BVA9501386 DOCKET NO. 93-08 849 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUE Entitlement to an increased evaluation for generalized dermatitis, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The appellant, his spouse and his daughter ATTORNEY FOR THE BOARD Jeanne Schlegel, Associate Counsel INTRODUCTION The appellant served on active duty from August 1942 to October 1945. This matter comes before the Board of Veterans' Appeals (the Board) from a rating determination by the Department of Veterans Affairs (VA) Regional Office (RO). In its October 1992 determination, the RO increased the appellant's disability rating for generalized dermatitis from a 10 percent to a 30 percent schedular evaluation. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends that the 30 percent disability evaluation currently in effect does not adequately reflect the severity of his service connected dermatitis. He states that his condition is terrible looking and causes him serious pain and discomfort. The appellant further contends that his skin condition has spread over his entire body, and is not just confined to his foot and ankle. 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 the weight of the evidence is against an increased rating for generalized dermatitis. FINDING OF FACT The appellant's service-connected skin disorder is manifested by itching, lesions, lichenification, and marked disfigurement; ulceration or systemic or nervous manifestations attributable to the service-connected disorder, extensive exfoliation or crusting, or exceptional repugnance is not shown. CONCLUSION OF LAW The schedular criteria for an increased evaluation in excess of 30 percent for generalized dermatitis is not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991). 38 C.F.R. § Part 4, Diagnostic Code 7806 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, the Board has found the appellant's claim well- grounded pursuant to 38 U.S.C.A. § 5107 (West 1991) in that his claim is plausible. Murphy v. Derwinski, 1 Vet.App. 78 (1990). This finding is based on the appellant's evidentiary assertion that his service connected disability has increased in severity. Proscelle v. Derwinski, 1 Vet.App. 629 (1992); King v. Brown, 5 Vet.App. 19 (1993). Once it has been determined that the claim is well-grounded, The VA has a statutory duty to assist the appellant in the development of evidence pertinent to the claim. 38 U.S.C.A. § 5107. The Board is satisfied that all available evidence necessary for an equitable disposition of the appeal has been obtained. Under applicable criteria, 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; 38 C.F.R., Part 4. Separate diagnostic codes identify the various disabilities. The VA has a duty to acknowledge and consider all regulations which are potentially applicable through 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 (1991). It is essential that each disability be viewed in relation to its history, and that medical examinations are accurately and fully described emphasizing limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.1 (1993). Medical evaluation reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2 (1993). When eczema is characterized by exudation or constant itching, extensive lesions, or marked disfigurement, a 30 percent disability evaluation is warranted. Where eczema is shown with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or is exceptionally repugnant, a 50 percent disability evaluation is warranted, which is the highest schedular evaluation provided under his diagnostic code. 38 C.F.R. Part 4, Code 7806 (1993). Service connection was initially granted for dermatophytosis of the feet and right ankle by a November 1982 rating decision at which time the appellant's skin disorder was described as dermatophytosis of the feet and right ankle, and was evaluated under Diagnostic Code 7813. A 10 percent schedular rating was assigned from July 1982 based on service records such as those from July 1944 which showed a severe chronic fungus infection of the feet, legs, hands and trunk, and records from March 1945 showing generalized chronic dermatitis and epidermophytosis of the hands bilaterally which was described as moderate and chronic. The separation examination conducted in October 1945 showed a diagnosis of generalized eczema and indicated that the appellant was hospitalized in July 1944 for eczema. Subsequently, the appellant was hospitalized in July 1982 with a diagnosis of possible thrombophlebitis of the right leg and fungal infection in both feet. In August 1982, he was treated for erythematous patchy areas on the surfaces of both feet and the medial aspects of the right ankle. In September and October 1982 the appellant complained of itching on the plantar aspects of the feet. In February 1989, the RO received correspondence from the appellant stating that he felt his condition had become worse and requesting that he be re-evaluated. A VA dermatology examination was conducted in April 1989. The examiner noted a long history of tinea pedis dating back to service. The examination revealed erythema, and a scaling of the feet with yellowed thickened dystrophic toenails. Mild dermatitis of the right lower leg was shown. The impression was tinea pedis with onychomycosis, stasis, and mild dermatitis of the lower legs. In May 1989 the appellant was rated, and the 10 percent evaluation of November 1982 was confirmed. A VA examination was conducted in May 1991. The appellant complained of an infection in the right leg and both feet. The examination revealed erythematous and a scaly rash with scattered areas of exfoliation on the plantar aspects of both feet. Chronic erythema of all of the torso was also shown. Erythematous rash on the abdomen, back and scalp was present. No active ulceration or discharge was noted. There was evidence of itching in the form of scratch marks on the right leg. The appellant was diagnosed with dermatophytosis of the feet and right ankle. It was also noted that the veteran had moderately severe bilateral varicose veins and venous insufficiency. In June 1991 the appellant was rated again for his skin condition. The RO determined that based on the May 1991 examination, there was no evidence of an increase in severity and the 10 percent evaluation was confirmed. A Notice of Disagreement was received from the appellant in December 1991. Outpatient treatment reports covering the period from January 1990 to September 1991 and, separately outpatient treatment records dated December 1991 and June 1989 were also received in December 1991. The report of June 1989 showed that the appellant complained of pain and swelling in the right lower leg and ankle. Pitting and edema was noted. The entry read "altered skin integrity and comfort related to right leg rash and pain." The reports also show that in October 1990 the appellant was seen for a follow up on his right ankle. The ankle was "better". The ankle was slightly swollen, but the appellant denied any drainage. The examiner's assessment was psoriasis. In March 1991, medication for the treatment of psoriasis was continued. In May 1991, an entry noted that the toes on the right foot were reddened and showed edema. In December 1991, the appellant complained of a right ankle rash. The ankle was swollen. The examiner's assessment was erythematous condition of the right ankle. The majority of the outpatient treatment records covered conditions other than the appellant's service- connected skin condition. Subsequently, the RO's January 1992 determination confirmed and continued the 10 percent evaluation in effect for his service- connected disability. Statements by the appellant's wife and daughter were also received in December 1991. The statements essentially said that the appellant has a severe infection manifested by swelling and rashes, and that he sometimes has trouble walking. It was emphasized that the condition becomes worse in the summer. In February 1992 outpatient treatment records were received dated January 30, 1992 indicating that the appellant complained of a swollen right ankle, scaly itchy scalp and itchy arms. He also complained that the right ankle drained a clear liquid daily, especially when crusted over. The examiner noted scaly skin on the face. Varicose veins were noted in the right leg. A four to five inch in diameter scaly area, with no drainage was noted on the right ankle. The examiner's assessment was apparently stasis dermatitis secondary to varicose veins. The appellant was continued on medication for the skin and advised to elevate the right leg. A VA compensation and pension examination was conducted in February 1992 specifically to evaluate the condition of the skin. The appellant complained that he has had recurrent skin rashes all over his body since 1942, and that the areas had become infected to the point where he has become "delirious" and has required intensive care therapy. He complained of severe itching and at times true pain especially in infected areas. The physical examination revealed crusted retitic patches, primarily in the right medial, lateral, and posterior ankle. A KOH test was performed on the right ankle to reveal any infection, however the tests were negative. Some toe web maceration and some scale on his feet were shown. There was hyperhidrosis of both feet. The right proximal upper extremity had a patch of excoriated lichenified papules, and there were excoriations present on the upper back. The left abdomen had erythema, with cutoff at the midline, which the appellant indicated was the site of the previous rash. There was no epidermal change in that area. Edema of the bilateral extremities was shown, greater on the right than the left. Bilaterally, there was toe nail dystrophy with thickening discoloration, and debris. The diagnoses was dermatitis, stasis dermatitis and tinea pedis. A hearing at the RO was held in March 1992. The appellant stated that this feet and ankles were the most affected by his skin condition, but that it also affects other areas such as his arms and head. He testified that it itches everyday and that there is some draining in his right ankle. He mentioned bumps on his skin that break open, water and then scab and scar and indicated that his condition becomes particularly worse in hot weather. He indicated that he uses Hydrocortisone cream about everyday. He revealed that some nervous manifestations such as itching at night followed by waking up and walking around three to four times a night he attributes as related to his skin condition. In June 1992 the appellant submitted color photographs of his skin condition as it appeared on his ankle and lower leg. All of the photographs were of the lower extremities and primarily showed the condition of the right ankle. Scaling, swelling and redness was shown in the photographs. The RO again considered the appellant's claim for an increased rating in March 1992. At that time, evidence including service medical records, medical summaries dating from June 1989 to January 1992, VA examinations from May 1991 and February 1992 , and the statements of the appellant's wife and daughter submitted in December 1991 was considered. The rating decision denied an increased evaluation for the appellant's skin condition described as generalized dermatitis evaluated under Diagnostic Code 7806, formerly the condition was rated as dermatophytosis of the feet and left ankle evaluated under Diagnostic Code 7813. The most recent VA examination was conducted in August 1992. Several color slides of the affected areas were taken and are of record. These appear to reflect the condition of the lower extremities and the arms. By history, the appellant provided that he had been treated with a variety of different medications, topically. He stated that he had times of worsening and times of improving of the skin, but felt that the condition had never completely cleared, and in fact had been worse for the last several years. The appellant complained of itching on numerous areas of the body, especially the areas covered by lesions. Objective medical findings show numerous excoriations scattered over dorsal arms and legs. There are a few isolated excoriated papules on the right upper arm. No primary lesions were noted on the upper arm. On the right lower leg, scaly plaque measuring 4x5 centimeters on the medial ankle was noted. On the right lateral leg, a 4x3 centimeter slightly eroded erythematous annular lesion was seen, and over the right lateral ankle region there was a 6x4 centimeter scaly plaque, similar to that seen on the medial ankle. Also noted was a 1+ pitting pretibial edema. Numerous excoriations were noted on the lower leg. The examiner stated that the findings and symptoms appear to be consistent with nummular eczema. It was noted that due to the chronic course of several lesions, some of them may be tending towards a lichens simplex chronicus, and it is likely to be a persistent process which cannot be easily cured, but can be controlled. The RO most recently rated the appellant's disability, generalized dermatitis, in October 1992. Upon consideration of the new evidence submitted, the color photos submitted June 1992 and the VA examination and slides of August 1992, an increased rating was granted. The RO determined that the evidence showed exudation or constant itching, extension lesions and marked disfigurement consistent with the schedular criteria for a 30 percent evaluation under Diagnostic Code 7806. The RO noted that the evidence did not show ulceration, excessive exfoliation or crusting, systemic or nervous manifestation or that the condition was especially repugnant, warranting a 50 percent schedular evaluation. The Board, having independently reviewed the evidence of record finds that the evidence does not warrant an increased rating for generalized dermatitis. 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. Francisco v. Brown, 7 Vet.App. 55 (1994). The photographs submitted by the appellant and the slides taken in conjunction with the August 1992 examination show lesions and scaling of the skin but not to an extent which is "exceptionally repugnant." The clinical findings of the VA examination in August 1992 did not include findings of ulceration or extensive exfoliation nor mention any systemic or nervous manifestations. The appellant indicated in the hearing testimony in March 1992 that he had some nervous manifestations resultant from his skin condition. However, no such manifestations were documented upon examination. Further, the Court has held that while a lay party is competent to testify as to facts within his own observation and recollection, such as visible symptoms, a lay party is not competent to provide probative evidence as to matters requiring expertise derived from specialized medical education, training, or experience, such as matters relating to a diagnosis or medical causation. Espiritu v. Derwinski, 1 Vet.App. 492 (1992). Thus, while the veteran and other lay parties are competent to provide testimony to establish that a symptom is present (such as nervousness, swelling or difficulty ambulating), they are not competent to link that symptom to a specific disease or injury. Consideration has been given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4 whether or not they were raised by the veteran, as required by Schafrath v. Derwinski, 1 Vet.App. 589 (1991). The evidence of record does not show that the appellant's disability presents such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards so as to warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1). Specifically, the right knee disability picture presented has not required frequent periods of hospitalization, nor has it resulted in marked interference in employment as to render impracticable the application of regular schedular standards. 38 C.F.R. § 3.321(b) (1993). The Board has considered the benefit of the doubt doctrine in its consideration of this case, however, the record does not demonstrate an approximate balance of positive and negative evidence as to warrant resolution of this case on that basis. 38 U.S.C.A. § 5107(b). ORDER An increased evaluation for generalized dermatitis is denied. RICHARD B. FRANK 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.