PSORIASIS

Summary

The veteran served from May 2001 to May 2007. The veteran appeals the denial of an increased disability rating for psoriasis, specifically for the period prior to June 7, 2018. The Board previously granted a 60 percent rating for the period after June 7, 2018, which is not currently under appeal. The primary issue is whether the veteran's treatment regimen prior to August 13, 2018, met the criteria for a higher rating, specifically regarding the use of Zyrtec and clobetasol-betamethasone. The Board reviewed the pre-August 13, 2018, rating criteria, which required systemic therapy like corticosteroids for at least six weeks. Evidence showed the veteran used topical clobetasol-betamethasone and oral Zyrtec. A VA examination in July 2014 found no significant body area affected and noted the conditions were controlled with medication, with unremarkable skin findings. The Board found that neither Zyrtec nor clobetasol-betamethasone met the criteria for systemic therapy like corticosteroids or immunosuppressive drugs. Zyrtec was deemed an antihistamine not significantly impacting the body as a whole, while clobetasol-betamethasone was topical, not systemic. The Board concluded the evidence persuasively weighed against a rating higher than 10 percent, and the benefit-of-the-doubt rule did not apply. The appeal is denied.

Rationale

Neither Zyrtec nor clobetasol-betamethasone met the criteria for systemic therapy like corticosteroids.; Zyrtec is an antihistamine, not a significant immunosuppressive drug.; Clobetasol-betamethasone is topical, not systemic.

Full Decision Text

Citation Nr: 26004977
Decision Date: 04/27/26	Archive Date: 04/27/26

DOCKET NO. 17-40 139
DATE: April 27, 2026

ORDER

Entitlement to a disability rating in excess of 10 percent prior to June 7, 2018, for psoriasis with onychodystrophy, upper extremities, and seborrheic dermatitis (hereinafter "psoriasis") is denied.

FINDING OF FACT

Prior to June 7, 2018, psoriasis did not manifest with 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 a 12-month period, or more severe symptoms.

CONCLUSION OF LAW

Prior to June 7, 2018, the criteria are not met for a disability rating in excess of 10 percent for psoriasis. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1-4.7, 4.118, DC 7816.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from May 2001 to May 2007.

The Veteran appeared at a Board hearing in May 2022; a transcript is of record. With respect to the Board hearing, the undersigned Veterans Law Judge clarified the issues on appeal, identified potential evidentiary deficits, and clarified the type of evidence that would support the Veteran's claim. These actions complied with any duties owed during a hearing. 38 C.F.R. § 3.103.

The Board denied the above claim in August 2024. In May 2025, pursuant to an April 2025 Joint Motion for Partial Remand ("JMPR"), the United States Court of Appeals for Veterans Claims ("CAVC" or "the Court") issued an Order vacating the August 2024 Board decision and remanded the matter to the Board. 

Ratings Principles

Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R., Part 4.  The ratings are intended to compensate impairment in earning capacity due to a service-connected disease or injury.  38 U.S.C § 1155; 38 C.F.R. § 4.1.  

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where there is a question as to which of the two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.  

Staged ratings, however, are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007).

The determination of whether an increased evaluation is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991).

The analysis below focuses on the most salient and relevant evidence and on what this evidence shows or fails to show.  The Veteran should not assume that the Board has overlooked pieces of evidence that are not specifically discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). 

1. Entitlement to a disability rating in excess of 10 percent prior to June 7, 2018, for psoriasis is denied.

The period on appeal begins in January 2014, when the Veteran submitted a claim for service connection for psoriasis. The Board granted a 60 percent disability rating for the period after June 7, 2018, the JMPR found no error with that determination, and the period after June 7, 2018 is not currently on appeal. 

The Veteran is rated under Diagnostic Code 7816 for psoriasis with onychodystrophy, upper extremities, and seborrheic dermatitis.

The disability rating criteria for the skin were amended on August 13, 2018. Here, only the
 in excess of 10 percent prior to June 7, 2018, for psoriasis is denied.

The period on appeal begins in January 2014, when the Veteran submitted a claim for service connection for psoriasis. The Board granted a 60 percent disability rating for the period after June 7, 2018, the JMPR found no error with that determination, and the period after June 7, 2018 is not currently on appeal. 

The Veteran is rated under Diagnostic Code 7816 for psoriasis with onychodystrophy, upper extremities, and seborrheic dermatitis.

The disability rating criteria for the skin were amended on August 13, 2018. Here, only the unamended disability rating criteria apply, as the relevant timeframe is prior to August 13, 2018.

Prior to August 13, 2018, under Diagnostic Code 7816, 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 7816.

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.  

For the period prior to August 13, 2018, the Board notes that a prior version of the Adjudication Procedures Manual (M21-1MR) was in effect during part of this period and is relevant here. As explained by the Court, it stated: 

The guidelines for rating skin conditions, set forth in the VA Adjudication Procedures Manual (M21-1MR), provide that '[t]he term 'systemic therapy such as corticosteroids or other immunosuppressive drugs,' that is contained in certain [diagnostic codes] under 38 C.F.R. § 4.118, refers to any oral or parenteral medication(s) prescribed by a medical professional to treat the underlying skin disorder.' M21-1MR, Part III, subpt. iv, ch. 4, sec. J(3)(f) . . . .

Warren v. McDonald, 28 Vet. App. 194, 198 (2016). The current M21-1 does not contain any such language, instead mirroring the current regulation. 

In Overton v. Wilkie, 30 Vet. App. 257 (2018), the Court recognized that the adoption of a procedure or consideration in a comprehensive guidance manual even if it is not binding as a matter of substance, amounts to a tacit acknowledgment by VA that such consideration or procedure is relevant to an adjudication that implicates it. Overton, 30 Vet. App. at 264 ("[The Board is required to discuss any relevant provisions contained in the M21-1 as part of its duty to provide adequate reasons or bases."); Healey v. McDonough, 33 Vet. App. 312, 320 (2021) ("Notwithstanding its non-binding nature, an agency cannot simply ignore an internal guidance manual when its contents relate to a particular claim or disability.").

Prior to the period on appeal, VA treatment records show use of triam
 consideration in a comprehensive guidance manual even if it is not binding as a matter of substance, amounts to a tacit acknowledgment by VA that such consideration or procedure is relevant to an adjudication that implicates it. Overton, 30 Vet. App. at 264 ("[The Board is required to discuss any relevant provisions contained in the M21-1 as part of its duty to provide adequate reasons or bases."); Healey v. McDonough, 33 Vet. App. 312, 320 (2021) ("Notwithstanding its non-binding nature, an agency cannot simply ignore an internal guidance manual when its contents relate to a particular claim or disability.").

Prior to the period on appeal, VA treatment records show use of triamcinolone acetonide (a corticosteroid) topically daily for a skin condition. There were no VA records dated for many years prior to the appeal period until January 2018.  Private treatment records note that the Veteran took prescribed Zyrtec. See, e.g., February 2013 private treatment record. At the May 2022 Board hearing, the Veteran also testified that Zyrtec was initially prescribed. 

A VA examination of the skin occurred in July 2014. The examiner diagnosed psoriasis and seborrheic dermatitis. The examiner noted that the Veteran had oral medication constantly or nearly constantly (over-the-counter Zyrtec) and topical corticosteroids (clobetasol/ betamethasone) 6 weeks or more, but not constantly. On physical examination, dermatitis and psoriasis affected none of the Veteran's total body area or total exposed body area. The examiner noted that physical examination showed unremarkable skin. The remarks section notes that the Veteran skin disorders were controlled with medications. The Veteran's skin was normal or absent any abnormalities. The examiner noted that the Veteran took Zyrtec for "diffuse itching."

A December 2014 rating decision granted service connection for psoriasis at 0 percent disabling.  

The Veteran's June 2015 Notice of Disagreement notes that the Veteran takes over the counter ("OTC") medications, Zyrtec, on a regular basis, without any improvement. 

The Veteran's July 2017 VA Form 9 notes that her skin issues were worsening every year and could cause significant medical costs in the future. 

A June 2018 VA treatment record notes increased itchiness of the feet and leg, relieved with allergy medication, and usage of Zyrtec. A VA nurse advised her to stop taking Zyrtec and issued the Veteran hydroxyzine for itching. 

In May 2025, pursuant to an April 2025 JMPR, the Court vacated a prior Board decision denying a higher disability rating. The JMPR notes that "the Board failed to provide an adequate statement of reasons or bases concerning evidence that [the Veteran] was prescribed Zyrtec in 2005, 2013, and 2014." Further, a July 2014 VA examination report notes that the Veteran "was treated with topical corticosteroid Clobetasol-betamethasone for 6 or more weeks in the past 12 months for her psoriasis" and the Board did not discuss whether the Veteran's "Clobetasol- betamethasone use constitutes systemic therapy." 

In September 2025, the Board remanded the matter for an opinion regarding whether prescribed Zyrtec or clobetasol-betamethasone were a (1) topical treatment affecting the body as a whole and (2) is "like" a corticosteroid or other immunosuppressive drug.

An October 2025 VA opinion states the following:

Rationale:

Zyrtec does not have a significant impact on the body as a whole. It is an antihistamine which targets the immune system response to allergens. This medication does not suppress the immune system significantly enough to put [the V]eteran at risk for opportunistic infections.

Clobetasol and betamethasone affecting the body as a whole is rare with proper short[-]term use. [The] Veteran is no longer requiring this medication.

As the Board found that the October 2025 VA opinion did not answer the questions presented by the Board, the Board remanded the matter again.

A VA opinion was obtained in February 2026. It states that Zyrtec is a systemic antihistamine medication but is not like a corticosteroid or other immunosuppressive drug. It further states that clobetasol-betamethasone is not a systemic treatment, it is only topical and acts locally where applied, and that it is a corticosteroid. 

Under the former disability rating criteria, a 30 percent rating is assigned for 20 to 40 percent of the entire body
. [The] Veteran is no longer requiring this medication.

As the Board found that the October 2025 VA opinion did not answer the questions presented by the Board, the Board remanded the matter again.

A VA opinion was obtained in February 2026. It states that Zyrtec is a systemic antihistamine medication but is not like a corticosteroid or other immunosuppressive drug. It further states that clobetasol-betamethasone is not a systemic treatment, it is only topical and acts locally where applied, and that it is a corticosteroid. 

Under the former disability rating criteria, 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.

Regarding whether the Veteran's usage of Zyrtec or clobetasol-betamethasone warrants a 30 percent rating, it must be a "systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more." According to the medical evidence, neither medication is both (1) a systemic therapy and (2) is like a corticosteroids or other immunosuppressive drug. Zyrtec is a systemic therapy, but not a corticosteroid or other immunosuppressive drug. Clobetasol-betamethasone is a corticosteroid but is not a systemic treatment. This medical evidence does not dispute either proposition. 

In contrast, any bare lay assertions to the effect that Zyrtec is corticosteroid or other immunosuppressive drug or that clobetasol-betamethasone is a systemic treatment would not be within the competency of a lay person. Any such lay statement is therefore not entitled to probative value. 

Consequently, the Board finds that the evidence of record persuasively weighs against a disability rating in excess of 10 percent under the pre-August 13, 2018, regulations because the Veteran's psoriasis does not more nearly approximate 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. The Veteran's medications were not systemic corticosteroid and/or other immunosuppressive drug. There is no evidence or argument to the contrary. 

Accordingly, the most probative evidence of record persuasively weighs against the claim of entitlement to a higher disability rating. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

Finally, the Veteran's representative noted an error in a March 2026 letter sent to the Veteran regarding the ability to change representation. See March 2026 Appellate Brief Presentation. Here, the Veteran did not attempt to change representation, so any error in the March 2026 letter is immaterial to the issue decided here. 

 

David Gratz

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	P. Yoffe, Counsel 

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.