URTICARIA

Summary

The veteran, who served in the United States Marine Corps from February 2000 to February 2004, appeals the denial of an increased rating for urticaria, residuals of a right foot fracture, and right knee osteoarthritis. The Board granted entitlement to a 30 percent evaluation for urticaria from July 7, 2009, finding that the veteran's condition required second-line treatment, such as topical corticosteroids, as defined by Diagnostic Code 7825 under both the pre- and post-August 13, 2018, rating criteria. The Board determined that a 60 percent evaluation was not warranted as the evidence did not demonstrate the need for third-line treatment or recurrent debilitating episodes despite continuous immunosuppressive therapy. The claims for residuals of the right foot first toe distal phalanx fracture and right knee osteoarthritis with chondromalacia patellae were remanded. The Board found that recent VA examinations did not adequately address the ameliorative effects of the veteran's medications on these conditions, citing the CAVC decision in Ingram v. Collins. A remand is necessary to obtain medical opinions estimating functional loss without the effects of medications like acetaminophen, topical corticosteroids, and naproxen, expressed in degrees of range of motion loss.

Rationale

Diagnostic Code 7825 applies to urticaria.; Veteran requires second-line treatment (topical corticosteroids) for control.; 30 percent evaluation warranted under both pre- and post-August 13, 2018 criteria.

Full Decision Text

Citation Nr: 25014415
Decision Date: 12/02/25	Archive Date: 12/02/25

DOCKET NO. 15-16 873
DATE: December 2, 2025

ORDER

Entitlement to an evaluation of 30 percent, but not higher, from July 7, 2009, for urticaria is granted.

REMANDED

Entitlement to an evaluation in excess of 10 percent for residuals of the right foot first toe distal phalanx fracture is remanded.

Entitlement to an evaluation in excess of 10 percent for right knee osteoarthritis with chondromalacia patellae is remanded.

FINDING OF FACT

During the entire period on appeal, the Veteran's urticaria has required at least the second line of treatment.

CONCLUSION OF LAW

The criteria for entitlement to an evaluation of 30 percent, but not higher, from July 7, 2009, for urticaria have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7825.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served in the United States Marine Corps from February 2000 to February 2004. 

This matter comes before the Board of Veterans' Appeals (Board) on appeal from the April 2013 and May 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) that granted service connection with a 10 percent evaluation for: (1) right knee osteoarthritis with chondromalacia patellae, (2) residuals of the right foot first toe distal phalanx fracture, and (3) urticaria. 

These matters have been before the Board on multiple occasions including in January 2025 in which it remanded the claims of an initial rating greater than 10 percent for urticaria (hives), an initial rating greater than 10 percent for right knee osteoarthritis with chondromalacia patella, and an initial rating greater than 10 percent for residuals of a right first toe distal phalanx fracture.

1. Entitlement to an evaluation of 30 percent, but not higher, from July 7, 2009, for urticaria is granted. 

The Veteran's urticaria is rated under 38 C.F.R. § 4.118, Diagnostic Code 7825, for urticaria. Prior to August 13, 2018, under Diagnostic Code 7825, a 10 percent evaluation is warranted for recurrent episodes occurring one to three times during the past 12-month period, and; requiring intermittent systemic immunosuppressive therapy for control. A 30 percent evaluation is applicable for recurrent debilitating episodes occurring at least four times during the past 12-month period, and; requiring intermittent systemic immunosuppressive therapy for control. A 60 percent evaluation is warranted for recurrent debilitating episodes occurring at least four times during the past 12-month period despite continuous immunosuppressive therapy. 

Effective August 13, 2018, Diagnostic Code 7825 states that for the purposes of this diagnostic code, chronic urticaria is defined as continuous urticaria at least twice per week, off treatment, for a period of six weeks or more. A 10 percent evaluation is warranted for chronic urticaria that requires first line treatment (antihistamines) for control. A 30 percent evaluation is applicable for chronic urticaria that requires second line treatment (e.g., corticosteroids, sympathomimetics, leukotriene inhibitors, neutrophil inhibitors, thyroid hormone) for control. A 60 percent evaluation is warranted for chronic refractory urticaria that requires third line treatment for control (e.g., plasmapheresis, immunotherapy, immunosuppressives) due to ineffectiveness with first and second line treatments.

As this regulatory change was enacted during the pendency of this appeal, the Board will consider both the old version of the regulation throughout the appeal and the new version of the rating criteria from the effective date of the regulatory change (August 13, 2018) and apply the version most favorable to the Veteran.

As a procedural starting point for this claim, in January 2012, the Veteran submitted an informal claim for service connection for a skin condition.

In April 2013, the Veteran underwent a skin conditions VA examination. The VA examiner noted a diagnosis of urticaria. In terms of treatment, the VA examiner highlighted that the Veteran was treated with antihistamines (hydroxyzine HCL) on a constant basis for the 12 months previous to this examination.
 pendency of this appeal, the Board will consider both the old version of the regulation throughout the appeal and the new version of the rating criteria from the effective date of the regulatory change (August 13, 2018) and apply the version most favorable to the Veteran.

As a procedural starting point for this claim, in January 2012, the Veteran submitted an informal claim for service connection for a skin condition.

In April 2013, the Veteran underwent a skin conditions VA examination. The VA examiner noted a diagnosis of urticaria. In terms of treatment, the VA examiner highlighted that the Veteran was treated with antihistamines (hydroxyzine HCL) on a constant basis for the 12 months previous to this examination. Also, the VA examiner indicated that the Veteran was treated with topical corticosteroids (triamcinolone acetonide) on a constant basis for the 12 months previous to this examination.

In May 2013, the AOJ in its rating decision granted service connection for urticaria with a 10 percent evaluation effective January 10, 2012.

In August 2013, the Veteran submitted a notice of disagreement for an increased rating for his skin condition.

In April 2015, the AOJ issued its statement of the case (SOC) continuing its denial for entitlement to an evaluation in excess of 10 percent for urticaria.

In May 2015, the Veteran submitted a Form 9.

In February 2019, the AOJ issued its SSOC continuing its denial for entitlement to an evaluation in excess of 10 percent for urticaria.

In April 2022, the Board held a hearing. In regard to his skin condition, the Veteran testified that his skin is very sensitive, turns red, and if he gets an itchy sensation, he starts scratching until he bleeds. The Veteran indicated that VA provided him with a cream that helps to soothe. Also, the Veteran stated that his skin condition has gotten worse over the years.

In January 2023, the Board remanded the claims of entitlement to an evaluation in excess of 10 percent for urticaria. The Board indicated that additional evidence has been added to the file by VA since the February 2019 SSOC and the matter has not been readjudicated by the AOJ in a SSOC since this issuance. Thus, the appeal was remanded so that a SSOC may be issued that considers all the evidence of record.

In February 2023, the AOJ issued its SSOC continuing its denial for entitlement to an evaluation in excess of 10 percent for urticaria.

In January 2025, the Board granted an effective date of July 7, 2009, but not earlier, for the award of service connection for urticaria (hives). The Board remanded the claim of an initial rating greater than 10 percent for urticaria (hives). The Board indicated that the Veteran should be provided with an opportunity to report for a new VA examination to ascertain the current severity and manifestations of the before-mentioned service-connected condition.

In February 2025, the Veteran underwent a skin diseases VA examination. The VA examiner noted a diagnosis of chronic urticaria. During the examination, the Veteran reported swelling and itching of the skin by scratching or bumping into things. Also, the Veteran stated that scratching mostly happens at night and affects all areas of the body, but it is worse in the back and face. Moreover, the Veteran mentioned that the use of topical cream helps soothe the skin when it is active and takes cetirizine daily to minimize flares. The VA examiner indicated that the Veteran has been treated with oral antihistamines for the past 12 months. Also, the VA examiner mentioned that the Veteran uses a topical cream (possibly triamcinolone) for 6 weeks or more, but not constant, during the past 12 months. Thus, the VA examiner stated that the Veteran has been receiving the first and second line of treatment. Lastly, the VA examiner assessed that the Veteran's skin condition impacts his ability to work because of the mild limitation of use of rough materials or performing duties requiring repetitive friction to the skin. However, the VA examiner stressed that to this day there has not been significant impact in his moderately active warehouse job held for over 5 years with active medication management.

In May 2025, the AOJ in its rating decision increased its evaluation of urticaria from 10 percent to 30 percent effective February 26, 2025.

In May 2025, the AOJ issued its SSOC. The AOJ continued its denial for entitlement to an initial rating greater than 10 percent for urticaria. Also, the AOJ continued its denial for an evaluation in excess of 30 for urticaria from February 26, 2025.

Upon review
 of rough materials or performing duties requiring repetitive friction to the skin. However, the VA examiner stressed that to this day there has not been significant impact in his moderately active warehouse job held for over 5 years with active medication management.

In May 2025, the AOJ in its rating decision increased its evaluation of urticaria from 10 percent to 30 percent effective February 26, 2025.

In May 2025, the AOJ issued its SSOC. The AOJ continued its denial for entitlement to an initial rating greater than 10 percent for urticaria. Also, the AOJ continued its denial for an evaluation in excess of 30 for urticaria from February 26, 2025.

Upon review of the evidence of record, the Board finds that a 30 percent evaluation for urticaria from July 7, 2009, is warranted. It is important to mention that the January 2025 Board decision determined that the effective date for the Veteran's urticaria is July 7, 2009. Therefore, the Board is bound by this favorable determination as the beginning of the period on appeal. Effective, August 13, 2018, Diagnostic Code 7825 states that a 30 percent evaluation is warranted for chronic urticaria that requires second line treatment such as corticosteroids, sympathomimetics, leukotriene inhibitors, and thyroid hormone for control. As mentioned before, since the August 13, 2018, amendment occurred during the pendency of this appeal, the Board will consider both the old and new versions of the rating criteria from the effective date and apply the version most favorable to the Veteran. The April 2013 and February 2025 VA examinations indicated that the Veteran has been taking topical corticosteroids (triamcinolone acetonide). Therefore, given that this medication falls under the second line of treatment for urticaria, a 30 percent evaluation from July 7, 2009, is applicable. 

A 60 percent evaluation is not warranted because the medical evidence of record does not show that at any time during the period on appeal the Veteran has required the third line of treatment for his skin condition as defined in Diagnostic Code 7825. Equally, pursuant to the rating criteria of Diagnostic Code 7825 prior to the August 13, 2018, amendment, a 60 percent evaluation is not applicable because the evidence does not demonstrate that the Veteran had recurrent debilitating episodes occurring at least four times during the past 12-month period despite continuous immunosuppressive therapy. 

Given the foregoing, a 30 percent evaluation for the Veteran's urticaria from July 7, 2009, is granted.

REASONS FOR REMAND

1. Entitlement to an evaluation in excess of 10 percent for residuals of the right foot first toe distal phalanx fracture is remanded.

2. Entitlement to an evaluation in excess of 10 percent for right knee osteoarthritis with chondromalacia patellae is remanded.

In March 2025, the Veteran underwent a foot conditions VA examination. The VA examiner noted a diagnosis of status post right great toe fracture. During the examination, the Veteran reported mild pain at the right first metatarsophalangeal joint. Also, the Veteran specified that he cannot run anymore. The VA examiner indicated that the Veteran does not have functional loss related to the diagnosed disability. Moreover, the VA examiner mentioned that the Veteran does not use any assistive devices.

In March 2025, the Veteran underwent a knee conditions VA examination. The VA examiner noted diagnoses of right knee meniscal tear and joint osteoarthritis. During the examination, the Veteran reported occasional popping sensation of the right knee with anterior knee pain and that the only thing he does to relieve the pain is to lay down. Also, the Veteran specified that he has had difficulty walking as a result of the right knee pain. Moreover, the Veteran did not report flare-ups of the right knee but did mention that he has functional loss or impairment manifested as difficulty in walking. The VA examiner assessed that the active and passive range of motion (ROM) measurements are: 140 degrees for flexion endpoint and 0 degrees for extension endpoint. The VA examiner stated that there was evidence of pain in weight-bearing which causes functional loss manifested as difficulty with walking. Moreover, the VA examiner indicated that the Veteran was able to perform repetitive-use testing with at least three repetitions but did not yield an additional functional loss or ROM. In terms of repeated use over time, the VA examiner specified that the Veteran's pain caused functional loss, and the estimated ROM were 120 degrees for flexion endpoint and 0 degrees for extension endpoint. In addition, the VA examiner acknowledged that the Veteran had a Meniscectomy in 2013.

Upon review of these latest medical examinations,
 passive range of motion (ROM) measurements are: 140 degrees for flexion endpoint and 0 degrees for extension endpoint. The VA examiner stated that there was evidence of pain in weight-bearing which causes functional loss manifested as difficulty with walking. Moreover, the VA examiner indicated that the Veteran was able to perform repetitive-use testing with at least three repetitions but did not yield an additional functional loss or ROM. In terms of repeated use over time, the VA examiner specified that the Veteran's pain caused functional loss, and the estimated ROM were 120 degrees for flexion endpoint and 0 degrees for extension endpoint. In addition, the VA examiner acknowledged that the Veteran had a Meniscectomy in 2013.

Upon review of these latest medical examinations, the Board finds that remand is warranted. The most recent medical records of March 2025 reveal that the Veteran has utilized medications and treatments such as acetaminophen, camphor/menthol, diclofenac NA, and naproxen to mitigate the effects of his service connected residuals of the right foot first toe distal phalanx fracture and right knee osteoarthritis with chondromalacia patellae. Pursuant to the recent United States Court of Appeals for Veterans Claims (CAVC) decision of Ingram v. Collins, 38 Vet. App. 130 (2025), remand is necessary to obtain a medical opinion that addresses whether the Veteran's medications are productive of ameliorative effects on his right foot and right knee service connected conditions. Also, Ingram stated that when diagnostic codes do not explicitly contemplate medications when rating a disability, the Board must discount the beneficial effects of medication when assigning an evaluation for that disability. It is important to note that Diagnostic Code 5284 (for other foot injuries) and Diagnostic Code 5003-5260 (for limitation of flexion of the leg), do not explicitly contemplate medication use. Therefore, Ingram is applicable to the facts in this case and an opinion must be rendered by a clinician that provides an estimate of additional functional loss described in degrees of additional loss of ROM without the effects of his medications for each of the service connected conditions of residuals of the right foot first toe distal phalanx fracture and right knee osteoarthritis with chondromalacia patellae. 

The matters are REMANDED for the following action:

1. The VA examiner must address if any of the medications used by the Veteran including, but not limited to, acetaminophen, camphor/menthol, diclofenac NA, and naproxen produced ameliorative effects on the Veteran's service connected conditions of: 

(a.) residuals of the right foot first toe distal phalanx fracture; and 

(b.) right knee osteoarthritis with chondromalacia patellae.

2. If the answer is yes, the VA examiner shall list which medications produced ameliorative effects and explain the nature and extent of the Veteran's symptoms and additional limitation of motion without these effects of the medications, to include during flare-ups (if applicable). Any additional functional loss with repetitive use testing or during flare-ups must be expressed in degrees of additional loss of range of motion for the conditions of:

(a.) residuals of the right foot first toe distal phalanx fracture; and 

(b.) right knee osteoarthritis with chondromalacia patellae.

A complete rationale must be given for all opinions and conclusions expressed. If it is not possible to provide a specific measurement without resorting to mere speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 

 

R. R. Watkins

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Colon, Ivan M.

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.