What Constitutes Near Constant Or Constant Systemic Therapy For Eczema?

[ABH1]

Happy New year fellow vets:)

Have had a claim in since nov 2010 and still waiting.... Oakland RO is a little behind...

See this thread for more fun info

Question, I have had intralesional injections monthly for treatment of my eczema using corticosteriods (kenalog 10) for over 12 months now with daily use of steroid creams under occlusion every night. Does this constitute near constant use of steroids or systemic therapy?

Am getting all kinds of different answers on this one so any help is greatly appreciated.

Respectfully,

Danny

[USMC5811]

I don't have personal knowledge of the subject matter, but here is a link to a remand that you may find to be an interesting read. That is if you have not read it already. Specifically Systemic Therapy defined and leaving the near constant or constant part to a dermatologist to determine for the court - not eczema, but a skin condition though http://www.va.gov/vetapp11/files1/1104448.txt

As to the meaning of "systemic therapy," although the rating criteria mention corticosteroids or other immunosuppressive drugs as examples of systemic therapy, a similar use of the term "such as" in the rating criteria has been held to demonstrate that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating.  See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002) (the use of the term "such as" demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating).  Thus, systemic therapy under DC 7806 is not necessarily limited to corticosteroids of other immunosuppressive drugs.

And this case which granted increase for Eczema due to near constant or constant systemic therapy: http://www.va.gov/vetapp07/files3/0724165.txt

However, the Board does find that the medical evidence demonstrates constant or near-constant systemic therapy (oral medications and subcutaneous injections) consisting of immunosuppressive drugs required during the past 12-month period.  In this case, the evidence of record documents that between September 2002 and April 2005, the veteran was receiving systemic therapy with immunosuppressant drugs.  The drugs were administered orally or by injection and were noted to be cyclosporine (Gengraf), methotrexate, etanercept (Enbrel), and adalimumab (Humira).  From April 2005 to March 2006, the medical evidence does not reflect whether the veteran was treated for eczema, but when he again was treated later in March 2006, his condition was apparently severe enough to again warrant systemic immunosuppressant therapy with Humira.  In the report of October 2006 VA examination, the veteran was noted to be taking both Humira and methotrexate.  Therefore, during the appeal period, and resolving reasonable doubt in the veteran's favor, especially with respect to the severity of his problem during times when not treated with immunosuppressants, the medical evidence reflects that the veteran's disability was severe enough to require near-constant systemic therapy with immunosuppressant drugs.  As such, under the revised rating criteria, the veteran's eczema of the hands, arms and elbows warrants a 60 percent rating.  38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Code 7806 (2006).

My two cents.....If you are stating that at one time, for a 12 month period, each month you were being treated monthly with injections of corticosteriods (kenalog 10 which is only to be injected once every 3-4 weeks) to treat your eczema that IS SC'd already....I would say YES....but my opinion is only worth the two cents. What did the C&P doctor write on your C&P paperwork?

Edited January 12, 2013 by USMC5811

[Berta]

Some skin disorders can be found to be so disfiguring to face and hands that VA must consider extraschedular analysis of the claim.

I dont think this applies to you but might help someone out there.

“In exceptional cases where schedular ratings are found to be inadequate, consideration of an extraschedular disability rating is made. 38 C.F.R. § 3.321(b)(1).  There is a three-step analysis for determining whether an extraschedular disability rating is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008).  First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id.  If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization).  If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. “

http://www.va.gov/vetapp12/Files2/1211227.txt

This case shows what I mean:

http://www.va.gov/vetapp04/Files/0407015.txt

More here:

As for the "new" criteria, the Board recognizes that the 
revised criteria have now done away with the 30 percent 
rating, and the next highest rating of 40 percent now 
requires persistent edema and stasis pigmentation or eczema, 
with or without intermittent ulceration.  However, while the 
evidence on and since January 12, 1998 may arguably support a 
finding of persistent edema, the evidence does not support a 
finding of persistent stasis pigmentation or eczema, and 
consequently, a higher rating under the "new" criteria is 
not warranted.  Similarly, without persistent stasis 
pigmentation or eczema, persistent ulceration, or massive, 
board-like swelling, a 60 or 100 percent rating under the 
"new" criteria is also not available.

http://www.va.gov/vetapp02/files02/0206309.txt

My point is this......I knew a vet who volunteered at the local VA. He had needed to have a shunt into his brain. He seemed to have no serious residuals.

The vet had worked in the public sector all his life prior to the brain surgery.

The shunt was a hole in the middle of his forehead exposing his brain (he let me look at it real good)

and it obviously would have impacted on anyone who dealt with him in his past employment.You couldn't miss it.

This vet had what VA calls a 'disfigurement' so severe that it warranted unemployability.

He might well have many other residuals too. I dont remember.

[ABH1]

I don't have personal knowledge of the subject matter, but here is a link to a remand that you may find to be an interesting read. That is if you have not read it already. Specifically Systemic Therapy defined and leaving the near constant or constant part to a dermatologist to determine for the court - not eczema, but a skin condition though http://www.va.gov/vetapp11/files1/1104448.txt

As to the meaning of "systemic therapy," although the rating criteria mention corticosteroids or other immunosuppressive drugs as examples of systemic therapy, a similar use of the term "such as" in the rating criteria has been held to demonstrate that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating.  See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002) (the use of the term "such as" demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating).  Thus, systemic therapy under DC 7806 is not necessarily limited to corticosteroids of other immunosuppressive drugs.

And this case which granted increase for Eczema due to near constant or constant systemic therapy: http://www.va.gov/vetapp07/files3/0724165.txt

However, the Board does find that the medical evidence demonstrates constant or near-constant systemic therapy (oral medications and subcutaneous injections) consisting of immunosuppressive drugs required during the past 12-month period.  In this case, the evidence of record documents that between September 2002 and April 2005, the veteran was receiving systemic therapy with immunosuppressant drugs.  The drugs were administered orally or by injection and were noted to be cyclosporine (Gengraf), methotrexate, etanercept (Enbrel), and adalimumab (Humira).  From April 2005 to March 2006, the medical evidence does not reflect whether the veteran was treated for eczema, but when he again was treated later in March 2006, his condition was apparently severe enough to again warrant systemic immunosuppressant therapy with Humira.  In the report of October 2006 VA examination, the veteran was noted to be taking both Humira and methotrexate.  Therefore, during the appeal period, and resolving reasonable doubt in the veteran's favor, especially with respect to the severity of his problem during times when not treated with immunosuppressants, the medical evidence reflects that the veteran's disability was severe enough to require near-constant systemic therapy with immunosuppressant drugs.  As such, under the revised rating criteria, the veteran's eczema of the hands, arms and elbows warrants a 60 percent rating.  38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Code 7806 (2006).

My two cents.....If you are stating that at one time, for a 12 month period, each month you were being treated monthly with injections of corticosteriods (kenalog 10 which is only to be injected once every 3-4 weeks) to treat your eczema that IS SC'd already....I would say YES....but my opinion is only worth the two cents. What did the C&P doctor write on your C&P paperwork?

Thank you for all that good info!

Well, my C&P was back in March 2011 and was not doing injections at that time. My injections (intralesional, which means they inject direct into my hands where my eczema is located) began in Dec 2011 to date. Since my claim has carried on so long, I hope that the raters look at the current info that is available in the VA hospital. As I understand, they do according to the regional office whom I visited about 6 months ago. Claim so far is at the 770 days mark. Crazy...

Some skin disorders can be found to be so disfiguring to face and hands that VA must consider extraschedular analysis of the claim.

I dont think this applies to you but might help someone out there.

“In exceptional cases where schedular ratings are found to be inadequate, consideration of an extraschedular disability rating is made. 38 C.F.R. § 3.321(b)(1).  There is a three-step analysis for determining whether an extraschedular disability rating is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008).  First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id.  If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization).  If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. “

http://www.va.gov/vetapp12/Files2/1211227.txt

This case shows what I mean:

http://www.va.gov/vetapp04/Files/0407015.txt

More here:

As for the "new" criteria, the Board recognizes that the 
revised criteria have now done away with the 30 percent 
rating, and the next highest rating of 40 percent now 
requires persistent edema and stasis pigmentation or eczema, 
with or without intermittent ulceration.  However, while the 
evidence on and since January 12, 1998 may arguably support a 
finding of persistent edema, the evidence does not support a 
finding of persistent stasis pigmentation or eczema, and 
consequently, a higher rating under the "new" criteria is 
not warranted.  Similarly, without persistent stasis 
pigmentation or eczema, persistent ulceration, or massive, 
board-like swelling, a 60 or 100 percent rating under the 
"new" criteria is also not available.

http://www.va.gov/vetapp02/files02/0206309.txt

My point is this......I knew a vet who volunteered at the local VA. He had needed to have a shunt into his brain. He seemed to have no serious residuals.

The vet had worked in the public sector all his life prior to the brain surgery.

The shunt was a hole in the middle of his forehead exposing his brain (he let me look at it real good)

and it obviously would have impacted on anyone who dealt with him in his past employment.You couldn't miss it.

This vet had what VA calls a 'disfigurement' so severe that it warranted unemployability.

He might well have many other residuals too. I dont remember.

Thanks so much Berta!