Disability Ratings for Skin Conditions
Emma Peterson: Good afternoon, and welcome to another edition of CCK Live. My name is Emma Peterson and today I’m joined by Alec Saxe and Bethany Cooke and we’re going to be talking about VA Disability Ratings for Skin Conditions. So Bethany, why don’t you tell us a little bit about some of the common skin conditions that we see out there.
Bethany Cooke: Some conditions that often get claimed are dermatitis or eczema, urticaria or hives, acne and chloracne, psoriasis, autoimmune disorders of the skin, skin cancer, and pseudofolliculitis Barbae, that’s far from an exhaustive list, but these are some of the most common skin conditions that a veteran might claim. Often, these conditions might manifest due to exposure. Many veterans are exposed to chemical or environmental hazards during their military service and these exposures can lead to a variety of skin conditions like the ones that I named which a veteran might be able to receive disability benefits for but other, they can be caused by a variety of things. Pseudofolliculitis Barbae, for example, can be caused by shaving and if these skin disabilities first manifest in service that might be another route to service connection.
Emma: Let’s talk a little bit more about that. Alec, how would a veteran go about getting a service connection for a skin disability?
Alec Saxe: The most traditional route would be through what’s called direct service connection and this really applies to all conditions including skin conditions. And you need to establish three elements to warrant service connection for your skin condition, that’s a current disability or a current diagnosis of the skin condition, an in-service event or injury or illness related to this skin condition. Oftentimes, this is the skin condition itself beginning in service, and then third is a medical nexus, linking the current diagnosis, the current skin condition, to the in-service incident, or injury, or skin condition itself. It’s important to note that while it may seem obvious that your skin condition and service are the same as the same condition you have after service, VA really does require medical proof of that. They may favor medical evidence over your lay statements to that effect so that’s why that third element is often the most crucial in establishing the direct service connection for anything including skin conditions.
So there’s also the avenue of presumptive service connection. VA has determined that there are certain conditions that are presumed service-connected to different things. The most common being herbicide exposure in Vietnam, right? Veterans who served in Vietnam who have the diseases that or the skin conditions that VA has said that are presumably related to that herbicide connection and that’s chloracne which we talked about and then Porphyria cutanea tarda, kind of difficult to say, but those have to manifest within one year of exposure to a degree of 10%. As far as the Porphyria cutanea tarda, since you probably never heard of it. It’s a rare disease, it’s characterized by painful blistering skin lesions that develop usually in relation to sun-exposed skin, that’s why it’s often colloquially described as the Empire’s disease. There is also the presumption for Gulf War veterans. An example being dermatitis, so, veterans who served in the Gulf War may have dermatitis or chronic undiagnosed or unexplained illnesses including skin disorders that you may be eligible for presumptive service connection through your service in the Gulf War.
Emma: Now, what about for veterans that were in the second Gulf War, I know they were exposed to burn pits. Any presumptions for those folks?
Alec: For burn pits as of now, well right now the good news is legislation is moving through Congress that is aiding in this effort to relate similarly to the first Gulf War, you know, these conditions that related a lot of same things that were happening in both, so that’s in the works, we have some literature and videos, I believe, on our website, you should check that out, our burn pit information online, but as of now, not yet for presumed service-connected conditions.
Emma: Okay, so the question then, now we’ve gotten service connection. How does VA go about rating these conditions? And really it boils down to distinguishing between how the condition affects a large part of your body, your entire body, or is localized, and it requires a localized treatment. In 2018, VA made updates to all 15 biosystems, including the skin. So, it’s important for folks out there who’ve had a skin condition pending for a while to take a look at both rating criteria because one or the other might be more favorable to you and you should certainly talk with your VSO, your accredited agent, a rep, or attorney, whoever you work with on your claim to figure out which of the diagnostic codes is gonna be better for you. But really as I mentioned, what it boils down to is the surface area and the percentage of the skin that’s affected. So, you’ll go for a VA examination and they’ll use calculations, they’ll calculate and take into account the surface area in inches, squared inches of the area that’s affected, then the examiner is gonna estimate the total percentage of your skin that’s affected. And so, really we’ll look at that, and then they’ll also look at the types of medication that you might be on. Bethany, can you tell us a bit more about how this actually pans out in real life?
Bethany: Yeah. The VA rate skin conditions under the regulation 38 CFR 4.118 and the diagnostic codes are from 7800 to 7833. However, most of the skin conditions are rated using the general reading formula for the skin which includes ratings of 0%, 10%, 30%, and 60% based on severity. And like you said Emma, the general reading formula determines the severity what rating is appropriate based on the treatment the skin condition requires and the percentage of the body that the skin condition covers. For example, a 60% rating, which is the highest rating, is assigned if the disability causes characteristic lesions involving more than 40% of the entire body or more than 40% of exposed areas affected, or if the skin disability requires constant or near-constant systemic therapy like corticosteroids, phototherapy, retinoids, or other immunosuppressive drugs over the 12-month period prior to the rating being assigned. Whereas in contrast, a 0% rating would mean the skin disability has required no more than topical therapy over the previous 12 months and characteristic lesions involving less than 5% of the body affected or exposed areas affected. And I think it’s important just because the reading criteria define treatment in terms of systemic therapy and topical therapy, it’s important to know what VA means by that. So VA defines systemic therapy as any treatment that is injected or taken by mouth, through the nose, or anally and this includes but is not limited to the treatments that are specifically listed within the reading criteria. And topical therapy is, in contrast, any treatment applied directly to the skin regardless of what type of drug it is.
Emma: Right. Thanks, Bethany. So Alec, what about scars? I mean a lot of folks out there, a lot of veterans out there have scars that affect the skin. Is that going to be rated the same way or is it rated somewhat differently?
Alec: Pretty similarly. Scar disabilities also fall under the 38 CFR Section 4.118 regulation that Bethany was just talking about. The diagnostic codes are the beginning 17800 to 7805. And scars are rated based on the number of scars or disfigurements that a veteran has. The area of the body affected, the distinguish between head, neck, face, and the rest of your body, their permanence, and the presence of pain or instability of the scars. So scars on the head, face, and neck are rated based on the skin loss, how many facial features or pairs of features, like your ears, for instance, are disfigured or just the amount of disfigurements you have ranging from one to six and that can kind of get you from the 0-80% potentially compensable rating. And then ratings for scars on areas of the body other than the head, face, or neck are generally based on the size of the scar. So again, the 7800 scars of the head, face, or neck, rated based on tissue loss, distortion, or asymmetry of features and that can range from 10% up to 80%. The more features, repaired features affected corresponds to a higher rating. Scars elsewhere in the body that are deep and nonlinear located on, for example, an extremity or two separate extremities, or your back, or torso are rated separately and they range from 10 to 40 percent. There are also superficial nonlinear scars not on the head, neck, or face, and this max out at a 10% rating. The superficial scars are not permanent in nature. They don’t affect the underlying soft tissue of the skin and they’re rated separately for each area of the body affected. And then painful or unstable scars, an unstable scar is one where there’s frequent loss of covering of skin over the scar, if more than one scar is considered unstable an additional 10% may be added to the rating. Five or more unstable and painful can warrant the highest rating of 30%, while one or two equals 10%, and then other scars including linear scars, the last diagnostic code that rates the scars, sometimes are rated based on the disabling effects the scar presents so VA will look at other diagnostic codes to rate these. If a veteran has a linear scar running along the elbow that prevents flexion, for example, VA might in fact rate it under the limitation of motion for the elbow.
Emma: All right. So, the issue with skin and conditions that can present difficulties is that each condition may have different causes and symptoms. Veterans might have multiple skin conditions and they would run into a problem that VA calls pyramiding. It’s a term VA uses for rating the same disability, same manifestation symptoms of a disability twice. Basically, there’s no double-dipping. So the long and the short are you can get multiple ratings, multiple DC’s assigned for your variety of skin conditions, as long as each has a clear and distinct diagnosis and affects a different area of the skin. So, if you had eczema on your face and dermatitis on your feet, you might get different ratings for that. But if you had both eczema and dermatitis on your feet, you probably would end up with one rating if it affects your feet in the same way. And VA will look to see which rating will give you the highest rating because they do have the duty to maximize, that is just something that people should keep in mind because oftentimes people do have more than one skin condition affecting them from their service. So, that really takes us through just sort of the broad strokes of skin conditions. There are lots out there and I certainly think they affect a wide variety of veterans out there. Before we sign off here any final thoughts, Alec?
Alec: No, I know this was a lot of information and it can be overwhelming. Especially with skin and scars so many are very related and a lot of these skin conditions probably never heard of or I’ve never heard of before practicing here obviously but just be sure to make sure that your medical providers through either VA or privately, are just really presenting the fullest picture of the disability and they generally know to look at the types of, distinguish between the types of skin disabilities and scars and they have these criteria in the back of their mind, but it’s nuanced, it’s a little you know, it can be tricky. As long as you have that medically documented it’s gonna help a lot in pursuing the claims.
Bethany: I would just emphasize the importance of the compensation pension exams. Once you’re granted service connection for this disability, that’s really going to be how the VA rates your condition. Your private treatment records will be helpful but they’re really not going to, for the most part, give VA the information that they’re going to use because they’re not going to talk in terms of the percentage of your body that’s affected. So, make sure you get a copy of that compensation and pension examination VA is using. So that if it does look like the VA examiner isn’t accounting for every area that’s affected, that you can combat that if necessary.
Emma: Just to piggyback off that, sometimes skin conditions will flare up at certain times of the year under certain conditions. So you can try to push VA to get you an exam during a flare-up period or you can provide lay evidence explaining that listen I just had treatment that’s why my skin condition was totally normal on the day of the exam but in actuality, every month it flares up and it becomes extremely painful. Lay evidence, picture evidence, statements from friends and family are all helpful but as Bethany noted and as Alec said that medical evidence from the VA exam is going to be very important especially for skin and scars.
Well, thank you so much for joining us. More information about VA disability ratings for skin conditions and a number of other topics can be found on our blog at cck-law.com-blog. Be sure to follow us on social media to stay tuned into the latest updates in veterans law. Thanks again.
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