Citation Nr: 24022723 Decision Date: 06/10/24 Archive Date: 06/10/24 DOCKET NO. 19-29 669 DATE: June 10, 2024 ORDER A compensable rating for pseudofolliculitis barbae (PFB) is denied. FINDING OF FACT The Veteran's PFB is manifested by visual characteristic lesions on less than five percent of his total body or exposed body areas. CONCLUSION OF LAW The criteria for a compensable rating for PFB are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7813-7806. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1969 to January 1972. In January 2022, the Veteran testified at a virtual Board hearing before undersigned Veterans Law Judge (VLJ). The hearing transcript has been associated with the claims file. In September 2022 and August 2023, the Board, in pertinent part, remanded the claim for entitlement to a compensable disability rating for pseudofolliculitis barbae for further development. The Board also noted in previous decisions that the while the Veteran had initiated an appeal of the issue of an earlier effective date for the award of service connection for PFB, the Veteran did not perfect an appeal for the issue. Thus, the issue is not before the Board, was not discussed in the September 2022 or August 2023 decision, and will not be addressed herein. Entitlement to a compensable rating for pseudofolliculitis barbae (PFB) The Veteran seeks a higher rating for his service-connected PFB, which is currently rated noncompensable (0 percent). Prior to March 7, 2018, the Veteran's PFB was rated under Diagnostic Code (DC) 7820. From March 7, 2018, his PFB has been rated by analogy pursuant to 38 C.F.R. § 4.118 under DC 7813-7806. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. The hyphenated diagnostic code in this case indicates that the skin disability should be rated as dermatophytosis (DC 7813) which is rated as dermatitis (DC 7806). VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, under DC 7806, a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or; at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7806. For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran's skin condition; and (2) whether the given treatment is "like" a corticosteroid or other immunosuppressive drug." Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. Effective August 13, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Additionally, effective August 13, 2018, a new General Rating Formula for the Skin applies to DC 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. See 38 C.F.R. § 4.118. Under this formula, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12- month period. A 30 percent rating is assigned at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating for the Skin for DCs 7806, 7809, 7813-7816, 7820-7822, and 7824. The Veteran was afforded a VA skin diseases examination in December 2017 which identified his skin condition as PFB. The Veteran reported that he had never sought medical treatment for his PFB since service and that he had not used any medication. He stated that he could not shave every day because if he did, he would get bumps. He used witch hazel after shaving. The examiner found that the Veteran's skin condition did not cause scarring or disfigurement of the head, face, or neck. The examiner also noted that the Veteran had not been treated with any oral/topical medications or had any treatments or procedures for his skin condition in the past 12 months. Finally, the examiner found that the Veteran did not have a visible skin condition at the time of the examination. In a separate medical opinion, the December 2017 VA examiner noted that the Veteran had "no active disease at this time." The Veteran was afforded another VA skin diseases examination in May 2018 which continued to identify his skin condition as PFB. The examiner found that the Veteran's skin condition did not cause scarring or disfigurement of the head, face, or neck. He did not have a visible skin condition at the examination; however, the examiner noted some papules in the beard area (anterior neck) and stated that the affected area was less than 5 percent of the total body area and less than 5 percent of exposed area. The Veteran was also found to not have any benign or malignant skin neoplasms, any systemic manifestations due to any skin diseases, or any debilitating or non-debilitating episodes in the last 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. The Veteran's PFB was noted to be treated with topical medications (over the counter witch hazel used after shaving) for 6 weeks or more, but not constant, in the past 12 months. It was also noted that the Veteran did not have any treatments or procedures other than systemic or topical medications in the past 12 months for exfoliative dermatitis or papulosquamous disorders. Finally, his PFB was not found to impact his ability to work. At the January 2022 Board hearing, the Veteran testified that his PFB had worsened since his last VA examination in May 2018, and in September 2022, the Board remanded his claim for a new VA examination to assess the current nature and severity of his PFB. Pursuant to the September 2022 Board remand, the Veteran was afforded another VA skin diseases examination in December 2022. The examiner noted that the Veteran's skin condition was PFB and noted its location as jawline and under chin. At the examination, no inflammation or bumps were appreciated. He was not noted to have any benign or malignant neoplasm or metastases related to his PFB. The Veteran's PFB was topically treated with over the counter witch hazel toner which he used constantly or near constantly over the past 12 months. The Veteran did not have any treatments or procedures other than systemic or topical medications in the past 12 months for any skin condition. The examiner found that the Veteran's PFB covered less than 5 percent of exposed areas but also selected that none of the Veteran's total body area was affected. In August 2023, the Board remanded the issue to clarify these conflicting area of affected skin findings. Pursuant to the August 2023 remand, the Veteran was afforded another VA examination in February 2024. The examiner noted that the Veteran's skin condition was PFB and noted its location as face and neck. The examiner observed dark spots along the jawline and neck. Over the past 12 months, the Veteran treated his PFB with constant or near constant use of topical corticosteroid or other immunosuppressive medications of: ketoconazole 2% shampoo 3 times a week, ketoconazole 2% topical cream BID, and hydrocortisone 2.5% topical cream. The Veteran did not have any treatments or procedures other than systemic or topical medications in the past 12 months for any skin condition. At this examination, the Veteran's exposed area and his total body area affected by PFB were noted and clarified to be less than 5 percent. Additionally, pursuant to the August 2023 remand, private treatment records from September 2023, January 2024, and February 2024 were associated with the Veteran's claims file. PFB located on the left superior lateral buccal cheek was only noted on the September 2023 treatment record. During the other treatment visits, the Veteran was noted to have additional skin diagnoses of seborrheic dermatitis, pruritus, benign nevi, and tinea versicolor in other parts of his body, such as his superior thoracic spine, right and left inferior central malar cheeks, left lower cutaneous lip, right cheek, and right inferior medial midback. At the September 2023 visit, the Veteran was instructed to apply antibacterial soap and/or benzoyl peroxide wash to affected areas, shave with the grain, and avoid cutting hairs to short. Topical retinoids and laser hair removal were also recommended as potential ways to improve his PFB. No prescriptions were listed for PFB; rather, the Veteran was noted to be prescribed ketoconazole 2% shampoo 3 times a week, ketoconazole 2% topical cream BID, and hydrocortisone 2.5% topical cream for his seborrheic dermatitis. Apart from noting that the Veteran's PFB was along his left superior lateral buccal cheek, these records do not contain a calculation of exposed area or total body area affected by PFB. The Board finds that the evidence of record persuasively weighs against the assignment of a compensable evaluation under the pre-August 13, 2018, regulations because the Veteran's PFB does not more nearly approximate at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. The Board also finds that the evidence of record persuasively weighs against the assignment of a compensable evaluation under the August 13, 2018, regulations because the Veteran's PFB does not more nearly approximate characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy required for a total duration of less than 6 weeks over the past 12-month period. The Board acknowledges that the Veteran believes that his PFB is more severe than the assigned disability rating reflects. At the January 2022 Board hearing, the Veteran testified that his PFB was on his left side cheek, neck (front, back, and sides), right side of his face, top of his head where his hair would normally be if he had hair, waist, stomach, arm pits, genital area, belly button, buttocks, front side of his thighs, shins, and knees, and back side of thighs, knees, and calves. He also testified that his skin bled and peeled off due to his PFB. The Veteran is competent to report observable symptoms; however, he is not competent as a lay person to attribute those symptoms to a specific skin diagnosis, as that requires specialized medical knowledge and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). After reviewing the entirety of the record, the Board finds that the extent of the PFB that the Veteran testified to in January 2022 is not corroborated by the contemporaneous treatment records or VA examination reports associated with his claims file. Notably, while the Veteran's private treatment records confirm he has skin conditions on other parts of his body for which he has been prescribed topical creams and shampoo, these relate to other skin diagnoses such as seborrheic dermatitis, pruritus, benign nevi, and tinea versicolor. The only skin condition that the Veteran is service-connected for is PFB, and on each of the VA examinations conducted in December 2017, May 2018, December 2022, and August 2023, his PFB was found to cover less than 5 percent of the exposed area and total body area. These findings are supported by the Veteran's private treatment records which also indicate his PFB is only along his left superior lateral buccal cheek. Therefore, limited probative value is afforded to the Veteran's statements regarding the area affected by his PFB. The Board has considered whether any other Diagnostic Codes related to disabilities of the skin would provide for a higher disability evaluation. However, the evidence does not reflect that the PFB would warrant a higher rating under a different diagnostic code. See 38 C.F.R. § 4.118. In conclusion, the Board finds that the evidence of record persuasively weighs against the Veteran's claim for a compensable rating for PFB. As the evidence of record persuasively weighs against a compensable rating, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). A. ISHIZAWAR Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Coburn The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.