SKIN CONDITIONS

Summary

The veteran, who served from September 2000 to September 2004, appeals the denial of service connection for erectile dysfunction (ED) and headaches, and seeks an increased rating for pseudofolliculitis barbae (PFB). The Board granted an initial 10 percent rating for PFB from September 21, 2020, to November 18, 2020, finding the evidence met the criteria for that rating, though not higher. For ED, the veteran claimed it was secondary to service-connected major depressive disorder (MDD) and related medications. While a VA examiner provided a negative nexus opinion, the Board found the evidence in relative equipoise, noting the examiner did not consider medication side effects and that the veteran's use of Zoloft aggravated his ED. Resolving doubt in the veteran's favor, the Board granted service connection for ED as secondary to MDD and its medications. For headaches, the veteran initially claimed a direct service connection due to an in-service assault but alternatively claimed it was secondary to MDD or tinnitus. The Board found the evidence in relative equipoise regarding headaches being caused or aggravated by MDD or its medications, particularly lamotrigine, which the veteran reported caused headaches. Resolving doubt in the veteran's favor, the Board granted service connection for headaches as secondary to MDD and its medications.

Rationale

Evidence tends to show characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected or exposed areas.; Veteran's testimony indicates condition impacts beard area and anterior upper neck, supporting at least 5 percent affected.; Evidence does not show condition covers more than 20 percent or requires more than intermittent systemic therapy for a higher rating.

Full Decision Text

Citation Nr: A26026627
Decision Date: 03/25/26	Archive Date: 03/25/26

DOCKET NO. 210114-133443
DATE: March 25, 2026

ORDER

Entitlement to an initial 10 percent rating, but not higher, for pseudofolliculitis barbae (PFB), from September 21, 2020, to November 18, 2020, is granted. 

Entitlement to service connection for erectile dysfunction (ED), as secondary to service-connected major depressive disorder (MDD), is granted. 

Entitlement to service connection for headaches, as secondary to service-connected MDD, is granted. 

FINDINGS OF FACT

1. From September 21, 2020, to November 18, 2020, the Veteran's PFB manifested by, at worst, characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; without more than intermittent systemic therapy.

2. Resolving all doubt in the Veteran's favor, his diagnosed ED is caused or aggravated by his service-connected MDD and/or medication used to treat MDD.

3. Resolving all doubt in the Veteran's favor, his diagnosed headache disability is caused or aggravated by his service-connected MDD and/or medication used to treat MDD. 

CONCLUSIONS OF LAW

1. From September 21, 2020, to November 18, 2020, the criteria for entitlement to an initial 10 percent rating, but not higher, for PFB have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.118, Diagnostic Code (DC) 7813.

2. The criteria for entitlement to service connection for ED, as secondary to service-connected MDD and/or medication used to treat MDD have been met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310.

3. The criteria for entitlement to service connection for headaches, as secondary to service-connected MDD and/or medication used to treat MDD have been met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. 

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from September 2000 to September 2004. 

On April 3, 2019, VA received the Veteran's VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, regarding service connection for ED and headaches. A June 13, 2019, rating decision, denied the claims. 

On June 12, 2020, VA received the Veteran's VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), regarding the June 2019 rating decision. 

On September 21, 2020, VA received the Veteran's VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, regarding service connection for PFB.

An October 30, 2020, HLR decision, denied service connection for ED and found a duty to assist error (DTAE) regarding service connection for headaches.

A November 18, 2020, rating decision, granted service connection for PFB and assigned an initial noncompensable rating, effective September 21, 2020. 

A December 3, 2020, supplemental decision, denied service connection for headaches.  

On December 21, 2020, VA received the Veteran's VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), selecting the Hearing docket. The Veteran testified at a Board hearing on January 22, 2025, and a hearing transcript is associated with the record. Therefore, regarding an initial increased rating for PFB, the Board may only consider the evidence of record at the time of the November 18, 2020, rating decision, as well as any evidence submitted by the Veteran at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). Regarding service connection for ED, the Board may only consider the evidence of record at the time of the June 13, 2019, rating decision, which was subject to HLR, as well as any evidence submitted by the Veteran at the hearing or within 90 days following the hearing. 38 C.F.R. § 
2025, and a hearing transcript is associated with the record. Therefore, regarding an initial increased rating for PFB, the Board may only consider the evidence of record at the time of the November 18, 2020, rating decision, as well as any evidence submitted by the Veteran at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). Regarding service connection for ED, the Board may only consider the evidence of record at the time of the June 13, 2019, rating decision, which was subject to HLR, as well as any evidence submitted by the Veteran at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). Regarding service connection for headaches, the Board may only consider the evidence of record at the time of the December 3, 2020, supplemental decision, as well as any evidence submitted by the Veteran at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). In other words, the Board cannot consider (1) evidence submitted during the period after the AOJ issued the decision(s), and before the hearing, or (2) evidence submitted more than 90 days after the Board hearing. Id.

If the Veteran would like the Department of Veterans Affairs (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.

Increased Ratings

Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 

Where there is a question as to which of 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 are appropriate for any rating claim 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); Fenderson v. West, 12?Vet. App.?119 (1999). 

In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disability. 38 C.F.R. § 4.14. A Veteran may have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes. The critical element in permitting the assignment of multiple ratings under various diagnostic codes is that none of the symptomatology for any one condition is duplicative or overlapping with the symptomatology of another condition. See Esteban v. Brown, 6?Vet. App.?259, 261-62 (1994). 

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be granted to the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. To deny a claim on the merits, the evidence must clearly weigh against the claim. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

1. Entitlement to an initial 10 percent rating, but not higher, for PFB, from September 21, 2020, to November 18, 2020, is granted.

A November 18, 2020, rating decision, granted service connection for PFB and assigned an initial noncompensable rating, effective September 21, 2020. This appeal arises from the Veteran's disagreement with the initial rating assigned. Thus, the rating review period begins September 21, 2020, and ends November 18, 2020. These dates represent, respectively, the effective date of the grant of service connection and the date of the rating decision on appeal.

The Veteran contends that symptoms of his
).

1. Entitlement to an initial 10 percent rating, but not higher, for PFB, from September 21, 2020, to November 18, 2020, is granted.

A November 18, 2020, rating decision, granted service connection for PFB and assigned an initial noncompensable rating, effective September 21, 2020. This appeal arises from the Veteran's disagreement with the initial rating assigned. Thus, the rating review period begins September 21, 2020, and ends November 18, 2020. These dates represent, respectively, the effective date of the grant of service connection and the date of the rating decision on appeal.

The Veteran contends that symptoms of his PFB are worse than that which is contemplated by his initial noncompensable rating, under DC 7813, throughout the entire period on appeal.

For the following reasons, from September 21, 2020, to November 18, 2020, the criteria for an initial 10 percent rating, but not higher, for PFB are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.118, DC 7813.

The Veteran's PFB is rated under DC 7813, which is evaluated under the General Rating Formula for the Skin. Under the General Rating Formula for the Skin, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. See 38 C.F.R. § 4.118, DC 7813.

A 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12- month period. Id. 

A 30 percent rating is assigned for at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. Id. 

A 60 percent rating is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. Id. 

VA regulations clarify that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. See 38 C.F.R. § 4.118(a).

The Federal Circuit found it was error to read the diagnostic code "as unambiguously elevating any form of corticosteroid treatment, including any degree of topical corticosteroid treatment, to the level of 'systemic therapy."  Johnson v. Shulkin, 2016-2144, 2017 U.S. App. LEXIS 12601 (Fed. Cir. 2017). The Federal Circuit went on to explain that "systemic therapy means 'treatment pertaining to or affecting the body as a whole,' whereas topical therapy means 'treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied.'"  Although a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, this possibility does not mean that all applications of topical corticosteroids amount to systemic therapy.

A November 2020 VA skin diseases examination shows that the Veteran has a full-grown beard on his face, and his PFB was
7). The Federal Circuit went on to explain that "systemic therapy means 'treatment pertaining to or affecting the body as a whole,' whereas topical therapy means 'treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied.'"  Although a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, this possibility does not mean that all applications of topical corticosteroids amount to systemic therapy.

A November 2020 VA skin diseases examination shows that the Veteran has a full-grown beard on his face, and his PFB was only related to the shaved areas of his anterior upper neck aspect. The examiner noted that the Veteran has treated the condition with cleansing astringent and witch hazel cleansing pads in the past 12 months. The examiner also noted that the Veteran has treated his condition with manual extraction of ingrown hair from the bumps/papules with the use of a tweezer twice weekly to prevent infection. The examiner noted that the condition covers less than five percent of the Veteran's total body area and exposed area. The examiner described the Veteran's appearance as having diffused, small papules, with a few scattered small pustules, without open skin or drainage, to his anterior upper neck aspect. 

During the January 2025 Board hearing, the Veteran testified that the condition is severe if shaving constantly, which is why he does not shave. However, he testified that he would like to shave if he did not look so bad. He testified that, if he shaved, his PFB would be visible below his neck all the way down below his jaw, and circles around the complete back of his head. He reported his past treatment with steroid creams and injections. He testified that it is safe to say that at least five percent of exposed area of face and neck is covered. 

Based on the foregoing evidence, the Board finds that the Veteran's PFB meets the criteria for an initial 10 percent rating, but not higher. In this regard, the evidence tends to show that the Veteran has characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected. Although the November 2020 VA examiner noted that only the Veteran's anterior upper neck aspect was evaluated for the condition, finding that the condition covers less than five percent of the Veteran's total body area and exposed area, the Veteran's January 2025 Board testimony highlights that the condition also impacts his beard area, which is full-grown. Given this, the evidence tends to show that condition covers at least five percent of entire body affected/exposed areas affected. However, the evidence does not show and the Veteran does not contend that the condition covers more than 20 percent of entire body affected/exposed areas affected or that he requires more than intermittent systemic therapy, which is required for a rating higher than 10 percent. 

For these reasons, an initial 10 percent rating, but not higher, for PFB, is warranted, and the claim is granted. To the extent that the claim is denied, the benefit of the doubt doctrine is not for application as the weight of the evidence is against the claim. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Lynch, 21 F.4th at 776.

Service Connection 

Service connection may be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability connected disability. 38 C.F.R. § 3.310(a). Service connection on a secondary basis may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); Allen v. Brown, 8?Vet. App.?374 (1995). 

In order to prevail on the issue of secondary service connection, the record must show: (1) a current disability; (2) a service-connected disability; and (3) a nexus between the current disability and the service-connected disability. See Wallin v. West, 11?Vet. App.?509 (1998); Allen, supra.

2. Entitlement to service connection for ED, secondary to service-connected MDD, is granted.

The Veteran contends that his ED is caused or aggravated by service-connected MDD, to include medications used to treat his MDD, namely Zoloft and Lexapro. 

For the following reasons, service connection for ED
 8?Vet. App.?374 (1995). 

In order to prevail on the issue of secondary service connection, the record must show: (1) a current disability; (2) a service-connected disability; and (3) a nexus between the current disability and the service-connected disability. See Wallin v. West, 11?Vet. App.?509 (1998); Allen, supra.

2. Entitlement to service connection for ED, secondary to service-connected MDD, is granted.

The Veteran contends that his ED is caused or aggravated by service-connected MDD, to include medications used to treat his MDD, namely Zoloft and Lexapro. 

For the following reasons, service connection for ED is warranted, and the claim is granted. 

The Veteran's service treatment records (STRs) are silent for any complaints, treatment, or diagnosis of ED. 

An April 2015 VA mental disorders examination shows that the Veteran reported having decreased libido. 

In an April 2019 statement, the Veteran reported having ED since developing MDD. 

A May 2019 VA male reproductive system conditions examination and medical opinion shows a diagnosis of ED and the Veteran's report that the condition worsened in 2017 due to stress/depression. The examiner provided a negative nexus opinion regarding the theory of secondary service connection, pertaining to a relationship between the Veteran's ED and MDD. 

A May 2019 VA treatment record shows that the Veteran reported having sexual side effects from Zoloft and the clinician prescribed Lexapro as an alternate medication; the record shows that sexual side effects of Lexapro were reviewed with the Veteran. Indeed, the Veteran's VA treatment records, showing previous medical trials, indicate that sertraline (Zoloft) has sexual side effects. 

A July 2022 VA treatment record shows that the Veteran's ED may be related to mood and/or medications. 

During the January 2025 Board hearing, the Veteran testified that he first noticed a difference in sexual nature and performance between 2010 and 2012, then worsened in 2019 when he was given Zoloft and Lexapro. He testified to being warned of potential sexual side effects of the medications.

Following a thorough review of the record, the Board finds that the evidence is in relative equipoise as to whether the Veteran's ED is caused or aggravated by service-connected MDD, to include medications used to treat his MDD, namely Zoloft and Lexapro. As previously noted, the Veteran has reported that he first noticed a difference in sexual nature and performance between 2010 and 2012, then worsened in 2019 when he was given Zoloft and Lexapro. The Veteran as a lay person is competent to give evidence about observable symptomatology. Layno v. Brown, 6 Vet. App. 465, 469-470 (1994).

The Board acknowledges the VA examiner provided a negative nexus opinion as to whether the Veteran's diagnosed ED is related to service-connected MDD; however, the Board also notes that the examiner did not consider the impact of medications used to treat service-connected MDD on the Veteran's ED. Nevertheless, at the very least, the evidence shows that the Veteran's use of Zoloft aggravated his ED, as the evidence shows that he was switched to Lexapro for this reason. However, the record also shows that use of Lexapro has similar risk. 

Under these circumstances and resolving all remaining reasonable doubt in the Veteran's favor, the Board finds that the evidence supports that the Veteran has ED due to his service-connected MDD, include medications used to treat his MDD, namely Zoloft and Lexapro. 

Accordingly, the claim is granted.

3. Entitlement to service connection for headaches, secondary to service-connected MDD, is granted. 

The Veteran contends that his headaches resulted from a 2003 in-service assault. Alternatively, he contends that his headache condition is caused or aggravated by service-connected MDD, to include medications used to treat his MDD, namely lamotrigine, and/or service-connected tinnitus. 

For the following reasons, service connection for a headache disability is warranted, and the claim is granted. 

The Veteran's STRs are silent for any complaints, treatment, or diagnosis of headaches.

A September 2008 VA treatment record shows that the Veteran reported having had frequent headaches for a month, which have since resolved. 

VA treatment records show that the Veteran was prescribed lamotrigine for his psychiatric condition, in October 2012. 

A July 2014 VA treatment record shows that the Veteran reported having short-term slight headache after he takes lamotrigine. He was encouraged to take the medication at bedtime.

An October 2014 VA treatment record shows that the Veteran reported that he has not been taking lamotrigine on a regular
 reasons, service connection for a headache disability is warranted, and the claim is granted. 

The Veteran's STRs are silent for any complaints, treatment, or diagnosis of headaches.

A September 2008 VA treatment record shows that the Veteran reported having had frequent headaches for a month, which have since resolved. 

VA treatment records show that the Veteran was prescribed lamotrigine for his psychiatric condition, in October 2012. 

A July 2014 VA treatment record shows that the Veteran reported having short-term slight headache after he takes lamotrigine. He was encouraged to take the medication at bedtime.

An October 2014 VA treatment record shows that the Veteran reported that he has not been taking lamotrigine on a regular basis because he gets a headache shortly thereafter. He reported that this occurs regardless of the time of day it is taken. The medication was ordered discontinued and he was advised to taper the medication as directed. The examiner prescribed topiramate, a migraine medication. 

VA treatment records from 2016 and 2017 show that the Veteran complained of and was treated for headaches. 

A May 2019 VA headaches examination and medical opinion shows a diagnosis of tension headaches. The Veteran reported that his current headaches started when he switched medications. The examiner provided a negative nexus opinion regarding the theory of secondary service connection, pertaining to a relationship between the Veteran's headaches and MDD. 

A November 2020 VA headaches examination and medical opinion shows the Veteran's report that he first started having headaches in 2004, which have worsened over time. The examiner provided a negative nexus opinion on the theory of direct service connection, stating, in part, that VA treatment records show that the Veteran's headaches are thought to be associated with medication, to include lamotrigine. 

Following a thorough review of the record, the Board finds that the evidence is in relative equipoise as to whether the Veteran's headache disability is caused or aggravated by service-connected MDD, to include medications used to treat his MDD, namely lamotrigine. As previously noted, in July 2014, the Veteran reported having short-term slight headache after taking lamotrigine when was encouraged to take the medication at bedtime; however, by October 2014 he reported that he has not been taking lamotrigine on a regular basis because he gets a headache shortly thereafter, regardless of the time of day it is taken. The record shows that the medication was ordered discontinued, and the Veteran was advised to taper the medication as directed, and he was prescribed topiramate, a migraine medication. Indeed, in providing a negative nexus opinion on direct service connection, the November 2020 VA examiner stated that the Veteran's headaches are thought to be associated with medication, to include lamotrigine.

(Continued on the next page.)

Under these circumstances and resolving all remaining reasonable doubt in the Veteran's favor, the Board finds that the evidence supports that the Veteran has headaches due to his service-connected MDD, including medications used to treat his MDD, namely lamotrigine.

Accordingly, the claim is granted.

 

 

G. A. WASIK

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Emmart, Timothy T.

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.