BVA9500261 DOCKET NO. 88-13 721 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Whether new and material evidence has been submitted to reopen the veteran's claim of entitlement to service connection for psoriasis. 2. Entitlement to an increased (compensable) evaluation for dermatitis of the scrotum, chest, and shoulders. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD William J. Jefferson, III Counsel INTRODUCTION The veteran had active service from August 1960 to October 1964. This matter came before the Board of Veterans' Appeals (Board) on appeal from a rating decision of Department of Veterans Affairs (VA), St. Petersburg, Florida, Regional Office (RO). Entitlement to service connection for psoriasis was denied in a September 1978 Board decision. In an August 1987 rating decision, an increased (compensable) evaluation dermatitis of the chest, scrotum, and shoulders was denied. The veteran disagreed with the determination in September 1987, and a substantive appeal was timely filed November 1987. The Board remanded the case in August 1988 to obtain additional clinical information. A personal hearing was held at the RO in August 1989. The Board entered a decision on the merits of the appeal in December 1990, denying a compensable evaluation for dermatitis of the scrotum, chest, and shoulders. The veteran filed an appeal to the United States Court of Veterans Appeals, hereinafter Court. In an April 1992 order, the Court remanded the case to the Board, pursuant to 38 U.S.C.A. § 7252 (a) (West 1991), for compliance with the Appellee's Motion for Remand. The Board was instructed to make specific findings on appellant's reasonably inferred claim of entitlement to service connection for psoriasis, and to readjudicate appellant's claim for an increased rating for his service connected dermatitis, including, "a written statement of the Board's findings and conclusions, on all material issues of fact and law presented on the record." [citation redacted]. However, in Hamilton et al. v. Brown, 4 Vet.App. 528 (1993), the court abandoned the multiple notice of disagreement theory, which was the theory on which the case was predicated. Therefore, the Court no longer maintained jurisdiction of the issue of entitlement to an increased evaluation for dermatitis of the scrotum, chest, and shoulders. The Board will proceed with the case, and consider the claims of entitlement to an increased (compensable) evaluation for dermatitis of the scrotum, chest, and shoulders, as reopened and the attempt to reopen the issue of entitlement to service connection for psoriasis, framed as whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for psoriasis. We note that in June 1993 the case was remanded by the Board to the RO to obtain additional clinical information, including a VA dermatology examination so that the examiner could render an opinion indicating the nature of the veteran's skin disorder shown during service, and its relationship to his current skin disorder. The RO was also to adjudicate the issue of whether new and material evidence had been submitted to reopen the claim of service connection for psoriasis. A rating decision dated in May 1994 determined that new and material evidence had not been submitted to reopen the claim of entitlement to service connection for psoriasis, and an increased (compensable) evaluation for dermatitis of the scrotum, chest and shoulders was denied. A supplemental statement of the case was issued in May 1994. CONTENTIONS OF APPELLANT ON APPEAL The veteran essentially argues that new and material evidence has been presented to reopen his claim of entitlement to service connection for psoriasis. He maintains that he had psoriasis during service, and at that time that his psoriasis was misdiagnosed since dermatitis and psoriasis are diagnosed interchangeably. He contends that service connection for psoriasis is warranted. It is also argued that the veteran's skin disorder is far more disabling than the current non- compensable evaluation indicates. In addition, the veteran contends that no reasons and bases were articulated in a March 1994 VA Form 21-507 statement, regarding whether psoriasis was shown prior to the veteran's discharge from service. It is maintained that a causal relationship exists between the veteran's service connected skin disorder and psoriasis, and an independent medical opinion is necessary in this case. 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(s). 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 new material evidence has not been submitted to reopen the claim of entitlement to service connection for psoriasis. The Board also determines that an independent medical opinion is not warranted; and that the preponderance of the evidence is against the veteran's claim of entitlement to an increased (compensable) evaluation for dermatitis of the scrotum, chest, and shoulders. FINDINGS OF FACT 1. Entitlement to service connection for psoriasis was denied on the merits in a September 1978 Board decision. 2. The evidence that has been submitted since the September 1978 Board decision, is either cumulative or of such limited probative value that when viewed in the context of all the evidence, it would not change the outcome. 3. The appeal of whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for psoriasis does not present a medical complexity or controversy necessitating an independent medical opinion. 4. The dermatitis of the scrotum, chest, and shoulders is not shown to involve exfoliation, exudation, or itching of an exposed surface or extensive area. CONCLUSIONS OF LAW 1. The September 1978 Board decision on the merits is final; additional evidence which has been submitted is not new and material to reopen the claim of entitlement to service connection for psoriasis. 38 U.S.C.A. §§ 1110, 1131, 5107, 5108, 7104 (b) (West 1991); 38 C.F.R. § 3.156 (a) (1993). 2. An independent medical opinion is not warranted. 38 C.F.R. § 20.901 (d) (1993). 3. An increased (compensable) evaluation for dermatitis of the scrotum, chest, and shoulders is not warranted. 38 U.S.C.A. §§ 1155, 3.321 (b), 4.7, Part 4, Code 7806 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION We find that the veteran's claims are "well grounded" within the meaning of 38 U.S.C.A. § 5107(a). That is we find that he has presented claims which are not implausible. As indicated previously, it is maintained on behalf of the veteran that no reasons or bases were articulated in a March 1994 statement concerning whether his skin condition prior to service was psoriasis, and that an independent medical opinion is warranted to address the causal relationship between the veteran's service connected skin disorder and psoriasis. We note that in June 1993, the Board requested that the veteran be afforded a VA dermatology examination to include an opinion indicating the nature of the skin disorder shown during service and its relationship to the veteran's current skin disorder. In an August 1993 VA dermatology examination report, the examiner indicated that it was possible that the veteran's skin rashes reported during service were psoriasis but a review of the veteran's service medical records was needed as the claims folder had not been provided. On a March 1994 VA Form 21-2507, compensation and pension exam request to a VA medical facility, further examination was not considered required and the statement of August 1993 was reported. A VA examiner reviewed the veteran's claims file and clinical findings from service in 1963-1964 were reported, and it was indicated: Not psoriasis, was acne and folliculitis. The statement was signed but it is illegible. This exam has been reviewed and approved by the examining provider. It is pertinent to note that 38 C.F.R. § 20 .901 provides that when in the judgment of the Board, additional medical opinion is warranted by the medical complexity or controversy involved in an appeal the Board may obtain an advisory medical opinion. In this case in August 1993, a VA dermatology examination was performed to evaluate the veteran's current skin disorder and to provide an opinion indicating whether the skin disorder shown during service had been, in fact, psoriasis. The clinician performing the examination initially indicated that it was possible that the chest rash and right shoulder-arm pit rash reported by the veteran as having been in 1963 or 1964 was psoriasis and that it could have been present in addition to scrotal dermatitis but verification was contingent upon review of pertinent records. In February 1994, the RO specifically requested that a VA examiner review the claims folder to determine if the skin disorder prior to discharge was psoriasis. Further examination was not required. Records were subsequently furnished to a VA medical facility for verification as indicated by the examiner. In a March 1994 opinion ostensibly from a VA employee, on a VA Form 21-2507, with an illegible signature, was that it was indicated that folliculitis and acne, not psoriasis, were the skin problems reported prior to discharge. It is also important to note that the presumption of regularity supports the official acts of public officers in the absence of clear evidence to the contrary, and it is presumed that they have properly discharged their official duties. Ashley v. Derwinski, 2 Vet.App. 62 (1992). Here, while the signature on the March 1994 VA form is illegible, it is presumed that the opinion was completed by a clinically qualified VA official. The examination was apparently reviewed and approved by the examining facility and completed the VA examination requested by the Board in its Remand decision. Additionally, while no analysis was offered in support of the opinion, the opinion was based on a review of the claims folder to include the veteran's service medical records, and its probative value must be weighed for exactly what it states, as would any other evidence. On the face of it, there is no new and material evidence which, if taken as true, would change the outcome of the service connection claim. The Board concludes that the issue of new and material evidence to reopen the claim for service connection of psoriasis is not difficult or medically complex, nor is there any opposing evidence, particularly of a clinical nature which would establish a controversy concerning the issue. An independent medical opinion is not warranted. We are satisfied that all relevant facts have been properly developed. 38 U.S.C.A. § 5107(a). I. Whether New and Material Evidence has been Submitted to Reopen the claim of Entitlement to Service Connection for Psoriasis As previously indicated, in a September 1978 decision by the Board, entitlement to service connection for psoriasis was denied. At that time, the Board considered the veteran's service medical records which revealed treatment for skin problems of the chest, back, and scrotum diagnosed as folliculitis and erythematous dermatitis in October and November 1963. Acneform eruptions of the chest and shoulders were reported at discharge from service in June 1964. No skin problems were shown in a 1965 VA medical examination. Private clinical records showed that in 1976 and 1977 the veteran received treatment for psoriasis. A VA medical examination in November 1977 revealed psoriasis of the elbows and hands. A 1978 statement from a private physician indicated that the veteran had received treatment for psoriasis since 1968, and at that time he had reported a history of psoriasis for five years. In the September 1978 decision, the Board essentially determined that psoriasis was not shown during service or until several years after service, and service connection for psoriasis was denied. Since the September 1978 Board decision, additional evidence has been submitted. The evidence consists of VA and private outpatient clinical records from the late 1970's through the late 1980's revealing treatment for psoriasis of the groin and extremities. None of it relates the veteran's post-service psoriasis to the period of active service, however. In August 1988, the Board remanded the increased rating issue for a VA dermatology examination. In a January 1989 VA dermatology examination, the veteran gave a history of skin trouble since 1961. It was indicated that the scalp, ears, anterior chest, abdomen, penis, scrotum, groin, and lower extremities had been affected. There were mild erythema and flaking of the scalp in the left temporal-occipital region, left ear, left upper abdomen and lower abdomen bilaterally. There were typical lesions of psoriasis of both elbows with erythema, scaling and plaquing; the dorsum of the hands and fingers; and the left hand. Similar small typical psoriatic lesions were present on the glans penis and large psoriatic plaques on the scrotum and groin areas and right knee. Similar small lesions of the right calf, lateral malleolus and toes of the foot were present. There was pitting of the nails of the fingers and toes. The diagnosis revealed: Dermatitis of the scalp, left ear, abdomen, elbows, hands, fingers, penis, scrotum, inguinal regions and lower extremities which is psoriasis, widespread, only fairly well controlled with treatment. At an August 1989 personal hearing, the veteran read into the testimony a statement which indicated that he had no skin problems prior to service; during service he was treated for dermatitis which has been evaluated as 0 percent disabling by the VA; and that his condition had worsened over the years and had more frequently been diagnosed as psoriasis. Transcript (hereinafter T.) at 5. In quoting from a medical treatise, the veteran opined that dermatitis and eczema are interchangeable terms, and that after being diagnosed with dermatitis, eczema, and psoriasis, psoriasis was the correct diagnosis all along. T. 5,6. The veteran also paraphrased an excerpt from a medical treatise that the term dermatitis, is all too frequently used to define general skin conditions that are later more defined, such as his had been, that being psoriasis. T. 6. At an August 1993 VA dermatology examination, the veteran related the clinical history of his skin condition, to include discussion of its incurrence during service, along with treatment after discharge from service by a dermatologist who had diagnosed psoriasis. Objectively, it was reported that there were erythematous plaques with scales on both elbows, dorsal metacarpals, fingers, dorsal hand, scalp, knees, lower legs, and lateral malleoli, and fingernail pitting. There was positive scrotal erythema. The assessment was psoriasis vulgaris; and mild to moderate scrotal dermatitis. The examiner commented that it was possible that the veteran's chest rash and right shoulder-arm pit rash in 1963 or 1964, prior to discharge was psoriasis. It was further indicated that service (medical) records were needed for verification. In addition, it was reported that the veteran may have developed psoriasis prior to discharge, in addition to having scrotal dermatitis, since both conditions can coexist. Submitted in October 1993 were private clinical records revealing treatment for psoriasis of the scalp, chest, and groin in 1968. Received in January 1994 were VA clinical records dated from 1965 through 1993, indicating that the veteran received treatment for dermatitis in 1967 and subsequently for psoriasis. In February 1994, in order to complete the August 1993 examination, the RO requested that a VA dermatology examiner review the claims folder to determine whether the veteran's skin condition prior to discharge from service was psoriasis. On a VA form 21-2507, compensation and pension examination request, treatment from October 1963 through June 1964 is recorded, and it is commented: Not psoriasis, was acne and folliculitis. The statement is signed, but the handwriting is illegible. The examination was reported as having been reviewed and approved by the examining provider. Analysis The Board is required to review all of the evidence submitted by a claimant since the last final denial on the merits of a claim, in order to determine whether a claim must be reopened and readjudicated on the merits. Glynn v. Brown, 6 Vet.App. 523 (1994). It is important to note that in a case where a final decision has been rendered, additionally submitted evidence must primarily be considered "new and material" or the appellant's claim cannot be reopened. Manio v. Derwinski, 1 Vet.App. 140 (1991). "New and Material" evidence is that evidence which has not been previously submitted, which bears directly and substantially upon the specific manner under consideration, and which is neither cumulative nor redundant. To justify the reopening of a claim on the basis of "new and material" evidence, there must be a reasonable possibility that the new evidence, when viewed in the context of all the evidence, both new and old, would change the outcome. Colvin v. Derwinski, 1 Vet.App. 171 (1991). The Board has reviewed all of the evidence which has been submitted since the September 1978 Board decision, the last final denial on the merits. The Board determines that the additional documents which have been submitted since the prior board decision are insufficient to reopen the claim of entitlement to service connection for psoriasis. We note that the VA and private clinical records from 1965 through the 1980's which have been submitted, revealing diagnoses and treatment for dermatitis and psoriasis, along with the September 1989 personal hearing, are cumulative of evidence previously considered. Previously, clinical records revealing psoriasis subsequent to service were considered, as were the veteran's contentions that the skin disorder shown during service was psoriasis rather than dermatitis. Furthermore, the veteran is not competent to render a medical conclusion regarding the difference between his service connected dermatitis and psoriasis or medical usage of medical terms. The 1989 VA dermatology examination which has been submitted, is relevant since the diagnosis describes several areas of the veteran's skin as dermatitis, and in fact being psoriasis. However, the correlation between dermatitis and psoriasis is plainly an interpretation of what the affected skin areas are in dermatological terms. The examination report, along with the private clinical records received in October 1993 revealing treatment for psoriasis of the scalp, chest, and groin in 1968, predating any other pertinent clinical records of psoriasis and which have not been previously considered, are not material. The aforementioned records do not show a specific causal relationship between any skin disorders or pertinent affected areas shown in service and his current skin disorder diagnosed as psoriasis. Evidence which does not show a connection between an appellant's current condition and his military service has been determined not "material"; and new evidence presented which is just closer in time to an appellant's service, has been considered a non sequitur, because the new evidence showed no service connection. White v. Brown, 6 Vet.App. 247, 252 (1994). We find that the aforementioned evidence, therefore, would not change the disposition of this claim. The August 1993 VA dermatology examination without benefit of the claims file, and in which it was reported that it was "possible" that the veteran's chest rash and right shoulder arm pit rash shown prior to discharge had been psoriasis, is relevant. The examination report suggests a possible causal relationship between the veteran's current skin disorder, described as psoriasis, and his military service. However, the August 1993 dermatology examination was requested so an examiner could address any possible causal relationship, and a definitive answer was contingent upon further review of the record, particularly the veteran's service records. The February 1994 VA clinical opinion specifically reported that the veteran had folliculitis and acne during service, and not psoriasis. Hence, in conjunction with the February 1994 VA clinical opinion, the August 1993 examination is not material since it does not tend to establish any causal connection, and when viewed in context of all the evidence, it would also not raise a reasonable possibility of changing the outcome of the case. The evidence is not evenly balanced as to the presence of psoriasis in active service. Therefore, the Board concludes that new and material evidence has not been submitted to reopen the veteran's claim of entitlement to service connection for psoriasis. II. Dermatitis of the Scrotum, Chest, and Shoulders The RO has assigned a noncompensable disability evaluation for dermatitis of the scrotum, chest, and shoulders, analogously, under the provisions of Diagnostic Code 7806, eczema, of the VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4. In October 1963, the veteran was treated for folliculitis of the chest. In November 1963, he had in addition a diffuse, erythematous dermatitis over the entire scrotum for which he was given medication and which improved. On retirement examination he had a mild acneform eruption of the skin over the chest and shoulders. In June 1965, he gave a history of a chronic rash of the scrotum for four years. Clinical records from the late 1960's through the late 1980's, reveal treatment skin problems of the upper and lower extremities, scalp, and groin, primarily assessed as psoriasis. A VA medical examination was performed in January 1989. It was reported that the veteran had fair control of his skin problems, which had been diagnosed as psoriasis, using a variety of topical creams and lotions, except for the skin of the scrotum and inguinal areas. It was indicated that he had much itching of the aforementioned regions. The examination revealed psoriatic lesions of numerous areas, including the scrotum. The scrotum had large plaques of psoriasis with much erythema and flaking. The examination did not reveal any skin problems associated with the chest and shoulders. Dermatitis (inflammation of the skin) of the scrotum which is psoriasis, widespread only fairly well controlled with treatment was part of the assessment. A VA dermatology examination was performed in August 1993. The veteran's skin disorder clinical history was reported. Objectively, it was reported that the veteran had erythematous plaques with scales on both elbows, dorsal metacarpal phalanges, fingers, dorsal hand, scalp, knees, lower legs, and lateral malleoli. Fingernail pitting was reported. The intergluteal fold and periumbilical areas were negative. Positive scrotal erythema was reported, and it was indicated that the inguinal folds were negative. The assessment was psoriasis vulgaris; mild to moderately severe scrotal dermatitis. Analysis The Board has reviewed the entire evidentiary data of record, and concludes that the preponderance of the evidence is against the veteran's claim of entitlement to an increased (compensable) evaluation for dermatitis of the scrotum, chest, and shoulders. Under the provisions of Diagnostic Code 7806, eczema, which is analogous to dermatitis exfoliativa, a 10 percent disability evaluation requires that there be exfoliation, exudation or itching, if involving an exposed surface or extensive area. Here, the objective clinical data shows extensive treatment of psoriasis of numerous areas, but not dermatitis. The record is negative for any findings revealing dermatitis of the chest and shoulders. Dermatitis of the scrotum has been reported and is described as mild to moderate itching of the scrotal area has been reported in the past. However, we also note that the scrotal region is neither exposed nor may it be considered an extensive area. Based on the clinical data of record, the Board finds that the veteran's disability picture does not approximate the criteria necessary for a higher disability evaluation. 38 C.F.R. § 4.7. Additionally, this case does not present such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization, requiring consideration on an extra-schedular basis. 38 C.F.R. § 3.321 (b). Therefore, we are compelled to conclude the preponderance of the evidence is against the veteran's claim, and an increased (compensable) evaluation for dermatitis of the scrotum, chest, and shoulders is not warranted. ORDER New and material evidence has not been submitted and the veteran's appeal to reopen his claim of entitlement to service connection for psoriasis is denied. Entitlement to an increased (compensable) evaluation for dermatitis of the scrotum, chest, and shoulders is denied. SAMUEL W. WARNER 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.