is secondary to his service-connected other specified trauma or stressor-related disorder. The examiner noted that positive possible causes of chronic urticaria include stress. As this statement suggests that the Veteran's chronic urticaria may be associated with his psychiatric disability, the Board finds that the foregoing evidence meets the low threshold as set forth in McLendon to secure a VA medical opinion on remand that addresses this theory of secondary service connection. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board notes that service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a), (b). The Board notes that in Spicer v. McDonough, 61 F.4th 1360, 1366 (Fed. Cir. 2023), the Federal Circuit held, "To the extent that the VA also applied 38 C.F.R. § 3.310(b) to reject Mr. Spicer's theory of compensation, that regulation is unlawful as inconsistent with 38 U.S.C. § 1110." Although the Federal Circuit did not explain its reason for this portion of its holding, the reasons given in the opinion dissenting from the Court's contrary conclusion, Spicer v. McDonough, 34 Vet. App. 310, 315 (2021) (Allen, J., dissenting), reflect the view that the language precluding compensation for any increase "not due to the natural progress of the nonservice-connected disease" conflicts with the broad causation requirement in 38 U.S.C. § 1110. Thus, the Board in its remand instructions will not reference this language. The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any health care providers who have provided treatment for his skin disorder. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA medical records, to include records dated since December 2024. 2. After completing the preceding development in paragraph 1, obtain a VA medical opinion from a qualified examiner that addresses the Veteran's service connection claim for a skin disorder. The claims file must be made available to the examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. A clear explanation for all opinions based on specific facts for the case as well as relevant medical principles is needed. If an examination is deemed necessary, one must be provided. The Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. Regarding the Veteran's diagnosed chronic urticaria, the examiner should provide an opinion as to the following questions: (a) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the disorder manifested during, or is otherwise related to, the Veteran's active duty service? (b) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the disorder is a medically unexplained chronic multisymptom illness without conclusive pathophysiology OR etiology? In providing an opinion, the examiner should address the statements from the June 2024 VA medical opinion indicating that the cause of chronic urticaria is often unknown. (c) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the disorder was caused or aggravated by the Veteran's service-connected other specified trauma or stressor-related disorder? If aggravation is found, the clinician should identify, to the extent possible, the baseline level of the disability prior to the aggravation. 3. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.C. Spragins, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.