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M21-1, Part III, Subpart iv, Chapter 4, Section L- Skin Conditions

Overview

In This Section
This section contains the following topics:

1.  General Principles for Rating Skin Disorders and Scars 

Introduction
Change Date
November 19, 2018

III.iv.4.L.1.a.  Applying Alternative Rating Criteria in Evaluating Skin Conditions
When 38 CFR 4.118 offers variable methods to evaluate a skin condition, assign a single evaluation using the criteria that results in the highest rating.
Example:  Under 38 CFR 4.118 diagnostic code (DC) 7806, dermatitis is to be rated using the general rating formula for the skin.  Within the general rating formula, skin conditions are rated on either skin involvement/type of treatment or as disfigurement of the head, face, or neck or scars, depending upon the predominant disability.  For examination findings of dermatitis involving at least 5 percent, but less than 20 percent, of the entire body (a 10-percent evaluation under 38 CFR 4.118 DC 7806) and scarring that is noncompensable under 38 CFR 4.118 DC 7800 through 38 CFR 4.118 DC 7805, a single evaluation of 10 percent is warranted under 38 CFR 4.118 DC 7806.  Assigning an evaluation for dermatitis based on percentage of involvement of the entire body and a separate evaluation based on the residual scarring amounts to pyramiding.
Reference:  For more information on avoidance of pyramiding, see

III.iv.4.L.1.b.Separate Evaluations for Multiple Skin Disorders Using the General Rating Formula
When evaluating separately diagnosed skin conditions and the predominant disability requires evaluation under the general rating formula for the skin, separate evaluations for each diagnosis are permissible when the evaluation is based on disability due solely to the individual diagnosis.
However, when it is most advantageous and allows for maximized benefits, multiple skin disorders evaluated under the same criteria may be assigned a single disability evaluation as discussed in M21-1, Part III, Subpart iv, 4.L.1.e.

III.iv.4.L.1.c.Separate EvaluationsUsing the General Rating Formula
A Veteran diagnosed with multiple skin conditions may receive separate evaluations using the general rating formula for the skin based on the percentage of exposed areas affected by each skin condition when
  • separate areas of skin are involved, and
  • the medical evidence clearly indicates that the percentages affected are due solely to each individual diagnosis.
Example:  The medical evidence clearly indicates that skin condition X alone affects 6 percent of the exposed skin, while skin condition Y alone affects 12 percent of the exposed skin.  The area affected by each skin disability is entirely separate.  In this scenario, separate evaluations may be assigned.
Important:
  • The evidence must identify which residual disability is due to which individual skin condition.
  • It may be necessary to request clarification from an examiner to identify the percentage of exposed skin affected only by one skin condition versus the other skin condition.
  • If an examiner cannot provide separate percentages due solely to each skin condition, separate evaluations cannot be granted using those criteria alone.  If two or more skin conditions involve the same area of skin, assign the highest evaluation based on the combined area of involvement.
  • This guidance applies equally to evaluations based on the percentage of the entire body affected as well.
Reference:  For more information on assigning a single evaluation for multiple skin disabilities in order to maximize benefits, see M21-1, Part III, Subpart iv, 4.L.1.e.

III.iv.4.L.1.d.Separate EvaluationsUsing the General Rating Formula Based on Medication Criteria
If the same medication(s) is/are used to treat each skin condition, separate evaluations may not be assigned unless alternative criteria are used to establish the disability evaluation for the separately evaluated skin condition(s) and separate areas of the skin are affected.
Example:  The Veteran has dermatitis of the neck involving at least 5 percent but less than 20 percent of exposed body area.  The Veteran also has psoriasis on the knees involving less than 5 percent of total body area.  Both conditions were treated with oral corticosteroids for a period of less than 6 weeks over the past 12-month period.  Separate 10-percent disability evaluations may be assigned.  Assign a 10-percent evaluation for dermatitis based on exposed area affected, and assign a separate 10-percent evaluation for psoriasis treated with oral steroids.
Important:  The decision maker should assign separate evaluations in a manner that provides the most advantageous rating for the Veteran.
III.iv.4.L.1.e.  Single Evaluations Using the General Rating Formula for Multiple Skin Disorders
A Veteran diagnosed with multiple skin conditions that are evaluated using the general rating formula for the skin based on the percentage of total body area or exposed areas affected may receive a single evaluation when
  • evaluating the disabilities together allows for maximization of benefits, or
  • the symptoms of and/or area affected by the multiple disabilities cannot be separated, as is directed by 38 CFR 4.14.
Example 1:  A Veteran has service-connected (SC) dermatitis that affects areas of the arms, covering 10 percent of the entire body area.  The Veteran also has SC tinea corporis affecting the groin and upper legs, covering 10 percent of the entire body area.  Different topical medications are used to treat each disability.  Evaluated individually, each skin disorder warrants a separate 10-percent evaluation under the general rating formula for the skin.  As the disabilities combine to affect a total 20 percent of the entire body and do not affect the same area of the body, a single 30-percent evaluation for dermatitis and tinea corporis may be assigned under 38 CFR 4.118, DC 7806-7813.  In this case, the single evaluation is assigned to maximize benefits since assignment of separate 10-percent evaluations would be a lesser benefit.
Example 2:  A Veteran has SC dermatitis and eczema.  Both disabilities affect the hands, covering a total of three percent of exposed body area.  The examiner is unable to differentiate the percent of body area affected by each disorder.  The same topical treatment is used for both conditions.  A single zero percent disability evaluation must be assigned since the evaluation of the same manifestation under different diagnoses must be avoided.
Notes:
  • When the Veteran has multiple SC skin disorders and maximization of benefits via assignment of a single evaluation appears possible but the examination results do not provide the specific measurements of affected body area, request a medical opinion to determine the actual percentage of body area affected.
  • When analysis shows that benefits maximization is possible with the assignment of a single disability evaluation, enter the disabilities as a single disorder in the Evaluation Builder.  For example, using the facts from Example 1 above, choose the predominant diagnosis and enter the single 20-percent finding for the percentage of body area affected.  This Evaluation Builder workaround must be utilized until updates are made for this functionality.

III.iv.4.L.1.f.Systemic Therapy Such as
Corticosteroids or Other Immunosuppressive Drugs
The term systemic therapy that is contained in the general rating formula for the skin and in certain additional DCs under 38 CFR 4.118 refers to treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin. Medications that are applied topically (directly to the skin), including topical corticosteroids or immunosuppressives, are not considered systemic for Department of Veterans Affairs (VA) purposes.
Notes:
  • When there is a question as to whether drug treatment is systemic therapy for rating purposes, request clarification from a VA or other licensed medical professional.
  • The changes to 38 CFR 4.118 effective on August 13, 2018, preclude any consideration of topical therapy, irrespective of the extent of application to the body, as systemic therapy.
  • For claims filed prior to August 13, 2018, where the skin condition is evaluated under the historical 38 CFR 4.118, medications that are applied topically (directly to the skin), including topical corticosteroids or immunosuppressives, are generally not considered systemic for VA purposes.  Under the historical rating criteria, a topical corticosteroid may only be considered systemic therapy where it is administered on such a large scale over the body that it affects the body as a whole.
    • If the evidence suggests that a skin disability is treated so extensively with a topical corticosteroid that it may be consistent with systemic therapy, refer the case to an appropriate dermatology specialist for an opinion addressing whether the topical corticosteroid is used so extensively on the body that it may be considered systemic therapy.
    • If the matter cannot be resolved after obtaining the medical opinion, refer the case to Compensation Service for an advisory opinion.
Example:  A Veteran is SC for dermatitis herpetiformis. Medical evidence shows she was treated with oral Dapsone for 7 weeks during the past 12-month period.  An evaluation of 30 percent is warranted for treatment with systemic therapy for a total duration of six weeks or more, but not constantly, during the past 12-month period.
References:  For more information on

III.iv.4.L.1.g.  Exposed Body Area
When evaluating disabilities under 38 CFR 4.118, exposed areas as referenced in evaluation criteria refer to the face, neck, and hands.

III.iv.4.L.1.h.  Application of the Bilateral Factor to Evaluations for Skin Conditions to Include Scarring
The bilateral factor under 38 CFR 4.26 only applies to skin conditions rated based on the skin evaluation criteria under 38 CFR 4.118, DCs 7801 or 7802 as the evaluation criteria and notes provided by these DCs specifically address entitlement to separate evaluations for multiple extremity involvement.  The bilateral factor may also be for application for conditions rated under a DC with evaluation criteria not considering skin involvement (such as when the predominant disability is that pertaining to musculoskeletal impairment).  Do not apply the bilateral factor to DCs for skin conditions to include scars that are
  • based on whole-body involvement
  • based on number of debilitating episodes, or
  • specific to the head, face, and/or neck.
Examples:
  • The bilateral factor is not for application to 38 CFR 4.118, DC 7804 as painful or unstable scars are not evaluated separately under this DC.
  • For ratings based on malignant skin neoplasms under 38 CFR 4.118, DC 7818, the bilateral factor is not for application when assigning a 100 percent evaluation for active malignancy/treatment for six months following cessation.  However, when evaluating based on residuals following the six month period, the bilateral factor may or may not apply depending on whether the residual is being evaluated based on a qualifying DC.
III.iv.4.L.1.i.  Revisions of the Skin Rating Schedule
Regulatory revisions to the rating schedule are generally not liberalizing, including those revisions to 38 CFR 4.118 effective on October 23, 2008, and August 13, 2018.  38 CFR 3.114(a) does not apply because the regulatory change did not characterize the change as a liberalizing change of law or VA issue.
Reference:  For more information on assigning effective dates based on regulatory updates to the rating schedule, see M21-1, Part III, Subpart iv, 5.C.7.m.

2.  Rating Scars or Other Disfigurement of the Head, Face, or Neck

Introduction
This topic contains information on rating scars or other disfigurement of the head, face, or neck, including

Change Date
August 13, 2018

III.iv.4.L.2.a.  Considering Color Photographs in Evaluating Scars or Other Disfigurement
When an examination report indicates that photographs have been taken of a scar or skin condition, consider the photographs when evaluating the condition.
Reference:  For more information on procedures for handling photographs associated with skin and scars examinations, see M21-1, Part III, Subpart iv, 3.D.4.l.

III.iv.4.L.2.b.  Evaluating Multiple Scars
Scars of the head, face, or neck are evaluated based on characteristics of disfigurement.  For all characteristics of disfigurement included in 38 CFR 4.118, DC 7800 that are evaluated based on size of area affected, the area affected by multiple scars may be added together to meet the total area criteria for the characteristic of disfigurement.  The characteristics of disfigurement criteria that can be met by adding the area affected by multiple scars include
  • length
  • hypo- or hyper-pigmentation
  • abnormal skin texture
  • absence of underlying soft tissue, and
  • induration or inflexibility.
Exception:  Multiple scars may not be added together to meet the width of scarring requirement.
Examples:
  • Two scars, one measuring two inches in length and the other measuring three inches in length, may be combined to meet the requirement of a scar five inches or more in length to qualify as a characteristic of disfigurement.
  • In contrast, two scars, one measuring .13 inches in width and the other measuring .12 inches in width, may not be combined to meet the requirement of a scar at least one-quarter inch wide at the widest part.
References:  For additional information about evaluating

III.iv.4.L.2.c.  Evaluating Tissue Loss of the Auricle, Anatomical Loss of the Eye, and Other Disabling Effects
Evaluate tissue loss of the auricle under 38 CFR 4.87, DC 6207 and anatomical loss of the eye under 38 CFR 4.79, DC 6061 or 6063, as appropriate.
When the evidence of record shows disabling effects other than disfigurement, such as pain, instability, or muscle/nerve injury, separately evaluate under the appropriate DC based on the functional impairment shown by the record.
Reference:  For more information on evaluating scars and what qualifies as a characteristic of disfigurement, see 38 CFR 4.118.

III.iv.4.L.2.d.Whether Scars or Disfigurement of the Head, Face, or Neck Are Part of the Claim
If a scar or other disfigurement of the head, face, or neck is noted on VA examination or in other evidence of record but has not been expressly claimed, whether to put it at issue and decide it as part of the claim depends on whether the scar is considered within scope of the pending claim.
References:  For more information on

3.  Rating Painful or Unstable Scars

 

Introduction
This topic contains information on rating painful or unstable scars, including

Change Date
August 13, 2018

III.iv.4.L.3.a.  Assigning a Separate Disability Evaluation for Functional Impairment Due to a Painful Scar
A separate disability evaluation for a painful scar under 38 CFR 4.118, DC 7804may be assigned when the evidence demonstrates functional impairment that is
  • distinct and separate from the functional impairment addressed by another DC, and is not
  • duplicative of or overlapping with the symptomatology addressed under another DC.
Example:  A separate 10-percent evaluation for disfigurement under 38 CFR 4.118, DC 7800 may be assigned in addition to a 10-percent evaluation for painful scars under 38 CFR 4.118, DC 7804 and a 10-percent evaluation for facial injury interfering with mastication under 38 CFR 4.73, DC 5325 as each evaluation is based on distinct and separate functional impairment and, therefore, provisions related to pyramiding are not violated.
Note:  An evaluation under 38 CFR 4.118, DC 7800 is entirely cosmetic in nature.
References:  For more information on

III.iv.4.L.3.b.  Objective Evidence of a Painful Scar
Under 38 CFR 4.118, DC 7804, an evaluation of 10 percent is assigned for one or two scars that are unstable or painful.
Do not establish a compensable evaluation for a painful scar unless there is some objective indication supporting subjective reports of pain or tenderness.
The physical examination section (for the trunk/extremities or the head/face/ neck as applicable) of the Scars/Disfigurement Disability Benefits Questionnaire (DBQ) asks the examiner if scars are tender to palpation and, if yes, to check the box.  If the examiner checks that a scar is tender to palpation consider pain to be objectively demonstrated.
Example:  On VA examination, the Veteran gave a history of a painful scar of the trunk.  On the DBQ, in the physical examination of the trunk and extremities, the examiner checked that the trunk scar was tender to palpation.  Accept that the scar is objectively painful.
Example:  On VA examination, the Veteran gave a history of a painful scar of the left arm.  On the DBQ, in the physical examination of the trunk and extremities, the examiner did not check that the scar was tender to palpation.  Do not accept that the scar is objectively painful.

III.iv.4.L.3.c.  Definition:  Unstable Scar
An unstable scar is a scar in which, for any reason, there is frequent loss of covering of skin over the scar.
Reference:  For more information on unstable scars, see 38 CFR 4.118, DC 7804.

III.iv.4.L.3.d.  Evaluating Unstable and Painful Scars
When a scar is both unstable and painful, add 10 percent to the evaluation that would otherwise be assigned based on the total number of unstable or painful scars under 38 CFR 4.118, DC 7804.
Example:  If a VA examination notes one right knee arthroscopy scar that is described as unstable and painful, the proper evaluation based on the painful and unstable scar is 20 percent.  Under 38 CFR 4.418, DC 7804, one painful scar is entitled to an evaluation of 10 percent.  Since the painful scar is also noted to be unstable, an additional 10 percent is added to that evaluation to arrive at an overall evaluation of 20 percent.

III.iv.4.L.3.e.Whether Painful or Unstable Scars Are Part of the Claim
If a painful or unstable scar is noted on VA examination or in other evidence of record but has not been expressly claimed, whether to put it at issue and decide it as part of the claim depends on whether the scar is considered within scope of the pending claim.
References:  For more information on

 

4.  Rating Specific Skin Conditions

 

Introduction
This topic contains information on rating specific skin conditions, including

Change Date
November 19, 2018

III.iv.4.L.4.a.      SC for Male Pattern Baldness or Androgenetic Alopecia
Do not grant SC for
  • male pattern baldness, or
  • androgenetic alopecia.
Note:  VA classifies these conditions as congenital or developmental abnormalities.
Important:  While SC is not warranted for alopecia of androgenetic origin, VA recognizes hair loss due to scarring alopecia and alopecia areata under 38 CFR 4.118, DCs 7830 and 7831, as disabilities for which SC is warranted if first manifest in service.
Reference:  For more information on congenital or developmental abnormalities, see

III.iv.4.L.4.b.Assigning Multiple Evaluations Due to Hair Loss
Assign separate evaluations for
  • complete loss of the eyebrows and eyelashes due to injury, burns, or local disease under 38 CFR 4.79, DC 6023
  • complete loss of the eyelashes due to injury, burns, or local disease under38 CFR 4.79, DC 6024, and
  • loss of all body hair due to alopecia areata or an analogous condition under 38 CFR 4.118, DC 7831.

III.iv.4.L.4.c.  Evaluating Mycosis Fungoides
Mycosis fungoides is a cutaneous manifestation of T-cell lymphoma that typically presents as some form of skin lesion and rarely progresses beyond the skin.
  • For rating purposes, it is not considered a systemic malignancy.  As such, with the revised skin rating schedule, mycosis fungoides should be evaluated under 38 CFR 4.118, DC 7822.
  • If the condition progresses to a lymphoma with appropriate diagnosis, such as Non-Hodgkin’s lymphoma (active disease/active treatment phase), it would warrant an evaluation under 38 CFR 4.118, DC 7715.
Note:  Prior to the rating schedule change of August 13, 2018, mycosis fungoides was evaluated as either
  • a skin malignancy if manifestations were cutaneous lesions only and treatment was confined to only
    • localized topical therapy, or
    • surgical excision (wide local excision or less extensive excision), or
  • non-Hodgkin’s lymphoma if manifestations were indicative of systemic disease with treatment consistent with systemic malignancy.
Historical_M21-1III_iv_4_SecL_12-21-17.docx May 15, 2019 72 KB
5-14-18_Key-Changes_M21-1III_iv_4_SecL.docx May 15, 2019 65 KB
12-21-17_Key-Changes_M21-1III_iv_4_SecL.docx May 15, 2019 66 KB
Historical_M21-1III_iv_4_SecL_5-14-18.docx May 15, 2019 63 KB
11-19-18_Key-Changes_M21-1III_iv_4_SecL.docx May 15, 2019 54 KB
in Chapter 4 Rating Specific Disabilities, Part III General Claims Process, Subpart iv General Rating Process
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