RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01281
BRANCH OF SERVICE:  Army	BOARD DATE:  20150227
SEPARATION DATE:  20020310

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Combat Engineer) medically separated for discoid lupus erythematosus (DLE).  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  The profile allowed for a standard physical fitness test.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  “Discoid lupus erythematosus” was forwarded by the MEB to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “discoid lupus erythematosus” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Due to more medical issues occurred such as PTSD, arthritis, and other related issues such as night sweats and depression, suicidal thought, I go through a lot everyday of my life.  Sometimes it hurts to get out of bed.  I am at 90% from VA.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

IPEB – Dated 20041026	VA* - (~1.5 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Discoid Lupus Erythematosus	7809	10%	Discoid Lupus 	7899-7809	0%	20050125	
Other x 0 (Not In Scope)	Other x 6	
RATING:  10%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20050406 (most proximate to date of separation (DOS)).

ANALYSIS SUMMARY:

Discoid Lupus Erythematosus.  The first note in the treatment record dated 9 September 2000 indicated the CI had an 8-year history of discoid lupus and not systemic lupus erythematosus.  His prescription for Hydroxychloroquine (an antimalarial medication with anti-inflammatory properties) was refilled according to protocol.  A dermatology consultant confirmed the diagnosis, continued the medication, ordered laboratory studies, and advised the CI to use sunscreen and to wear a hat.  Scattered lesions of the face appeared and cleared with treatment with a potent topical steroid (Temovate-clobetasol).  Reference to a P2 profile for sun exposure precautions was made.  On 9 March 2001 laboratory results were reported to be normal and the discoid lupus was controlled with strict sun avoidance.  A dermatology evaluation on 28 January 2003 noted the CI wore “sun block religiously” and was treated as ringworm since childhood.  Scattered hyperpigmented lesions were noted on the right ear, cheeks and right mandibular border, the largest measured 20 mm x 20 mm.  In March 2003, the CI did not have systemic symptoms such as joint pain, photophobia, malar rash, kidney problems, oral lesions, or serositis.  New arthritis symptoms raised concern for possible conversion to systemic lupus erythematosus in August 2004, while an erythematous patch was noted on the scalp and prior noted skin changes remained unchanged.  A P3 profile for cutaneous lupus was issued on 24 August 2004 with limitation that he should have minimal exposure to sunlight and be near a Medical Treatment Facility to receive routine monitoring of blood work and access to a dermatologist or rheumatologist to control the condition with medication.  The commander’s statement dated 21 September 2004 indicated the CI was limited by his medical condition and was not able to participate in any outdoor activities, which did not allow him to perform critical duties as a combat engineer.  At the MEB examination dated 1 September 2004, the CI reported sensitivity to sunlight.  The MEB physical examination dated 2 September 2004 recorded a 2.25 cm brown healed skin discoloration of the right face and other similar lesions of the right neck superiorly (1.25 cm) and the left face/cheek (1.25 cm).  A 0.75 cm scar was present on the superior scalp along with a 0.5 cm ulcer (lesion).  Additionally, there were annotations that the diagnosis of cutaneous lupus erythematosus was confirmed by biopsies in 1999, 2002, and 2004; the skin problem was worse with sunlight; the CI lost hair with the problem; and he took no medications at the time of the examination.

The MEB narrative summary (NARSUM) dated 7 October 2004 noted the CI had a 5-year history of discoid lupus localized to his scalp and face.  Multiple treatments included intralesional steroid injections of Kenalog (triamcinolone) and topical steroids.  He required preventative measures for photo protection (sunlight or certain wavelengths of light) including sunscreen, long sleeved clothing and a hat.  When deployed to a sunny area, it flared, and was deemed that the condition would be uncontrollable in an austere environment.  There was no evidence to support progression to systemic lupus erythematosus, and laboratory studies including CBC, urinalysis, hepatic panel, ANA, and ENA screening were normal or negative.  Physical examination revealed a 4 x 3 mm erythematous patch on the vertex of his scalp and two discrete 1.0 x 1.0 cm hyperpigmented atrophic patches on both the right cheek and right mandible.  The examiner noted an examination can vary based on the CI’s treatment status; and, at the time of the NARSUM examination, the CI’s cutaneous lupus was under relatively good control and would remain so as long as he maintained good photo protective measures and procedures.  However, in the absence of maintaining the protective measures, the CI was advised the condition will flare.

After separation the CI noted another “spot” on the skull on 22 December 2004 and was referred to Dermatology.  Initial VA evaluation after separation on 11 January 2005 revealed lupus patches on the pinna (outer part) of the ears bilaterally, the right cheek, and two patches around the vertex (top) of the scalp.  At the VA Compensation and Pension examination dated 25 January 2005, performed approximately a month after separation, the CI reported he was diagnosed with discoid lupus in July of 1999 after he developed “a red circle on his face and nose.”  Treatment was with topical medication and the lesion on his nose abated, but the lesion on the face remained.  Various topical steroids of different potencies were tried with limited effects or no relief.  Injected steroids directly into the lesions improved them and his hair grew back.  When he was deployed his condition worsened due to the heat and sunlight, and he was eventually evacuated from the theater and was medically separated from the service due to this discoid lupus.  Since discharge, he had no further treatment, but the CI noted that if he waited too long for treatment the hair will fall out in the area of the discoid lupus and stated that he had no recurrence of facial lesions, but he had recurrence of lesions of the scalp.  A flare once a year lasted 2 or 3 months and then two additional months for the hair to grow back.  Examination of the skin revealed 0.25 cm brown areas in the upper right ear pinna and a 0.5 cm round, brown area in the right mid-pinna.  There were also a 1.75 cm x 1.25 cm area on the right cheek; the right lower jaw had a 1.0 cm round, brown, discolored area; and there was a 0.5 cm area in the occipital scalp that was pink with missing hair.  All of the lesions were flat without ulceration or drainage and some were hyperpigmented and atrophic.  The surface of the body covered by the lesions was less than 1% at the time of the examination.  In addition tinea versicolor (a superficial fungal infection) was present on the forearms and shoulders.  A dermatology evaluation on 7 February 2005 indicated the CI did not have any discoid lupus on the face, trunk or extremities, and had only two well defined mild erythematous bald patches and an atrophic, depressed scar on the vertex of his scalp.  The use of a potent topical steroid was continued.  In June 2005 the CI was noted to have a 3 cm depressed, hyperpigmented, discoid macule of the right mandible along with the aforementioned scalp findings.  “The trunk and the extremities [were] spared.”  A temporally remote (61 months after separation) VA examination was reviewed; however, it offered very limited or no probative post-separation evidence since the CI reported “no current skin problems, denies rash, suspicious lesions or lumps.”  However, almost 8 months later new lesions of the scalp and right ear were treated with intralesional steroid injections.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 7809 for the DLE, while the VA assigned a 0% rating using code 7899-7809 (discoid lupus).  Code 7809 affords the opportunity to rate as disfigurement of the head, face, or neck using code 7800, as scars using codes 7801-7805 (dermatitis) using code 7806.  Each of the aforementioned codes was considered for a route to a higher rating; however, none could provide a rating greater than 10% assigned by the PEB.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the DLE condition.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the DLE condition and IAW VASRD §4.118, the Board unanimously recommends no change in the PEB adjudication.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130909, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXX, AR20150011047 (PD201301281)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  

This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl			     
						         
CF: 
(  ) DoD PDBR
(  ) DVA