[Federal Register Volume 66, Number 237 (Monday, December 10, 2001)]
[Proposed Rules]
[Pages 63634-63640]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 01-30431]


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SOCIAL SECURITY ADMINISTRATION

20 CFR Part 404

[Regulations No. 4 and 16]
RIN 0960-AF29


Revised Medical Criteria for Evaluating Skin Disorders

AGENCY: Social Security Administration.

ACTION: Proposed rules.

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SUMMARY: We propose to revise the criteria in the Listing of 
Impairments (the listings) that we use to evaluate claims involving 
skin disorders. We apply these criteria when you claim benefits based 
on disability under title II and title XVI of the Social Security Act 
(the Act). The proposed revisions will reflect advances in medical 
knowledge, treatment, and methods of evaluating skin disorders.

DATES: To be sure your comments are considered, we must receive them by 
February 8, 2002.

ADDRESSES: You may give us your comments by using: our Internet site 
facility (i.e., Social Security Online) at: http://www.ssa.gov/regulations/, e-mail to [email protected]; telefax to (410) 966-2830; 
or by letter to the Commissioner of Social Security, P.O. Box 17703, 
Baltimore, Maryland 21235-7703.
    You may also deliver them to the Office of Process and Innovation 
Management, Social Security Administration, L2109 West Low Rise 
Building, 6401 Security Boulevard, Baltimore, Maryland 21235-6401, 
between 8:00 a.m. and 4:30 p.m. on regular business days. Comments are 
posted on our Internet site, or you may inspect them physically on 
regular business days by making arrangements with the contact person 
shown in this preamble.
    Electronic Version: The electronic file of this document is 
available on the date of publication in the Federal Register at http://www.access.gpo.gov/su docs/aces/aces140.html. It is also available on 
the Internet site for SSA (i.e., Social Security Online): http://www.ssa.gov/regulations/.

FOR FURTHER INFORMATION CONTACT: Suzanne DiMarino, Social Insurance 
Specialist, Office of Process and Innovation Management, Social 
Security Administration, L2109 West Low Rise, 6401 Security Boulevard, 
Baltimore, Maryland 21235-6401, (410) 965-1769 or TTY (410) 966-5609. 
For information on eligibility or filing for benefits, call our 
national toll-free number 1-800-772-1213 or TTY 1-800-325-0778, or 
visit our Internet web site, Social Security Online, at http://www.ssa.gov.

SUPPLEMENTARY INFORMATION:

What Programs Would These Proposed Regulations Affect?

    These proposed regulations would affect disability determinations 
and decisions we make for you under title II and title XVI of the Act. 
In addition, to the extent that Medicare and Medicaid eligibility are 
based on entitlement to benefits under title II and eligibility for

[[Page 63635]]

benefits under title XVI, these proposed regulations would also affect 
the Medicare and Medicaid programs.

Who Can Get Disability Benefits?

    Under title II of the Act, we provide for the payment of disability 
benefits if you are disabled and belong to one of the following three 
groups:
     Workers insured under the Act,
     Children of insured workers, and
     Widows, widowers, and surviving divorced spouses (see 20 
CFR Sec. 404.336) of insured workers.
    Under title XVI of the Act, we provide for Supplemental Security 
Income (SSI) payments on the basis of disability if you have limited 
income and resources.

How Do We Define Disability?

    Under both the title II and title XVI programs, disability must be 
the result of any medically determinable physical or mental impairment 
or combination of impairments that can be expected to result in death 
or that has lasted or can be expected to last for a continuous period 
of at least 12 months. Our definitions of disability are shown in the 
following table:

----------------------------------------------------------------------------------------------------------------
                                                                         Disability means you have a medically
                                                                       determinable impairment(s) that meets the
     If you file a claim under . . .           And you are . . .           statutory duration requirement and
                                                                                    results in . . .
----------------------------------------------------------------------------------------------------------------
title II................................  an adult or child..........  the inability to do any substantial
                                                                        gainful activity (SGA).
title XVI...............................  an adult...................  the inability to do any SGA.
title XVI...............................  a child....................  marked and severe functional limitations.
----------------------------------------------------------------------------------------------------------------

What Are the Listings?

    The listings contain examples of impairments that we consider 
severe enough to prevent you as an adult from doing any gainful 
activity. If you are a child seeking SSI benefits based on disability, 
the listings describe impairments that we consider severe enough to 
result in marked and severe functional limitations. Although the 
listings are contained only in appendix 1 to subpart P of part 404 of 
our rules, we incorporate them by reference in the SSI program in 
Sec. 416.925 of our regulations, and apply them to claims under both 
title II and title XVI of the Act.

How Do We Use the Listings?

    There are listings for adults (part A) and for children (part B). 
We apply the medical criteria in part A when we assess your claim if 
you are an adult, i.e., a person age 18 or over.
    If you are a child, we first use the criteria in part B. If the B 
criteria do not apply, and the specific disease process(es) has a 
similar effect on adults and children, we then use the criteria in part 
A. (See Secs. 404.1525, 404.1526, 416.925 and 416.926.)
    We use the criteria in the listings only to make favorable findings 
of disability. We never deny a claim or find that disability has ceased 
because your impairment(s) does not meet or medically equal a listing.

Why Are We Proposing To Revise the Listings for Skin Impairments?

    We are proposing these revisions to update the medical criteria and 
provide more information about how we evaluate skin impairments. We 
last published final rules containing comprehensive revisions to the 
skin listings in the Federal Register on March 27, 1979 (44 FR 18170). 
In subsequent rules published December 6, 1985 (50 FR 50068), we 
indicated that due to advances in medical treatment, technology, and 
program experience we would periodically review and update the 
listings. The current listings for the evaluation of skin impairments 
would no longer be effective on July 2, 2003 (66 FR 34361 (June 28, 
2001)).

How Long Would These Proposed Rules Be Effective?

    These proposed rules would remain in effect for 8 years from the 
date we publish them as final rules in the Federal Register, unless we 
extend them, or revise and issue them again.
    We will continue to apply our current listings until we evaluate 
the public comments on these proposed rules and determine whether they 
should be issued as final rules. If we finalize these proposed rules, 
when any final rules become effective, we will apply them to new 
applications filed on or after the effective date of the final rules, 
and to cases that are pending in the administrative review process. In 
accordance with our usual practice, we would explain how we would apply 
any final rules in greater detail in the preamble to the final rules.
    When we conduct reviews to determine whether your disability 
continues, we would not find that your disability has ended based only 
on any changes in the listings. Our regulations explain that we 
continue to use our prior listings when we review your case if you 
receive disability benefits or SSI payments based on our determination 
or decision that your impairment(s) met or equaled the listings. In 
these cases, we determine whether you have experienced medical 
improvement, and if so, whether the medical improvement is related to 
the ability to work. If your impairment(s) still meets or equals the 
same listing section that we used to make our most recent favorable 
determination or decision, we will find the medical improvement is not 
related to the ability to work. If your condition has medically 
improved so that you no longer meet or equal the prior listing, we 
evaluate your case further to determine whether you are currently 
disabled. We may find that you are currently disabled, depending on the 
full circumstances of your case. See 20 CFR 404.1594(c)(3)(i), 
416.994(b)(2)(iv)(A). If you are a child who is eligible for SSI 
payments, we follow a similar rule when we decide whether you have 
experienced medical improvement in your condition. 20 CFR 
416.994a(b)(2).

What Revisions Are We Proposing To Make?

    To present the skin listing criteria in part A of Appendix 1 in a 
more logical order, and make the listings easier to use, we propose to:
     Revise the titles to put them in plain language;
     Revise the order and update the diagnostic groupings of 
skin impairments;
     Add a listing for photosensitivity disorders;
     Provide a more uniform and clearly defined statement of 
severity required for a listing-level skin impairment;
     Expand the guidance in the introductory text to the 
listing; and
     Make nonsubstantive editorial changes.
    In addition, we propose to add a set of childhood skin listings in 
part B of Appendix 1.

How Are We Proposing To Change the Introductory Text to the Adult 
Skin Listings?

    We propose to change the heading title from 8.00 Skin to 8.00 Skin 
Disorders.
    We propose to expand and significantly reorganize the introductory

[[Page 63636]]

text to the skin impairments listings in current 8.00A and 8.00B in 
order to provide additional guidance in applying the skin listings. In 
doing so, we propose to:
     Expand and supplement the first sentence of current 8.00A 
and move it into proposed 8.00C;
     Expand and supplement the second sentence of current 8.00A 
and move it into proposed 8.00F;
     Expand the third sentence of current 8.00A and move it 
into proposed 8.00C(3); and
     Expand the material in 8.00B and move it into proposed 
8.00D.
    We also propose to add new material in all the proposed sections of 
the introductory text. A detailed description of the new and modified 
paragraphs follows.

Proposed 8.00A--What Skin Impairments Do We Evaluate With These 
Listings?

    This new section provides a detailed description of the more common 
impairments that may be disabling covered by the skin listings.

Proposed 8.00B--What Documentation Do We Need?

    We propose to add a new section that discusses the documentation we 
require in evaluating skin impairment(s) cases. The proposed section 
explains the information we expect to find in a complete dermatologic 
case record in order to make a reasonable assessment of severity. It 
also explains the importance of diagnostic procedures, which produce 
laboratory findings or other evidence from generally acceptable 
methods, in accurately diagnosing skin impairments.

Proposed 8.00C--How Do We Determine if Your Skin Impairment(s) Prevents 
You From Doing Any Gainful Activity?

    This section, which is partially new and partially based on 
modification to the first sentence of current 8.00A, will explain the 
three factors we consider when evaluating the severity of skin 
impairments. The proposed section consists of three subsections:
     Proposed 8.00C1 defines ``extensive lesions'', a term in 
proposed listings 8.02 through 8.07. That definition explains that the 
term extensive not only refers to the amount of surface area affected, 
but also to the limitations resulting from the lesions. Hence, these 
listings require a qualitative, as well as a quantitative, evaluation 
of the effect of the skin lesions. This section also gives examples of 
extensive lesions. We will determine whether you can ambulate 
effectively or can perform fine and gross movements effectively based 
on the medical and other evidence in the case record, generally without 
developing additional evidence about your ability to perform the 
specific activities listed as examples.
     Proposed 8.00C2 explains how we evaluate symptoms 
(including pain) consistent with our rules in Secs. 404.1525(f) and 
416.925(f) and Secs. 404.1529 and 416.929.
     Proposed 8.00C3 explains that while skin impairments often 
respond to treatment, there is a wide variation in how people respond, 
including side effects to drug therapy. Therefore, we will consider 
each case on an individual basis.

Proposed 8.00D--How Do We Assess Impairments That Involve More Than One 
Body System?

    This section modifies current 8.00B. It clarifies that other 
impairments, in addition to systemic ones, can involve the skin and 
explains how we evaluate such impairments under the listings. It also 
broadens the list of examples of impairments that affect skin and other 
body systems.

Proposed 8.00E--How Do We Evaluate Burns?

    We propose to include this new section on burns in the introductory 
text to the skin listings in response to many inquiries that we receive 
on how we evaluate these injuries. This new paragraph notes that burns 
frequently affect more than one body system. It then explains that we 
evaluate the specific impairment resulting from burns using the 
criteria of the affected body system.

Proposed 8.00F--How Do We Determine if an Impairment Will Continue at a 
Disabling Level of Severity in Order to Meet the Duration Requirement?

    We propose to add this section to explain how we will determine if 
the duration requirement is or will be met. This section is partially 
new and partially based on the second sentence of current 8.00A.
    We state that the extensive skin lesions must persist for at least 
3 months despite continuing treatment as prescribed in order for us to 
infer that the duration requirement will be met. Currently, each 
listing requires that the skin lesions not respond to prescribed 
treatment, but there is no statement of how long the lesions must last 
despite prescribed treatment before we can evaluate the skin 
impairment(s) under the listing criteria. Since most skin impairments 
improve significantly within 3 months after treatment begins, we 
propose that skin lesions must have persisted for at least 3 months 
despite continuing treatment as prescribed. The proposed timeframe will 
allow us to predict, with a high degree of certainty, which impairments 
resulting in the inability to perform gainful activity will also 
satisfy the duration requirement of the Act. In addition, the proposed 
timeframe will help to ensure that we do not decide cases prematurely 
or unnecessarily delay making decisions.

Proposed 8.00G--How Do We Assess Impairments if There Is No Prescribed 
Treatment, or the Extensive Lesions Have Not Persisted for at Least 3 
Months?

    This section explains how we assess a skin impairment when there is 
no record of ongoing treatment, such treatment has lasted less than 3 
months, or the extensive lesions have not yet persisted for at least 3 
months. It describes how we continue through the sequential evaluation 
process if the listing(s) cannot be met due to insufficient 
longitudinal treatment records.

How Are We Proposing To Change the Criteria in the Listings for 
Evaluating Skin Impairments in Adults?

8.01 Category of Impairments, Skin

    Most of the changes we propose to make to the skin listings are not 
significant. For instance, we propose to update the medical terminology 
and to broaden and reorganize the skin listings.
    A significant change we do propose to make is to add a listing, 
8.07, for photosensitivity disorders. Currently, such disorders may be 
found equivalent in severity to a listed skin impairment. We also 
propose to define ``extensive lesions'' and to add to each listing a 
requirement that the extensive lesions must persist, despite continuing 
treatment as prescribed, for a period of at least 3 months. This is 
explained in 8.00F of the introductory text.
    The following is a detailed explanation of the proposed listing 
criteria.

Proposed Listing 8.02--Ichthyosis

    We propose to revise the title of listing 8.02 to ichthyosis so 
that it covers the general group of disorders characterized by 
noninflammatory scaling of the skin. This prevents the need to also 
cite the inherited disorder ichthyosiform erythroderma, which we do not 
commonly see. We also propose to move exfoliative dermatitis to listing 
8.05 with the other dermatitis disorders.

[[Page 63637]]

Proposed Listing 8.03--Bullous Disease (e.g., Pemphigus, Erythema 
Multiforme Bullosum, Epidermolysis Bullosa, Bullous Pemphigoid, 
Dermatitis Herpetiformis)

    We propose to revise the title of listing 8.03 so that we can apply 
it to all types of bullous diseases. Then, through the use of examples, 
we propose to cite the four currently listed diseases and epidermolysis 
bullosa.

Proposed Listing 8.04--Chronic Infections of the Skin or Mucous 
Membranes

    We propose to revise the title of listing 8.04 so that the listing 
will include infections other than deep mycotic (fungal) infections. In 
this listing we propose to use the words ``fungating'' (to grow 
exuberantly like a fungus or spongy growth) and ``ulcerating'' (a 
lesion through the skin or a mucous membrane resulting from loss of 
tissue, usually with inflammation) to modify the term ``extensive 
lesions'' because they are descriptive of the different types of 
lesions frequently associated with the more severe types of chronic 
infections. Listing-level severity is characterized by either fungating 
or ulcerating lesions.

Proposed Listing 8.05--Dermatitis (e.g., Psoriasis, Dyshidrosis, Atopic 
Dermatitis, Exfoliative Dermatitis, Allergic Contact Dermatitis)

    We propose to revise the title of listing 8.05 so that we can use 
it to evaluate miscellaneous inflammatory conditions of the skin, 
rather than just the three conditions currently cited. The new title 
will allow us to use this listing to evaluate environmental skin 
conditions such as allergic contact dermatitis.

Proposed Listing 8.06--Hidradenitis Suppurativa

    We propose to remove the reference to acne conglobrata from listing 
8.06 because it is not usually disabling and frequently responds well 
to current treatment. Also, we propose different severity criteria for 
this listing. We are taking out the condition of ``not amenable to 
surgical treatment'' since most lesions associated with hidradenitis 
suppurativa involve local inflammation of the apocrine glands and occur 
in the axillae, inguinal areas, or perineum. Due to advances in medical 
treatments, these conditions do not usually require surgery; but if 
surgery is needed, continuing treatment as prescribed includes any 
necessary surgical procedures.

Proposed Listing 8.07--Photosensitivity Disorders (e.g., Xeroderma 
Pigmentosum)

    We propose to add a listing for evaluating photosensitivity 
disorders, such as xeroderma pigmentosum, in adults. Some individuals 
with these disorders are now surviving into adulthood and thus we 
believe it appropriate to have a separate listing for these disorders. 
For more information about this new listing disorder, we refer you to 
the following:
    1. Photosensitivity (Section 15), in: Harper J, Oranje A, Prose N, 
(eds) Textbook of Pediatric Dermatology, vols 1 & 2, Oxford: Blackwell 
Science, 2000:895-936.
    2. Roelandts R., The Diagnosis of Photosensitivity, Arch Dermatol, 
2000:136:1152-7.
    3. Epstein JH., Photosensitivity and Photoallergy, Semin Cutan Med 
Surg., 1999:18:274-84.

Why Are We Proposing To Add Listings for Evaluating Skin 
Impairments in Children?

    We propose to add new listings to evaluate claims filed by persons 
under age 18 who have skin impairments to maintain consistency with the 
other body system listings which have both adult and child criteria.

How Do the Skin Listings We Are Proposing for Children Differ From 
Those We Are Proposing for Adults?

    The skin listings we are proposing for children are identical in 
content to those we are proposing for adults, except that we propose to 
include examples of erythropoietic porphyrias and hemangiomas in 
108.00D, and not in 8.00D. We did this because the skin manifestations 
of these disorders are not likely to be the primary manifestations in 
adults. For example, most hemangiomas disappear spontaneously or are 
surgically removed in childhood. When the hemangiomas are associated 
with Kasabach-Merritt Syndrome, a rare condition in which the low 
number of blood platelets cause bleeding, the hemic manifestations are 
obvious in adults. Similarly, in erythropoietic porphyria, a rare 
metabolic disorder characterized by a deficiency of the enzyme 
ferrochelatase that is essential to the synthesis of hemoglobin, a 
major symptom in children is the hypersensitivity of their skin to 
sunlight and some types of artificial light. Generally, by adulthood, 
anemia is a prominent manifestation in the more severe cases, with 
possible complications related to liver and gallbladder function.

Clarity of These Proposed Rules

    Executive Order 12866 requires each agency to write all rules in 
plain language. In addition to your substantive comments on these 
proposed rules, we invite your comments on how to make these proposed 
rules easier to understand.
    For example:
     Have we organized the material to suit your needs?
     Are the requirements in the rules clearly stated?
     Do the rules contain technical language or jargon that is 
not clear?
     Would a different format (grouping and order of sections, 
use of headings, paragraphing) make the rules easier to understand?
     Would more (but shorter) sections be better?
     Could we improve clarity by adding tables, lists, or 
diagrams?
     What else could we do to make the rules easier to 
understand?

Regulatory Procedures

Executive Order (E.O.) 12866

    We have consulted with the Office of Management and Budget (OMB) 
and determined that these proposed rules meet the requirements for a 
significant regulatory action under E.O. 12866. Thus, they were subject 
to OMB review.

Regulatory Flexibility Act

    We certify that these proposed rules would not have a significant 
economic impact on a substantial number of small entities because they 
affect only individuals. Thus, a regulatory flexibility analysis as 
provided in the Regulatory Flexibility Act, as amended, is not 
required.

Paperwork Reduction Act

    These proposed rules contain reporting requirements at 8.00B, 
8.00C, 8.00D, 108.00B, 108.00C, and 108.00D. The public reporting 
burden is accounted for in the Information Collection Requests for the 
various forms that the public uses to submit the information to SSA. 
Consequently, a 1-hour placeholder burden is being assigned to the 
specific reporting requirement(s) contained in these rules. We are 
seeking clearance of the burdens referenced in these rules because they 
were not considered during the clearance of the forms. An Information 
Collection Request has been submitted to OMB. We are soliciting 
comments on the burden estimate; the need for the information; its 
practical utility; ways to enhance its quality, utility and clarity; 
and on ways to minimize the burden on respondents, including the use of

[[Page 63638]]

automated collection techniques or other forms of information 
technology. Comments should be submitted to the Social Security 
Administration at the following address: Social Security 
Administration, Attn: SSA Reports Clearance Officer, Rm. 1-A-20 
Operations Building, 6401 Security Boulevard, Baltimore, MD 21235-6401.
    Comments can be received for between 30 and 60 days after 
publication of this notice. Comments will be most useful if received by 
SSA within 30 days of publication.

List of Subjects in 20 CFR Part 404

    Administrative practice and procedure, Blind, Disability benefits, 
Old-Age, Survivors, and Disability Insurance, Reporting and 
recordkeeping requirements, Social Security.

    Dated: December 3, 2001.
Jo Anne B. Barnhart,
Commissioner of Social Security.
    For the reasons set out in the preamble, we propose to amend 
subpart P of part 404 of 20 CFR chapter III as set forth below:

PART 404--FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE 
(1950-)

    1. The authority citation for subpart P of part 404 continues to 
read as follows:

    Authority: Secs. 202, 205(a), (b), and (d)-(h), 216(i), 221(a) 
and (i), 222(c), 223, 225, and 702(a)(5) of the Social Security Act 
(42 U.S.C. 402, 405(a), (b), and (d)-(h), 416(i), 421(a) and (i), 
422(c), 423, 425, and 902(a)(5)); sec. 211(b), Pub. L. 104-193, 110 
Stat. 2105, 2189.

Appendix 1 to Subpart P of Part 404--Listing of Impairments 
(Amended)

    2. Item 9 of the introductory text before part A is amended by 
revising the heading title, revising the expiration date for section 
8.00, and adding section 108.00 and its expiration date as follows:
* * * * *
    9. Skin Disorders (8.00 and 108.00): (date 8 years from the date of 
publication of final rules in the Federal Register).
* * * * *
    3. The list of sections for part A of appendix 1 is amended by 
revising 8.00 to read ``8.00 Skin Disorders''.
    4. The list of sections for part B of appendix 1 is amended by 
revising of 108.00 to read ``108.00 Skin Disorders''.
    5. Section 8.00 in part A of appendix 1 is revised and section 
108.00 in part B of appendix 1 is added to read as follows:

APPENDIX 1 TO SUBPART P OF PART 404--LISTING OF IMPAIRMENTS

* * * * *

Part A

* * * * *

8.00  Skin Disorders

    A. What skin impairments do we evaluate with these listings? We 
use these listings to evaluate skin impairments that may result from 
hereditary, congenital, or acquired pathological processes. Examples 
of impairments covered by these listings include: ichthyosis, 
bullous diseases, chronic infections of the skin or mucous 
membranes, dermatitis, hidradenitis suppurativa, and 
photosensitivity disorders.
    B. What documentation do we need? Your case record should 
include information about onset, duration, frequency of flare-ups, 
and prognosis; location, size, and appearance of lesions; and, when 
applicable: history of exposure to toxins, allergens, or irritants; 
familial incidence; seasonal variation; and stress factors. To 
confirm the diagnosis, we often need laboratory findings (e.g., 
biopsy or serological testing) or evidence from other medically 
acceptable methods consistent with the prevailing state of medical 
knowledge and clinical practice.
    C. How do we determine if your skin impairment(s) prevents you 
from doing any gainful activity? We base our assessment of severity 
on whether your skin lesions are extensive, how your symptoms 
(including pain) limit you, the extent of your treatment, and how 
your treatment affects you.
    (1) Extensive skin lesions. Extensive skin lesions are those 
that involve sufficient surface area over multiple body sites or 
involve critical body areas, and result in very serious limitations. 
Examples of extensive lesions that result in very serious 
limitations include:
    (a) Skin lesions that interfere with motion of joints that very 
seriously limit your use of more than one extremity, i.e. two upper 
extremities, two lower extremities, or one upper and one lower 
extremity; or
    (b) Skin lesions on the palms of the hands or the axillary areas 
that very seriously limit your ability to do fine and gross motor 
movements; or
    (c) Skin lesions on the soles of the feet, the perineum, or the 
inguinal areas that very seriously limit your ability to ambulate.
    (2) Symptoms (including pain). Symptoms (including pain) may be 
important factors contributing to the severity of your skin 
impairment(s). We assess the impact of symptoms as explained in 
Secs. 404.1525(f), 404.1529, 416.925(f), and 416.929.
    (3) Treatment. Skin impairments frequently respond to treatment, 
however response to treatment can vary widely, with some impairments 
becoming resistant to treatment.
    (a) We assess the effects of treatment by determining if there 
is improvement in the symptoms, signs, and laboratory findings of 
the disorder, and if there are side effects that may result in 
functional limitations. We assess the effects of medication, 
therapy, surgery, or any other form of treatment you receive when 
determining the severity and the duration of the impairment(s). An 
assessment of these issues may require:
    (i) a description of the treatment prescribed (e.g., the type, 
dosage, method and frequency of administration of medication or 
therapy);
    (ii) your response to the treatment;
    (iii) any adverse effects of such treatment; or
    (iv) the expected duration of the treatment.
    (b) Because treatment itself or the effects of treatment may be 
temporary, in most cases sufficient time must elapse to allow us to 
evaluate the impact and expected duration of treatment and side 
effects. You must follow prescribed treatment for at least 3 months 
before your impairment can be determined to meet a skin listing. We 
consider your specific response to treatment when we evaluate 
overall severity of your impairment.
    D. How do we assess impairments that involve more than one body 
system? These listings are only examples of common skin disorders 
that we consider severe enough to prevent you from doing any gainful 
activity. If your impairment(s) does not meet the criteria of any of 
these listings, we must also consider whether you have an impairment 
that satisfies the criteria of a listing in another body system. 
Also, when your impairment involves more than one body system, we 
first evaluate the predominant feature under the appropriate body 
system. For example:
    (1) Tuberous sclerosis has cutaneous manifestations, but the 
more dominant feature involves the brain, often resulting in 
seizures (11.02 and 11.03) and organic mental disorders (12.02);
    (2) Malignant tumors of the skin (e.g., malignant melanoma) are 
neoplastic diseases and we first evaluate them under 13.00ff;
    (3) Connective tissue disorders or immune system disorders 
(e.g., systemic lupus erythematosis or HIV infection) involve more 
than one body system. We first evaluate these disorders under 
14.00ff;
    (4) Scleroderma, although at times limited to skin only, usually 
involves other body systems as a part of generalized systemic 
sclerosis which we evaluate under listing 14.04. However, when it 
involves skin contractures restricting joint motion we also consider 
the appropriate criteria in 1.00ff;
    (5) Facial disfigurement resulting from skin lesions may also be 
associated with physical functional loss such as impairment of 
sight, hearing, speech, and mastication, which we evaluate under the 
appropriate criteria in 2.00ff and 5.00ff. Facial disfigurement or 
any kind of physical deformity due to skin lesions may also result 
in psychological impairment(s) with socialization, mood, or other 
related limitations. We evaluate those impairments under the 
appropriate criteria in 12.00ff.
    E. How do we evaluate burns? Electrical, chemical, or thermal 
traumatic burns frequently affect more than one body system (e.g., 
musculoskeletal, special senses, respiratory, cardiovascular, skin, 
renal, neurological, or mental). Consequently, we evaluate 
impairments that can result from severe burns under the criteria of 
the affected body systems. For example, we evaluate soft tissue 
injuries resulting from burns under the musculoskeletal system 
criteria in 1.00ff and

[[Page 63639]]

we evaluate renal failure resulting from burns under the genito-
urinary system criteria in 6.00ff.
    F. How do we determine if an impairment will continue at a 
disabling level of severity in order to meet the duration 
requirement? If you have extensive skin lesions, and they persist 
for at least 3 months despite continuing treatment as prescribed, 
these listings allow us to infer that they will continue at that 
level of severity for at least 12 months. By persist, we mean the 
longitudinal clinical record shows that, with few exceptions, the 
lesions have been at the level of severity specified in the listing 
and that this pattern could be expected to continue. Where adverse 
effects of treatment contribute to the impairment severity, the 
duration or expected duration of the treatment must be considered in 
assessing the duration of the impairment(s).
    G. How do we assess skin impairments if there is no prescribed 
treatment, or extensive lesions have not persisted for 3 months?
    (1) For your impairment to meet a skin listing, you must have 
extensive lesions that persist for at least 3 months despite 
continuing treatment as prescribed, and you must follow that 
treatment, unless you have an acceptable reason for failing to 
follow prescribed treatment (see Secs. 404.1530 and 416.930).
    (2) If you have not received ongoing treatment nor have an 
ongoing relationship with the medical community despite the 
existence of a severe impairment(s), or if your skin lesions have 
not persisted for at least 3 months, but you are undergoing 
continuing treatment as prescribed, you still may have an 
impairment(s) that medically equals the listings. An individual who 
has an impairment(s) that does not meet or medically equal the 
listings may or may not have the residual functional capacity to 
engage in substantial gainful activity. For such an individual, we 
proceed to the fourth, and if necessary, the fifth steps of the 
sequential evaluation process in Secs. 404.1520 and 416.920. When we 
decide whether an adult continues to be disabled, we use the rules 
in Secs. 404.1594 and 416.994, as appropriate. We will base our 
evaluation on the current objective medical evidence and other 
available evidence. We will take into consideration your medical 
history, symptoms, and acceptable medical source opinions.
    8.01 Category of Impairments, Skin
    8.02 Ichthyosis, with extensive lesions that persist for at 
least 3 months despite continuing treatment as prescribed.
    8.03 Bullous disease (e.g., pemphigus, erythema multiforme 
bullosum, epidermolysis bullosa, bullous pemphigoid, dermatitis 
herpetiformis), with extensive lesions that persist for at least 3 
months despite continuing treatment as prescribed.
    8.04 Chronic infections of the skin or mucous membranes, with 
extensive fungating, or extensive ulcerating lesions that persist 
for at least 3 months despite continuing treatment as prescribed.
    8.05 Dermatitis (e.g., psoriasis, dyshidrosis, atopic 
dermatitis, exfoliative dermatitis, allergic contact dermatitis), 
with extensive lesions that persist for at least 3 months despite 
continuing treatment as prescribed.
    8.06 Hidradenitis suppurativa, with extensive lesions involving 
the axillae, inguinal areas, or perineum that persist for at least 3 
months despite continuing treatment as prescribed.
    8.07 Photosensitivity disorders (e.g., xeroderma pigmentosum), 
with extensive lesions that persist for at least 3 months despite 
continuing treatment as prescribed.
* * * * *

Part B

* * * * *

108.00  Skin Disorders

    A. What skin impairments do we evaluate with these listings? We 
use these listings to evaluate skin impairments that may result from 
hereditary, congenital, or acquired pathological processes. Examples 
of impairments covered by these listings include: ichthyosis, 
bullous diseases, chronic infections of the skin or mucous 
membranes, dermatitis, hidradenitis suppurativa, and 
photosensitivity disorders.
    B. What documentation do we need? Your case record should 
include information about onset, duration, frequency of flare-ups, 
and prognosis; location, size, and appearance of lesions; and, when 
applicable: history of exposure to toxins, allergens, or irritants; 
familial incidence; seasonal variation; and stress factors. To 
confirm the diagnosis, we often need laboratory findings (e.g., 
biopsy or serological testing) or evidence from other medically 
acceptable methods consistent with the prevailing state of medical 
knowledge and clinical practice.
    C. How do we determine if your skin impairment(s) results in 
marked and severe limitations? We base our assessment of severity on 
whether your skin lesions are extensive, how your symptoms 
(including pain) limit you, the extent of your treatment, and how 
your treatment affects you.
    (1) Extensive skin lesions. Extensive skin lesions are those 
that involve sufficient surface area over multiple body sites or 
involve critical body areas, and result in very serious limitations. 
Examples of extensive lesions that result in very serious 
limitations include:
    (a) Skin lesions that interfere with motion of joints that very 
seriously limit your use of more than one extremity, i.e. two upper 
extremities, two lower extremities, or one upper and one lower 
extremity; or
    (b) Skin lesions on the palms of the hands or the axillary areas 
that very seriously limit your ability to do fine and gross motor 
movements; or
    (c) Skin lesions on the soles of the feet, the perineum, or the 
inguinal areas that very seriously limit your ability to ambulate.
    (2) Symptoms (including pain). Symptoms (including pain) may be 
important factors contributing to the severity of your skin 
impairment(s). We assess the impact of symptoms as explained in 
Secs. 404.1525(f), 404.1529, 416.925(f) and 416.929.
    (3) Treatment. Skin impairments frequently respond to treatment, 
however response to treatment can vary widely, with some impairments 
becoming resistant to treatment.
    (a) We assess the effects of treatment by determining if there 
is improvement in the symptoms, signs, and laboratory findings of 
the disorder, and if there are side effects that may result in 
functional limitations. We assess the effects of medication, 
therapy, surgery, or any other form of treatment you receive when 
determining the severity and the duration of the impairment(s). An 
assessment of these issues may require:
    (i) a description of the treatment prescribed (e.g., the type, 
dosage, method and frequency of administration of medication or 
therapy);
    (ii) your response to the treatment;
    (iii) any adverse effects of such treatment; or
    (iv) the expected duration of the treatment.
    (b) Because treatment itself or the effects of treatment may be 
temporary, in most cases sufficient time must elapse to allow us to 
evaluate the impact and expected duration of treatment and side 
effects. You must follow prescribed treatment for at least 3 months 
before your impairment can be determined to meet a skin listing. We 
consider your specific response to treatment when we evaluate 
overall severity of your impairment.
    D. How do we assess impairments that involve more than one body 
system? These listings are only examples of common skin disorders 
that we consider severe enough to result in marked and severe 
functional limitations. If your impairment(s) does not meet the 
criteria of any of these listings, we must also consider whether you 
have an impairment that satisfies the criteria of a listing in 
another body system. Also, when your impairment involves more than 
one body system, we first evaluate the predominant feature under the 
appropriate body system. For example:
    (1) Tuberous sclerosis has cutaneous manifestations, but the 
more dominant feature involves the brain, often resulting in 
seizures (111.02 and 111.03) and organic mental disorders (112.02);
    (2) Malignant tumors of the skin (e.g., malignant melanoma) are 
neoplastic diseases and we first evaluate them under 113.00ff;
    (3) Connective tissue disorders or immune system disorders 
(e.g., systemic lupus erythematosis or HIV infection) involve more 
than one body system. We first evaluate these disorders under 
114.00ff;
    (4) Scleroderma, although at times limited to skin only, usually 
involves other body systems as a part of generalized systemic 
sclerosis which we evaluate under listing 114.04. However, when it 
involves skin contractures restricting joint motion we also consider 
the appropriate criteria in 101.00ff;
    (5) Facial disfigurement resulting from skin lesions may also be 
associated with physical functional loss such as impairment of 
sight, hearing, speech, and mastication, which we evaluate under the 
appropriate criteria in 102.00ff and 105.00ff. Facial disfigurement 
or any kind of physical deformity due to skin lesions may also 
result in psychological impairment(s) with socialization, mood, or 
other related limitations. We evaluate those impairments under the 
appropriate criteria in 112.00ff;
    (6) We evaluate erythropoietic porphyrias under 107.00ff;
    (7) We evaluate hemangiomas associated with thrombocytopenia and 
hemorrhage (e.g., Kasabach-Merritt Syndrome) involving

[[Page 63640]]

coagulation defects, under 107.00ff. But, when hemangiomas impinge 
on vital structures or interfere with function or feeding, we 
evaluate them under the appropriate body system.
    E. How do we evaluate burns? Electrical, chemical, or thermal 
traumatic burns frequently affect more than one body system (e.g., 
musculoskeletal, special senses, respiratory, cardiovascular, skin, 
renal, neurological, or mental). Consequently, we evaluate 
impairments that can result from severe burns under the criteria of 
the affected body systems. For example, we evaluate soft tissue 
injuries resulting from burns under the musculoskeletal system 
criteria in 101.00ff and we evaluate renal failure resulting from 
burns under the genito-urinary system criteria in 106.00ff.
    F. How do we determine if an impairment will continue at a 
disabling level of severity in order to meet the duration 
requirement? If you have extensive skin lesions, and they persist 
for at least 3 months despite continuing treatment as prescribed, 
these listings allow us to infer that they will continue at that 
level of severity for at least 12 months. By persist, we mean the 
longitudinal clinical record shows that, with few exceptions, the 
lesions have been at the level of severity specified in the listing 
and that this pattern could be expected to continue. Where adverse 
effects of treatment contribute to the impairment severity, the 
duration or expected duration of the treatment must be considered in 
assessing the duration of the impairment(s).
    G. How do we assess skin impairments if there is no prescribed 
treatment, or extensive lesions have not persisted for 3 months? 
    (1) For your impairment to meet a skin listing, you must have 
extensive lesions that persist for at least 3 months despite 
continuing treatment as prescribed, and you must follow that 
treatment, unless you have an acceptable reason for failing to 
follow prescribed treatment (see Secs. 404.1530 and 416.930).
    (2) If you have not received ongoing treatment nor have an 
ongoing relationship with the medical community despite the 
existence of a severe impairment(s), or if your skin lesions have 
not persisted for at least 3 months, but you are undergoing 
continuing treatment as prescribed, you still may have an 
impairment(s) that medically equals the listings or, in the case of 
a childhood claim for SSI payments under Title XVI, functionally 
equals the listings. (See Secs. 404.1526, 416.926, and 416.926a.) 
When we decide whether a child receiving SSI payments continues to 
be disabled, we use the rules in Sec. 416.994a. We will base our 
evaluation on the current objective medical evidence and other 
available evidence. We will take into consideration your medical 
history, symptoms, and acceptable medical source opinions.
    108.01  Category of Impairments, Skin
    108.02  Ichthyosis, with extensive lesions that persist for at 
least 3 months despite continuing treatment as prescribed.
    108.03  Bullous disease (e.g., pemphigus, erythema multiforme 
bullosum, epidermolysis bullosa, bullous pemphigoid, dermatitis 
herpetiformis), with extensive lesions that persist for at least 3 
months despite continuing treatment as prescribed.
    108.04  Chronic infections of the skin or mucous membranes, with 
extensive fungating or extensive ulcerating lesions that persist for 
at least 3 months despite continuing treatment as prescribed.
    108.05  Dermatitis (e.g., psoriasis, dyshidrosis, atopic 
dermatitis, exfoliative dermatitis, allergic contact dermatitis), 
with extensive lesions that persist for at least 3 months despite 
continuing treatment as prescribed.
    108.06  Hidradenitis suppurativa, with extensive lesions 
involving the axillae, inguinal areas, or perineum that persist for 
at least 3 months despite continuing treatment as prescribed.
    108.07  Photosensitivity disorders (e.g., xeroderma 
pigmentosum), with extensive lesions that persist for at least 3 
months despite continuing treatment as prescribed.
* * * * *
[FR Doc. 01-30431 Filed 12-7-01; 8:45 am]
BILLING CODE 4191-02-U