RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01795
BRANCH OF SERVICE:  Army	BOARD DATE:  20150115
SEPARATION DATE:  20040827

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Helicopter Repairer) medically separated for a skin condition.  This condition could not be adequately rehabilitated to meet the requirements of her Military Occupational Specialty or physical fitness standards, so she was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The skin condition, characterized as “eczema (atopic dermatitis), severe …,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501; no other conditions were submitted by the MEB.  The PEB adjudicated “adult onset eczema exacerbated by heat” as unfitting, rated 10%.  The CI made no appeals and was medically separated.

CI CONTENTION:  “My condition which they labeled eczema is actually called polymorphus light eruption [PLE].  I'm now allergic to UVA and UVB rays of the sun and it is permanent with no cure except staying out of sunlight.  My ulnar nerve in my left arm renders my arm useless without warning.  My migraines are becoming worse and rendering me useless to my family and myself.”

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:

Service IPEB – Dated 20040712	VA - (5 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Adult Onset Eczema …	7806	10%	Eczematous Dermatitis…	7806	60%	20050124	
No Additional MEB/PEB Entries in Scope  	No Additional VA Entries in Scope  	
Combined:  10%	Combined:  80%	
Derived from VA Rating Decision (VARD) dated 20050517.

ANALYSIS SUMMARY:

Adult Onset Eczema Condition.  According to the MEB narrative summary (NARSUM), the CI developed an intermittent itchy skin rash after reassignment to Hawaii in October 2002.  The first service treatment record (STR) for care of rash was in May 2003; however, according to the commander’s statement, the CI developed itching of the skin in December 2002 when in direct sun for extended periods of time.  According to the commander, the CI next developed itching and a rash in April 2003 following a field exercise.  The CI was seen in the clinic on 14 May 2003 for a rash on the sun exposed areas of her arms, legs and the back of her neck.  She returned to clinic 22 May 2003 without improvement in the rash which was stated to have been present for 3 weeks by that time.  The CI reported a burning sensation of the rash when the temperature rose.  Although there are no STRs, the commander’s statement reported the CI developing itching and swelling of the face, arms, torsos and thighs in August 2003 when she was out in the sun for an hour on the range.  She was subsequently assigned range duty later in August in the shade but developed itching without rash.  A dermatology evaluation on 3 September 2003, diagnosed atopic dermatitis (eczema) with patches of lichenification (thickening due to scratching) and hyperpigmentation on the antecubital fossa of the elbows (front of elbow where it bends) and chest.  At the dermatology appointment on 30 September 2003, the CI reported the rash was provoked by sun light.  On examination there was no active skin disease.  There was mild post-inflammatory hyperpigmentation of the antecubital areas of the elbows, chest and neck with lichenification (thickening due to scratching).  The dermatologist diagnosed the condition atopic dermatitis (eczema) but noted the possibility of urticaria due to sun exposure.  A second opinion dermatology evaluation on 21 November 2003 also concluded with diagnosis of atopic dermatitis (mild active).  The CI reported aggravation by sun or increased body temperature.  The CI also reported increased sensitivity to environmental things (e.g. in the house).  On examination, there were lichenified hyperpigmented patches in the antecubital fossa of the elbows, popliteal fossa of the knees (back of the knee where it bends), and the upper chest.  At the time of allergy evaluation on 26 November 2003, the skin examination was unchanged.  The CI reported flares of the skin with sun exposure only.  Skin testing on 29 December 2003 was positive for reaction to common allergens (dust, grass pollens, animal dander).  At a clinic appointment on 6 January 2004, the CI reported severe itching while participating in physical training in the grass.  Allergy clinic follow-up on 21 January 2004 recorded there had been no acute flares of the atopic dermatitis skin condition, but the CI reported a red bumpy rash when exposed to the sun that lasted for 1 to 1.5 hours.  She reported itching with exercise but no rash.  The allergist noted consideration for further testing for sun sensitivity (light box exposure).  According to the MEB NARSUM, the CI underwent photo testing (exposure to ultraviolet radiation) in March 2004 but the exposure did not provoke urticaria (i.e. not solar urticaria).  After several treatments in a light box (used for certain skin conditions provoked by sun exposure), her eczema became significantly worse to the point that it involved her entire torso and lower extremities in a confluent fashion and produced severe symptoms of itching.  The CI indicated that this was the similar type of rash that she had experienced in the past when exposed to increased environmental temperature.  The dermatology MEB NARSUM on 28 May 2004, recorded the clinical history noted above.  The MEB NARSUM described the skin examination at the time of the phototherapy induced exacerbation in March, but reported that at the time of the NARSUM, the CI's condition was of a mild nature and well-controlled with topical steroids.  The diagnosis was atopic (allergic rhinitis) and the examiner opined that increased temperature (rather than sunlight or ultraviolet radiation caused the rash.

At a VA dermatology evaluation on 30 September 2004, a month after separation, the CI was using vitamin E lotion only, having “tried and failed” multiple treatments including oral steroids, steroid creams, antihistamines, an immunosuppressant skin cream (Elidel), and “light box treatments.”  She had no rash at the time, only “dark spots” where the rash had been.  
The examiner noted oval hyperpigmented patches on the extremities and lower back, compatible with post-inflammation, but no active lesion or scale.  She was prescribed a steroid ointment to use as needed for future flares.  At the VA Compensation and Pension (C&P) general medical exam performed on 18 November 2004 (3 months after separation), the CI’s only medication was steroid cream to be used as needed.  The CI had numerous hyperpigmented dark, irregularly-shaped spots scattered primarily on the posterior neck area, the buttocks area, and both lower extremities.  No active skin rash was described.  At the VA C&P dermatology exam performed on 24 January 2005 (5 months after separation), the CI reported that she had a bad attack prior to discharge that required a course of oral steroids (prednisone), and was prescribed topical steroids as the flare cleared up.  The lesions from an acute breakout (either water-filled papules or pink hives) would take 2 days to two months to clear, but “when they disappear they leave behind hyperpigmented patches on her skin.”  She was being treated with topical medications.  On the day of the exam, the CI reported she had itching “everywhere.”  The examiner stated, “She is taking her medications that has cleared up her sores, but the itching is still present.  The lesions are all over her body, which include both hands, thighs, legs, belly, chest, back and feet.”  The examiner described “hyperpigmented papules from 1mm to 5cm” over 75% of the skin surface and 80% of the exposed skin surface.  The lesions were not fluid filled, were described as initially red but were “starting to darken up” at the time of the exam.  “She does not have any scars, but just has hyperpigmented lesions all over.  …  She still continues to have itching and new lesions still pop on in medications; her eczema covers almost   75% of her total body surface and 80% of her exposed surfaces.”  At a remote VA C&P exam       5 years after separation on 23 March 2009, the CI still complained of recurrent rashes with sun exposure.  On exam she had, “… splotches of hyperpigmentation where in the past she has had active atopic dermatitis noted, but no active lesions,” and the examiner stated, “Veteran currently does not have any active rash and therefore the rash is: percent of exposed areas affected 0%.  Percent of entire body affected 0%.”  A 25 May 2010 dermatology note indicated the diagnosis as polymorphous light eruption.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated adult onset eczema condition at 10% and coded 7806 (Dermatitis or eczema), citing exacerbation by heat and requirement for systemic steroids once in the prior 12 months.  The VA rated the eczematous dermatitis at 60%, coded 7806, based on the 24 January 2005 C&P examination citing the percentage of exposed body and entire body covered with lesions.  The service records reflected significant flares of skin disease in April 2003, August 2003, and March 2004 (after phototherapy).  Otherwise the skin disease was mildly active involving the antecubital fossa of the elbows, the popliteal fossa of the knees, upper chest and back of the neck.  At the time of the dermatology examination a month after separation there was evidence of post-inflammatory pigmentation but no active skin disease.  Post-inflammatory hyperpigmentation is a common disorder, and can result from a variety of skin conditions (including various rashes, medications reactions, trauma, ultraviolet light exposure, pregnancy, endocrine conditions).  As such, unless there are specific complications that affect the member’s duty status, hyperpigmentation is not normally considered to be unfitting for service.  Although the VA rated these conditions together, under code 7806 as eczematous dermatitis, Board consensus was that these actually represented two distinct skin conditions for fitness consideration purposes, and that the disability rating should apply to only to the unfitting condition, eczema.  The NARSUM, MEB, and PEB all referred to atopic dermatitis or eczema as the unfitting condition, and there was no evidence in the STR that the PEB intended to characterize the hyperpigmentation as unfitting.  Review of the STR indicated that the CI had been treated with systemic therapy for duration of less than 6 weeks, so the Board determined that rating the eczema under code 7806 was dependent on the amount of affected body surface.  Since the eczema was described as “of a mild nature and well-controlled with topical steroids” in the NARSUM and as “no active lesion” in the dermatology consult on 30 September 2004, the Board concluded that less than 5% of the entire body and exposed body surface areas were affected.  
The dermatology C&P examination on 24 January 2005 described new lesions on the abdomen that had been red but were “starting to darken up,” but this exam was later after separation and represented post-separation worsening, and the lesions did not affect sun-exposed areas and appeared to affect less than 5% of the entire body.  Since, the CI was being treated with topical therapy (triamcinolone) only; the Board determined that the condition should be rated at 10% under code 7806.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the skin 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 surmised from the record or PEB ruling in this case that no prerogatives outside the VASRD were exercised.  In the matter of the skin condition and IAW VASRD §4.118, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends no re-characterization of the disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130910, 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 XXXXXXXXXXXXXXXXXX, AR20150008228 (PD201301795)

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