Citation Nr: 0001907 Decision Date: 01/24/00 Archive Date: 02/02/00 DOCKET NO. 98-10 033 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to an increased evaluation for service-connected psoriasis, currently rated as 30 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Appellant ATTORNEY FOR THE BOARD Bernard T. DoMinh, Counsel INTRODUCTION The veteran served on active duty from July 1956 to December 1959. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 1998 rating decision by the Columbia, South Carolina, Regional Office (RO) of the Department of Veterans Affairs (VA), which denied the veteran's claim of entitlement to an increased evaluation in excess of 30 percent for psoriasis. FINDINGS OF FACT The veteran's service-connected psoriasis is currently manifested by constant exfoliation, exudation, and constant itching over an extensive area, but without associated systemic or nervous manifestations, disfigurement, or and exceptionally repugnant appearance. CONCLUSION OF LAW The criteria for an evaluation in excess of 30 percent for service-connected psoriasis have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.118, Diagnostic Code 7816 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Background The veteran's service medical records show that he was treated for dermatitis on several occasions during active duty. In an April 1971 RO decision, he was granted service connection and a noncompensable evaluation for dermatitis. In the years thereafter, his skin symptoms increased in severity. In an October 1974 rating decision, the RO changed the skin disorder's rating diagnosis to psoriasis and granted the veteran a 10 percent evaluation. The report of a June 1996 VA skin examination shows that the veteran had what was characterized by the evaluating physician as typical psoriatic outbreaks, manifested by thick scaling and mild erythema on the right elbow, the hairline of the scalp, the left ear, the naval, the buttocks, and the right anterior knee, all of which were deemed to be consistent with psoriatic changes. The diagnosis was psoriasis. On the basis of this examination, the RO issued a rating decision in June 1996 which awarded the veteran a rating increase, from 10 percent to 30 percent, for his service-connected skin disorder. In December 1997, the veteran reopened his claim. He submitted written correspondence in which he contended that he was entitled to an evaluation higher than 30 percent for psoriasis on the basis of worsening symptomatology. Pursuant to this, he was examined by VA in January 1998. The report of this skin examination shows that his psoriasis was located diffusely through his scalp and behind his ears, bilaterally. A 2-centimeter by 2-centimeter psoriatic patch was located on his right elbow. The examiner also noted that there was a marked psoriatic outbreak on the veteran's umbilicus and at the cleft of his buttocks, which were the areas which appeared to be the most severely affected. The examiner observed some ulceration and fissures in the umbilicus, with marked skin crusting. Marked skin crusted was also observed at the cleft of the buttocks, but without significant ulceration or exfoliation. The examiner concluded that, due to the locations of the veteran's psoriasis, his skin disorder was not exceptionally repugnant in appearance. The diagnosis was moderately severe psoriatic outbreak with the most severe areas affected being at the umbilicus and the cleft of the buttocks, with psoriasis being diffusely present within the hairline of the scalp. In written statement dated in June 1998, the veteran reported that he was unable to use cortisone and quinine medications which had been prescribed for his psoriasis because he was allergic to them. The transcript of a September 1998 RO hearing shows that the veteran expressed his general contention that his psoriasis had become worse, and that it warranted the assignment of a 50 percent rating in accordance with the applicable rating schedule. He reported that he used only Vaseline to treat his skin problem, as the psoriasis did not respond to specially medicated shampoos and topical skin medications. He testified that he experienced constant itching of the skin at his ears, scalp, right elbow, right knee, naval, and buttocks. His also reported that the skin at these affected areas would slough off in scales and flakes, and that the skin of his buttocks and naval would crack, peel, and bleed constantly. The veteran described having constant scabbing at the affected areas of his skin and scalp. He stated that although his thick hair hid most of his scalp lesions from view, his lesions in this area were very active and would always produce scabs which he would constantly pick from his hair. He said that the scalp lesions were visible as white spots at the edges of his hairline. He described them as being unsightly, making him self-conscious and embarrassed of his condition. He admitted that he was unwilling to visit a professional barber to cut his hair out of concern that too much hair would be cut off, exposing his scalp lesions to full view. Instead, he had his daughter trim his hair while keeping as much of it on to hide his scalp. The veteran described in detail how each day he would attempt to clean off as much of the loose skin, scales and scabs from his affected areas, using towels wrapped around scissor points to pick out loose naval skin, but that his itching symptoms persisted and within a day he would be sloughing off skin tissue and crusted exudate from the same areas. He reported that the floor area around his den chair at home would become covered with bits of sloughed skin and scabs as he habitually picked at his lesions because of their itchiness, and that he had to vacuum the floor of this room daily to remove them. II. Analysis As a preliminary matter, the Board finds that the veteran's claim of entitlement to an increased evaluation in excess of 30 percent for psoriasis is plausible and capable of substantiation, and thus well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). When a veteran claims that a service-connected disability is more severely disabling than as rated, the claim is well grounded. Proscelle v. Derwinski, 2 Vet. App. 629 (1992); Shipwash v. Brown, 8 Vet. App. 218 (1995). When a veteran submits a well-grounded claim, VA must assist him in developing facts pertinent to that claim. 38 U.S.C.A. § 5107(a). The Board is satisfied that all relevant evidence has been obtained and that no further assistance to the veteran with respect to this claim is required to comply with 38 U.S.C.A. § 5107(a). Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1999). Separate diagnostic codes identify the various disabilities. 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 (1999). 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. Evaluations are based upon lack of usefulness of the part or system affected, especially in self-support. 38 C.F.R. § 4.10 (1999). The veteran's service-connected psoriasis is evaluated on the basis of eczema. 38 C.F.R. § 4.118, Diagnostic Code 7816. A noncompensable evaluation for eczema is warranted where the skin disorder is manifest by slight, if any, exfoliation, exudation, or itching, if on a nonexposed surface or small area. A 10 percent evaluation is warranted where the skin disorder is manifest by exfoliation, exudation, or itching, if involving an exposed surface or an extensive area. A 30 percent rating is warranted where there is constant exudation or itching, extensive lesions, or marked disfigurement. A 50 percent rating, which is the highest rating provided by the schedule, is warranted where the evidence demonstrates ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or if the skin disorder is exceptionally repugnant. VA examination of the veteran's skin in January 1998 revealed a history of psoriasis and shows that his psoriatic lesions were located in his scalp, behind both ears, on his right elbow, his umbilicus, and the cleft of his buttocks. In the examining physician's judgment, the areas of the veteran's umbilicus and buttocks were the most adversely affected by psoriasis and the outbreak of psoriasis in these areas was described as marked. The physician observed marked skin crusting, ulceration, and fissures in the umbilicus. He also observed marked skin crusting at the cleft of the buttocks, but without significant ulceration or exfoliation. Because of the locations of the veteran's psoriasis, it was the examiner's judgment that the veteran's skin disorder was not exceptionally repugnant in appearance and in his diagnosis the psoriasis was characterized as being a moderately severe outbreak. No systemic or nervous manifestations associated with the psoriatic lesions were mentioned by the examiner or complained of by the veteran. The veteran's manifestations, by his own statements, involve the skin only and his embarrassent at the lesions. The examiner determined that the most severe areas of the veteran's body affected by his skin disorder were his umbilicus and the cleft of the buttocks, with psoriasis being diffused within the hairline of the scalp. Based on the above objective findings, and on the description of the veteran's skin disorder as presented by him at the RO hearing of September 1998, the Board concludes that the evidence does not indicate that an assignment of an evaluation higher than 30 percent is warranted for the veteran's service-connected psoriasis. The regions of the veteran's body affected by psoriasis meets the definition of an "extensive area" as provided in the rating schedule for a 10 percent rating. Additionally, the Board concedes that the psoriasis is manifest by persistent skin lesions and constant itching and exudation, as contemplated by the schedule for a 30 percent rating. However, for a 50 percent rating to be assigned the evidence must demonstrate not only that there is ulceration or extensive exfoliation or crusting (which is clearly present), but that there is also systemic and nervous manifestations, or that the skin manifestations are exceptionally repugnant. While the Board is not unsympathetic to the veteran's subjective self-perception of the severity of his skin disorder, it must give more probative weight towards the objective medical evidence which addresses his psoriasis. The medical evidence does not characterize the veteran's psoriasis as having been manifested by lesions which are exceptionally repugnant and do not associate any systemic or nervous manifestations with these lesions. The constellation of skin symptoms more closely approximates that criteria which are contemplated in the rating schedule for a 30 percent evaluation. In view of these facts, the 30 percent evaluation currently assigned for the service-connected psoriasis is appropriate. The veteran's claim for an increased rating must therefore be denied. ORDER An increased evaluation in excess of 30 percent for service- connected psoriasis is denied. Iris S. Sherman Member, Board of Veterans' Appeals