Citation Nr: 0007934 Decision Date: 03/23/00 Archive Date: 03/28/00 DOCKET NO. 92-19 853 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to an increased rating for pseudofolliculitis barbae with sebaceous cyst of the neck, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. S. Tierney, Counsel INTRODUCTION The veteran served a period of active duty for training from June 1976 to September 1976, and served on active duty from August 1978 through November 1978. This matter comes before the Board of Veterans' Appeals (Board) from a March 1992 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. The case was remanded by the Board in January 1994 and again in April 1999 for further development. The requested development was completed and the case was returned to the Board in February 2000. FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of the issue currently on appeal has been obtained by the RO and associated with the veteran's claims folder. 2. The veteran's pseudofolliculitis barbae with recurring cysts on the neck is intermittently pruritic and productive of occasional exudation. 3. The disfigurement associated with the service-connected skin disability is marked. CONCLUSION OF LAW The criteria for a rating of 30 percent for pseudofolliculitis barbae with sebaceous cyst of the neck have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.10, 4.118, Diagnostic Codes 7806, 7814, 7819 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran contends that he is entitled to an increased rating due to the extensive lesions, scars and disfigurement of his facial area and the continuous recurrence of sebaceous cysts. The veteran's claim for an increased rating for the service- connected skin disability is well grounded within the meaning of 38 U.S.C.A. § 5107(a). Additionally, the facts relevant to the claim has been properly developed and the statutory obligation of VA to assist the veteran in the development of the claim has been satisfied. 38 U.S.C.A. § 5107(a). Facts In accordance with 38 C.F.R. §§ 4.1, 4.2 (1999) 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 disability at issue. The Board has found nothing in the historical record which would lead it to conclude that the current evidence of record is not adequate for rating purposes, nor has the Board found any of the historical evidence in this case to be of sufficient significance to warrant a specific discussion herein. Service connection for pseudofolliculitis barbae with sebaceous cyst of the neck was granted in a rating decision of December 1977. A 10 percent rating was assigned from September 30, 1976, pursuant to Diagnostic Codes 7806 and 7819. A 10 percent rating has been in effect for the disability since then. In February 1992, the veteran filed the current claim for a rating in excess of 10 percent for his service-connected skin disability. A VA medical record dated in February 1992 shows that the veteran had had a cyst on the right cheek removed and was having the sutures removed. A VA outpatient treatment record dated later in February 1992 notes that the veteran was seen for chronic cystic acne. Examination revealed that the veteran's lower face was very scarred with a few firm cysts. In addition, he had a lot of "icepick" scarring. The diagnosis was acne. A VA examination in February 1992 showed no burn scars. It was noted that he had had facial dermatitis since 1976, limited to his face and neck. He had multiple deep scars and cysts on the face in the beard area. There were no nervous manifestations. The diagnosis was pseudofolliculitis barbae with severe scarring, treated with multiple modalities in past, including surgery and antibiotics. VA outpatient treatment records dated March 24, 1992, show that the veteran had diffuse scars on the right side of his face and a scar on the right mandible. The diagnosis was acne with old acne cysts and scars. Additional VA medical records dated in August 1994 show that the veteran was being treated for follow up of a cyst on the neck where the veteran had had a steroid injection one month earlier. The veteran reported that the cyst had decreased in size but was still there and was still bothersome. Examination revealed a mobile cyst approximately one centimeter by one centimeter. It was on the neck in the hairline of his beard. It was nontender with no erythema and no discharge. The diagnosis was a noninfected, epidermal inclusion cyst. The doctor recommended removing the cyst. Another VA outpatient treatment record dated in March 1997 shows that the veteran had had a cyst under his chin for three to four months. It was noted that he had a rash on his chin that did not have pus or a bloody discharge. At a VA dermatology examination in June 1997, the veteran complained of pain and occasional itching of pseudofolliculitis barbae. The examination showed that there were several skin-colored papules and cysts on the veteran's cheeks and chin. Multiple ice pick scars were present on the cheeks. The diagnoses were pseudofolliculitis barbae and acne vulgaris. Colored photographs were submitted. Private medical records from Thomas L. Fisher, M. D., S. C., show that in April 1997, the veteran had a nodule on the left side of his neck. The veteran reported that the lesions drained foul smelling matter. The examination revealed a hard nodule with a small amount of pus which was drained. The diagnosis was scar; abscess and it was noted that there was a cyst in the scar. Additional records from Dr. Fisher show that the veteran had a cyst removed from the left side of his neck in July 1997. It was noted that the veteran had scarring of the cheeks and neck. The diagnosis was pseudofolliculitis barbae. Other medical records show that the veteran was prescribed Retin A for pseudofolliculitis barbae in July 1997 and November 1997. A VA dermatology examination report dated in August 1999 notes that the veteran had had pseudofolliculitis barbae beginning in 1976, that he had had multiple attempts at therapy, none of which was successful, and that the symptoms had been relatively stable, although severe over the years. The veteran's main complaint was that he had developed cystic lesions that were unresponsive to treatment. The lesions occurred either on the face or on the neck. The veteran reported that the cysts started as firm lumps and eventually became inflamed and filled with pus which, when drained had a foul-smelling, anaerobic fluid. The veteran reported that this occurred on the average once a month. The condition had resulted in scarring over his entire face and neck in the area of his beard. The veteran reported that the scarring was non-tender or painful but that it was intermittently pruritic. An examination of the head and neck revealed no adenopathy or thyromegaly. His face, in the area of his beard, was covered by small pock marks that were curricular and approximately two to three millimeters in diameter. There was no linear scarring, retraction, or deformity. The oral pharynx was without lesion. There were presently two firm, subcutaneous, superficial cysts on either side of the larynx, just below the mandible. They both measured approximately .5 centimeter by 1 centimeter. There were no other cysts or signs of drainage, infection or inflammation in that area. No foul- smelling drainage was detected. The scarring was non-tender and not painful on objective demonstration, and it was not poorly nourished and subject to repeated ulceration. The service-connected disability did not affect the function of the veteran's neck, jaw or face. The diagnoses were pseudofolliculitis barbae with intercurrent infected cysts requiring drainage and subsequent scarring. Colored photographs were taken and associated with the claims file. Analysis Disability evaluations are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4 (1999). The Board attempts to determine the extent to which the veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10 (1999). Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (1999). Tinea barbae and benign new skin growths are to be evaluated as eczema under Diagnostic Code 7806. 38 C.F.R. § 4.118, Diagnostic Codes 7814, 7819. Eczema. warrants a 10 percent evaluation if there is exfoliation, exudation or itching, if involving an exposed surface or extensive area. A 30 percent rating for eczema is warranted with constant exudation or itching, extensive lesions, or marked disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7806. Slight disfiguring scars of the head, face or neck are evaluated as noncompensably disabling. Moderate disfiguring scars of the head, face or neck are evaluated as 10 percent disabling. Severe disfiguring scars of the head, face or neck, especially if producing a marked and unsightly deformity of the eyelids, lips, or auricles, are evaluated as 30 percent disabling. Disfiguring scars of the head, face or neck which involve complete or exceptionally repugnant deformity of one side of the face or marked or repugnant bilateral disfigurement are evaluated as 50 percent disabling. 38 C.F.R. § 4.118, Diagnostic Code 7800 (1999). The note following Diagnostic Code 7800 provides that where in addition to tissue loss and cicatrization there is marked discoloration, color contrast, or the like, the 50 percent rating under Diagnostic Code 7800 may be increased to 80 percent, the 30 percent to 50 percent, and the 10 percent to 30 percent. Superficial scars which are poorly nourished, with repeated ulceration are evaluated as 10 percent disabling. 38 C.F.R. § 4.118, Diagnostic Code 7803 (1999). Superficial scars which are tender and painful on objective demonstration warrant a 10 percent rating. 38 C.F.R. § 4.118, Diagnostic Code 7804 (1999). Other scars may be rated on limitation of function of the part affected. 38 C.F.R. § 4.118, Diagnostic Code 7805 (1999). When 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. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (1999). The evidence shows that the veteran has pseudofolliculitis barbae with recurring cysts on his neck. A VA outpatient treatment record dated in August 1994 shows that the cyst was nontender, but the veteran reported that it was bothersome. A private medical record dated in April 1997 shows that the veteran had a nodule on the left side of his neck which had some pus and was drained. At the June 1997 VA examination, the veteran reported pain and occasional itching of the pseudofolliculitis barbae. The veteran's pseudofolliculitis barbae and recurring cysts involve an exposed surface and there is evidence of exudation and itching. Although the exudation and itching associated with the disability are not constant, the lesions and associated scarring are, in the Board's opinion, productive of marked disfigurement. In this regard the Board notes that the February 1992 VA outpatient treatment record shows that the veteran's lower face was very scarred and that he had a lot of ice pick scarring. The February 1992 VA examination report shows that the veteran had severe scarring as a result of the pseudofolliculitis barbae of the face and neck. The June 1997 VA examination report also shows that the veteran had multiple ice pick scars on the cheeks. A private medical record dated in July 1997 notes scarring of the cheeks and neck. The August 1999 VA examination report shows that the veteran had scarring over the entire face and neck in the area of his beard. In concluding that the disability is productive of marked disfigurement, the Board has also considered the photographs depicting the condition. Accordingly, the disability meets the criteria for a 30 percent evaluation under Diagnostic Code 7806. There are no systemic or nervous manifestations of the disability, and the disfigurement does not approach exceptional repugnancy. Therefore, the disability does not more nearly approximate the criteria for a 50 percent evaluation under Diagnostic Code 7806. The Board has also considered whether it would be to the veteran's advantage to separately rate the disfigurement from the other manifestations of the disability. Without consideration of the disfigurement, the disability would warrant a 10 percent evaluation under Diagnostic Code 7806 since the disability involves a limited area and the exudation and itching associated with the disability are only occasional. The degree of disfigurement evidenced by the medical evidence and the photographs depicting the condition is moderate, in the Board's opinion. In this regard, the Board notes that although severe scarring has been noted, the disfigurement has not been described as severe. In addition, the facial scars do not produce marked and unsightly deformity of the eyelids, lips or auricles. Therefore, the disfigurement would not warrant an evaluation in excess of 10 percent under Diagnostic Code 7800. Accordingly, it would not be to the veteran's advantage to separately rate the disfigurement. In accordance with Esteban v. Brown, 6 Vet. App. 259 (1994), the Board has also considered whether the scarring otherwise warrants a separate compensable evaluation. The medical evidence reflects that the scarring is not tender, painful, poorly nourished and subject to repeated ulceration, or productive of functional impairment. Therefore, there is no appropriate basis for assigning a separate compensable evaluation under Diagnostic Code 7803, 7804, or 7805. ORDER An increased rating of 30 percent for pseudofolliculitis barbae with sebaceous cyst of the neck is granted, subject to the criteria applicable to the payment of monetary benefits. SHANE A DURKIN Member, Board of Veterans' Appeals