BVA9507411 DOCKET NO. 91-42 733 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUE Entitlement to an increased schedular disability rating for service-connected keratinous cysts, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his wife. ATTORNEY FOR THE BOARD L. L. Gann, Associate Counsel INTRODUCTION The veteran had active service from May 1970 to January 1972. This appeal arises from rating decisions dated in April and May 1991 from the Newark, New Jersey, Regional Office (RO), which confirmed the 10 percent schedular disability rating assigned for the veteran's service-connected keratinous cysts. This case has been remanded twice by the Board of Veterans' Appeals (Board) in August 1992, and again in December 1993, for additional evidentiary development. The case was most recently returned and docketed at the Board in March 1995, and is now ready for appellate review and consideration. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that his keratinous cysts warrant a schedular disability rating in excess of the 10 percent rating currently in effect. He notes that he suffers from chronic exacerbations of these lesions on his face, neck, back, and genital area, which often require surgical resection. He asserts that some of his resected cysts have never completely healed, or have resulted in deep, disfiguring scars. He also experiences constant itching and pain in the affected areas. 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 a schedular rating of 30 percent is warranted for the veteran's service-connected keratinous cysts. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. In June 1982, the RO awarded service connection for the veteran's keratinous cysts. A 10 percent schedular disability rating was assigned, and currently remains in effect. 3. The veteran's skin condition is manifested by the presence of numerous epidermal inclusion cysts located from his scalp to his thighs, as well as several deep scars found on his neck, face, and back, secondary to the surgical removal of previous cysts. The most recent Department of Veterans Affairs (VA) examiner found the presence of open comedones located on the face and chest. 4. His skin disorder more nearly approximates the criteria for a 30 percent schedular evaluation. CONCLUSION OF LAW A 30 percent schedular disability is warranted for the veteran's service-connected keratinous cysts. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.7, Part 4, Diagnostic Code 7899-7806 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board notes that the veteran's claim is well grounded within the meaning of 38 U.S.C.A. § 5107 (West 1991). A well grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). We are also satisfied that all relevant facts have been properly developed so that further assistance to the veteran is not required. The original claim for benefits was received at the RO in February 1982. Service connection for "Keratinous cysts" was granted by the RO in a June 1982 decision. A 10 percent schedular disability rating pursuant to Diagnostic Code 7899-7806 was granted, effective from February 5, 1982. This rating was confirmed by the RO in rating decisions dated in April and May 1991, from the current appeal arises. The RO has subsequently maintained this 10 percent evaluation in March 1993 and March 1994 rating actions. The veteran's skin disorder is evaluated pursuant to 38 C.F.R. Part 4, Diagnostic Code 7899-7806 (1994), which states that a skin condition manifested by exfoliation, exudation or itching, if involving an exposed surface or extensive area, will be granted a 10 percent disability evaluation. Where exudation or itching are constant, with extensive lesions or marked disfigurement, a 30 percent disability rating will be warranted. In cases with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or where the condition is exceptionally repugnant, a 50 percent schedular rating will be granted. 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 (1994). The veteran has presented numerous records concerning treatment for his service-connected skin condition since 1982. In April 1989, he underwent surgical resection of four infected cysts located on his face in April 1989. A pathology report diagnosed three of these lesions as "epidermal inclusion cysts," while the fourth was diagnosed as "connective tissue." In April 1991, the veteran underwent a VA examination, which found the presence of a "moderate" number of deep-seated firm nodules on his neck, trunk, and scrotum, measuring 0.5 to 2 centimeters. There was a post-excisional wound on his back which was "healing well," and well-healed scars on the face and trunk. The diagnosis was multiple keratinous cysts with a history of recurrent infections and inflammation caused by irritation in high friction areas. He again underwent resection for multiple cysts in October 1992. Six cysts, located on the back, posterior neck, and both sides of the face, were surgically removed. The surgeon, Dr. Rosen, noted that indicated that one of the two cysts located on the veteran's neck had "been previously excised." In a November 1992 letter from Dr. Di Bona, the veteran's treating physician, these resected cysts were referred to as "multiple sebaceous cysts." A letter from Dr. T. Schacter, also dated in November 1992, stated that he also performed a resection of a cyst/abscess located on the veteran right posterior buttock in October 1992 A letter from Dr. Rosen, dated in January 1993, stated that surgical resection of multiple cysts in October 1992 was necessitated in light of the constant itching and irritation caused by these lesions. Dr. Rosen also noted the presence of some exfoliation and ulceration, as well as post-operative scarring and "some disfigurement." In February 1993, the veteran underwent another VA examination, at which time he noted a 20-year history of multiple cysts located from his thighs to the top of his scalp. These cysts begin as an "itchy" papule and within three to four days, become enlarged and inflamed. Examination revealed the presence of multiple small and large cysts on the back, neck, and face, with multiple scarred sinus tracts secondary to old cysts and multiple surgical scars. The diagnosis was "multiple epidermal inclusion cysts" with recurrent areas of inflammation and infection. The examiner opined that "this condition is usually genetic and chronic requiring close follow-up" by dermatologists. Another VA examination was performed in January 1994. The examiner found multiple excision scars located on the back and posterior neck, as well as multiple "ice pick scars" on the face. No active lesions were noted, although open comedones were present on the cheek and chest. The examiner believed that these could be chloracne-type lesions seen in relation to Agent Orange exposure. Upon review of the entire record, we find that the veteran's current disability picture more nearly approximates the criteria outlined for a 30 percent schedular rating pursuant to Diagnostic Code 7899-7806. Although his skin condition does not appear to result in "constant" symptomatology, as shown by his most recent January 1994 VA examination which found no presence of active cysts, the evidence amply demonstrates that his skin condition is chronic and recurrent, and that these cysts clearly leave scars which are "disfiguring." Photographs submitted in February 1994 do not indicate any active lesions, but the presence of several large scars, particularly noticeable on his posterior neck and his face, are shown. Moreover, VA examining dermatologists have noted the presence of papules located over an extensive area of the veteran's body, from his head to his thighs, and multiple surgical resections of cysts have been performed not only in the face and neck area, but also on his back and on his buttocks. We find this evidence sufficient to demonstrate that his lesions are "extensive." We do not conclude, however, that a rating in excess of 30 percent is currently warranted. Although Dr. Rosen indicated in his January 1993 letter that the lesions which he removed in October 1992 demonstrated "ulceration" and "exfoliation," subsequent VA examinations have not noted the presence of these manifestations, nor has any evidence been presented that the disorder has resulted in systemic or nervous manifestations. Moreover, while the submitted photographs do indicate the presence of disfiguring scars in certain areas of the face, neck and back, they do not demonstrate that the veteran's skin disorder is "exceptionally repugnant." We note that these pictures were taken at a time when his skin disorder was allegedly "inactive." Nevertheless, we must base our decision on the record before us, and the totality of the evidence presented at this time does not establish that a rating of 50 percent is warranted. Therefore, in light of the extensive nature of his lesions, and the residual scarring caused by these cysts, we conclude that a schedular rating of 30 percent is warranted for the service-connected keratinous cysts. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.7, Part 4, Diagnostic Code 7899-7806 (1994). Should the veteran obtain any additional evidence which he believes is reflective of increased severity of his condition, he is encouraged to submit such records, including contemporaneous photographs, to reopen his claim. ORDER A 30 percent schedular disability rating for service-connected keratinous cysts is granted, subject to the regulations controlling the payment of benefits. JACK W. BLASINGAME 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.