MALIGNANT SKIN NEOPLASMS (OTHER THAN MALIGNANT MELANOMA)

Summary

The Veteran served from May 1988 to July 1998. This case involves an appeal concerning entitlement to service connection for squamous cell carcinoma, claimed as secondary to service-connected eczema and psoriasis, and an increased rating for toenail psoriasis. The Veteran argued that treatments for his eczema and psoriasis, including topical corticosteroids and exposure to sunlight, increased his risk of skin cancer. The Board found the Veteran's current squamous cell carcinoma to be service-connected, granting the claim. This decision was based on a private medical opinion from Dr. S.A., which persuasively linked the cancer to the Veteran's service-connected psoriasis and its treatments, citing medical literature on increased cancer risk. The Board found the VA examiner's negative nexus opinion inadequate as it did not address the causal link or aggravation from treatment. For the toenail psoriasis claim, the Veteran sought an increased rating. Despite the Veteran's contention of intermittent topical corticosteroid use, the Board denied an increased rating. The decision noted that both VA examiners found the psoriasis covered less than five percent of the body and no exposed area, and that the Veteran's use of topical corticosteroids did not meet the criteria for systemic therapy required for higher ratings under DC 7816.

Rationale

Favorable private medical opinion linking cancer to psoriasis and treatments; Inadequate VA examiner opinion that did not address nexus to treatment; Medical literature supports increased risk of skin cancer from psoriasis and treatments

Full Decision Text

Citation Nr: A26040241
Decision Date: 04/29/26	Archive Date: 04/29/26

DOCKET NO. 210726-174513
DATE: April 29, 2026

ORDER

Entitlement to service connection for squamous cell carcinoma is granted.

Entitlement to an initial compensable evaluation for toenail psoriasis is denied.

FINDINGS OF FACT

1. The evidence of record shows that the Veteran's squamous cell carcinoma was caused by his treatment for service-connected eczema and psoriasis.

2. During the entire period on appeal, the Veteran's toenail psoriasis covered less than five percent of total body area and no exposed area, and was not manifested by constant or near-constant 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 over the past 12-month period.

CONCLUSIONS OF LAW

1. The criteria for service connection for squamous cell carcinoma, secondary to service-connected painful/unstable scars associated with eczema and psoriasis on an aggravation basis, have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.303, 3.304, 3.310.

2. The criteria for an initial compensable evaluation are not met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.118, Diagnostic Code 7816.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service from May 1988 to July 1998.

This appeal is being processed in the modernized review system, commonly referred to as the "AMA," as established by the Veterans Appeals Improvement and Modernization Act of 2017. 115 Pub. L. No. 55, 131 Stat. 1105.

This matter comes before the Board of Veterans' Appeals (Board) on appeal of a May 2021 and a June 2021 rating decision issued by a Department of Veterans Affairs (VA) regional office, an agency of original jurisdiction (AOJ).  

The Veteran initiated his appeal by submitting a July 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), and elected the Hearing docket. A hearing was held in January 2025 before a Veterans Law Judge, and a transcript of the hearing has been associated with the claims file.

Therefore, the Board may only consider the evidence of record at the time the AOJ issued the rating decision on appeal, as well as any evidence presented by the Veteran or her representative during the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a).

The Board notes that in July 2021 Notice of Disagreement, the Veteran listed his rating for psoriasis of the right and left legs, and at the January 2025 hearing, the Veteran, through his representative, stated he was appealing his rating for scars of the anterior trunk, which were both most recently decided in a February 2018 rating decision. However, this rating decision was issued more than one year prior to the receipt of such appeal, as the claim for service connection for scars of the anterior trunk was most recently granted in a February 2018 rating decision. Thus, as the Veteran did not file a request for an extension of time to submit his notice of disagreement based on good cause in a timely manner, and the Veteran's notice of disagreement was received more than one year after the issuance of the rating decision, it is untimely. 38 U.S.C. § 7105; 38 C.F.R. §§ 19.22, 19.51, 19.52, 20.104. Further, the AOJ has not waived the requirement to timely file a notice of disagreement, and the Board declines to do so. Hall v. McDonough, 34 Vet. App. 329, 332 (2022); Ferko v. McDonough, 37 Vet. App. 262 (en banc); Percy v. Shinseki, 23 Vet. App. 37, 45 (2009). Thus, this matter is not properly before the Board and will not be addressed herein. 

Service Connection

Service connection will be granted if the evidence demonstrates that a current disability resulted from a disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1131, 5107(b); 38 C
 not waived the requirement to timely file a notice of disagreement, and the Board declines to do so. Hall v. McDonough, 34 Vet. App. 329, 332 (2022); Ferko v. McDonough, 37 Vet. App. 262 (en banc); Percy v. Shinseki, 23 Vet. App. 37, 45 (2009). Thus, this matter is not properly before the Board and will not be addressed herein. 

Service Connection

Service connection will be granted if the evidence demonstrates that a current disability resulted from a disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304.

Generally, to establish service connection, there must be competent and credible evidence demonstrating: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus or link between the in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).  

Service connection may also be granted for a disability that is proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310.

Ordinarily, a lay person is competent to report symptoms and experiences observable by their senses; however, a lay person is usually not competent to prove a matter requiring medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 470 (1994).

1. Entitlement to service connection for squamous cell carcinoma, to include as secondary to eczema and psoriasis.

The Veteran contends that his squamous cell carcinoma is due to treatment from his service-connected psoriasis, specifically, the use of a corticosteroid for his eczema and psoriasis as well as exposure to sunlight predisposed him to skin cancer. 

In the June 2021 rating decision on appeal, the AOJ made a favorable finding that the Veteran has a current diagnosis of squamous cell carcinoma. 38 C.F.R. § 3.104(c). No clear and unmistakable error has been shown by the evidence of record as to that finding; therefore, the Board is bound by that finding. Id. The Board further acknowledges that the claimed primary disability of eczema and psoriasis is currently service-connected. Thus, the Board's analysis will focus on the nexus element of service connection.

In support of his claim, in April 2025, the Veteran submitted a literature review which examined the connection between skin cancer and different medications and therapies used to treat eczema and psoriasis, and concluded that evidence suggests that patients undergoing psoriasis therapies might have a higher risk of cutaneous malignancies, especially for non-melanoma skin cancers, compared with psoriasis-free patients. The Veteran also submitted a separate study which compared the risk of skin cancers, including squamous cell carcinoma, in patients with rheumatoid arthritis. 

In May 2021, the Veteran was afforded a VA examination. The examiner rendered a negative nexus opinion, opining that most squamous cell carcinomas of the skin result from prolonged exposure to ultraviolet radiation, either from sunlight or from tanning beds or lamps, and therefore the condition is less likely than not proximately due to or the result of the Veteran's eczema and psoriasis. The examiner did not render an opinion as to aggravation.

In April 2025, the Veteran submitted an opinion from Dr. S.A., an internal medicine resident physician who reviewed the Veteran's medical and service records. Dr. S.A. noted the Veteran's ongoing management of psoriasis, including the use of topical therapies, and stated that it is well known in medical literature and clinical practice that psoriasis increases risk for squamous cell skin cancer, primarily due to the chronic inflammation and immune dysregulation inherent in psoriasis, as well as the treatments used for psoriasis, such as psoralen ultraviolet light A (PUVA) therapy, immunosuppressive medications, and TNF-a inhibitors have been linked to an elevated risk of nonmelanoma skin cancers, including squamous cell carcinoma. Additionally, studies have shown that the risk of squamous cell carcinoma increases with the severity of psoriasis and the use of specific treatments. Based on the foregoing, Dr. S.A. opined that the Veteran's squamous cell carcinoma is more likely than not a direct result of and aggravated due to service-connected psoriasis and medications associated with it.

The Board notes
 cell skin cancer, primarily due to the chronic inflammation and immune dysregulation inherent in psoriasis, as well as the treatments used for psoriasis, such as psoralen ultraviolet light A (PUVA) therapy, immunosuppressive medications, and TNF-a inhibitors have been linked to an elevated risk of nonmelanoma skin cancers, including squamous cell carcinoma. Additionally, studies have shown that the risk of squamous cell carcinoma increases with the severity of psoriasis and the use of specific treatments. Based on the foregoing, Dr. S.A. opined that the Veteran's squamous cell carcinoma is more likely than not a direct result of and aggravated due to service-connected psoriasis and medications associated with it.

The Board notes that the May 2021 VA examiner did not address whether the Veteran's treatment for his eczema and psoriasis caused or aggravated his current squamous cell carcinoma, and therefore finds it inadequate for adjudication purposes. The Board further notes that the April 2025 private opinion included a thorough analysis supported by relevant medical literature and a review of the Veteran's file. The Board therefore finds that the April 2025 private opinion is the most probative evidence of record in terms of a nexus. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (noting that the probative value of a medical opinion derives from the factually accurate, fully articulated, sound reasoning for the conclusion).

Accordingly, the most probative evidence of record persuasively weighs in favor of a finding that the Veteran's current squamous cell carcinoma was caused by his service-connected eczema and psoriasis, to include his treatment for same. Service connection for squamous cell carcinoma is therefore granted.

Increased Rating

Disability evaluations are determined by comparing a Veteran's present symptoms with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In general, it is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21.

 "Staged" ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods when the service-connected disability exhibits symptoms warranting different ratings irrespective of whether an initial or established rating. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The effective date of an award of increased compensation should not be assigned mechanically based on the date of an examination. Rather, all of the facts should be examined to determine the earliest date that it is ascertainable that an increase in disability first manifested. Swain v. McDonald, 27 Vet. App. 219, 224 (2015). Further, where an increase in the rating assigned is at issue, if factually ascertainable, the effective date assigned may be up to one year prior to the date the application for increase was received. See 38 U.S.C. § 5110(b)(3); 38 C.F.R. § 3.400(o)(2); Gaston v. Shinseki, 605 F.3d 979, 982-83 (Fed. Cir. 2010).

Effective August 13, 2018, under DC 7816, a 10 percent rating is warranted if there is 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 less than 6 weeks over the past 12-month period. A 30 percent rating is warranted if there is one of the following: characteristic lesions involving 20 to 40 percent of the entire body affected or 20 to 
 is 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 less than 6 weeks over the past 12-month period. A 30 percent rating is warranted if there is one of the following: characteristic lesions involving 20 to 40 percent of the entire body affected or 20 to 40 percent of exposed areas affected; or 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 6 weeks or more, but not constantly, over the past 12-month period. A maximum 60 percent rating is warranted if there is at least one of the following: characteristic lesions involving more than 40 percent of the entire body affected 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, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. 38 C.F.R. § 4.118, DC 7816.

Systemic therapy means "treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin," and topical therapy means "treatment that is administered through the skin." 38 C.F.R. § 4.118. 

2. Entitlement to a compensable initial evaluation for toenail psoriasis

The Veteran contends that he is entitled to an increased initial rating for his service-connected toenail psoriasis. He is currently rated as noncompensable from April 19, 2019, under DC 7816. 

In January 2018, the Veteran underwent a VA examination. The Veteran stated the condition began on both sides of the groin and spread all over the body over time. He stated his symptoms are skin peeling and a foul smell, and reported the use of several ointments for treatment. The examiner noted treatment with constant or near-constant use of topical corticosteroids and other topical medications, but no systemic corticosteroids or other immunosuppressive medication. The examiner noted that the Veteran's psoriasis covered less than five percent of his total body area, and no exposed area. 

In March 2020, the Veteran appeared for a VA examination. The Veteran reported a gradual onset of diffuse skin irritation affecting the groin, anterior torso and lower legs, and described his current symptoms as periodic with flare ups treated with oral medication. He also reported he later began experiencing erosion of the toenails and was diagnosed with a psoriasis related toenail complication. The examiner noted constant or near-constant use of oral medication for the Veteran's psoriasis, but noted no use of corticosteroids or other immunosuppressive medications. The examiner noted the Veteran's psoriasis covered less than five percent of his total body area and none of the exposed area. 

In January 2025, the Veteran appeared for a hearing in front of the undersigned Veterans Law Judge. He stated that he has been prescribed topical corticosteroids, which he applies from his legs to his feet. He reported he did not apply the corticosteroids on any visible skin locations. He stated that he had not been prescribed any other medication to suppress his immune system, and while he had been prescribed other medications, these were not corticosteroids. The Veteran, through his representative, stated that the Veteran's intermittent use of a topical corticosteroids should qualify him for a 10% rating.

However, based on the foregoing, the Board finds that a compensable rating for the Veteran's toenail psoriasis is not warranted. The January 2018 and March 2020 VA examiners found the condition to cover less than five percent of total body area and no exposed area. The Board acknowledges the Veteran's contention that his use of a topical corticosteroid qualifies him for a higher 10 percent rating; however, under the new rating criteria, the VA has differentiated between systemic therapy and topical therapy, as detailed above. The Veteran stated at the January 2025 hearing that the only corticosteroid he has been prescribed for his toenail psoriasis is topical, which is
 should qualify him for a 10% rating.

However, based on the foregoing, the Board finds that a compensable rating for the Veteran's toenail psoriasis is not warranted. The January 2018 and March 2020 VA examiners found the condition to cover less than five percent of total body area and no exposed area. The Board acknowledges the Veteran's contention that his use of a topical corticosteroid qualifies him for a higher 10 percent rating; however, under the new rating criteria, the VA has differentiated between systemic therapy and topical therapy, as detailed above. The Veteran stated at the January 2025 hearing that the only corticosteroid he has been prescribed for his toenail psoriasis is topical, which is further supported by the VA examiners' findings. Neither the January 2018 nor the March 2020 VA examiner noted the use of systemic corticosteroids or other immunosuppressive medication.

Accordingly, the Board finds no basis to award an increased initial rating for the Veteran's toenail psoriasis, and the claim is denied.

 

 

Marcus N. Fulton

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Marshall, J.

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.