RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01345
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20040618

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Food Service Specialist, medically separated for “hydradenitis suppurativa” with a disability rating of 10%.  

CI CONTENTION:  The CI made no specific contention.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20040211	VARD - 20040727	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Hidradenitis Suppurativa	7899 7806	10%	Hidradenitis Suppurativa	7806-7801	20%	20030623	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Hidradenitis Suppurativa.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s skin condition began in 1998 with a history of recurrent axillary, inguinal, and mid chest as well as axillary hidradenitis suppurativa (skin disease marked by papules, pustules, cysts, abscesses and scarring).  She had multiple surgical procedures including laser treatments and open marsupialization of the lesions as they arose.  

The 24 March 2003 MEB NARSUM examination, 15 months prior to separation, showed active hidradenitis suppurativa in the breast folds with chronic scarring and acute changes.  The examiner noted a history of chronic skin disease which mainly affected her breasts, axillae, buttocks, and groin areas. 
On 25 March 2003, the CI had 3-4 cm of fluctuance without erythema in the breast folds over the sternum area.  The CI was issued a P3 profile on 3 April 2003 for hidradenitis suppurativa (chronic scarring, draining skin).  The 25 April 2003 commander’s statement indicated the CI was incapable of performing her duties as a food service specialist due to the limitations of her profile and pain noticed during the performance of her duties as well as limitations due to chemicals and extreme temperatures. 

At the 23 June 2003 VA Compensation and Pension (C&P) evaluation, 12 months before separation, the CI reported a history of multiple excisions and continuous symptoms of oozing yellow, white fluid, pain, open wounds, itching, scarring, and constant pain.  Physical examination showed a 17 cm x 3 cm scar of the right axilla that was not tender and an 11 cm x 13 cm of the left axilla that was tender with partial adherence on the right and left.  Tissue loss of the left axillary areas was greater than 6 square inches with keloid formation on the right and left.  Limited motion was present on the left due to scarring.  Sensation was reduced on the left and right upper extremities.  Three lesions were present on the left thigh, one of which was open, 1 cm in size, and draining.  The suprapubic area had a 2 cm raised tender area.  There were elevated tender areas of the sternal region in an area of 8 cm x 3 cm with induration (thickening associated with inflammation) greater than 6 square inches.  Tight tissue in the sternal region did not allow normal movement of breast tissue.  Examination of the rectal/genital areas was declined secondary to pain in the pelvic areas secondary to lesions.  The examiner noted excisions and scarring represented about 8% of the body surface area.  

The CI underwent a wide local excision of skin and soft tissue from between the breasts over the sternum and from the inframammary fold of the left breast on 2 July 2003.  Pathology revealed suppurative granulomatous dermatitis consistent with hidradenitis suppurativa. A wound separation was noted of the left inframammary crease on 4 August 2003.  The CI had an infected cyst of the right axilla on 15 September 2003.  In December 2003, the CI had a painful lump under the right arm. 

During the 12 December 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported sharp pain in her arms and chest and had no feeling in the back of her arms due to surgery.  Physical examination showed bilateral axillae with surgical scars, an anterior chest scar with a keloid, scarring under the left breast and bilateral inguinal scars.  The CI had a painful, tender, fluctuant nodule of the chest on 21 January 2004. 

The 10 February 2004 MEB NARSUM addendum, 4 months prior to separation, noted flare-ups with infection of the buttocks, groin area, and around the breasts as well as problems around the axillary areas with cysts, infection, and drainage.  She required about 15 different I&D (incision and drainage) procedures in the prior 6 months.  Physical examination showed a 5 inch scar under the right axilla with keloid formation; a 5 inch scar across the left axilla with keloid formation; a scar between the breasts and small scars under the breasts on both sides without active lesions; scarring of the upper inner thighs with four areas of redness and some inflammation with some drainage from two sites; and scarring in the pilonidal area (sacrum/coccyx).  The examiner indicated the total body involved in hidradenitis was estimated at 5% of the total body surface area; however, 100% of axillary areas had been involved and showed the results of surgery.  The examiner’s diagnosis was hidradenitis suppurativa of the axillae, breasts, groin, and buttocks with areas of chronic infection, drainage, and scarring.  He noted the condition was persistent despite aggressive surgical and medical therapy with chronic exacerbations that limited her ability to function and caused discomfort and distress.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the skin condition 10%, coded 7899-7806 (dermatitis or eczema), citing status post multiple surgical procedures affecting 5 percent of total body surface area.  The VA rated the skin condition 20%, coded 7806-7801 (dermatitis or eczema-burn scars or scars due to other causes, not of the head, face, or neck, that are deep and nonlinear), based on the C&P examination 12 months before separation, citing scarring of the left axilla that causes limited motion of the arm and that has an area in excess of 12 square inches (77 square cm).  

Panel members noted the PEB rated the hidradenitis suppurativa using code 7899-7806, which requires “at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period.”  However, hidradenitis suppurativa is not eczema, and while code 7806 bases rating of total surface area, hidradenitis suppurativa is an inflammatory disease consisting of papules, pustules, cysts, abscesses, and scarring.  The NARSUM addendum examiner indicated the involved area was approximately 5% of body surface area; however, the axillary areas had 100% involvement, but the examiner did not provide two dimensional measurements, but noted each axilla had 5 inch scars with keloid formation.  Nevertheless, the VA rated the hidradenitis suppurativa using code 7806-7801, which integrated both the dermatitis and scarring, which better reflects the spectrum of the hidradenitis suppurativa.  Therefore, the CI’s scar of the left axilla (143 sq. cm.) warrants a 20% rating that requires “area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.)” based on C&P examination measurements, which were more precise than the NARSUM addendum and were unlikely to have changed significantly over the subsequent 7 months.  Members also noted the VA examiner indicated limitation of motion of the left arm, but was silent on the right arm which also had significant, deep scarring.

Members then discussed code 7801 Note (2), which states:  “If multiple qualifying scars are present, or if a single qualifying scar affects more than one extremity, or a single qualifying scar affects one or more extremities and either the anterior portion or posterior portion of the trunk, or both, or a single qualifying scar affects both the anterior portion and the posterior portion of the trunk, assign a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity, assign a separate evaluation based on the total area of the qualifying scars that affect the anterior portion of the trunk, and assign a separate evaluation based on the total area of the qualifying scars that affect the posterior portion of the trunk. The midaxillary line on each side separates the anterior and posterior portions of the trunk. Combine the separate evaluations under §4.25. Qualifying scars are scars that are nonlinear, deep, and are not located on the head, face, or neck.” 

The CI had multiple qualifying scars, including the left axilla (143 sq. cm.) discussed above and the right axilla (51 sq. cm).  Therefore, IAW with code 7801 Note (2) the right axilla scar warrants a 10% rating for an “area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.).”  Other scars also were present; however, they were less than 39 sq. cm. and do not warrant additional ratings.  

While examiners were silent proximate to separation about limitation of motion of the right axilla, the profile unequivocally did authorize a P3 profile for the hidradenitis suppurativa (chronic scarring, draining skin disease) and the commander’s statement did note the limitations of her profile and pain.  Therefore, the scars as the end manifestation of the hidradenitis suppurativa are unfitting and warrant a rating IAW with the VASRD.  Furthermore, the CI had an additional inflamed cyst and a painful lump of the right axilla after the VA examination and the NARSUM addendum examiner indicated not only was there a 5 inch scar under the right axilla, but also 100% hidradenitis suppurativa involvement of both axillae.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the hidradenitis suppurativa (left axilla) condition, coded 7806-7801 and the panel majority recommends a disability rating of 10% for the hidradenitis suppurativa (right axilla) condition, coded 7806-7801.  
BOARD FINDINGS:  In the matter of the hidradenitis suppurativa, the panel recommends a disability rating of 20%, coded 7806-7801 IAW VASRD §4.118 for the left axilla and the panel majority recommends a disability rating of 10%, coded 7806-7801 IAW VASRD §4.118 for the right axilla.  The single voter for dissent submitted the appended minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends 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	
Hidradenitis Suppurativa (Left Axilla)	7806-7801	20%	
Hidradenitis Suppurativa (Right Axilla)	7806-7801	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160918, w/atchs  
Exhibit B.  Service Treatment Record  
Exhibit C.  Department of Veterans Affairs Treatment Record  

MINORITY OPINION:  The minority voter agrees with the majority that it is fair to concede rating analogously under code 7801 in lieu of code 7806 as elected by the PEB.  This is premised on the general provisions of VASRD §4.20 (analogous ratings) and §4.7 (higher of two evaluations).  §4.7 allows for rating the condition as dermatitis or scarring whichever is the predominant disability.  The minority does not endorse that the predominant disability was related to the scar component of the disease as contended by the majority and leveraged in support of the 7801 criteria underpinning its rating recommendations.  Barring unfitting functional limitations, not supported by the evidence as addressed below, scars are not subject to service rating.  The PEBs appropriately rated coding choice can be defended on that basis alone and the minority voter considered that alternate rating under a scar code was itself a significant concession to fairness.  

The minority voter strongly disagrees the majority’s separate ratings recommendation.  The majority’s parsing of the quoted language in Note (2) of code 7801 requires that the separate axillae be classified as separate extremities.  The axilla is defined as the depressed hollow region located under the shoulder joint, medial to the upper arm; which is anatomically at least as much a part of the trunk as of the upper extremity.  The VA rated the scarring associated with the condition separately as limitation of arm motion and painful scar disabilities.  The minority voter opined that the VA rating decision was based on the same evidence as the majority recommendation and specifically incorporating both axillae to arrive at an overall 20% rating of the hidradenitis condition under criteria of code 7801.  

In addition to the above two significant concessions, the majority must rely on other concessions to justify its separate ratings.  First, the majority vests the authority for its separate ratings in the VASRD note on the premise that the resulting separate ratings are individually exempt from the DES requirement that a service rating be linked to an unfitting condition.  The minority voter disagrees with that premise.  There are numerous VA codes which carry similar notes that could result in additional ratings, and fairly so under the mission of the DVA, but these should not force service ratings for attendant conditions that are not unfitting and thereby exceeding the scope of the DES mission.  

The minority voter therefore asserts that, even if the clinical and VASRD linkages in its rationales are conceded, the majority recommendations on their face must demonstrate that service ratings are justified for an unfitting left axillary condition and an unfitting right axillary condition.   The profile was U1 with no limitations specific to the upper extremities alone.  For example, the profile (corroborated specifically by the NARSUM) permitted push-ups.  The limitations elaborated in the commander’s statement were confined to infectious precautions for a food handler and the need to avoid exertion and sweating that would exacerbate the condition.  The NARSUM documented full range of motion and normal strength of all extremities and characterized the pain as “slight.”  In the context of defending a linkage of the right axillary condition to fitness (in effect acknowledging that such a link was necessary), the majority conceded that there was no evidence proximate to separation for limitation of motion.  The preponderance of evidence compellingly refutes any argument that the axillary lesions, alone or by combined effect, rendered the CI unfit. The minority voter asserts that the predominant disability impacting duty performance was related to the chronic inflammatory process of the disease and not to scarring.

Finally, even if all of the above minority objections are overcome, the majority rating recommendation remains dependent on its opinion that the C&P evidence carried the determinant probative value.  Although hidradenitis suppurativa is clearly not a static condition, the majority asserts that the C&P examiner’s findings were “unlikely to have changed significantly” in the 7-month interval between it and the NARSUM addendum (not to mention in the full year interval before separation).  There were numerous STR entries in the interval between the two examinations and none of them implicated the axillae other than a right axillary nodule that responded to conservative treatment.  Neither the addendum nor any subsequent STR evidence corroborated the C&P findings.  The minority asserts that exclusive reliance on the C&P evidence for rating, superseding the totality of the evidence was overly speculative on the part of the majority.

The minority voter believes that the multiple concessions required to endorse the majority recommendations deviation from DES determination of fitness prior to application of the rating criteria and a liberal application of the VASRD.  Consistent with the DoDI 6040.44 standard that Physical Disability Board of Review recommendations are fair and equitable to both the Service and the CI, the Secretary is respectfully requested to consider the minority recommendation that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Hidradenitis Suppurativa	7806-7801	20%	

AR20180004006, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure