Citation Nr: 9914879 Decision Date: 05/26/99 Archive Date: 06/07/99 DOCKET NO. 97-07 689 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania THE ISSUE Entitlement to service connection for a skin disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Shawkey INTRODUCTION The veteran served on active duty from November 1951 to August 1953 and from May 1969 to March 1973. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a December 1996 RO rating decision that denied the veteran's claim of service connection for a skin disability due to exposure to Agent Orange. In an April 1997 letter, the veteran's representative took notice of the fact that the December 1996 rating did not consider the veteran's claim on a direct service incurrence basis. Accordingly, a supplemental statement of the case was issued in August 1997 which addressed the veteran's claim on a direct basis and as secondary to Agent Orange exposure. Since the statement of the case and supplemental statements of the case address the veteran's claim of service connection for a skin disability on both a direct basis and as secondary to Agent Orange exposure, and contain the applicable law and regulations, both issues with respect to this claim are properly before the Board. 38 C.F.R. § 19.29 (1998). FINDINGS OF FACT Atopic dermatitis is attributable to service. CONCLUSION OF LAW Atopic dermatitis was incurred in service. 38 U.S.C.A. § 1110 (West 1991); 3.303 (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Background The veteran's service medical records show that shortly after his return from Vietnam in December 1971, he was treated for skin lesions that were rather universal with recurrences and relapses of a seven month duration. An impression was given of xerosis secondary to winter heating and shower, and urticaria, recurrent, of six months duration. He was found to have a normal evaluation of his skin at his retirement examination in October 1972. In October 1974 the veteran underwent observation and examination at a VA hospital for a number of complaints. According to the hospital report, the veteran had had urticaria since 1971. On examination the veteran was noted to have a few lesions on the trunk compatible with urticaria. In December 1988 the veteran underwent a VA examination and was found to have a normal evaluation of his skin. In July 1995 the veteran underwent an Agent Orange examination and was diagnosed as having chronic relapsing dermatitis affecting mostly the limbs. The veteran went to the Walter Reed Army Medical Center in April 1996 for complaints of itchy feet and concerns about his toe nails curling under. In July 1996 the veteran filed a claim of service connection for a skin disability. He claimed that this disability was due to exposure to Agent Orange. At an August 1996 VA examination the veteran complained of itching and burning over his legs, arms, ears and the back of his neck. A description of eczematous changes was given. Also given was a diagnosis of "eczematous dermatitis in [the veteran] who states he was exposed to Agent Orange." The veteran was later examined by a VA physician in December 1996 and was given a provisional diagnosis of "dermatitis chemical" with findings of tinea pedis and onychosis on both feet. These findings were noted to be unchanged on a March 1997 VA dermatology clinic record. At a later VA examination in May 1997, the veteran was diagnosed as having tinea pedis and onychomycosis. The examiner issued an addendum opinion in July 1997 stating that the veteran's urticaria (in service) was not related to his tinea pedis or onychomycosis. At a hearing held at the RO in July 1997, the veteran said that his skin problems began in Vietnam and have continued ever since. He said that he continued to go to Army medical facilities after service and was given medication, but that the medication never helped. He said that his current symptoms were located from his knees on down and on his shoulder blades, back and ears. In May 1999 the Board requested that the veteran's claims file be reviewed by a medical expert for an opinion on whether the veteran's current skin problems were related to service and/or exposure to Agent Orange. Based on his review, the physician opined that the veteran's skin problems were not due to Agent Orange. He based his opinion on the lack of evidence of hypertrichosis, healed blisters or facial evidence of chloracne. He stated that nowhere in the record was there any evidence of cutaneous stigmata of Agent Orange or photosensitivity. He went on to state that it was "[f]ar more likely than not," that the veteran's recurrent and itchy dermatitis was a continuation of a problem he experienced in service. He said that the most likely diagnosis depicted in the record was atopic dermatitis and that characteristic pruritus, which was elicited by complex etiological factors, was the cardinal feature of this disease. He said that other characteristic lesions were dry skin (xerosis), eczema, and a distribution that may be generalized, but which has a predilection for the side and back or the neck and upper and lower extremities. He said that this diagnosis was associated with the persistent, prolonged course marked by remissions and exacerbation seen in the veteran. He further said that "[t]his diagnosis is consistent with [the veteran's] request to refill his 1% hydrocortisone cream (6/5/89), with his complaint of itching and burning of his arms, legs, ears and back of neck (C&P evaluation-8/9/98), with a history of universal skin lesions (1/24/72), and with the dermatological diagnosis of xerosis (2/7/72)." II. Legal Analysis The veteran's claim of service connection for a skin disability is well grounded, meaning plausible, and VA has fulfilled its duty to assist him in developing the facts pertinent to his claim. 38 U.S.C.A. § 5107(a). Service connected may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. The veteran's service medical records show treatment for skin lesions in 1972, with a history dating back to 1971. Diagnoses included xerosis secondary to winter heating and shower and urticaria, recurrent. Following service the veteran was treated for skin problems that included lesions on his trunk as well as itching and burning over his legs, arms, ears and back of his neck. Postservice diagnoses include urticaria, chronic relapsing dermatitis affecting mostly the limbs, tinea pedis and onychomycosis. In July 1997 a VA examiner evaluated the veteran and found that he had tinea pedis and onychomycosis and that these findings were not related to service. He provided no rationale for his opinion, nor is it evident that he reviewed the veteran's claims file before examining the veteran since the medical history portion of the examination report is blank. In contrast, the veteran's claims file (including photographs of the veteran's face) was reviewed in May 1999 by the Chief of Dermatology at a VA medical facility. Based on his review, the physician stated that the veteran's skin problem was not related to exposure to Agent Orange since the photographs did not show any cutaneous stigmata of Agent Orange. However, he went on to state that it was "far more likely than not" that the veteran's recurrent itchy dermatitis was the continuation of a problem he experienced in service. He said that the most likely diagnosis, as depicted in the veteran's medical records, was atopic dermatitis and that the cardinal feature of this disease was characteristic pruritus, as well as characteristic remissions and exacerbations. He made specific reference to certain medical records which further supported his opinion including the veteran's complaints of itching and burning in 1989, his request to refill his 1% hydrocortisone cream in 1989, his history of universal skin lesions shown in service, as well as the diagnosis of xerosis in service. In view of the veteran's documented inservice skin problems, postservice examination findings and treatment of skin problems, and the 1999 expert medical opinion linking the veteran's atopic dermatitis to service, the weight of evidence favors the grant of service connection for this disability. ORDER Service connection for atopic dermatitis is granted. G. H. SHUFELT Member, Board of Veterans' Appeals