DERMATITIS OR ECZEMA

Summary

The veteran, who served in the U.S. Army from December 1993 to March 1999, appeals the denial of service connection for alopecia, including a claim for secondary service connection due to migraine medication. The veteran first reported hair loss in May 2005, attributing it to basic training and hair relaxer use. Medical records indicated potential contributions from relaxers, genetics, and traction from braiding, with some notes suggesting amitriptyline might be a potentiating factor in hair loss. However, multiple VA examinations consistently opined that the veteran's alopecia was less likely than not related to service, either directly or secondarily to migraines and their medications. These opinions cited medical literature indicating that the specific type of alopecia (central centrifugal scarring alopecia) is primarily caused by hair products, traction, genetics, and that drug-induced alopecia typically reverses upon discontinuation of the medication. The Board found the veteran competent to report symptoms but not to render medical opinions on etiology or nexus. The Board concluded that the competent medical evidence, particularly the VA opinions, preponderated against service connection, as the veteran's condition was primarily linked to non-service factors and the claimed secondary relationship to migraines and medication was not supported by medical literature. Therefore, service connection for alopecia was denied.

Rationale

Competent medical evidence preponderates against service connection.; Alopecia primarily linked to non-service factors (relaxers, genetics, traction).; No medical literature supports causal relation between alopecia and migraine medication.

Full Decision Text

Citation Nr: 22037738
Decision Date: 06/30/22	Archive Date: 06/30/22

DOCKET NO. 12-30 572
DATE: June 30, 2022

ORDER

Entitlement to service connection for alopecia, to include as secondary to service-connected migraine medication, is denied.

FINDING OF FACT

The evidence is against a finding that alopecia is related to the Veteran's active-duty service or is secondary to service-connected migraine medication. 

CONCLUSION OF LAW

The criteria for entitlement to service connection for alopecia, to include as secondary to service-connected migraine medication, are not met.  38 U.S.C. §§ 101, 315, 502, 503, 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty in the United States Army from December 1993 to March 1999.

This matter comes back before the Board of Veterans' Appeals on appeal from an August 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO).

The claim was previously before the Board and remanded in November 2016, June 2018, November 2020, May 2021, and September 2021.  The matter has now come back before the Board for final adjudication.

1. Alopecia

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service.  38 U.S.C. §§ 1131; 38 C.F.R. § 3.303(a).  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).  As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service.  Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004).

Secondary service connection may be established for a disability that is proximately due to, or the result of, a service-connected disease or injury.  38 C.F.R. § 3.310(a).  Substantiating a secondary service connection claim requires competent evidence of: (1) a diagnosis of the disability for which service connection is being sought; (2) a service-connected disability; and (3) that the current disability was either caused or aggravated by the already service-connected disability.  38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc).

When 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. § 5107(b); 38 C.F.R. § 3.102.  Furthermore, it is the responsibility of the Board to assess the credibility and weight to be given to the evidence.  Hayes v. Brown, 5 Vet. App. 60 (1993).

The Veteran is seeking service connection for alopecia, also claimed as hair loss.  The Veteran maintains that she first received treatment for alopecia in 2005.  See May 2010 Correspondence.  The Veteran also contends that her alopecia is caused by her service-connected migraines, specifically, her medication taken for migraines.

In May 2005, the Veteran's VA treatment records first note hair loss.  The Veteran reported hair loss became a problem following basic training and was using a chemical relaxer on her hair.  The Veteran reported using relaxers on her hair between every four to six weeks.  The physician noted the Veteran's hair was thin on the crown.  In addition, the Veteran reported that her sister also suffers from alopecia.  See May 2005 VA Dermatology Consult.

During her July 2005 VA medical treatment, it is noted that amitriptyline is reported to be associated with some cases of alopecia and may be a potentiating affect in hair loss but does not appear to be the sole cause.  See July 2005 Dermatology Note.

In March 2007, the Veteran's VA medical treatment records note
 became a problem following basic training and was using a chemical relaxer on her hair.  The Veteran reported using relaxers on her hair between every four to six weeks.  The physician noted the Veteran's hair was thin on the crown.  In addition, the Veteran reported that her sister also suffers from alopecia.  See May 2005 VA Dermatology Consult.

During her July 2005 VA medical treatment, it is noted that amitriptyline is reported to be associated with some cases of alopecia and may be a potentiating affect in hair loss but does not appear to be the sole cause.  See July 2005 Dermatology Note.

In March 2007, the Veteran's VA medical treatment records note the Veteran reported a family history of thinning hair in female relatives, but the physician believes that most of the damage was secondary to relaxer use or secondary to styling as opposed to female pattern hair loss.  See March 2007 Addendum Dermatology Note.

The Board notes the Veteran's VA medical treatment records find that chemical relaxers were likely contributing to her hair breakage.  See October 2007 VA Dermatology Note.  She was advised to stop braiding her hair to reduce hair loss risk.  See January 2010 VA Primary Care Note.  The Veteran reported hair improvement after she stopped perming her hair.  See id.  Based on the Veteran's history, it was found that her alopecia was likely for perms and braiding.  See November 2010 Dermatology Note.

In July 2017, the Veteran underwent her first VA examination for skin diseases.  Here, the examiner confirmed a diagnosis of alopecia with a date of diagnosis in May 2005.  The examiner opined that it was less likely than not that the Veteran's alopecia was incurred in or caused by service.  See July 2017 VA Skin Diseases Disability Benefits Questionnaire (DBQ), July 2017 VA Medical Opinion DBQ.  However, as discussed in the Board's November 2020 remand, this examination is not adequate as the examiner did not consider the Veteran's lay statements regarding hair loss during service.  

A March 2019 VA medical opinion was obtained addressing whether the Veteran's migraine medication caused her alopecia.  After review of the record, the examiner opined that it is less likely than not that the Veteran's alopecia was related to her service-connected migraines and/or the medications, including Amitriptyline, Zolmitriptan, or Butalbital.  The examiner noted that the Veteran's type of alopecia was a non-scarring hair loss based on the examiner's experience.  See March 2019 VA Supplemental Opinion.

In an August 2020 VA medical opinion, the examiner opined that it was less likely than not that the Veteran's alopecia was caused or aggravated by the Veteran's migraines and/or medications.  The examiner noted that alopecia is a stand-alone condition from the Veteran's migraine headaches.  See August 2020 VA Medical Opinion DBQ.  The examiner also opined that it was less likely than not that the Veteran's alopecia was proximately due to or the result of the Veteran's service-connected condition.  The examiner noted that the Veteran was diagnosed, both clinically and biopsy, with central centri fungal scarring alopecia.  The examiner explained that this type of alopecia is caused by the use of chemical relaxers, traction (tight braids), excessive heat, and genetics.  Therefore, there is no relation between the Veteran's alopecia and migraine medication, Amitriptyline.  The examiner does note that this medication can cause hair loss including alopecia, but in those cases, once the medication is discontinued, the hair loss would reverse.  See July 2020 VA Medical Opinion DBQ 2.

The Veteran underwent another VA examination in January 2021.  Here, the examiner confirmed a diagnosis of centri fungal scarring alopecia with a date of diagnosis in 2005.  See January 2021 VA Skin Disease DBQ.  In addition, the examiner opined the Veteran's alopecia was less likely than not incurred in or caused by service.  Additionally, the examiner opined that it was less likely than not that the Veteran's condition was proximately due to or the result of the Veteran's service-connected condition.  See January 2021 VA Medical Opinion DBQ 2.  However, as discussed in the Board's May 2021 remand, this examination is also not adequate as the examiner again failed to address the Veteran's lay statements regarding service connection on a direct basis.  Further, with respect to the opinion of service connection on a secondary basis, while the opinion is negative, the examiner cited to the July 2005 treatment record indicating that Amitriptyline
 examiner opined the Veteran's alopecia was less likely than not incurred in or caused by service.  Additionally, the examiner opined that it was less likely than not that the Veteran's condition was proximately due to or the result of the Veteran's service-connected condition.  See January 2021 VA Medical Opinion DBQ 2.  However, as discussed in the Board's May 2021 remand, this examination is also not adequate as the examiner again failed to address the Veteran's lay statements regarding service connection on a direct basis.  Further, with respect to the opinion of service connection on a secondary basis, while the opinion is negative, the examiner cited to the July 2005 treatment record indicating that Amitriptyline is reported to be associated with some cases of alopecia.  Thus, the rationale for the negative opinion is unclear.  

Another VA medical opinion was obtained in May 2021.  Here, the examiner opined the Veteran's alopecia was less likely than not incurred in or caused by service.  In addition, the examiner opined that the Veteran's alopecia was less likely than not proximately due to or the result of his medication taken for the service-connected migraines.  See May 2021 VA Medical Opinion DBQ.  Again, this examination is also not adequate as discussed in the September 2021 remand since the examiner still did not consider the Veteran's lay statements of hair loss in service, and restated prior opinions already determined by the Board to be insufficient.  Additionally, the examiner provided no rationale for the negative secondary opinion, and wholly failed to address the question of aggravation. 

A November 2021 VA medical opinion also included negative medical opinions.  Here, the examiner opined that the Veteran's alopecia was less likely than not incurred in or caused by service.  The examiner stated there is no objective medical reason to accept the proposition that the Veteran's reported symptoms in service and thereafter represent the onset of her current disability.  The Veteran's report about her symptoms do not align with how the disability is known to develop and are generally inconsistent with medical knowledge.  In addition, the examiner opined it was less likely than not proximately due to or the result of the Veteran's service-connected condition.  The examiner found that current medical literature does not support a causal relation between the Veteran's hair loss disability and service-connected migraine headaches, to include prescribed medications.  See November 2021 VA Medical Opinion DBQ.

In the March 2022 VA medical opinion, the examiner opined that it was less likely than not that any diagnosed hair loss disability is related to or caused by an in-service injury, event, or disease.  After review of the record and pertinent records, the examiner noted medical literature does not support that the rigors of military service are either necessary and/or sufficient for the development of central centrifugal scarring alopecia.  The examiner noted the Veteran's reports of her hair symptoms align with how the disability is known to develop; that is to say, as per the medical literature, there is a known strong association between central centrifugal scarring alopecia and the use of chemical relaxers on hair, as well as the use of hot combs, and genetic factors.  See March 2022 VA Medical Opinion DBQ.

The examiner also opined that it is less likely than not that the diagnosed hair loss disability was caused by her service-connected migraine headaches, to include the mediations prescribed.  Specifically, the examiner found that medical literature does not support that hypothesis.  Drug-induced alopecia is associated with toxicity to the hair follicle at the time of the toxic insult or up to three months after the initial insult.  In both instances, the hair damage ceases with the discontinuation of the offending agent.  Furthermore, central centrifugal scarring alopecia is when the hair follicle is damaged by skin scarring and does not regrow.  See id.

Lastly, the examiner opined that it was less likely than not that the Veteran's alopecia was aggravated by her service-connected migraines, to include medications.  The examiner stated that the medical evidence of record does not demonstrate aggravation or progression beyond the known natural history of hair loss disease as there is no clinical concordance between the activity of the dermatologic condition and the medication for migraines.  This has been supported by medical literature.  See id.

The last medical opinion was received in April 2022.  Here, the examiner opined again that it is less likely than not that the Veteran's alopecia was incurred in or caused by service.  The examiner explained that based on the medical evidence of record and medical literature, the use of chemical relaxers is neither necessary nor sufficient to cause scarring alopecia.  The pathogenesis of this condition is multifactorial.  The examiner notes that genetic and hereditary factors increase
 does not demonstrate aggravation or progression beyond the known natural history of hair loss disease as there is no clinical concordance between the activity of the dermatologic condition and the medication for migraines.  This has been supported by medical literature.  See id.

The last medical opinion was received in April 2022.  Here, the examiner opined again that it is less likely than not that the Veteran's alopecia was incurred in or caused by service.  The examiner explained that based on the medical evidence of record and medical literature, the use of chemical relaxers is neither necessary nor sufficient to cause scarring alopecia.  The pathogenesis of this condition is multifactorial.  The examiner notes that genetic and hereditary factors increase the likelihood of the condition to develop.  See April 2022 VA Medical Opinion DBQ.

The Board has considered the Veteran's statements regarding relationship between the Veteran's alopecia and migraine headaches.  Although the Veteran is competent to testify to symptoms she experiences, determining the etiology of a disability such as alopecia, and rendering a nexus between that disability and a disability like migraines, requires specialized medical knowledge and training.  The Veteran is not shown to possess such a background, and her contentions are not considered competent.  See Jandreau v. Nicholson, 492 F.3d 1372 (Fed, Cir. 2007).  

In addition, as the competent evidence of record does not show that the Veteran's alopecia was proximately due to, the result of, or aggravated by her service-connected migraines, to include medication, secondary service connection is not warranted.  The VA examiners have established that discontinuation of the medication would result in the reversing of the hair loss.  The Veteran reported her hair grew back as a result of discontinuing hair treatments, such as perms and relaxers.

The Board has considered the Veteran's statements regarding the relationship between the Veteran's alopecia and military service.  Although the Veteran is competent to testify to symptoms of a diagnosis, as above, she is not competent to render a medical opinion regarding a relationship between her active and inactive service and her claimed alopecia.  Jandreau, 492 F.3d at 1377.

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The competent medical evidence of record establish that the Veteran's condition started after service.  The VA medical opinions not previously deemed insufficient by the Board discussed above are collectively probative, as they are based on accurate medical histories and provide explanations that contain clear conclusions and supporting data.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).  Furthermore, the Veteran's type of alopecia has been established by medical examiners, through medical knowledge and literature, is a result of genetics and hair procedures, to include relaxers, perms, and braiding.  The Board also notes that the Veteran reported a family history of hair thinning and alopecia.  The Veteran failed to provide evidence to support her claim that her alopecia was a result of her active service.

In light of the foregoing, the evidence is against a finding of service connection on a direct and secondary basis.   Accordingly, the appeal seeking service connection for alopecia must be denied.

 

 

L. BARSTOW

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Glaeser, Jennifer

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.