Citation Nr: 0002404	
Decision Date: 01/31/00    Archive Date: 02/02/00

DOCKET NO.  98-07 234	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Medical & Regional Center 
Office in Fort Harrison, Montana


THE ISSUE

Entitlement to an increased evaluation for neurodermatitis of 
various body areas, currently evaluated as 30 percent 
disabling.  


REPRESENTATION

Appellant represented by:	Disabled American Veterans


WITNESS AT HEARING ON APPEAL

Appellant


ATTORNEY FOR THE BOARD

K.L. Salas, Associate Counsel


INTRODUCTION

The veteran had active military service from September 1970 
to August 1974.  

This appeal arose from a May 1996 rating decision by the 
Department of Veterans Affairs (VA) Medical and Regional 
Office Center (M&ROC) in Fort Harrison, Montana.  The M&ROC 
denied the claim of entitlement to an increased evaluation 
for the veteran's dermatological disability previously rated 
as neurodermatitis of the hands and left knee.  

The case has been forwarded to the Board of Veterans' Appeals 
(Board) for appellate review.  

The Board has recharacterized the veteran's service-connected 
dermatological disability in view of the evidentiary record 
which is discussed in greater detail below.


FINDING OF FACT

Neurodermatitis of various body areas is productive of 
impairment compatible with ulceration or extensive 
exfoliation or crusting, and systemic or nervous 
manifestations, or exceptionally repugnant.  


CONCLUSION OF LAW

The criteria for an increased evaluation of 50 percent for 
neurodermatitis of various body areas have been met.  
38 U.S.C.A. §§ 1155, 5107 (West 1991);  38 C.F.R. §§ 4.7, 
4.20, 4.21, 4.118, Diagnostic Code 7806 (1999).  


REASONS AND BASES FOR FINDING AND CONCLUSION

Factual Background

A review of the service medical records discloses that the 
veteran was treated for neurodermatitis of the hand in 
September 1972.  In October 1972 he was evaluated for dry 
skin of the hands.  No skin abnormality was shown when he was 
examined for separation from service in August 1974.

Private medical records show the veteran was treated for 
dermatitis of the hands from 1983, during the 1980's and 
1990's.

VA medical treatment reports show the veteran was treated for 
a rash of the hands during 1993 and 1994.

The veteran underwent a VA dermatological examination in 
February 1995.  He reported a rash on his hands and feet.  
Various treatments including salves and antibiotics had been 
used with no success.  Cracking, bleeding and irritation were 
more severe.  The veteran reported that his hands would crack 
and peel with pain and bleeding.  In the interim, the skin 
was dry and scaly.  

Examination showed the hands to appear powdery white with a 
pinkish flamed hue.  There were hard kernels with white hard 
centers at the back of his right hand and up along the crease 
of the junction of the fingers and hand bilaterally.  The 
backs of the hands were scaly and hard.  There were no open 
sores at the time but on the left hand there were two areas 
where the skin had peeled just opposite the hypothenar 
eminence at the heel of the hand.  They were heeling at the 
time and they were still annular in shape and slightly 
hypersensitive.  The veteran stated that he also had a patch 
behind his left knee and on evaluation there was a large 
patch behind the left knee on the medial side that was two 
centimeters in diameter.  




It was cracked centrally in three different places and the 
skin was very hard and patchy with the outside edges 
inflamed.  The impression was probable neurodermatitis of the 
hands and behind the left knee, rule out virus as an 
etiologic infective agent, and eczematoid reaction behind the 
left knee, posterior aspect.  

In February 1995 the M&ROC granted entitlement to service 
connection for neurodermatitis of the hands and left knee, 
with assignment of a 30 percent evaluation.

A November 1995 medical record from the veteran's treating 
physician noted a history of breaking out of the feet and 
hands that had progressively worsened.  There were apparently 
numerous courses of therapy with little improvement.  

The physician noted thick scaling and fissuring of the 
veteran's feet, especially on the plantar surfaces.  There 
were also fissures and scaling between the toes.  The palms 
showed less scaling but there were punctate keratotic lesions 
and fissuring, especially of the fingertips.  In addition, 
there was erythema, scaling and itching of the groin and 
popliteal area.  It was the opinion of the physician that the 
condition was due to a fungus.  She stated that with the 
amount of involvement of the veteran's hands and feet, there 
could be considerable discomfort.  

The veteran attended a VA outpatient dermatology consultation 
in January 1996.  Examination revealed thick hyperkeratotic 
crusts and a fissure bilaterally on the plantar surface of 
the great toes and deep fissures on the heels.  The examiner 
also observed marked dystrophy of the nails of the great toes 
and interdigital desquamation between the toes.  The palms 
showed hyperkeratotic papules on the palms with increased 
desquamation.  The impression was probable tinea pedis and 
manus with onychomycosis and palmar hyperkeratotic papules 
suggestive of verruca.  Medications were prescribed.  

Another VA examination was conducted in January 1996.  The 
veteran reported skin lesions on the hand, legs, feet, arms 
and thighs in service.  He reported that his skin problem 
continued to be eruptive and seemed to get worse, especially 
on the feet.  His legs behind the knees would also break out 
with a rash and he claimed occasional involvement of the 
chest and arms as well.  

With respect to the feet, the veteran reported that he was 
often in so much pain that he had difficulty walking.  He 
reported that the lesions, scaling, and cracking of the feet 
were constant, and did not seem to get any better.  He added 
that dryness and redness of the palms of the hands with 
scaling and little nodules continued to be constant.  

On examination there was an eczematoid and reddened eruption 
behind the right knee and also over the lower part of the 
lateral side of the lower right leg.  The ones on the lower 
part of the right leg were described as circular, red, 
raised, scaly lesions with central sloughing.  On the feet 
there was extensive scaling and thickening over the heels, 
the lateral part of the feet bilaterally, and across the 
metacarpal heads and toes, onto the great toes of each foot.  
There was skin cracking along the heels and also on the skin, 
under, and lateral to the great toes on both feet.  There was 
extensive mycotic erosion and infection of the toenail and 
toenail bed of the left great toe.  There was no bleeding of 
the feet, but the feet were very painful to the touch and 
there were some discreet nodules also along the outer edges 
of the feet on the soles.  The veteran was observed to walk 
more on the inside of his feet to avoid the cracking areas.  
He reported that he used pads in the shoes to help relieve 
the pressure and pain.  

The impressions were an eczematoid eruption on the legs and 
behind the right knee; extensive fungal infection of the feet 
with involvement of the heels, the lateral side of the feet 
the toes - especially the great toes and the medial side of 
the bottom of the feet along the great toes, and several 
areas of extensive cracking of the skin of the sole of the 
foot; extensive thickening of the skin of the sole on the 
lateral sides of both feet secondary to the infestation; and 
rule out sarcoid lesions on the feet as well as scaling and 
redness of the palmar surfaces of the hands.  


Photos showed thickening of the skin of the bottoms of the 
feet, especially the heels, cracking of the skin of the heels 
and toes, and nail changes.  There also was a photo of a 
round patch on what appears to be the back of the knee and 
another photo of several red dots on the back of the leg.  

Follow-up VA treatment reports from 1996 indicated that 
medications were not working.  

A VA treatment record from February 1997 notes that 
medication had not effectuated any change in the veteran's 
condition.  There was still significant dryness and fissuring 
of the hands and feet, and the condition appeared to be 
spreading.  There was a dry fissured area on the soles with 
excessive dryness of the palms and soles.  There were red 
patches on the trunk including a four-centimeter red patch on 
the left popliteal fossa.  There was also scaling of the 
scalp and ear and marked onychodystrophy.  The impression was 
psoriasiform dermatitis.  The examiner noted that a cure was 
unlikely.  

In March 1997 the veteran testified at a personal hearing at 
the M&ROC.  He testified that his feet, left leg, torso, 
head, ears, and scalp were all involved, and he thought he 
was beginning to have involvement on his face as well.  He 
stated that his hands, feet, and left leg were affected the 
worst.  He testified that he had rough skin continuously with 
splitting of his skin, and bleeding and oozing.  He testified 
that he had difficulty walking or holding onto things and had 
decreased sensation in his hands.  Treatment consisted of 
creams for his hands.  He understood that the creams were 
exfoliating.  He stated that he was not allowed to take 
showers anymore and was using a non-water-based soap.  

The veteran testified that as a result of his dermatitis, his 
clothes were ruined and he could not go swimming anymore.  He 
testified that he did not like to be seen in public without 
his shirt on, and he felt that people reacted abnormally to 
him upon shaking his hand.  

The veteran felt that it would be hard for him to hold down a 
regular full time job because of difficulties in standing and 
holding.  He testified that he had a ranch and was doing 
carpentry work on the side.  He stated that he was self 
employed and set the pace of his work.  He did not feel that 
he could work a 40-hour workweek.  

An official dermatologic examination for VA compensation 
purposes was conducted in April 1997.  The veteran reported 
rashes on the hands, feet, popliteal fossae and abdomen, not 
helped by various medications.  He complained of significant 
discomfort of his feet because of fissuring as well as of 
hand pain.  The other areas were described as "quite 
pruritic."  

The examination revealed numerous follicular papules on the 
trunk, especially over the mid-abdomen, and lower chest, and 
several on the back.  The papules were erythematous and 
somewhat firm to palpation.  There were also numerous 
eczematoid patches distributed over the distal arms and legs.  
Lichenified eczematous patches were noted in the left 
popliteal fossae.  On the palms there was very thick 
keratotic skin with numerous punctate keratotic papules.  The 
feet were very keratotic with deep fissuring noted in several 
areas.  Also noted was onychodystrophy present over the left 
great toe.  

The assessment was palmoplantar keratoderma manifested by 
excessive formation of keratin over the palms and soles.  
According to the dermatologist the cause was multi-factorial.  
The veteran denied a family history of skin problems.  
Psoriasis, lichens planus, atopic dermatitis, and allergic 
contact dermatitis were also considered.  The keratotic 
papules on the hands were compatible with punctate 
keratoderma, which could be seen in palmoplantar keratoderma.  
The dermatologist was unsure as to why the veteran was 
getting erythematous papules over the chest, as those 
appeared to be new.  A biopsy was done to rule out 
folliculitis, perforating diseases such as perforating 
folliculitis, follicular eczema or an unusual presentation of 
sarcoidosis.  

The doctor stated that because of the long-standing history 
of eczema, he felt that patch testing would be beneficial in 
the future.  He also stated that a future biopsy of the palms 
or soles was a possibility for evaluating the keratoderma, 
although most biopsies of keratoderma were non-specific.  A 
medication was prescribed to exfoliate the keratotic skin on 
the hands and feet.  

In his substantive appeal the veteran reported that he had a 
marked increase in ulcerations, exfoliation, and crusting on 
most of both of his legs, arms, torso, scalp, and groin area.  
He reported that this was documented in treatment records.  
He stated that he had been told that medication for his skin 
was having adverse effects on his liver function.  He stated 
that his condition was repugnant and noted that because of 
his sores he could not go swimming, and was limited in 
activities he could do with his children.  

A January 1999 private medical report shows involvement of 
the left and right lower extremities, the feet, the hands and 
the nails.  The head, face, neck and back were described as 
normal.  There were dusky red macules on the legs coalescing 
into small patches.  There were also some changes of post 
inflammatory hyperpigmentation.  The bottoms of the feet were 
remarkable for a moccasin-like distribution of red erythema 
with swelling.  

The toenails were remarkable for changes of onychomycosis.  
On the palms of the hands were several punctate lesions.  The 
diagnosis was progressive pigmented purpura with associated 
post inflammatory hyperpigmentation of the lower legs 
bilaterally, onychomycosis and tinea pedis, and punctate 
keratoses of the palms.  The doctor noted that the veteran 
was reassured about the benign nature of the disease.  

Photographs of the legs appearing to correspond with the 
physician's description of the veteran's skin condition were 
received.  


Criteria

Disability evaluations are determined by the application of a 
schedule of ratings based on average impairment of earning 
capacity.  Separate diagnostic codes identify the various 
disabilities.  38 U.S.C.A. § 1155;  38 C.F.R. Part 4 (1999).  
In determining the disability evaluation, VA must acknowledge 
and consider all regulations that are potentially applicable 
based upon the assertions and issues raised in the record, 
and explain the reasons and bases used to support its 
conclusions.  Schafrath v. Derwinski, 1 Vet. App. 589 (1991).  

The percentage ratings contained in the rating schedule 
represent, as far as practicable, the average impairment in 
earning capacity resulting from such diseases and injuries 
and their residual conditions in civil occupations.  For 
application of the rating schedule, accurate and fully 
descriptive medical examinations are required with emphasis 
on the limitation of activity imposed by the disabling 
condition.  It is essential, both in examinations, and in the 
evaluation of disability, that each disabling condition be 
viewed in relation to its history.  38 C.F.R. § 4.1 (1999).  
See also 38 C.F.R. § 4.2 (1999).  

The degree of impairment resulting from a disability is a 
factual determination and generally the Board's primary focus 
in such cases is upon the current severity of the disability.  
Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. 
Brown, 6 Vet. App. 396, 402 (1994).  

While not all criteria have been shown for an increased 
evaluation, findings sufficiently characteristic to identify 
the disease and the disability therefrom, and coordination of 
rating with impairment of function are expected in all 
instances.  38 C.F.R. § 4.21.  

When an unlisted condition is encountered it will be 
permissible to rate under a closely related disease or injury 
in which not only the functions affected, but the anatomical 
localization and symptomatology are closely analogous.  

Conjectural analogies will be avoided, as will the use of 
analogous ratings for conditions of doubtful diagnosis, or 
for those not fully supported by clinical and laboratory 
findings.  Nor will ratings assigned to organic diseases and 
injuries be assigned by analogy to conditions of functional 
origin.  38 C.F.R. § 4.20.

A 30 percent evaluation may be assigned for eczema with 
exudation or itching constant, extensive lesions, or marked 
disfigurement.  A 50 percent evaluation may be assigned for 
eczema with ulceration and extensive exfoliation or crusting, 
and systemic or nervous manifestations, or exceptionally 
repugnant.  38 C.F.R. § 4.118, Diagnostic Code 7806.  

Ratings shall be based as far as practicable, upon the 
average impairments of earning capacity with the additional 
proviso that the Secretary shall from time to time readjust 
this schedule of ratings in accordance with experience.  To 
accord justice, therefore, to the exceptional case where the 
schedular evaluations are found to be inadequate, the Under 
Secretary for Benefits or the Director, Compensation and 
Pension Service, upon field station submission, is authorized 
to approve on the basis of the criteria set forth in this 
paragraph an extra-schedular evaluation commensurate with the 
average earning capacity impairment due exclusively to the 
service-connected disability or disabilities.  The governing 
norm in these exceptional cases is:  A finding that the case 
presents such an exceptional or unusual disability picture 
with such related factors as marked interference with 
employment or frequent periods of hospitalization as to 
render impractical the application of the regular schedular 
standards.  38 C.F.R. § 3.321(b) (1) (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 for 
that rating.  Otherwise, the lower rating is assigned.  38 
C.F.R. § 4.7.  

When all the evidence is assembled, VA is responsible for 
determining whether the evidence supports the claim or is in 
relative equipoise, with the appellant prevailing in either 
event, or whether a preponderance of the evidence is against 
the claim, in which case, the claim is denied.  Gilbert v. 
Derwinski, 1 Vet. App. 49 (1990).

When after consideration of all of the evidence and material 
of record in an appropriate case before VA there is an 
approximate balance of positive and negative evidence 
regarding the merits of an issue material to the 
determination of the matter, the benefit of the doubt in 
resolving each such issue shall be given to the claimant.  
38 U.S.C.A. § 5107(b) (West 1991);  38 C.F.R. §§ 3.102, 4.3 
(1999).  

Analysis

Initially, the Board finds that the veteran's claim of 
entitlement to an increased evaluation for his 
neurodermatitis of multiple body areas is well grounded 
within the meaning of 38 U.S.C.A. § 5107(a); that is, a 
plausible claim has been presented.  Murphy v. Derwinski, 1 
Vet. App. 78 (1990).

In general, an allegation of increased disability is 
sufficient to establish a well grounded claim seeking an 
increased rating.  Proscelle v. Derwinski, 2 Vet. App. 629 
(1992).  The veteran's assertions concerning the severity of 
his neurodermatitis of multiple body areas (that are within 
the competence of a lay party to report) are sufficient to 
conclude that his claim for an increased evaluation for that 
disability is well grounded.  King v. Brown, 5 Vet. App. 19 
(1993).  

The Board is satisfied that all relevant facts have been 
adequately developed to their full extent, and that VA has 
met its duty to assist.  Godwin v. Derwinski, 1 Vet. App. 419 
(1991); White v. Derwinski, 1 Vet. App. 519 (1991).  

The RO has rated the veteran's neurodermatitis of multiple 
body areas as 30 percent disabling by analogy to eczema under 
Diagnostic Code 7806.  The current 30 percent evaluation 
contemplates neurodermatitis with exudation or itching 
constant, extensive lesions, or marked disfigurement.  The 
next, and maximum schedular evaluation of 50 percent under 
this code contemplates neurodermatitis with ulceration or 
extensive exfoliation or crusting, and systemic or nervous 
manifestations, or exceptionally repugnant.  

The Board is of the opinion that the evidentiary record 
supports a grant of the maximum schedular evaluation of 50 
percent.

The veteran has alleged the existence of crusting and 
ulceration, and has stated that his condition is 
exceptionally repugnant.  Upon viewing photographs provided 
by him, the Board cannot agree that the service-connected 
dermatitis is exceptionally repugnant.  It does appear from 
the photos that some crusting may be occurring, and crusts 
were noted in a VA outpatient treatment record from January 
1996.  

In addition, significant fissuring of the veteran's feet has 
been documented and medication has been prescribed to promote 
exfoliation.  The evidentiary record is replete with well 
documented treatment of neurodermatitis not only by VA, but 
by private medical professionals.  The treatment reports 
suggests that the dermatological disorder is getting worse, 
and has been refractory to a number of treatment regimens, 
although there have been periodic remissions and 
exacerbations in various body areas.  The clinical picture 
reflects great efforts to control manifestations of 
neurodermatitis.  

In the judgment of the Board the veteran has shown symptoms 
more nearly approximating the criteria for a 50 percent 
evaluation.  As noted previously, not all criteria have to be 
shown for an increased evaluation, but findings sufficiently 
characteristic to identify the disease and the disability 
therefrom, and coordination of rating with impairment of 
function are expected.  38 C.F.R. § 4.21.  

A note in the diagnostic codes pertaining to skin disorders 
states that in rating various skin disorders as eczema, the 
location, extent of involvement and repugnant or otherwise 
disabling manifestations of the disorder should be taken into 
account.  In considering the claim on appeal for resolution, 
the Board has taken into consideration the intensity of the 
dermatological disability, pain with walking, need for an 
aggressive treatment regimen, and the appearance of lesions.  
For the foregoing reasons, the Board finds that the 
evidentiary record supports a grant of entitlement to the 
maximum schedular evaluation of 50 percent for 
neurodermatitis of multiple body areas.


Additional Matter

The United States Court of Appeals for Veterans Claims 
(Court) has held that the Board is precluded by regulation 
from assigning an extraschedular rating under 38 C.F.R. 
§ 3.321(b)(1) in the first instance.  Floyd v. Brown, 9 Vet. 
App. 88 (1996).  However, the Board is still obligated to 
seek all issues that are reasonably raised from a liberal 
reading of documents or testimony of record and to identify 
all potential theories of entitlement to a benefit under the 
law or regulations.  

In Bagwell v. Brown, 9 Vet. App. 337 (1996), the Court 
clarified that it did not read the regulation as precluding 
the Board from affirming an RO conclusion that a claim does 
not meet the criteria for submission pursuant to 38 C.F.R. 
§ 3.321(b)(1), or from reaching such conclusion on its own.  
The Court has further held that the Board must address 
referral under 38 C.F.R. § 3.321(b)(1) only where 
circumstances are presented which the VA Under Secretary for 
Benefits or the Director of the VA Compensation and Pension 
Service might consider exceptional or unusual.  Shipwash v. 
Brown, 8 Vet. App. 218, 227 (1995).

In the veteran's case at hand, the Board notes that the M&ROC 
not only provided the veteran with the criteria referable to 
assignment of extraschedular evaluations, it also discussed 
its provisions in light of his claim, and determined that the 
dermatological disability was not unusual or exceptional in 
nature.  The Board agrees with the determination of the 
M&ROC.

In this regard the Board notes that the treatment for the 
appellant's dermatological disability has been strictly on an 
outpatient basis.  He has, on the basis of the evidence of 
record, never required inpatient care.  The clinical record 
cannot therefore be said to reflect a need for frequent 
inpatient care of the claimant's neurodermatitis of multiple 
body areas.  

As to employment, the veteran has testified as to how he 
feels his dermatological disability would prevent him from 
working a regular full time job.  Nonetheless, he is self-
employed and accommodates the duration of his employment with 
the disabling manifestations of his disability.  Marked 
interference in his ability to work has not been shown by the 
competent medical evidence of record.  

The Board finds that the current schedular criteria with a 
disability evaluation of 50 percent adequately compensate the 
veteran for the nature and extent of severity of his 
neurodermatitis of multiple body areas.  Having reviewed the 
record with these mandates in mind, the Board finds no basis 
for further action on this question.  In other words, the 
Board sees no basis for referral of the case to the VA Under 
Secretary for Benefits or the Director of the VA Compensation 
and Pension Service for consideration of extraschedular 
evaluation pursuant to the provisions of 38 C.F.R. 
§ 3.321(b)(1).


ORDER


Entitlement to an increased evaluation of 50 percent for 
neurodermatitis of multiple body areas is granted, subject to 
the governing criteria applicable to the payment of monetary 
awards.  



		
	RONALD R. BOSCH
	Member, Board of Veterans' Appeals