DISEASES OF KERATINIZATION

Summary

The Veteran served honorably in the United States Coast Guard from June 1969 to June 1973. The Veteran appealed the denial of service connection for alopecia universalis and an increased rating for bilateral hearing loss. The Board granted service connection for alopecia universalis, finding it was proximately related to TCE exposure during service. This finding was supported by a private physician's opinion and medical literature, despite a conflicting VA C&P opinion that the Board disregarded due to an incomplete review of the literature. The Veteran's claim for an increased rating for bilateral hearing loss was denied. Although the Veteran's audiogram indicated hearing loss, the results did not meet the severity criteria for a compensable rating under the VA schedule. The Board noted the Veteran's subjective complaints of hearing difficulty but emphasized that schedular ratings are mechanically applied based on audiometric results, leaving no room for discretion or the benefit of the doubt doctrine in this specific context.

Rationale

Private physician nexus opinion; Medical literature supports TCE-Caused alopecia; Disregarded conflicting VA C&P opinion

Full Decision Text

Citation Nr: A26023520
Decision Date: 03/16/26	Archive Date: 03/16/26

DOCKET NO. 210129-137042
 DATE:  

ORDER

Entitlement to service connection for alopecia universalis is granted.

Entitlement to an initial compensable disability evaluation for bilateral hearing loss is denied.

FINDINGS OF FACT

1. Resolving all doubt in favor of the Veteran, the Veteran developed alopecia universalis, contemporaneously with end stage renal disease, as a result of exposure to trichloroethylene (TCE).

2. The Veteran's hearing loss manifests as Level II acuity in the right ear and Level I acuity in the left ear.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for alopecia universalis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for a compensable disability evaluation for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served honorably in the United States Coast Guard from June 1969 to June 1973.

The rating decisions on appeal were issued in October 2020 (bilateral hearing loss) and November 2020 (alopecia universalis) and constitute initial decisions; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.

In the January 29, 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on October 21, 2024.

Therefore, the Board may only consider the evidence of record at the time of the October 2020 and Novembre 2020 agency of original jurisdiction (AOJ) decisions on appeal, as well as any evidence submitted by the Veteran or his representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801. 

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. 

Service Connection

1. Entitlement to service connection for alopecia universalis is granted.

The Veteran contends that he developed alopecia universalis proximate to end stage renal disease as a result of exposure to trichloroethylene (hereinafter, "TCE") and tetracycline ethanol in connection with his work as an engineman. See October 2024 Board Hearing Transcript (the Board recognizes that the Veteran testified that he has alopecia totalis (complete hair loss of the head) during his hearing, but described symptoms consistent with alopecia universalis (complete hair loss of the head and body); the Board has recharacterized the diagnostic description accordingly); see also June 2020 C&P Examination Report.

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).

In connection with his claim for service connection, the Veteran submitted a positive nexus opinion from M.H.K., M.D., who reported that he has been following the Veteran for about ten years
 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).

In connection with his claim for service connection, the Veteran submitted a positive nexus opinion from M.H.K., M.D., who reported that he has been following the Veteran for about ten years. He reported that the Veteran received a kidney transplant for end stage renal disease, and while the exact etiology of the Veteran's kidney disease is unknown, it was originally speculated to be due to hypertension. However, hypertension was ruled out as an etiology for his end stage renal disease because the Veteran's blood pressure stabilized after the transplant, which is an unexpected finding; it would be expected that the Veteran's blood pressure would have remained elevated if hypertension had been the cause. Pivoting to alternative causes, M.H.K., M.D., then opined as follows:

"During his four-year service as a member of United States Coast Guard, which began in 1969, [the Veteran] was exposed for a prolonged time to potentially harmful chemicals including, above all, trichloroethylene (TCE). Due to the nature of his assignments, [the Veteran] had very frequent direct contact with TCE, which was used at that time as a ubiquitous component of cleaning solutions used for maintenance of engines and other equipment. Over the years he has developed alopecia and progressive kidney disease, both known consequences of prolonged exposure to TCE. TCE was finally banned in 1977. As [the Veteran] does not have a history of any other known risk factors for development of kidney disease, it appears more likely than not that TCE might have indeed caused his kidney problems."

"If the medical evidence of record is insufficient, or, in the opinion of the Board, of doubtful weight or credibility, the Board is always free to supplement the record by seeking an advisory opinion, ordering a medical examination or citing recognized medical treatises in its decisions that clearly support its ultimate conclusions." See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991).

The Board has considered medical treatise evidence in support of a relationship between TCE exposure and the development of alopecia. There is evidence of a relationship between TCE exposure and alopecia in mouse models. See Sarah J. Blossom, et al. Chronic Exposure to a Trichloroethylene Metabolite in Autoimmune-Prone MRL+/+ Mice Promotes Immune Modulation and Alopecia. 95 J. TOXIC. SCI. 401 -11 (Feb. 2007), available at https://pubmed.ncbi.nlm.nih.gov/17077186/. There are also case reports of humans developing alopecia following occupational exposure to TCE. See Dustin H. Marks, et al., Development of Lichen Planopilaris-Like Alopecia following Occupational Exposure to Trichloroethylene and Tetrachloroethylene. 5 J. SKIN APPENDAGE DISORD. 374-78 (Nov. 2019), available at https://pubmed.ncbi.nlm.nih.gov/31799267/ (Conclusion: Although causation cannot be proven, the close temporal relationship and rapid progression of LPP-like alopecia in an atypical patient demographic support a strong correlation between chemical exposure to TCE/PCE and scarring hair loss.") (emphasis in original). 

The National Institute of Health (NIH)'s Center for Disease Control (CDC)'s Agency for Toxic Substances and Disease Registry (ATSDR) reports that "end stage renal disease" is a "health effect[] with evidence that is equipoise and above for causation for TCE" and that impaired immune system function is a "health effect[] with positive findings in at least one study that evaluated exposure to TCE and/or PCE." See CDC, ATSDR, Health Effects Linked with Trichloroethylene (TCE), Tetrachloroethylene (PCE), Benzene, and Vinyl Chloride Exposure, (Camp Lejeune, North Carolina) (Nov. 12, 2024), available at https://www.atsdr.cdc.gov/camp-lejeune/risk-factors/health-effects-linked-with-trichloroethylene-tce-tetrachloroethylene-pce-benzene-and-vinyl.html.

Indeed, the theory in the medical community is that alopecia universalis is believed to be an autoimmune condition.
 effect[] with positive findings in at least one study that evaluated exposure to TCE and/or PCE." See CDC, ATSDR, Health Effects Linked with Trichloroethylene (TCE), Tetrachloroethylene (PCE), Benzene, and Vinyl Chloride Exposure, (Camp Lejeune, North Carolina) (Nov. 12, 2024), available at https://www.atsdr.cdc.gov/camp-lejeune/risk-factors/health-effects-linked-with-trichloroethylene-tce-tetrachloroethylene-pce-benzene-and-vinyl.html.

Indeed, the theory in the medical community is that alopecia universalis is believed to be an autoimmune condition. See NIH, National Center for Advancing Translational Sciences, Genetic and Rare Diseases Information Center (GARD), Alopecia Universalis Congenita, ("Alopecia universalis (AU) is a condition characterized by the complete loss of hair on the scalp and body. It is an advanced form of alopecia areata, a condition that causes round patches of hair loss. Although the exact cause of AU is unknown, it is thought to be an autoimmune condition in which the person's immune system mistakenly attacks the hair follicles.") (last updated Feb. 2026), available at https://rarediseases.info.nih.gov/diseases/614/alopecia-universalis-congenita.

To summarize the research, the Veteran has end stage renal disease, a known complication of TCE exposure. Indeed, he has already been granted entitlement to service connection for his kidney transplant, as directly related to TCE exposure. See October 2020 Rating Decision. Proximate to his end stage renal disease, he also developed alopecia universalis, which is believed to be an autoimmune disorder (i.e., a disease characterized by impaired immune system function). Impaired immune system function is a known complication of TCE exposure. Additionally, there is evidence that TCE exposure promotes alopecia in mouse models and evidence of a strong correlation between TCE exposure and the development of alopecia in humans.

The Board has considered the C&P examination report from November 2020, which stated that "alopecia is not known to be caused by exposure to TCE." As the examiner's factual premise is based on an incomplete review of the medical literature, the Board has disregarded the opinion. The June 2020 examination opinion is similarly premised on an incomplete review of the medical literature.

In reviewing the evidence of record, the Board agrees with the assessment of the Veteran's private physician, which has been corroborated by pertinent medical literature. As such, the claim is granted

Increased Rating

2. Entitlement to an initial compensable disability evaluation for bilateral hearing loss is denied.

The Veteran was granted entitlement to service connection for bilateral hearing loss and tinnitus in June 2014. Thereafter, the Veteran filed a claim for increased compensation for bilateral hearing loss in April 2020. The Veteran contends that he is entitled to an increased disability evaluation for his service-connected hearing loss because his disability is more severe than currently evaluated, because his disability has worsened since last assessed, and because he struggles to understand what relatives and social acquaintances are saying on account of diminished hearing acuity. See October 2024 Board Hearing Transcript.

Although the Veteran submitted an audiogram in connection with his claim, in October 2024, during his hearing, this is inadequate for rating purposes because it does not contain Maryland CNC testing of speech recognition. See infra. As such, the Board cannot consider it. 

For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (Disability due to Impaired Hearing)

Ratings for hearing loss are determined in accordance with the findings obtained on audiometric examinations. Hearing loss disability evaluations range from noncompensable, or 0 percent, to a maximum of 100 percent based on the degree of hearing impairment. In disability examinations, the VA measures the degree of hearing loss with a controlled speech discrimination test, the Maryland CNC test, along with an average hearing threshold test, known as the puretone audiometric test, in the frequencies, or pitches, of 1000, 2000, 3000, and 4000 vibrations per second (Hertz, which is abbreviated as Hz). 


 percent. 38 C.F.R. § 3.385 (Disability due to Impaired Hearing)

Ratings for hearing loss are determined in accordance with the findings obtained on audiometric examinations. Hearing loss disability evaluations range from noncompensable, or 0 percent, to a maximum of 100 percent based on the degree of hearing impairment. In disability examinations, the VA measures the degree of hearing loss with a controlled speech discrimination test, the Maryland CNC test, along with an average hearing threshold test, known as the puretone audiometric test, in the frequencies, or pitches, of 1000, 2000, 3000, and 4000 vibrations per second (Hertz, which is abbreviated as Hz). 

To evaluate the degree of disability from bilateral service-connected hearing loss, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII. 

An exceptional pattern of hearing impairment occurs when the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86(a). In that situation, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Further, when the average puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86(b).

Pursuant to his claim, the Veteran underwent a VA hearing loss examination in October 2020. The VA audiometric evaluation identified puretone thresholds, in decibels, as follows:

	500 Hz	1000 Hz	2000 Hz	3000 Hz	4000 Hz	Avg. 1000 Hz - 4000 Hz

Right Ear	35	30	60	80	80	62.5

Left Ear	25	25	40	70	70	51.25

Speech audiometry, using the Maryland CNC test, revealed speech recognition ability of 96 percent in the right ear and 94 percent in the left ear. The average of the 1000-4000 Hz thresholds is 62.5 decibels for the right ear and 51.25 decibels for the left ear. Under 38 C.F.R. § 4.85 and Table VI, these results correspond to Level II acuity in the right ear and Level I acuity in the left ear. Those levels warrant a noncompensable, or 0 percent rating under Table VII. The Veteran's test results do not demonstrate an exceptional pattern of hearing loss, as per 38 C.F.R. § 4.86.

The Board acknowledges the Veteran's statements regarding the difficulty his hearing loss has caused, particularly with regard to the Veteran's social interactions. See October 2024 Board Hearing Transcript. The Board has carefully considered these statements, and in no way discounts the Veteran's asserted hearing difficulties. However, it must be emphasized that schedular disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numerical designation assigned after audiometric results are obtained. Hence, the Board has no discretion in this matter and must predicate its determination on the basis of the results of the audiometric studies in the record. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The Veteran's additionally reported complaints, although understandably difficult, are representative of sensorineural hearing loss and are therefore contemplated by the rating schedule. See Doucette v. Shulkin, 28 Vet. App. 366 (2017).

The key question at issue in this case turns on how severe the disability has become during the period under review. Based on the evidence described above, the Board finds that the disability is simply not severe enough to warrant a compensable disability rating under the rating criteria. Should the Veteran's disability worsen in severity, he may file a new claim for increase at any time. 

In sum, there is no basis for an increased rating above the noncompensable disability evaluation to which the Veteran is already entitled. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, given the mechanical method of deriving schedular ratings for hearing loss, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C
 on how severe the disability has become during the period under review. Based on the evidence described above, the Board finds that the disability is simply not severe enough to warrant a compensable disability rating under the rating criteria. Should the Veteran's disability worsen in severity, he may file a new claim for increase at any time. 

In sum, there is no basis for an increased rating above the noncompensable disability evaluation to which the Veteran is already entitled. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, given the mechanical method of deriving schedular ratings for hearing loss, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

 

H.M. WALKER

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	A. Hennessy

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.