Entitlement to service connection for a bilateral wrist sprain (initially claimed as peripheral neuropathy diagnosed as carpal tunnel syndrome) is granted.

Citation Nr: 26001436 Decision Date: 01/30/26 Archive Date: 01/30/26 DOCKET NO. 17-05 878A DATE: January 30, 2026 ORDER Entitlement to service connection for a bilateral wrist sprain (initially claimed as peripheral neuropathy diagnosed as carpal tunnel syndrome) is granted. Entitlement to service connection for left thumb paresthesias is granted. Entitlement to service connection for a bilateral elbow disability, however diagnosed, is granted. Entitlement to a 60 percent rating (but no higher) for xerosis cutis with seborrheic dermatitis ("skin disability") prior to January 16, 2016, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 60 percent for a skin disability is denied. Entitlement to a 20 percent rating (but no higher) for right ankle tendonitis is granted, subject to the laws and regulations governing the payment of monetary benefits. REMANDED Entitlement to service connection for a disability manifested by an intestinal parasite, other than irritable bowel syndrome (IBS) and gastroesophageal reflux disease (GERD), is remanded. Entitlement to a rating in excess of 30 percent for IBS with GERD and hiatal hernia is remanded. FINDINGS OF FACT 1. The Veteran first experienced bilateral wrist pain during his active duty service. 2. The Veteran received a laceration to his left thumb during service resulting in paresthesia. 3. The Veteran first experienced bilateral elbow pain during his active duty service. 4. Resolving reasonable doubt in his favor, the Veteran's skin disability was manifested by characteristic lesions involving more than 40 percent of the entire body. 5. The Veteran's skin disability does not cause scarring or disfigurement of the head, face, or neck. 6. The Veteran's right ankle tendonitis manifested in the functional loss equivalent to marked limited range of motion, with plantar flexion and dorsiflexion being limited with symptoms of constant pain that impacts his range of motion. CONCLUSIONS OF LAW 1. The criteria for service connection for a bilateral wrist sprain (initially claimed as peripheral neuropathy diagnosed as carpal tunnel syndrome) are met. 38?U.S.C. §§?1110, 1131, 5107 (2024); 38?C.F.R. §§?3.102, 3.303 (2025). 2. The criteria for service connection for left thumb paresthesias are met. 38?U.S.C. §§?1110, 1131, 5107 (2024); 38?C.F.R. §§?3.102, 3.303 (2025). 3. The criteria for service connection for a bilateral elbow disability are met. 38 U.S.C. §§?1110, 1131, 5107 (2024); 38?C.F.R. §§?3.102, 3.303 (2025). 4. The criteria for a 60 percent rating for a skin disability for the period prior to January 16, 2016, have been met. 38 U.S.C. §§ 1155, 5107 (2024); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Code (Code) 7899-7806 (2025). 5. The criteria for a rating in excess of 60 percent for a skin disability have not been met. 38 U.S.C. §§ 1155, 5107 (2024); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Code 7899-7806 (2025). 6. The criteria for entitlement to an evaluation of 20 percent, but no higher, for right ankle tendonitis have been met.?38 U.S.C. §§ 1155, 5107 (2024);?38 C.F.R. §§ 3.102, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Code 5024-5271 (2025). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1989 to November 2012, to include combat in Iraq and Afghanistan. This case comes before the Board of Veterans' Appeals (Board) from July and August 2013 rating decisions issued by the Department of Veterans Affairs (VA) agency of original jurisdiction (AOJ). These issues were denied by the Board in an April 2024 Board decision. The Veteran appealed that decision to the Court of Appeals for Veterans Claims (Court), which vacated the decision pursuant to a January 2025 Joint Motion for Remand (JMR). This case is once again before the Board. In October 2025, the Veteran presented testimony before the undersigned Veterans Law Judge; a transcript of that hearing is associated with the Veteran's claim file. Preliminarily, the Board notes that the Veteran appears to be attempting to allege that the AOJ committed clear and unmistakable error (CUE) in prior rating decisions that, according to argument, failed to assign the correct date when it granted a 60 percent rating for his skin disability. However, any allegation of CUE was not adjudicated by the AOJ in the rating decision on appeal. The AOJ must adjudicate a CUE allegation pertaining to a final rating decision in the first instance. Under the legacy system, the Board would be obligated to refer a new theory of CUE to the AOJ to be adjudicated in the first instance. See Godfrey v. Brown, 7 Vet. App. 398, 410 (1995). However, because the Board is granting a 60 percent rating for the Veteran's skin disability throughout the appeal period, there is no need to refer the CUE claim. Additionally, the Board notes that the Veteran has been granted service connection for right and left wrist sprains, effective July 23, 2015 (the date of his claim specifically seeking service connection for "Bilateral Wrists, Chronic Condition [with] Recurrent Pain[.]" See January 2016 rating decision. In written argument, the Veteran has stated that what he initially claimed as "peripheral neuropathy diagnosed as carpal tunnel bilateral" was a misdiagnosis and "was eventually re-diagnosed as chronic wrist pain" so that the effective date of his bilateral wrist sprain should be December 1, 2012, the day following his separation from service. While the Veteran appears to be claiming that an earlier effective date is warranted for the grant of left and right wrist sprains, that issue is not before the Board since the Veteran did not appeal the January 2016 rating decision that assigned the effective date. However, after reviewing the evidence of record, and in light of Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the Board has recharacterized the issue of service connection for peripheral neuropathy diagnosed as carpal tunnel syndrome to encompass any bilateral wrist disability. Service Connection Generally, a veteran is entitled to service connection for a disability resulting from a disease or injury incurred or aggravated during active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Where lay evidence is competent, the Board must weigh the competent lay evidence against the other evidence of record in determining credibility. Buchanan v. Nicholson, 451 F.3d 1331, 1334-37 (Fed. Cir. 2006). However, the absence of corroborating records is an insufficient basis on which to find lay statements not credible. Id. at 1337. In deciding an appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). A claimant is entitled to the benefit of the doubt when the positive and negative evidence is in approximate balance, which includes but is not limited to equipoise. See Lynch v. McDonough, 999 F.3d 1391, 1394 (Fed. Cir. 2021). 1. Entitlement to service connection for a bilateral wrist disability During his November 2012 VA hand and finger disability benefits questionnaire (DBQ), the Veteran reported that he had pain in his right wrist since 2004, with no injury or trauma. The pain increased when he dorsiflexed his hand and with computer typing. During an August 2013 peripheral nerves condition DBQ, the Veteran reported pain in his bilateral wrists, right greater than left. He reported limited extension of the right wrist and that both hands were hypersensitive to touch. The examiner noted that bilateral wrist x-rays from June 2012 were unrevealing and that the Veteran had not had EMG/NCT testing. The AOJ denied service connection for left and right upper extremity peripheral neuropathy with carpal tunnel syndrome condition in August 2013. Thereafter, the Veteran sought service connection for a bilateral wrist disability. During his January 2016 wrist conditions DBQ, the Veteran reported pain in his right and left wrists approximately six years prior. He explained that he had pain in his bilateral wrists since 2004, without injury or trauma. Chronic left and right wrist sprains were diagnosed with a date approximately six years prior to the DBQ. In a January 2016 rating decision, the AOJ granted service connection for left and right wrist sprain, finding such "directly related to military service." The Board notes that the Veteran's reported symptoms during the August 2013 DBQ were the exact same as those reported during the January 2016 DBQ. Additionally, the Board notes that the Veteran has stated that his claim for carpal tunnel syndrome was a "mis-diagnosis and was eventually re-diagnosed as chronic wrist pain" and that such pain began in 2008. The Veteran's service treatment records (STRs) confirm that he reported right and left wrist pain during service. Based on the foregoing, the Board is left with the Veteran's competent and credible statements and testimony that he experienced wrist pain in service and since service. Accordingly, and resolving reasonable doubt in his favor, the Board finds that service connection for bilateral wrist sprain is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304; Gilbert, 1 Vet. App. at 49. 2. Entitlement to service connection for a left thumb radial nerve injury There is no question that the Veteran received a left thumb laceration during service. Service connection is in effect for painful scars and scars of the left hand at the base of the thumb and left hand laceration over first metacarpophalangeal joint. See Codesheet. The Veteran first sought service connection for status post laceration of the left thumb area (snuffbox) with paresthesia and scarring in May 2012. See May 2012 Statement in Support of Claim. During his November 2012 hand and finger DBQ, the Veteran did not report limitation of motion or evidence of painful motion of his thumb. There was no functional loss for the left thumb, and no tenderness or pain. The examiner noticed a faint linear well-healed superficial scar lateral to the left first metacarpo-phalangeal (MCP) joint. The AOJ granted service connection for a left-hand painful scar and scar at the base of the thumb (claimed as status post laceration to left thumb [snuffbox] area with scarring). The AOJ also granted service connection for left hand laceration of the first MCP joint See July 2013 rating decision. In his July 2014 notice of disagreement, the Veteran emphasized that he had paresthesia of the left thumb that was chronic in nature. During a January 2016 hand and finger DBQ, the Veteran reported paresthesia over the dorsal aspect of his left thumb that made it difficult to carry objects and do pushups. Confusingly, the examiner noted that the Veteran denied any functional loss involving the left thumb. During a November 2023 VA peripheral nerves conditions DBQ, the Veteran reported numbness to the side of the thumb, tingling to the interphalangeal joint, uncomfortableness to the MCP joint, and pain when pressure is applied. Mild incomplete paralysis of the radial nerve was diagnosed. The examiner noted the Veteran's report of tingling and numbness to the thumb but stated that there is "no way to determine whether the [V]eteran is actually experiencing tingling or numbness, objectively on a physical exam." The examiner opined that there was no medical or scientific evidence that provided any indication of a relationship between the development of status post laceration to left thumb area with paresthesia and a toxic exposure risk activity. The examiner concluded that the laceration was caused by some type of blunt force trauma or force, not by hazardous exposure. In a January 2024 addendum opinion, the examiner also concluded that it was less likely that the Veteran's paresthesia of the left thumb is related to his military service, although there was evidence he sustained an injury to the thumb. Despite the laceration he received in service, he had full range of motion to the left thumb joints, circulation intact approximate skin, and decrease sensation to the medial aspect of the IP joint. "The provisional diagnosis on the date of injury upon initial examination/inspection was possible ulnar nerve injury but later changed to radial branch nerve injury." Despite the Veteran's reports of tingling and numbness, and the examiner's explanation that such are signs of a nerve injury, the examiner concluded that such was less likely due to the laceration because weakness and paralysis would also be present. Additionally, injury to the nerve resulting from a laceration is represented by a deep cut; here, he had a "Grade 1 skin tear" because such a tear can be realigned to the normal anatomical position. The Veteran's scar was superficial, long, and thin. To the extent the examiner relied generally on a reference to medical literature, the Board finds the opinion inadequate. See Bailey v. O'Rourke, No. 16-2826 (Vet. App. July 10, 2018) (holding that a medical opinion stating only that there is nothing in the medical literature supporting an association between a disability and a Veteran's military service is inadequate as a matter of law). Although the examiner recommended that the Veteran undergo an EMG after this examination, a review of the claim file shows that the scheduled EMG was cancelled at the Veteran's request. During his October 2025 Board hearing, the Veteran competently and credibly testified that he has had this numbing and tingling sensation in his left thumb since his separation from service. Given the above, the Board cannot conclusively disassociate the current disability from the documented left thumb laceration during service. Therefore, the Board resolves reasonable doubt in the Veteran's favor and finds that service connection for left thumb paresthesias is granted. 3. Entitlement to service connection for a bilateral elbow disability A June 2012 STR notes the Veteran's report of "numerous issues prior to retirement[,]" to include bilateral elbow pain in the lateral upper condyle area. Lateral epicondylitis was diagnosed. The Veteran sought service connection for these disabilities while still in service. See June 2012 VA Form 21-526c, Pre-Discharge Compensation Claim, and May 2012 Statement in Support of Claim. During his January 2016 elbow and forearms conditions DBQ, bilateral lateral epicondylitis was diagnosed, with a diagnosis date in 2006. The Veteran reported bilateral elbow pain since 2006 and stated that he was diagnosed during service with bilateral lateral epicondylitis. Physical therapy helped alleviate some of the discomfort but he still experienced pain that was exacerbated by lifting/moving objects. No etiological opinion was provided. In his January 2017 notice of disagreement and March 2017 VA Form 9, substantive appeal, the Veteran reported recurring pain at both elbow joints that began during service and continued since service. During his November 2023 VA elbow and forearm conditions DBQ, the Veteran was diagnosed with a bilateral elbow strain. The Veteran reported intermittent pain initially but "by 2010 it was mostly on." The examiner determined that it was less likely that the Veteran's bilateral elbow condition was related to his military service despite him reporting such during service. The examiner noted no evidence of a specific injury, event or disease "to justify the claim during service or post service." The examiner specifically noted that epicondylitis presents as tearing and swelling of the elbow, which the Veteran did not have. The Board notes here that the examiner's rationale was focused on lateral epicondylitis, and not the diagnosis of elbow strain. The January 2025 JMR noted that this opinion was inadequate because it failed to discuss "specific lay statements in providing a negative nexus opinion." During his October 2025 Board hearing, the Veteran testified that he "did not spend [his] time at the doctor's office" during service because he was a senior officer. He often took what was known as "Ranger candy, also known as Motrin." Upon review of the record, and considering the Veteran's competent and credible testimony of symptoms in and since service, combined with the fact that he applied for service connection for such disability prior to his separation from service, the Board finds that the Veteran's bilateral elbow disability is related to his service. Accordingly, and after resolving all doubt in her favor, the Board finds that service connection for a bilateral elbow disability, however diagnosed, is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and, above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. In any claim for an increased rating, "staged" ratings may be warranted where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield,?21?Vet. App.?505?(2007); Fenderson v. West,?12?Vet. App.?119?(1999). 4. Entitlement to a rating in excess of 10 percent for right ankle tendonitis Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. When evaluating musculoskeletal disabilities based on limitation of motion, there must be consideration of functional loss caused by factors that could occur during flare-ups or after repeated use and, therefore, not be reflected on range of motion testing.?38 C.F.R. § 4.40. Consideration must also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement.?38 C.F.R. § 4.45; see DeLuca v. Brown, 8 Vet. App.?202?(1995); see also Mitchell v. Shinseki,?25?Vet. App.?32, 37?(2011) ("functional loss caused by pain must be rated at the same level as if that functional loss were caused by some other factor that actually limited motion" (emphasis removed)). Nonetheless, even when the background factors listed in §§ 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to?38 C.F.R. § 4.71a?(musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under §§ 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald,?815 F.3d 781, 785?(Fed. Cir. 2016). The provisions of?38 C.F.R. § 4.59?acknowledge that a claimant's disability may cause actual pain or painful motion but still not be severe enough to warrant a compensable rating under the appropriate Code. Accordingly, when there is evidence of painful motion, § 4.59 operates to provide at least the minimum compensable rating available under the Code for the joint. See Sowers v. McDonald,?27?Vet. App.?472, 478?(2016). However, pain alone does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system. Pain in, like deformity of or insufficient nerve supply to, a particular joint may result in functional loss, but only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Mitchell v. Shinseki,?25?Vet. App.?32, 38-39?(2011). The Veteran asserts that his right ankle tendonitis should be rated higher than the 10 percent currently assigned. His right ankle disability is rated under?38 C.F.R. § 4.71a, Code 5024-5271. In general, hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. Here, the hyphenated diagnostic code indicates that the Veteran's disability is rated under the criteria for tenosynovitis (Code 5024) and ankle limitation of motion (Code 5271). Effective February 7, 2021, VA amended the rating criteria for Code 5271. 85 Fed. Reg. 76,453 (Nov. 30, 2020). Under the new criteria, a 10 percent rating is warranted for moderate limited motion of the ankle (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion.) A 20 percent rating is warranted for marked limited motion of the ankle (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion.) Normally, because this regulatory change was enacted during the pendency of this appeal, the Board must consider both the old and new versions of the rating criteria from the effective date and apply the version most favorable to the Veteran. However, because the Veteran is being assigned the maximum rating pursuant to Code 5271 pursuant to the old criteria, the new criteria will not be further discussed. The former criteria for Code 5271 did not define "moderate" and "marked." According to MERRIAM WEBSTER, "moderate" means "tending toward the mean or average amount or dimension". See www.merriam-webster.com/dictionary /moderate. "Marked" means "having a distinctive or emphasized character." See www.merriam-webster.com/dictionary/marked. Standard motion of an ankle joint is from zero degrees to 20 degrees for dorsiflexion and zero degrees to 45 degrees for plantar flexion.?38?C.F.R. §?4.71, Plate II. The Veteran's February 2012 STR notes that passive dorsiflexion in his right ankle was decreased. During an August 2013 VA ankle conditions DBQ, the Veteran reported sharp pain in his outer right ankle with impact during running. He managed his pain with activity modification. He had full range of motion with no pain, with no additional limitation in ROM following repetitive-use testing, and had full muscle strength with no instability. The "Remarks" section, however, noted subjective pain on movement. The examiner was unable to determine whether pain, weakness, fatigability, or incoordination significantly limited functional ability without resorting to mere speculation. During his January 2016 VA ankle conditions DBQ, the Veteran reported consistent pain in his right ankle that occurred once a month; he stopped running due to ankle pain, and took Motrin as needed. He had full range of motion with no pain noted on exam, and was able to perform repetitive use testing with no additional loss of function. Pain significantly limited functional ability with flare-ups but the examiner was unable to describe such in terms of range of motion. During his September 2023 VA ankle conditions DBQ, the Veteran stated that resting, rubbing, and stretching his ankle "make it better" but that walking and exercise increases the pain significantly, which he rated as eight out of 10. He experiences pain on the inside and outside of his ankle and reported instability. On range of motion testing, plantar flexion was to 40 degrees and dorsiflexion was to 15 degrees, with pain in active and passive range of motion. There was no additional loss of function following repetitive use or repeated use. The Veteran denied flare-ups. VA examinations must include joint testing for active and passive motion in both weight-bearing and non-weight-bearing circumstances. Correia v. McDonald, 28?Vet. App.?158 (2016). Additionally, estimated ranges of motion should be provided during flare-ups, if feasible, even if the Veteran is not experiencing one during the examination. See Sharp v. Shulkin, 29?Vet. App.?26 (2017). In this case, the VA ankle examinations of record do not fully comport with the requirements of Correia or Sharp. Because the maximum rating pursuant to Code 5271 is being assigned, as discussed below, the Board finds that remand for a new examination is not appropriate because it would not have a reasonable possibility of substantiating the claim. After considering the Veteran's symptoms of constant pain , as well as his limited range of motion during some VA examinations and the examiners' inability to determine range of motion either during flare-ups or during repeated use, the Board finds that the Veteran's right ankle tendonitis manifests in the functional loss equivalent of marked limitation of range of motion. As a result, a 20 percent rating is warranted. The Veteran cannot be assigned a higher rating pursuant to Code 5271?as 20?percent is the maximum rating. The Board has considered whether any other Code related to disabilities of the ankle would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Code. See?38 C.F.R. § 4.71a. The only Code for the ankle that provides for a rating in excess of 20 percent is Code 5270. The criteria for Code 5270, ankylosis of the ankle, requires that the ankle be stopped at a certain point in range of motion. Because the Veteran can still move his ankle even after considering whether he has the functional equivalent of ankylosis and it is not actually stopped at a point of range of motion, a rating pursuant to Code 5270 is not appropriate and a rating in excess of 20 percent must be denied. 5. Entitlement to a compensable rating for a skin disability prior to January 16, 2016 The Veteran contends that he is entitled to 60 percent rating for his skin disability for the entire period on appeal since his symptoms have remained the same since his separation from service. He has been assigned a staged rating and is currently rated as 10 percent disabling for the period prior to January 16, 2016, and 60 percent disabling thereafter. As will be discussed in detail below, the Board finds that a uniform rating of 60 percent is warranted for the entire period on appeal. Changes to the rating criteria for the skin became effective August 13, 2018. Claims pending prior to the effective date will be considered under both the old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. 83 Fed. Reg. 32, 592 (July 13, 2018). As the current appeal is an initial increased rating claim arising from the Veteran's May 2012 application for compensation, it must be considered under both the old and new criteria. For the entire period on appeal, the Veteran's skin disability has been rated under Code 7899-7806. In general, hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. Here, the hyphenated diagnostic code indicates that the Veteran's disability is rated under the criteria for dermatitis or eczema (Code 7806). Under the older criteria, a 10 percent rating was warranted for at least 5 percent, but less than 20 percent, of the entire body or 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. A 30 percent rating was warranted for 20 to 40 percent of the entire body or of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating was warranted for more than 40 percent of the entire body or 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. Under the older criteria for rating skin disabilities, a topical corticosteroid may constitute systemic therapy under DC 7806 based on the factual circumstances of the case. Johnson v. Shulkin, 862 F.3d 1351, 1354-56 (Fed. Cir. 2017); 38 C.F.R. § 4.118. Under the new criteria, Code 7806 directs that dermatitis/eczema be rated under the General Rating Formula for the Skin. Under the General Rating Formula, a 10 percent rating is warranted for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected or of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating is warranted for at least one of the following: characteristic lesions involving 20 to 40 percent of the entire body or of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, 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 60 percent rating is warranted for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or 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. This is the highest rating available under the DC. Under the new criteria, systemic therapy is defined as treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin. On VA skin diseases examination in November 2012, the Veteran's complaints included constant scaliness of the face and scalp and extremely dry and irritated skin. He treated his seborrheic dermatitis with tar shampoo topically daily for more than 6 weeks. This treatment was not a corticosteroid or immunosuppressive. He also treated his seborrheic dermatitis with steroid lotion twice a day for more than 6 weeks. This treatment was a topical corticosteroid. He treated his seborrheic dermatitis with antibiotic tablets twice a day for more than 6 weeks, which was considered systemic therapy but was not a corticosteroid or an immunosuppressive. Physical examination showed normal skin color, tone, temperature, texture, and turgor, seborrheic dermatitis manifested by "minimal scaliness of the nasolabial fold and the bimalar skin," a clear scalp, and affecting more than 5 percent but less than 20 percent of the exposed areas of the skin and less than 5 percent of the total skin area, and xerosis cutis manifested by dryness on the extremities which affected none of the exposed areas of the body and less than 5 percent of the total skin area. The diagnoses included seborrheic dermatitis and xerosis cutis. On VA outpatient treatment in July 2014, the Veteran's complaints included seborrhea on his scalp and "dry skin on his entire body" which had not improved with daily use of lotion. He "reports using ketoconazole shampoo to wash the hair, groin and axillary vaults and uses on soap on the remainder of the body." Physical examination showed macules on the face, neck, arms, generalized xerotic patches, and multiple scalp scales. The diagnoses included seborrhea and xerosis cutis. He was advised to use rotating dandruff shampoos every month to treat his seborrhea. He also was advised to discontinue using ketoconazole "due to drying effect" and to use gentle skin care instead. He further was advised to use urea 10% lotion daily. During his January 2016 VA skin diseases DBQ, the Veteran reported having the same skin symptoms since 2004 (for seborrheic dermatitis) and since 2006 (for xerosis cutis). The examiner determined that the Veterans xerosis cutis covered approximately 40 percent of his total body area. During his October 2025 Board hearing, the Veteran testified that he had skin problems throughout his military service but did not always go to the doctor's; instead, he used "creams and things like that." As long as his skin did not get worse, he would not return to the doctor. He explained that 100 percent of his body is itchy, and he gets "super dry" during the winter. He steps in the shower and his skin burns. His "delicate areas" are wrinkled and dry. He explained that he noted for the first VA examiner "the things he could easily see" and he made the assessment; he did not do a full examination. The Veteran noted that he underwent many examinations that day, so that his skin examination may not have been as in depth as expected. The second examiner told the Veteran that she did not "do ratings" and refused to write down the Veteran's symptoms. He testified to monthly flare-ups that cause his eczema to go all around his face. The rest of his body is just continuously itchy, dry, and fragile. His skin also peels in certain sections. The Veteran emphasized in his testimony that his condition has been the same since his separation from service. After a thorough consideration of the evidence of the record, and resolving any reasonable doubt in his favor, the Board finds that the Veteran's skin disability has remained essentially the same since his separation from service. The Board acknowledges the findings of the November 2012 VA examiner but finds that the Veteran's testimony regarding the consistency of his skin disability symptoms to be more persuasive, especially considering the number of examinations the Veteran underwent that day. Accordingly, the Board finds that the evidence is in approximate balance, and that a 60 percent rating of the Veteran's skin disability prior to January 16, 2016, is warranted. See Lynch, 999 F.3d at 1394. Having found that a 60 percent rating is warranted prior to January 16, 2016, there is now a uniform rating for the entire period on appeal. The Board will now consider whether a rating in excess of 60 percent is warranted at any point during the appeal period. The Board notes that the 60 percent rating assigned is the highest possible schedular rating available under the Code under both the old and new rating criteria. Rating the Veteran's disability under the old criteria would therefore provide no benefit to the Veteran. The Board has considered whether higher ratings can be assigned based on scars or disfigurement of the head, face, or neck. However, there is no evidence that the Veteran's skin disability caused visible or palpable tissue loss or that it created six or more characteristics of disfigurement. Therefore, higher ratings under the diagnostic codes for scars and disfigurement are not applicable in this matter. REASONS FOR REMAND As an initial matter, the medical evidence associated with the record is incomplete. The most recent VA treatment records associated with the claim file are from November 2023. During his October 2025 Board hearing, the Veteran testified that he received additional treatment since that time. Any additional VA treatment records should be obtained on remand. 1. Entitlement to service connection for a disability manifested by an intestinal parasite, other than IBS and GERD 2. Entitlement to a rating in excess of 30 percent for IBS with GERD and hiatal hernia In a claim for an increased disability rating, the Board must analyze the Veteran's disabilities under both Code 7319 for IBS and Code 7346 for GERD, as directed at 38 C.F.R. § 4.114, to determine which diagnostic code results in the highest rating to reflect the predominant disability picture. However, the Board is unable to determine from the evidence of record whether the Veteran's IBS or GERD is his predominant disability. Notably, the most recent examination conducted in January 2024 does not address which condition is predominant. The Board cannot make a fully informed decision on the issue of a higher disability rating for the Veteran's service-connected disability because there is no opinion of record as to which of his disabilities is predominant. Additionally, the Veteran seeks service connection for a disability manifested by an intestinal parasite, other than IBS and GERD. To date, it is unclear whether the Veteran has such a disability that is distinct from the already service-connected disabilities. Accordingly, a medical examination is required to answer this question. The matters are REMANDED for the following action: 1. Identify and obtain any outstanding VA and private treatment records that are not already associated with the claim file, to include VA treatment records since November 2023. If any record identified cannot be obtained, the Veteran and his representative should be notified of this in writing, to include all efforts taken by VA to attempt to obtain any such record. The Veteran should also be offered the option to provide any such record himself. 2. Then, schedule the Veteran for an examination by an appropriate clinician to determine the current level of severity of his service-connected IBS with GERD. The Veteran's claim file and a copy of this remand should be provided to the examiner and the examination report should reflect that these items were reviewed. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. (a) The examiner is asked to specifically address whether IBS or GERD is predominant in the Veteran's overall disability picture. If the examiner cannot distinguish between reported symptoms of IBS and GERD, or cannot distinguish the predominant disability, the examiner must provide a full rationale for this opinion. (b) The examiner is also asked to specifically address whether the Veteran has had, at any point during the appeal period, a disability manifested by an intestinal parasite that is distinguishable from his already service-connected IBS and GERD. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion. 3. If upon completion of the above action the issues remain denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Matta, Counsel 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.