RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00308
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040802

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Infantry, medically separated for “acne rosacea fulminans”, with a disability rating of 10%.

CI CONTENTION:  “Please see evidence section in Department of Veteran Affairs Rating decisions – Oct 26, 2004 for further explanation.”  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 based upon a 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 PEB - 20040331	VARD - 20041026  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Acne Rosacea Fulminans	7828	10%	Acne Rosacea Fulminans/Face	7828-7806	60%	20040805	
Migraine Headaches	Not Unfitting 
	Migraine Headaches	8100	50%		
Pes Planus w/Metatarsalgia		Bilateral Pes Planus with Metatarsalgia	5276	10%		
Right Hand Median Nerve Partial Sensory Defect		Right Wrist Strain With Right Median Neuropathy	NSC**	8515		
Vision Defect		No VA Entry	
Adjustment Disorder		Major Depressive D/O w/Insomnia	9434	100%	20040805	
Insomnia						
COMBINDED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  100%	

ANALYSIS SUMMARY:  

Acne Rosacea Fulminans.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s acneiform condition began in approximately March 2003 after using facial products and explosively worsened soon after deployment.  The CI was medically evacuated after being unresponsive to multiple medications and continued worsening.  The facial eruption had a burning sensation, which was helped with Tylenol #3 (codeine, a narcotic and acetaminophen, a pain reliever) or Percocet (oxycodone, a narcotic and acetaminophen).   Medrol (methylprednisolone, a steroid) gave slight improvement of the redness, but did not resolve the problem that was confined to the face and was marked by erythematous papules and pustules and was diagnosed as acne rosacea fulminans.  A skin biopsy in June 2003 demonstrated acute inflammation with abscess formation and foreign body giant cell reaction consistent with acne rosacea.  In July 2003 the rosacea symptoms had improved markedly with use of a combination of prednisone, Minocin (minocycline, an antibiotic), and Metrogel (metronidazole, a topical antibiotic); however, she had emotional difficulty with the condition because of her appearance, prognosis and lifestyle (see below).  She could not tolerate the heat; her cheeks burned; and she had to use a sunscreen with an SPF of 45 at least once a day.  Differin (adaptalene) gel was added to the skin treatment regimen along with doxepin (an antidepressant medication) for sleep, to decrease itching, and to aid in mitigating depressive symptoms.  Topical medications were temporarily discontinued due to irritation and Zithromax (azithromycin, an antibiotic) replaced the Minocin.  However, despite continued treatment the CI continued to experience flares of the rosacea marked by erythematous papules of the central face and right neck.  Because of scarring and pitting on both sides of her cheeks, zygomatic areas and temporal regions she sought a plastic surgical opinion in December 2003.  

Despite treatment, the acne rosacea fulminans the condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “acne rosacea fulminans” for PEB adjudication.

At the MEB examination (recorded on DD Forms 2807-1 dated 18 December 2003 and 2808 dated 5 January 2004), approximately 7 months prior to separation, the CI reported skin changes during, after, and currently due to deployment.  She was treated with numerous medications and was unable to have prolonged sun exposure or conduct physical activities that caused exertion.   Physical examination revealed a myriad of facial scars without inflammatory papules and generalized erythema (redness) of the face.  

Because of continued flares, Azelex (azelaic acid to treat acne rosacea) cream was added to the treatment in January 2004.  The dermatologist noted that 85-90% of the facial skin was involved as a result of rosacea fulminans.  The NARSUM dated 12 February 2004 indicated the CI had a detailed physical examination on 5 January 2004 (see above) and noted the CI had chronic mild to moderate facial erythema with flare-ups easily provoked by physical exertion, heat, and excessive sweating.  She also had random outbreaks, approximately once a month, of painful pustules that sometimes required pain medications.  She was profiled from field duty to avoid exposure to sunlight and heat as well as physical exertion or wearing personal protective gear.  In April 2004 the CI underwent a full facial peel, which was performed with 50% glycolic acid.  In June 2004, the CI developed a rash of the bilateral knees, elbows, hands, thighs, upper arms and ankles associated with body aches, headaches and malaise after sun exposure.  A tele dermatology consultant considered a viral exanthem (papular acrodermatitis or Fifth’s disease) or a streptococcal exanthem (rash) versus a drug eruption, which was treated with prednisone.  A trial of punch grafting for acne scarring of the right temple was carried out in July 2004.

At the VA Compensation and Pension (C&P) examination on 5 August 2004, performed 3 days after separation, the CI reported her medical history related to the acne rosacea fulminans and noted she missed 120 days of work in the prior year because of acne issues.  She took Zithromax every other day and used Metrogel and an acid type of cream [Azelex] daily and used prednisone about every other month for severe inflammation. Physical examination of the CI’s face revealed multiple, small erythematous papules with a few pustules on the malar areas.  She had multiple ice pick and crater type scars on the temple extending down onto the cheeks and chin, but had very little involvement of the neck and had a papules with very few pustules on her forehead area.  Most of the scarring lesions measured 0.5 cm x 0.5 cm.  She had an area of scarring behind the left ear, which measured about 4 x 0.5 cm from where eight punch biopsies were taken.  The site was slightly red but without exudate, induration, inflammation, retraction, ulceration or keloid formation.  On her right temporal area, she had about eight larger scars where the grafts were implanted.  They measured 0.5 cm x 0.5 cm and were slightly brown and discolored, but otherwise without major abnormalities.  Photographs were to be taken on the day of the examination.  The examiner estimated the face involvement was about 70 percent.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 7828 code (Deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face and neck, or; deep acne other than on the face and neck), citing acne rosacea fulminans “Scars are not unfitting, not ratable, acne is currently described as ‘facial scars without inflammatory papules, but with generalized mild erythema of the face.’”

The VA assigned a 60% rating using an analogous 7828-7806 code (acne-More than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period) based on the VA C&P examination 3 days after separation, citing acne rosacea fulminans, facial area.  Board members discussed the disparate codes and ratings between the PEB and the VA.  Proximate to separation the CI had a history of severe acne rosacea fulminans with persistent scarring and facial erythema, which required continuous medication including prednisone and pain medication when she had flares of the papules and pustules on a monthly basis.  Therefore, a 30% rating is reasonable using code 7828 (dermatitis or eczema-deep acne (deep inflamed nodules and pus-filled cysts) affecting 40 percent or more of the face and neck) because of the history of the severity in the past, the flares proximate to and post-separation as well as the continuous use of medication including prednisone.  The VA rating of 60% seems to be high for erythema of face since the surface area of the anterior head is about 4.5% of the body, but other exposed areas, as a general statement, could also include the hands or portions of the arms or legs depending on the type of clothing a person is wearing at any given time.  Therefore, in the absence of more precise details, a 30% rating would be more likely, which is not inconsistent with the proposed rating using the 7828 proffered pattern.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the acne rosacea fulminans condition, coded 7828.  

Contended PEB Conditions-Migraine Headaches, Pes Planus with Metatarsalgia, Right Hand Median Nerve Partial Sensory Defect, Vision Defect, Adjustment Disorder, and Insomnia.  The Board’s main charge is to assess the fairness of the PEB’s determination that the migraine headaches, pes planus with metatarsalgia, right hand median nerve partial sensory defect, vision defect, adjustment disorder, and insomnia conditions were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The migraine headaches, pes planus with metatarsalgia, right hand median nerve partial sensory defect, adjustment disorder, and insomnia were not profiled, but the vision defect was profiled E2.  None of the conditions were implicated in the commander’s statement and none were not judged to fail retention standards.   

Migraine Headaches.  At an Emergency Room visit in February 2001, the CI was given Tylenol (acetaminophen, a pain reliever) for a severe headache.  In January 2004 the CI reported chronic headaches for 1 year with a severity of 3/10 at which time the question of a migraine headache was raised.  Treatment consisted of Zomig (zolmitriptan for migraine headache treatment) at the onset of a headache and 2 hours thereafter if needed.  At a follow-up visit 2 weeks later magnetic resonance imaging (MRI) was reported to be normal and the CI noted the Zomig was working well.  At the VA C&P examination the CI report the migraines had become worse over time and she was occasionally nauseous; however, when she took the Zomig early, the level of the headache would decrease, but would not be eliminated completely.  Sometimes she had to lie down in a dark room at work with permission and would miss part of the day, but usually not the full day.  

Pes Planus with Metatarsalgia.  In December 2003 the CI complained of pain bilaterally in the first toes, which was worse with activity.  The diagnosis of hallux valgus with mild pes planus with early hammer toe formation of the second to fifth toes bilaterally was made.  Conservative measures and surgery were discussed.  An X-ray series, ordered for bilateral foot pain, demonstrated hallux valgus (bunion) configurations of the first digits with mild pes planus and early bunion formation in January 2004.  In February 2004 the CI had a tender 3-4 mm non-mobile nodule dorsal/medial to the first metatarsal of the right foot suggestive of a ganglion.  At the VA examination the CI was noted to have a long history of pes planus, which was recorded on her entry examination and she developed bunions with hallux valgus bilaterally.  On examination she had moderate pes planus and mild hallux valgus bilaterally and a slight bunion on the left.

Right Hand Median Nerve Partial Sensory Defect.  The CI was in a motor vehicle accident in July 2001 and complained of shoulder pain and right wrist pain.  X-rays revealed no significant abnormality.  At the VA examination the CI related a median neuropathy occurred when she was a teenager and put her right hand through a window and had severe lacerations of the right wrist for which she underwent multiple surgeries of the wrist with realignment of the nerve and other repair procedures.  At the time of the examination she noted loss of sensation was restricted to the thumb and thenar eminence (palm area proximate to the thumb) and sometimes she had tingling or abnormal sensations of the first finger.  Additionally, her wrist tingled when it was tapped or pressed on.  She was able to write with her right hand and could manage with both hands, but had decreased grip strength and decreased thumb flexion and opposition and had electrical and dysesthesia (abnormal) sensations with stroking or tapping or with flexion or extension of the wrist.

Vision Defect.  The CI had 20/40 unaided vision corrected to 20/20 on entrance with high K (keratometry to measure the curvature of the cornea) readings (47.75/43.50 @ 177 on the right and 47.75/43.00 @ 173) that were congenital in nature, but no sign of keratoconus (cone shape of the cornea) on entrance to the service.  In June 2004 the CI still had elevated K readings with an average of 47.00 on the right and 46.75 on the left that were slightly higher compared to the tests 4 years earlier.

Adjustment Disorder.  The Psychiatric Medical Board Addendum dated 28 January 2004 indicated the CI had anxiety secondary to rosacea with associated insomnia (see below), which was treated with supportive psychotherapy beginning in early July 2003.  She did not like to go outside fearful that others would look at her as well as being concerned about sun exposure.  Over the next several weeks her anxiety/depression improved and she discontinued treatment in August 2003.  In November 2003 she was psychiatrically hospitalized for approximately 2 days in association with becoming overwhelmed with rosacea and a possible MEB and was diagnosed with depressive disorder and adjustment disorder.  Thereafter she reported doing well and had brief periods of insomnia, but generally reasonable sleep (see below).  On the mental status examination she was neatly dressed and groomed and was initially slightly moderately anxious, but appeared to relax as the interview progressed.  She described her mood as “okay” and her affect was overall euthymic.  Thinking was generally logical and goal-directed without evidence of a psychotic thought.  Her axis I diagnosis was history of adjustment disorder with both anxiety and depression in association with the diagnosis of rosacea and her General Assessment of Function (GAF) score was approximately 70 (some mild symptoms).

Insomnia.  The CI had insomnia with anxiety and was treated initially with Ambien (zolpidem, a sedative for treatment of insomnia) and later with low dose Seroquel (quetiapine used with antidepressant medication) and her sleep improved.  The symptoms improved with a brief trial of sleeping medication and sleep hygiene.

There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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 any of the contended conditions; and so, no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the acne rosacea fulminans condition, the Board unanimously recommends a disability rating of 30%, coded 7828  IAW VASRD §4.118.  In the matter of the contended migraine headaches, pes planus with metatarsalgia, right hand median nerve partial sensory defect, vision defect, adjustment disorder, and insomnia conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Acne Rosacea Fulminans	7828  	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150513, 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

06 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170000670  (PD201500308)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days  suspense date]:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

			       
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA