BVA9502903 DOCKET NO. 93-11 876 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for chloracne. REPRESENTATION Appellant represented by: Military Order of the Purple Heart ATTORNEY FOR THE BOARD K. Hudson, Associate Counsel INTRODUCTION The veteran had active service from August 1968 to March 1970, and from March to April 1974. This appeal ensues from the veteran's timely appeal from a March 1992 regional office (RO) rating decision which denied service connection for chloracne as a result of exposure to Agent Orange. The Board of Veterans' Appeals (Board) denied the claim by decision dated in September 1993, and the veteran appealed the decision to the United States Court of Veterans Appeals (Court). By a subsequent Order issued pursuant to a joint motion to remand filed by both parties, the Court, in [citation redacted], vacated the Board decision and remanded the case to the Board for further action in accordance with the Court's order. In September 1994, the case was remanded to the RO for additional action prior to an appellate decision. In a recent statement from the veteran, received in October 1994, he also referred to disabilities such as "psoriasis of the liver" and "Hodgkin's skin disease." From the context, it is impossible to tell whether or not he is claiming that such disorders are due to Agent Orange exposure. He is advised that this decision is limited to the issue of service connection for chloracne. If he wishes to file a claim for service connection for other claimed residuals of Agent Orange exposure, he should so notify the regional office, since the statement of October 1994 is not of sufficient specificity as to constitute an informal claim. See, 38 C.F.R. § 3.155(a) (an informal claim must identify the benefit sought) (1994). CONTENTIONS OF APPELLANT ON APPEAL The veteran essentially contends that he suffers from chloracne as a result of exposure to Agent Orange while in Vietnam. He points to medical evidence supportive of his claim, and contends that where there is conflicting medical evidence, the benefit of the doubt should be resolved in his favor. 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 evidence supports a grant of service connection for residuals of chloracne. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appellant's appeal has been obtained by the originating agency. 2. The veteran had combat service in Vietnam during the Vietnam era. 3. The veteran's statements that he had skin lesions in service is consistent with the circumstances of his service. 4. Qualified medical evidence establishes that the lesions as described by the veteran in service were consistent with chloracne, and that the veteran currently has residual scarring consistent with chloracne. CONCLUSION OF LAW Chloracne was incurred in active wartime service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1154, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, we find that the appellant's claim is well-grounded; that is, it is plausible. 38 U.S.C.A. § 5107(a) (West 1991); Murphy v. Derwinski, 1 Vet.App. 78 (1991). The relevant facts have been properly developed, and, accordingly, the statutory obligation of the Department of Veterans Affairs (VA) to assist in the development of the appellant's claim has been satisfied. Id. Factual Background Service personnel records document that the veteran was stationed in Vietnam from March 1969 to March 1970. His occupational specialty throughout this time period was harborcraft crewman. Service medical records show that in May 1969, he was treated for a heat rash in both thighs. In January 1970, a rash in the groin area was noted, with an impression of tinea cruris. No further mention of a skin disorder was made during service, including on the separation examination. The medical records pertaining to the veteran's second period of active duty, from March to April 1974, are likewise devoid of any mention of complaints or findings of a skin abnormality. Subsequent to service, records first show a skin condition in December 1982, when North Carolina Division of Prisons medical records showed a number of scattered excoriated lesions on the head and trunk. Although the veteran related these to Agent Orange exposure, the examiner noted they appeared factitial. During a hospitalization from December 1986 to January 1987, findings of generalized dermatitis, appearing infected and in various states of infection was noted; dermatology consult resulted in a diagnosis of impetigo. On a VA examination in March 1987, several infected lesions on the right arm and right upper back were noted. A VA nursing admission assessment of September 1987 also noted cysts on the back, arms and legs. On a VA examination in November 1989, for scars on the scalp and left leg did not find any scars. However, in December 1989, on an examination during a hospitalization, the veteran had numerous excoriations on the legs, buttocks, abdomen and back. During a VA hospitalization in February 1990, an examination revealed folliculitis of the hair follicles over the body and scattered areas. Scabbed lesions were noted on the shoulders and left forehead in March 1990. In August 1990, multiple skin lesions over the veteran's body that were small and erythematous were noted. A VA outpatient treatment note dated in January 1991 showed a complaint of "boils" on the arms and legs. Examination revealed 1-2 centimeter erythematous, fluctuant tender areas on the arms and legs. Numerous excoriations were also noted on both arms and legs. The pertinent diagnosis was carbuncles. According to a letter dated in May 1991 from G. Winton, M.D., the veteran had recurring skin problem which initially began in August 1969. At that time the veteran was an infantryman in Vietnam, and exposed to Agent Orange. He began to develop a skin rash consisting of pimples and boils on the head, neck and other parts of the body, which were aggravated by heat and only cleared after they were incised and drained. Since discharge, he has continued to have similar problems with his skin with cysts occurring every few weeks. On examination, he had a few healing acneiform lesions on the neck, upper arms, and lower trunk. There was also evidence of scarring on the neck and lower face. Dr. Winton's impression was that the veteran's skin condition was entirely consistent with exposure to Dioxin or Agent Orange, which caused chloracne. Acneiform lesions could continue to occur for several decades following acute exposure. A VA dermatology consultation performed in February 1992 reported a history of skin problems beginning following the veteran's return from Vietnam. He complained of pustular lesions on the face, back, neck, buttocks, and thighs that was recurrent, worse in hot, damp weather. Examination revealed a reddened area on the left thigh and a few small pimple-like lesions on the buttocks. He noted that there were no blackheads or straw cysts or other signs consistent with chloracne, and he diagnosed furunculosis. A VA Agent Orange protocol examination was conducted in July 1992, at which time a history of a recurrent skin disorder, apparently chloracne, was noted. Examination revealed scars of boils on the neck and buttocks, and the diagnosis was history of chloracne. The veteran was informed, by letter dated in August 1992, that the examination had found he was experiencing a recurrent skin disorder (chloracne). A VA dermatological examination was conducted in February 1993, by the same physician who had conducted the February 1992 examination. The veteran described crops of boils and pustules primarily on the posterior aspect of his neck, behind the ears and a bit on the face. He did not currently have any active lesions, nor did he describe a history of cysts or comedones. Examination revealed numerous hypopigmented scars over the back of the neck with some cicatrix. He had similar hypopigmented scars clustered on the forearms bilaterally, and punctate excoriations over the forearms and over the legs. There were no comedones or straw cysts. He indicated some scars over the thighs that he though were indicative of boils and pointed to one typical lesion that was a small erythematous papula pustule centered over a hair follicle on his left anterior thigh. It was concluded that the veteran had neurotic excoriation by history, folliculitis, with nothing compatible to support a diagnosis of chloracne; in fact, the examiner felt the veteran did not have any significant primary skin disease, but had severe psychiatric problems, some of which were manifested as secondary to injury to the skin. In November 1994, the veteran was examined by D. Clemons, M.D., who wrote that the veteran had been diagnosed in the past with chloracne by several physicians. He stated he had acneform eruptions since being stationed in Vietnam. Examination revealed scattered areas of folliculitis about the trunk and posterior neck and scalp as well as small furuncles about the trunk and arms. There were old acneform scars with several deeper crateriform scars from previous larger areas of furunculosis. There was no evidence of comedone formation or large cyst as would be indicative of active chloracne. Currently, he only had folliculitis and furunculosis. He stated that although active chloracne could not be diagnosed at this point, the current lesions may also have been related to Agent Orange, although he could not say for certain that there was a relationship. Analysis Service connection may be established for chronic disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303 (1994). In addition, service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1994). The veteran's active duty included service in Vietnam during the Vietnam era, and he contends that he was exposed to Agent Orange during that period of time, and developed chloracne as a result. The new regulations pertaining to Agent Orange exposure, expanded to include all herbicides used in Vietnam, stipulate the diseases for which service connection may be presumed due to an association with exposure to herbicide agents. 38 C.F.R. § 3.309(e) (1994). The specified diseases are chloracne or other acneform disease consistent with chloracne, Hodgkin's disease, non-Hodgkin's lymphoma, porphyria cutanea tarda, soft-tissue sarcoma, multiple myeloma, and respiratory cancers. Id. Regarding chloracne, regulations only provide a presumption of service connection if the disease is manifested within a year of service. 38 C.F.R. § 3.307(a)(6) (1994). If a veteran who served in Vietnam during the Vietnam era develops a disease listed as associated with Agent Orange exposure, exposure to Agent Orange will be presumed. 38 C.F.R. § 3.307(6)(iii) (1994). In addition, the Secretary of Veterans Affairs formally announced in the Federal Register, on January 4, 1994, that a presumption of service connection based on exposure to herbicides used in Vietnam was not warranted for certain conditions, to specifically include skin cancer, or for "any other condition for which the Secretary has not specifically determined a presumption of service connection is warranted." 59 Fed. Reg. 341 (1994). In this case, the medical records dated many years after service show the veteran reported that he was exposed to Agent Orange in Vietnam, and shortly thereafter developed skin lesions, which have recurred since that time. However, the contemporaneous medical records do not confirm the presence of any skin disorder characteristic of chloracne during service. In this regard, there is no indication that the heat rash and tinea cruris noted in service consisted of the cysts and comedones the dermatologists who have examined the veteran have said are representative of chloracne. Nevertheless, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, conditions or hardships of such service even though there is no official record of such incurrence or aggravation. 38 U.S.C.A. § 1154(b) (West 1991). Although the service personnel records do not confirm the veteran was in combat, nor does he have any awards or decorations denoting combat participation, he has been granted service connection for post-traumatic stress disorder based on combat stressors; therefore, we must presume the veteran was in combat. In this case, the development of chloracne would be consistent with the circumstances of the veteran's service. Although active chloracne has not been diagnosed, residual acneform scarring has been observed, in May 1991 and November 1994. Further, the record discloses "cysts" in September 1987, "boils" diagnosed as carbuncles in January 1991, and boil scars in July 1992. Although the physician who examined the veteran in February 1993 did not feel that the history reported by the veteran was characteristic of chloracne, those examining him in May 1991, July 1992, and November 1994 believed the described symptoms were consistent with chloracne. We believe that the opinions by three different physicians, of findings consistent with a history of chloracne, must outweigh the opinion by one physician of no evidence of chloracne. In this regard, they were apparently all based on the same evidence, specifically, the veteran's history and observed residual scarring, and two of the three contain justifications for their conclusions as thorough as that provided by the disagreeing physician. Consequently, the evidence of residual scarring from chloracne, coupled with the veteran's history of the disease within a year of service, with the resolution of all reasonable doubt in the veteran's favor, supports service connection for residuals of chloracne. It should be stressed, however, that this decision only encompasses residuals of chloracne, and service connection for other diagnosed skin diseases, such as folliculitis and furunculosis is not within the scope of our jurisdiction in this decision. ORDER Service connection for chloracne residuals is granted. 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. (CONTINUED ON NEXT PAGE) 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.