BVA9503669 DOCKET NO. 93-10 702 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for a psychiatric disorder, variously diagnosed, as secondary to service-connected multiple sebaceous cysts with repeated infection abscess formation. 2. Entitlement to an increased evaluation for multiple sebaceous cysts with repeated infection abscess formation, currently evaluated as 50 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Ronald R. Bosch, Counsel INTRODUCTION The veteran served on active duty from March 1951 to April 1954 and from December 1954 to March 1956. In November 1979, a rating decision was issued showing chronic anxiety, tension state, as not service-connected. The veteran was never notified of the denial of entitlement to service connection for a psychiatric disorder. The Board is accordingly adjudicating the current claim of entitlement to service connection for a psychiatric disorder, variously diagnosed, as secondary to service-connected multiple sebaceous cysts with repeated infection abscess formation on a de novo basis. This appeal arose from a May 1990 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. The RO denied entitlement to an increased evaluation for multiple sebaceous cysts with repeated infection abscess formation. In a rating decision issued in October 1991, the RO denied entitlement to service connection for chronic anxiety and depression as secondary to service-connected multiple sebaceous cysts with repeated infection abscess formation. The above determination was affirmed by the RO in December 1992. The case has been forwarded to the Board of Veterans' Appeals (Board) for appellate review. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that he has developed a chronic psychiatric disorder as the result of his service-connected dermatologic disorder, thereby warranting a grant of service connection on a secondary basis. He further contends that his dermatologic disorder is more disabling than currently evaluated, thereby warranting entitlement to an increased evaluation. He argues that in view of the fact that surgery is contraindicated for other disorders due to the nature and extent of his skin disability, a higher evaluation should be granted. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against grants of entitlement to service connection for a psychiatric disorder, variously diagnosed, as secondary to service-connected sebaceous cysts with repeated infection abscess formation; and an increased evaluation for sebaceous cysts with repeated infection abscess formation. FINDINGS OF FACT 1. A psychiatric disorder, variously diagnosed, is not shown to be causally related to service-connected sebaceous cysts with repeated infection abscess formation. 2. Multiple sebaceous cysts with repeated infection abscess formation is productive of dermatologic impairment compatible with not more than ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptional repugnance. CONCLUSIONS OF LAW 1. A psychiatric disorder, variously diagnosed, is not proximately due to or the result of service-connected multiple sebaceous cysts with repeated infection abscess formation. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.310(a) (1994). 2. The criteria for an evaluation in excess of 50 percent for multiple sebaceous cysts with repeated infection abscess formation have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321(b)(1), 4.7, 4.20, 4.118, Diagnostic Code 7806 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board finds that the veteran's claims are well grounded within the meaning of 38 U.S.C.A. § 5107(a), in that it is at least plausible that his dermatologic disorder has caused the development of a psychiatric disorder and has increased in severity. The Board is satisfied that all relevant facts have been properly developed, and that no further assistance to the veteran is required in order to comply with 38 U.S.C.A. § 5107(a). I. Entitlement to service connection for a psychiatric disorder, variously diagnosed, as secondary to service-connected multiple sebaceous cysts with repeated infection abscess formation. Service connection may be granted for a disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). The veteran contends that he developed a psychiatric disorder as secondary to his service-connected dermatologic disability. However, the evidentiary record in this regard is not supportive. In this regard, the Board observes that the veteran reported he was nervous and distressed when examined by VA in May 1973. A psychiatric disorder was initially diagnosed by VA following an examination conducted in September 1979. The veteran was diagnosed with chronic anxiety, tension state. The VA examiner did not related the psychiatric disorder to the veteran's dermatologic disability. An August 1991 VA psychiatric examination concluded in diagnoses of dysthymia, and generalized anxiety disorder. The above diagnoses were again noted to account for the claimant's psychiatric symptomatology when he was examined by VA in September 1992. The examiner stated he did not believe that the veteran's psychiatric condition was secondary to his skin disease. The observes that nervous manifestations are contemplated in the veteran's current 50 percent evaluation for his service-connected dermatologic disorder under diagnostic code 7806 of the VA Schedule for Rating Disabilities. However, the evidentiary record has not shown that a separate, distinct chronic acquired psychiatric disorder has developed secondary to his service connected dermatologic disability. There is no competent medical evidence of record linking the veteran's variously diagnosed psychiatric disorder to his service-connected multiple sebaceous cysts with repeated infection abscess formation. Grottveit v. Brown, 5 Vet.App. 91, 92 (1993). As the veteran is not shown to have a psychiatric disorder, variously classified, as secondary to his service- connected multiple sebaceous cysts with repeated infection abscess formation, the Board finds no basis upon which to predicate a grant of entitlement to service connection. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.310(a). II. Entitlement to an increased evaluation for multiple sebaceous cysts with repeated infection abscess formation, currently evaluated as 50 percent disabling. In accordance with 38 C.F.R. § 4.1 and 4.2, and Schafrath v. Derwinski, 1 Vet.App. 589 (1991), the Board has reviewed the service medical records and all other evidence of record pertaining to the history of the appellant's dermatologic disorder. The Board has found nothing in the historical record which would lead to a conclusion that the current evidence of record is inadequate for rating purposes. A review of the service medical records discloses that in 1953 and 1954 the veteran received treatment for ischiorectal abscesses and in the groin region. The appellant was hospitalized by VA during May and June 1957. He was admitted for treatment of a draining sinus of the left groin. The sinus had been present on an intermittent basis for the past 4 to 5 years. It was first contracted in February 1953, when he was en route to overseas duty and while still in the service. It arose spontaneously and drained a purulent material. The relevant hospital discharge diagnoses were condylomata acuminata and hidradenitis suppurativa. In August 1958, the RO granted entitlement to service connection for a draining sinus of the left groin which was assigned a noncompensable evaluation. At an April 1972 VA special surgical examination, a clinical inspection of the inguinal area revealed multiple healed sinuses in both inguinal areas. There were multiple sebaceous cysts and areas of hidradenitis throughout this area. These multiple sebaceous cysts and areas of hidradenitis extended all over the perineum down to the rectum. There was an infected sebaceous cyst over the perineum at the junction of the scrotum and the perineum. In the right gluteal area was a sinus and a large operative scar from surgery about three years previously. Throughout the entire back were multiple sebaceous cysts and areas of hidradenitis. Over the right scapula was a 3" by 2" area which was red, swollen and tender. This was evidently an infected area of hidradenitis or sebaceous cyst. The examination diagnoses were residual scars, incision and drainage, hidradenitis, groin, right buttock; sebaceous cysts, multiple, inguinal region, scrotum, perineum, entire skin of back. The RO reclassified the veteran's skin disability as multiple epidermal inclusion cysts with hidradenitis, suppurative, and granted an increased (compensable) evaluation of 10 percent when it issued a rating decision in February 1973. At a May 1973 VA skin examination, a clinical inspection revealed over the front of the chest about 8 or 10 sebaceous cysts which were from 1/2 to 1 centimeter in diameter. Over the back were probably 150 that ran from the back of the neck to the buttocks area. They had reached from 1 1/2 to 3 1/2 centimeters in size. Only one was infected at present and this was just mildly red. There were two large scars, probably 4 inches in length over the round part of the right buttock which were indented, but not draining. There were two or three pigmented areas of where infected cysts were on the inner thigh and buttock. The diagnosis was multiple inclusion cysts, back and chest. In a June 1973 rating decision, the RO granted an increased evaluation of 30 percent for multiple epidermal inclusion cysts of the back and chest, moderately severe. A February 1975 VA dermatology examination concluded in a diagnosis of multiple epidermal inclusion cysts and infected sebaceous cysts, extensive, covering the whole back to the buttocks, arms, face, and neck. At a May 1975 VA examination, the appellant reported that in April 1956 he began to have cystic nodules develop over the skin while serving in Korea. He had had many since then. At one time he had 84 removed from the back. This had been done one month previously. One of the cysts on the lower right flank was still open and draining. The appellant stated that he often ran a fever when the cysts became infected. He had had several removed from the scrotal groin area, particularly on the left. On examination were seen multiple scars and cysts ranging in size from 1 to 8 millimeters in diameter and elevated above the skin level from 1 to 4 millimeters. A large open wound, 3 centimeters long and 1 1/2 centimeters wide, was still present in the lower right back. The examination diagnosis was multiple epidermal (sebaceous inclusion) cysts. In a July 1975 rating decision, the RO granted an increased evaluation of 50 percent for multiple epidermal inclusion cysts of the back, chest, and buttocks. A February 1977 VA dermatology examination concluded in a diagnosis of multiple epidermal inclusion cysts with secondary infection and a history of previous surgery involving predominantly the back; buttocks, especially the right; chest; and in a minor degree the umbilical area, the neck, the jaw, the cheek and the roof of the nose. A September 1979 VA general medical examination concluded in a relevant diagnosis of multiple sebaceous cysts (acne vulgaris?) with a history of repeated infection and abscess formation. A December 1987 VA outpatient treatment report shows a diagnosis of cystic acne/hidradenitis, not very inflammatory. In April 1990 the veteran submitted color photographs of the skin areas on his body affected by his dermatologic disability. At an April 1990 VA examination, the appellant reported that he was being followed in the Dermatology section of the local VA medical facility. He complained of chronic sebaceous cyst formation on the back, buttocks, abdominal wall and both groin areas. Some were infected and some were draining. He had been experiencing difficulty sitting at times. There was a painful area in the back making it difficult to lie down. On examination of the skin were seen scattered marble sized, soft nodes, tender and draining. There were some scarring, infection and drainage. The diagnosis was chronic sebaceous cyst formation on the back, buttocks, abdominal wall, and spinal area with several infected and draining. On file is a letter from a private physician dated in December 1990. Lewis R. Domke, M.D., advised that the veteran had been under his care for rectal bleeding. Due to his history of suppurative hidradenitis, he had problems with recurrent infections and it was suggested that he not undergo any major surgery due to his problem with infections and cysts. He had had multiple cyst removals and perirectal abscesses in the past. It was thought that he should not undergo any surgical procedures unless the surgery was necessary for a life-threatening illness. A January 1993 VA general medical examination of the skin disclosed 15 to 20 nodules in the subcutaneous tissue especially over the back, but also in the areas over the chest and over the deltoid region. None of these was currently draining, but there was numerous evidence of previous areas where they had been draining, or where he had had previous incisions and drainage. The veteran's dermatologic disability is rated as 50 percent disabling under diagnostic code 7806 by analogy to eczema. 38 C.F.R. § 4.20. The 50 percent evaluation, the highest evaluation under this code, contemplates ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptional repugnance. The Board is of the opinion that the above clinical requisite criteria are compatible with the most recent dermatologic evaluations conducted by VA. The appellant's dermatologic disorder continues to manifest itself as it has in previous years with no evidence of chronic worsening which would permit a grant of an evaluation higher than the current 50 percent evaluation. Undoubtedly the veteran has experienced significant disabling exacerbations of his skin disability in the recent past; nonetheless, the most recent examinations conducted by VA in April 1990 and January 1993 are consistent in demonstrating no pathological development or worsening of the appellant's dermatologic disorder. He merely requires treatment on a symptomatic basis at the local VA medical facility. No question has been presented as to which of two or more evaluations would more properly classify the current severity of the skin disorder. 38 C.F.R. § 4.7. The claimant's dermatologic disorder has not rendered his disability picture unusual or exceptional in nature, and has not markedly interfered with employment. It has not required frequent inpatient care as to render impractical the application of regular schedular standards, thereby precluding a grant of an increased evaluation on an extraschedular basis. 38 C.F.R. § 3.321(b)(1). The Board does not mean to trivialize the nature and extent of the appellant's dermatologic disorder which is significant and persistent. His symptomatologic manifestations are contemplated in the current 50 percent evaluation and a level of impairment in excess of such evaluation has not been demonstrated. For the foregoing reasons the Board concludes that the record does not support a grant of an increased evaluation for multiple sebaceous cysts with repeated infection abscess formation. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321(b)(1), 4.7, 4.20, 4.118, Diagnostic Code 7806. ORDER Service connection for a psychiatric disorder, variously diagnosed, as secondary to service-connected multiple sebaceous cysts with repeated infection abscess is denied. An increased evaluation for multiple sebaceous cysts with repeated infection abscess formation is denied. ALBERT D. TUTERA Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.