Citation Nr: 0006550 Decision Date: 03/10/00 Archive Date: 03/17/00 DOCKET NO. 98-18 980 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to a rating in excess of a noncompensable evaluation for a skin disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Marisa Kim, Associate Counsel INTRODUCTION The veteran had active military service from January 1994 to June 1997. This appeal is before the Board of Veterans' Appeals (Board) from a July 1997 rating decision from the Waco, Texas, Department of Veterans Affairs (VA) Regional Office (RO) that granted service connection for a history of xerosis and petechia as noncompensable. FINDINGS OF FACT 1. The medical evidence shows that the veteran's skin disability results in exfoliation and itching and involves exposed surfaces and extended areas. 2. The medical evidence does not show constant exudation, extensive lesions, marked disfigurement, ulceration, extensive crusting, or systemic or nervous manifestations of a skin disability. CONCLUSION OF LAW The criteria are met for an increased rating to 10 percent for a skin disability. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.1, 4.2, 4.7, 4.10, 4.20, 4.118, Diagnostic Code 7806 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION Factual Background The veteran's skin disability began as recurrent rashes in Korea and milder recurrences that continued after service. Service medical records showed treatments in 1996 for skin rashes on the veteran's face, forearms, legs, and trunk. The April 1996 diagnosis was contact dermatitis. In November 1996, the veteran reported dry itchy skin on her trunk for 2- 3 months diagnosed as xerosis on trunk and petechia secondary to a drug eruption that was resolving. Examination revealed no petechia on the veteran's legs but did show a faint, livid pattern on her upper thighs. The diagnosis was an allergic drug reaction. The service medical records show no other treatment or diagnosis of chronic skin disabilities. The military discharge examination report revealed no symptoms or residuals of a skin disability. The August 1997 outpatient treatment report showed that the veteran's skin was warm, dry, and pink. She complained of welts on her legs that had been present since she served in Korea. The welts increased at night. The impression was a skin rash. At the June 1998 outpatient treatment, the veteran reported a history of atopic dermatitis since 1995. She reported that the rash resembled bug bites. The objective finding was of totally clear skin. The assessment was urticaria versus contact dermatitis, by history. In the October 1998 appeal, the veteran asserted that the prior dermatology examination was inadequate for rating purposes. The veteran was examined at the allergy and immunization clinic in January 1999. She complained of having itching and small hives on her arms and difficulty breathing since last night. The assessment was acute urticaria, and the veteran was treated with medications. The veteran underwent a VA examination in February 1999. She reported no current dermatosis. When dermatosis occurred, it usually located on her thighs, arms, and legs but not on her stomach. It occurred more in warmer weather or when the veteran perspired. Physical examination showed 7-8 of 1-2 millimeter reddish, papules or pustules on the veteran's upper back and shoulders. There was no ulceration, exfoliation, or crusting. There were no associated systemic or nervous manifestations. The diagnosis was miliaria rubra versus cholinergic urticaria, both by history. Today's rash was nonspecific. The veteran did not respond to the RO's August 1999 letter that requested health care providers' names and addresses. The veteran underwent a VA examination in September 1999. The veteran complained of recurrent skin rash with itching, burning, and occasional swelling of the face, lips, and eyes and occasional shortness of breath. Physical examination revealed slightly raised, thin red streaks after the examiner stroked the flexure aspect of the left arm. There was no evidence of dermatosis, ulceration, exfoliation, or crusting. There were no systemic or nervous manifestations such as current facial, lip, or eye swelling. The diagnosis was mild dermographism, cholinergic urticaria, and pressure urticaria. The veteran, assisted by her representative, provided sworn testimony at a video hearing before the Board in February 2000. She testified that, after service, she saw a doctor who diagnosed cholinergic allergic urticaria, allergy to extreme hot water or extreme cold water, and exercise-induced allergies where sweating caused a rash. She had these outbreaks 2-3 times per year. Transcript (February 2000), page 3. The dermatologist gave the veteran Selenium 2 percent shampoo and hydrocortisone moisturizer. She used the moisturizer on her face daily and on her body whenever rashes occurred. Transcript (February 2000), page 4. She used another hydrocortisone cream for her legs. Transcript (February 2000), page 8. Her face did not bleed, itch, or hurt when she washed, but it became scaly and resembled a bad, peeling sunburn. The rash affected the insides of the veteran's arms and legs, torso, stomach, abdomen, breasts, face, neck, and back. Transcript (February 2000), page 4. The rash usually started on one particular part but spread to all other parts. Transcript (February 2000), page 8. The flare-up episodes lasted anywhere from 24-72 hours up to a week. During the episodes, the veteran's skin burned and itched, and afterwards, her skin peeled while it took 2 weeks to return to normal. Transcript (February 2000), page 7. The veteran saw an allergist 2-3 times per month and a pulmonologist once each month for allergies and suspected asthma. She testified that it was difficult to get an appointment to see the VA dermatologist during flare-ups because the VA made her get a referral from her family doctor each time. She was disappointed because the VA had not correctly diagnosed her skin disability in 3 years and she felt that she should not have to pay a private doctor. She was disappointed with the VA dermatologist because he did not follow up with any medical care or give her a final diagnosis. Instead, she received medications for an entire year and never received her laboratory results. She cared for the rashes at home because of the stress dealing with the VA. Transcript (February 2000), pages 5-6. The veteran worked as an emergency room nurse. She covered her scaly, flaky rashes because they resembled measles and she did not want patients to perceive her as contagious or unprofessional. Transcript (February 2000), page 8. Criteria In determining the disability evaluation, the VA has a duty to acknowledge and consider all regulations which are potentially applicable based upon the assertions and issues raised in the record and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Schedule). 38 C.F.R. Part 4 (1999). The percentage ratings contained in the Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (1999). Regulations require the evaluation of the complete medical history of the veteran's condition. 38 C.F.R. §§ 4.1, 4.2 (1999). However, where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation, regulations do not give past medical reports precedence over current findings. 38 C.F.R. § 4.2 (1999). The veteran's skin disability will be evaluated under the criteria of eczema, an analogous disease, because xerosis, petechia, miliaria rubra, urticaria, and dermographism are not specifically listed in the rating schedule. When a disability not specifically provided for in the rating schedule is encountered, it will be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. See 38 C.F.R. § 4.20 (1999). Eczema with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant eczema, is entitled to a 50 percent evaluation. Eczema with exudation or itching constant, extensive lesions, or marked disfigurement is entitled to a 30 percent evaluation. Eczema with exfoliation, exudation or itching, if involving an exposed surface or extensive area is entitled to a 10 percent evaluation. Eczema with slight, if any, exfoliation, exudation or itching, if on a nonexposed surface or small area, is entitled to a noncompensable evaluation. 38 C.F.R. § 4.118, Diagnostic Code 7806 (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 (1999). Analysis The veteran's claim for a rating in excess of a noncompensable evaluation for a skin disability is well grounded. When a veteran is awarded service connection for a disability and subsequently appeals the initial assignment of a rating for that disability, the claim continues to be well grounded. Shipwash v. Brown, 8 Vet. App. 218, 224 (1995); see also Fenderson v. West, 12 Vet. App. 119 (1999). An increased rating to 10 percent is warranted because the rashes, when they occur, result in exfoliation and itching and involve exposed surfaces and extended areas. Although the February 1999 and September 1999 examiners noted no exfoliation, the veteran testified she had 2-3 outbreaks of rashes every year and that her skin peeled for 2 weeks before returning to normal. The veteran reported itching to the September 1999 examiner, and she testified to using hydrocortisone medications to control the itching. The rashes involved exposed surfaces of the veteran's body and extended areas. The veteran testified that she dressed to cover the rashes for work and that the rashes always spread from one part of her body to encompass the insides of her arms and legs, torso, stomach, abdomen, breasts, face, neck, and back. A higher 30 percent rating is not warranted because the evidence does not show constant exudation, extensive lesions, or marked disfigurement. Although the veteran reported itching, she testified that the outbreaks are limited to 2-3 outbreaks per year and last no more than 1-7 days. Although the veteran reported occasional swelling of her face, lips, and eyes in September 1999, the February 1999 and September 1999 examiners found no associated systemic or nervous manifestations of a skin disability. Accordingly, the veteran's disability picture more nearly approximates the criteria for a 10 percent evaluation. Finally, extraschedular considerations do not apply in this case because exceptional circumstances have not been claimed or demonstrated. See Smallwood v. Brown, 10 Vet. App. 93, 97-98 (1997); 38 C.F.R. § 3.321(b)(1999). The evidence does not show that the service-connected disability markedly interferes with employment or causes frequent hospitalizations. ORDER Entitlement to a 10 percent evaluation is granted, subject to the controlling laws and regulations governing the payment of monetary awards. V. L. Jordan Member, Board of Veterans' Appeals