[Federal Register Volume 67, Number 147 (Wednesday, July 31, 2002)]
[Rules and Regulations]
[Pages 49590-49599]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-19331]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AF00


Schedule for Rating Disabilities; the Skin

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

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SUMMARY: This document amends that portion of the Department of 
Veterans Affairs (VA) Schedule for Rating Disabilities that addresses 
the Skin. The intended effect of this action is to update the portion 
of the rating schedule that deals with skin to ensure that it uses 
current medical terminology and unambiguous criteria, and that it 
reflects medical advances that have occurred since the last review.

DATES: Effective Date: This amendment is effective August 30, 2002.

FOR FURTHER INFORMATION CONTACT: Caroll McBrine, M.D., Consultant, 
Policy and Regulations Staff (211B), Compensation and Pension Service, 
Veterans Benefits Administration, Department of Veterans Affairs, 810 
Vermont Avenue NW., Washington, DC 20420, (202) 273-7230.

SUPPLEMENTARY INFORMATION: As part of a comprehensive review of the 
rating schedule, VA published a proposal to amend 38 CFR 4.118, which 
addresses disabilities of the skin, in the Federal Register of January 
19, 1993 (58 FR 4969). Comments were received from the American Legion, 
Paralyzed Veterans of America, Veterans of Foreign Wars, Disabled 
American Veterans, and VA employees.
    One commenter suggested that VA withdraw the proposed regulations 
and reissue them based on more objective standards, and also made 
specific suggestions for changes to many diagnostic codes.
    We do not agree that the proposed regulations should be withdrawn.
    We made the process of revision as open as possible. For example, 
prior to publication of the proposed amendment, we published an advance 
notice of proposed rulemaking in the Federal Register to receive public 
comments about the revision. We also contracted with an outside 
consultant, who convened a panel of non-VA physician specialists in 
skin diseases to make recommendations for revisions of this section of 
the rating schedule. We asked the Veterans Health Administration to 
review our proposed changes. We published the proposed revision only 
after reviewing all of these sources of information. We received 
several other comments on the proposed rule after it was published in 
the Federal Register, but none of the commenters suggested withdrawing 
the proposed revision. In response to comments, we have however, made 
further revisions to some of the criteria for the sake of clarity and 
more objectivity and have added definitions and explanatory notes under 
some conditions. These added changes are discussed in more detail 
below. The same commenter who suggested withdrawing the proposed 
revision also made specific suggestions for changes to many diagnostic 
codes. With the additional changes we have made in the final revision, 
we believe we have made the evaluation criteria for skin conditions 
reasonably clear and objective.
    Under diagnostic code (DC) 7800, disfigurement of the head, face, 
or neck, the former rating schedule provided evaluation levels of 50, 
30, 10, and zero percent based on whether there is repugnant deformity 
of one or both sides of the face, whether the disfigurement is 
``severe,'' producing a marked and unsightly deformity of eyelids, 
lips, or auricles, and on whether the disfigurement is ``moderate'' or 
``slight.'' Following these criteria was a note stating that each level 
could be increased to the next higher evaluation level on the basis of 
marked discoloration or color contrast and that the most repugnant, 
disfiguring conditions, including scars and diseases of the skin, could 
be submitted with photographs for central office rating. The proposed 
amendment added an 80-percent evaluation level and deleted the part of 
the note that provided authority to elevate evaluations in the presence 
of marked discoloration or color contrast based on the rationale that 
these criteria are subject to inconsistent interpretations. The 
proposed evaluation criteria were based at 80 percent on whether 
disfigurement is so disfiguring as to preclude occupational interaction 
with the public, at 50 percent on whether it is repugnant on casual 
inspection, at 30 percent on whether it is disagreeable on casual 
inspection, at 10 percent on whether it is noticeable on casual 
inspection, and at zero percent on whether it is noticeable, but only 
on close inspection.
    One commenter felt that the deleted note should be retained. 
Another commenter, while offering no alternative language for us to 
consider, stated that the words ``repugnant,'' disagreeable,'' and 
``noticeable,'' used to describe degrees of disfigurement, are too 
subjective to be useful and are not

[[Page 49591]]

based on medical criteria. In a similar vein, another commenter said 
that we should establish objective criteria for rating scars that 
should include evaluation of size, configuration, color, etc. One 
commenter felt that the difference between casual and close inspection, 
part of the criteria used to determine disfigurement, is a distinction 
that is difficult to understand.
    In response to these comments, we have further revised the 
evaluation criteria for DC 7800 by basing them on the number of 
objective characteristics of disfigurement that are present and whether 
there is asymmetry or gross distortion of the features. We provided a 
new note following DC 7800 describing the eight specific 
characteristics of disfigurement, for purposes of evaluation under 
Sec. 4.118: Scar 5 or more inches (13 or more cm.) in length; scar at 
least one-quarter inch (0.6 cm.) wide at widest part; surface contour 
of scar elevated or depressed on palpation; scar adherent to underlying 
tissue; skin hypo- or hyper-pigmented in an area exceeding six square 
inches (39 sq. cm.); skin texture abnormal (irregular, atrophic, shiny, 
scaly, etc.) in an area exceeding six square inches (39 sq. cm.); 
underlying soft tissue missing in an area exceeding six square inches 
(39 sq. cm.); and skin indurated and inflexible in an area exceeding 
six square inches (39 sq. cm.). For an 80-percent evaluation, there 
must be visible or palpable tissue loss and either gross distortion or 
asymmetry of three or more features or paired sets of features (nose, 
chin, forehead, eyes (including eyelids), ears (auricles), cheeks, 
lips), or six or more characteristics of disfigurement must be present. 
For a 50-percent evaluation, there must be visible or palpable tissue 
loss and either gross distortion or asymmetry of two features or paired 
sets of features, or four or more characteristics of disfigurement must 
be present. For a 30-percent evaluation, there must be visible or 
palpable tissue loss and either gross distortion or asymmetry of one 
feature or set of paired features, or two or three characteristics of 
disfigurement must be present. For a 10-percent evaluation, one 
characteristic of disfigurement must be present. In our judgment, these 
further revised criteria are sufficiently clear and objective to assure 
that evaluations take into account the most significant characteristics 
of disfigurement and will be consistent from veteran to veteran. We 
have provided two additional notes under DC 7800, one directing the 
rater to rate tissue loss of the auricle under DC 6207 (loss of 
auricle) and anatomical loss of the eye under DC 6061 (anatomical loss 
of both eyes) or DC 6063 (anatomical loss of one eye), as appropriate; 
and the second directing the rater to take into consideration 
unretouched color photographs.
    The former rating schedule designated DC 7801 as ``scars, burns, 
third degree,'' and DC 7802 as ``scars, burns, second degree.'' We 
proposed to revise these codes so that they additionally addressed 
scars from causes other than burns and so that the conditions would be 
evaluated based on actual residual disability, i.e., the size of the 
area of underlying soft tissue damage or limitation of motion, rather 
than on the initial assessment of the severity of a burn. We proposed 
to redesignate DC 7801 as ``scars, other than head, face, or neck, with 
underlying soft tissue damage causing deep contour defect or limited 
motion'' and DC 7802 as ``scars, other than head, face, or neck, that 
are superficial and that do not cause limited motion.'' We proposed 
that under DC 7801 scars with an area or areas exceeding 144 square 
inches (929 sq. cm.) receive a 40-percent evaluation; with area or 
areas exceeding 72 square inches (465 sq. cm.) a 30-percent evaluation; 
with area or areas exceeding 12 square inches (77 sq. cm.) a 20-percent 
evaluation; and with area or areas exceeding 6 square inches (39 sq. 
cm.) a 10-percent evaluation. We proposed that under DC 7802 scars with 
area or areas approximating 144 square inches (929 sq. cm.) receive a 
10-percent evaluation. A commenter felt that historical precedent 
requires continuation of the wording ``third degree'' and ``second 
degree'' under DC's 7801 and 7802, formerly burn scars.
    We disagree. One objective of the rating schedule revision is to 
incorporate medical advances and to delete obsolete concepts and 
conditions. Our consultants, a panel of non-VA physician specialists in 
skin diseases, as well as medical textbooks such as ``Christopher's 
Textbook of Surgery'' 140-41 (Loyal Davis, M.D., ed., 9th ed. 1968), 
indicate that the clinical estimation of the degree of a burn is not 
always accurate and does not necessarily relate to long-term 
disability. The severity of residual scarring from burns of all depths 
varies. Furthermore, burn scars that are not caused by thermal injury, 
but by chemical, electrical, or friction injury, as well as scars 
resulting from non-burn injuries that permanently alter the skin, can 
lead to comparable residuals. For these reasons, a determination of 
disability that is based on the extent of the scarring itself and its 
effects, rather than on the etiology of the scarring, is preferable 
because it will result in wider application of these criteria and 
afford consistency in the evaluation of comparable scarring, whatever 
the etiology. For more clarity and consistency of language, we have, 
however, modified the titles slightly, for better differentiation of 
superficial and deep scars, as discussed below.
    We proposed that DC 7801 (formerly titled ``scars, burns, third 
degree'') be retitled ``scars, other than head, face, or neck, with 
underlying soft tissue damage causing deep contour defect or limited 
motion.'' According to one commenter, the term ``deep contour defect'' 
is confusing. When there is soft tissue damage beneath the skin, in 
addition to scarring of the skin, the overlying scar shows a greater 
anatomical change in contour than when there is skin damage alone. The 
defect that appears in a scarred area when there is underlying soft 
tissue damage is known as a deep contour defect and could also be 
called a deep scar. The lesser change that results in a scarred area 
when there is skin damage alone, without soft tissue damage beneath the 
skin, is known as a superficial contour defect and could also be called 
a superficial scar. A superficial scar may have an irregular surface 
that is either raised or depressed, but the abnormal contour goes no 
deeper than the skin. To make the distinction between the scars to be 
evaluated under DC's 7801 and 7802 clearer, we have removed the term 
``deep contour defect'' and have retitled DC 7801 ``scars, other than 
head, face, or neck, that are deep or that cause limited motion'' and 
retitled DC 7802 ``scars, other than head, face, or neck, that are 
superficial and that do not cause limited motion.'' We have also added 
a definition of deep scar, as one associated with underlying soft 
tissue damage, in a note under DC 7801 and of superficial scar, as one 
not associated with underlying soft tissue damage, in a note under DC 
7802.
    We proposed to retitle DC 7803 (formerly titled ``scars, 
superficial, poorly nourished, with repeated ulceration'') ``scars, 
superficial, unstable with frequent loss of epidermal covering.'' One 
commenter felt that the meaning of ``unstable'' under DC 7803 is 
unclear, and wondered whether this means that the wound is infected or 
unhealed.
    The term ``unstable'' in the title of DC 7803 does not imply a 
specific etiology but only indicates that there is frequent loss of 
covering of the skin over the scar. An unstable scar may result from a

[[Page 49592]]

number of causes, including poor healing or infection. For further 
clarity, we have added a note under DC 7803 defining unstable scar as 
one where, for any reason, there is frequent loss of covering of skin 
over the scar. We have also removed the term ``with frequent loss of 
epidermal covering'' from the title and repeated the definition of 
superficial scar under this code.
    One commenter suggested that we not repeat identical criteria when 
several different conditions are evaluated using the same criteria.
    While it is feasible to use general rating formulas when related 
conditions are listed consecutively, we have repeated criteria under a 
number of diagnostic codes in this section for several reasons. First, 
conditions evaluated under identical criteria in this section are not 
consecutive diagnostic codes. The repetition of criteria will save time 
by eliminating the need to seek the appropriate evaluation criteria, 
lessen the chance of error by eliminating the need to search other 
pages of the rating schedule, and eliminate the ``double references'' 
that are present under some diagnostic codes (where the schedule says 
to see a certain diagnostic code and there is a reference under that 
diagnostic code to see yet another diagnostic code). Additionally, 
while rating specialists may readily locate the appropriate rating 
criteria, others who use the schedule may find it more difficult. While 
eliminating the repetition of criteria would save space, we believe 
that the advantages gained favor their repetition in this case. Where a 
general rating formula applies to several diagnostic codes that are 
listed consecutively, the proximity of the conditions and the rating 
formula eliminates most of the potential problems discussed above.
    In the former schedule, DC 7806 (dermatitis or eczema) was 
evaluated at levels of 50, 30, 10, or zero percent. The criteria called 
for a 50-percent evaluation for ulceration or extensive exfoliation or 
crusting, with systemic or nervous manifestations, or being 
exceptionally repugnant; a 30-percent evaluation for constant exudation 
or itching, with extensive lesions, or with marked disfigurement; a 10-
percent evaluation for exfoliation, exudation or itching, if involving 
an exposed surface or extensive area; and a zero-percent evaluation for 
slight, if any, exfoliation, exudation or itching, if on a nonexposed 
surface or small area. DC's 7809 (discoid lupus erythematosus), 7815 
(bullous disorders), 7816 (psoriasis), and 7817 (exfoliative 
dermatitis) did not include specific evaluation criteria, but were 
ordinarily rated as analogous conditions, using the same criteria as 
for DC 7806. We proposed to evaluate all five of these conditions, plus 
four new conditions-cutaneous manifestations of collagen-vascular 
diseases not listed elsewhere (DC 7821), papulosquamous disorders not 
listed elsewhere (DC 7822), vitiligo (DC 7823), and diseases of 
keratinization (DC 7824)--under identical criteria, with evaluation 
levels of 100, 50, 30, 10, and zero percent. We proposed a 100-percent 
evaluation for generalized scaling, crusting, systemic manifestations, 
pruritus and for being so disfiguring as to preclude interaction with 
the public; a 50-percent evaluation for ulceration or extensive 
exfoliation or crusting, and systemic manifestations, or being so 
disfiguring as to be repugnant on casual inspection; a 30-percent 
evaluation for exudation or constant itching, or extensive lesions, or 
being so disfiguring as to be disagreeable on casual inspection; a 10-
percent evaluation for exfoliation, exudation, or itching, if involving 
an exposed surface or extensive area; and a zero-percent evaluation for 
minimal exfoliation, exudation or itching, if on a nonexposed surface 
or small area. We proposed to evaluate a second group of skin 
disorders-disfigurement of the head, face, or neck (DC 7800), acne (DC 
7828), chloracne (DC 7829), scarring alopecia (DC 7830), and alopecia 
areata (DC 7831)--solely on the basis of disfigurement, as described 
above under the discussion of DC 7800, and made 80 percent the maximum 
evaluation for this group based on disfigurement that precludes 
occupational interaction with the public. There were several comments 
regarding similarities between the proposed criteria for a 100-percent 
evaluation for the first group (DC 7806 and conditions rated under the 
same criteria) and the criterion for an 80-percent evaluation for the 
second group (DC 7800 and conditions rated under the same criteria).
    One commenter objected to the fact that when interaction with the 
public is precluded, one group of skin conditions may be assigned an 
evaluation of 100 percent and another group may be assigned no more 
than 80 percent. Another commenter suggested that we add an 
intermediate evaluation level between 50 and 100 percent for the skin 
conditions for which we proposed evaluation levels of 100, 50, 30, 10, 
and zero percent. An evaluation of 60 percent or more for a single 
disability would allow a veteran to advance a claim under 38 CFR 
4.16(a), which allows a claim for individual unemployability in cases 
where there is a service-connected disability rating that is less than 
total but which renders an individual unable to secure or follow a 
substantially gainful occupation.
    In response to these comments, and because the more specific 
criteria we have provided for DC 7800 are not as readily applicable to 
other skin conditions as those we proposed, we have further revised the 
criteria for DC's 7806, 7809, 7815, 7816, 7817, 7821, 7822, 7823, and 
7824. We have removed the proposed criteria, which were the same for 
all these conditions and have provided criteria that are more objective 
and more specific for each condition.
    For dermatitis or eczema, DC 7806, instead of the proposed 
evaluation levels of 100, 50, 30, 10, and zero percent based on the 
presence of scaling, crusting, whether there are systemic 
manifestations, itching, exudation, exfoliation, etc., or, 
alternatively, on the extent of disfigurement, we have now provided 
evaluation levels of 60, 30, 10, and zero percent, as the commenter 
suggested. As part of the more condition-specific criteria we have 
provided, we have also removed the 100-percent evaluation level because 
dermatitis is rarely totally disabling. However, since a 60-percent 
evaluation level may now be assigned, a claim for individual 
unemployability, when appropriate, is feasible under 38 CFR 4.16 (a) 
for those individuals unable to secure or follow a substantially 
gainful occupation as a result of service-connected skin disease. The 
criteria are based on the extent (in percentage) to which the entire 
body or exposed areas are affected by the condition or on the treatment 
required. For a 60-percent evaluation for dermatitis, more than 40 
percent of the entire body or more than 40 percent of exposed areas 
must be affected, or constant or near-constant systemic therapy such as 
corticosteroids or other immunosuppressive drugs is required. For a 30-
percent evaluation, 20 to 40 percent of the entire body or 20 to 40 
percent of exposed areas must be affected, or systemic therapy for a 
total duration of six weeks or more, but not constantly, during the 
past 12-month period is required. For a 10-percent evaluation, at least 
5 percent, but less than 20 percent, of the entire body, or at least 5 
percent, but less than 20 percent, of exposed areas must be affected, 
or intermittent systemic therapy for a total duration of less than six 
weeks during the past 12-month period is required. For a zero-percent 
evaluation, less than 5 percent of the entire body or less than 5 
percent of exposed areas must be affected, with no more than topical 
therapy required during the past 12-month period. We

[[Page 49593]]

also added an alternative direction to rate as disfigurement of the 
head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 
7805), depending upon the predominant disability. This will provide an 
alternative means of evaluation in cases, for example, where the active 
disease has been controlled but there are significant residuals, such 
as scarring. These criteria are much more objective than the proposed 
criteria and will assure more consistent evaluations.
    We had proposed criteria identical to those for DC 7806 for DC's 
7815 (Bullous disorders (including pemphigus vulgaris, pemphigus 
foliaceous, bullous pemphigoid, dermatitis herpetiformis, epidermolysis 
bullosa acquisita, benign chronic familial pemphigus (Hailey-Hailey), 
and porphyria cutanea tarda)); 7816 (Psoriasis); 7821 (Cutaneous 
manifestations of collagen-vascular diseases not listed elsewhere 
(including scleroderma, calcinosis cutis, and dermatomyositis)); and 
7822 (Papulosquamous disorders not listed elsewhere (including lichen 
planus, large or small plaque parapsoriasis, pityriasis lichenoides et 
varioliformis acuta (PLEVA), lymphomatoid papulosus, and pityriasis 
rubra pilaris (PRP))). The further revised evaluation criteria we have 
provided for DC 7806 remain appropriate for those four conditions, and 
we have provided identical criteria under each diagnostic code.
    We also proposed to provide evaluation criteria identical to those 
for DC 7806 for the evaluation of DC's 7809 (Discoid lupus 
erythematosus or subacute cutaneous lupus erythematosus), 7817 
(Exfoliative dermatitis (erythroderma)), 7823 (Vitiligo), and 7824 
(Diseases of keratinization). However, the proposed criteria were not 
specific enough to these conditions to assure consistent evaluations, 
and the revised criteria for DC 7806 are also not appropriate for their 
evaluation. We have therefore provided more disease-specific evaluation 
criteria for these conditions, and also revised the evaluation levels 
in order to make them appropriate for the usual range of severity of 
each individual condition. The evaluation criteria for each of these 
conditions is discussed in more detail below.
    Discoid lupus erythematosus (DC 7809) can present in a number of 
different ways (scaling, plaques, atrophy, erythema, scars, etc.), and 
we have therefore directed that it be rated as disfigurement (DC 7800), 
scars (DC's 7801, 7802, 7803, 7804, or 7805), or dermatitis (DC 7806), 
depending upon the predominant disability.
    Exfoliative dermatitis (DC 7817) is a disease that may be very 
severe, and its treatment is different from that of most other skin 
conditions. It may require the use of corticosteroids, 
immunosuppressive retinoids, PUVA (psoralen with long-wave ultraviolet-
A light) or UVB (ultraviolet-B light) treatments, or electron beam 
therapy. It may also be associated with systemic manifestations, such 
as fever, weight loss, and hypoproteinemia (low level of protein in the 
blood, often associated with edema). We have provided evaluation levels 
of 100, 60, 30, 10, and zero percent for this condition, based on the 
extent of involvement of the skin, whether there are also systemic 
manifestations, and the type and duration of treatment. For a 100-
percent evaluation, generalized involvement of the skin, plus systemic 
manifestations (such as fever, weight loss, and hypoproteinemia) must 
be present, and constant or near-constant systemic therapy such as 
therapeutic doses of corticosteroids, immunosuppressive retinoids, PUVA 
(psoralen with long-wave ultraviolet-A light) or UVB (ultraviolet-B 
light) treatments, or electron beam therapy during the past 12-month 
period is required. For a 60-percent evaluation, generalized 
involvement of the skin without systemic manifestations must be 
present, and constant or near-constant systemic therapy during the past 
12-month period is required. For a 30-percent evaluation, there can be 
any extent of involvement of the skin, and systemic therapy for a total 
duration of six weeks or more, but not constantly, during the past 12-
month period is required. For a 10-percent evaluation, there can be any 
extent of involvement of the skin, and systemic therapy for a total 
duration of less than six weeks during the past 12-month period is 
required. For a zero-percent evaluation, there can be any extent of 
involvement of the skin with no more than topical therapy required 
during the past 12-month period. These criteria are specific to this 
condition and are more objective than the proposed criteria.
    We proposed to evaluate vitiligo (DC 7823) under the same 
evaluation criteria as those we proposed for DC 7806 (dermatitis or 
eczema). Vitiligo is a condition in which the only abnormal finding is 
hypopigmented skin; the only treatment for it is cosmetic. The proposed 
criteria, however, included findings such as ulceration, itching, 
crusting, exfoliation, and systemic manifestations, none of which is 
specific to, or even occurs in, vitiligo. It is unlikely that an 
evaluation higher than zero percent could have been assigned for 
vitiligo using those criteria. Disfigurement was another of the 
proposed criteria under DC 7806. Of the characteristics of 
disfigurement described under DC 7800, only one--hypopigmentation--is 
present in vitiligo, and that is its only disabling effect. For one 
characteristic of disfigurement of the head, face, or neck under DC 
7800, a 10-percent evaluation is assigned. We have therefore provided 
evaluation levels for vitiligo of ten and zero percent, providing ten 
percent if exposed areas are affected, and zero percent if they are 
not. These criteria will assure consistent evaluations for vitiligo, 
and they are internally consistent with the evaluations for 
disfigurement of the head, face, or neck, where the maximum evaluation 
based on the presence of hypopigmentation alone is 10 percent.
    We also proposed to evaluate DC 7824, diseases of keratinization 
(including icthyoses, Darier's disease, and palmoplantar keratoderma) 
under the same evaluation criteria as those we proposed for DC 7806 
(dermatitis or eczema). The further revised criteria for DC 7806 are 
not entirely appropriate for evaluating diseases of keratinization. We 
have therefore provided evaluation levels of 60, 30, 10, and zero 
percent for diseases of keratinization, based on requirements for 
therapy, the extent of cutaneous involvement, whether there are 
systemic manifestations, and whether the skin involvement is constant 
or episodic. A 60-percent evaluation requires either generalized 
cutaneous involvement or systemic manifestations and constant or near-
constant systemic medication, such as immunosuppressive retinoids, 
during the past 12-month period. A 30-percent evaluation requires 
either generalized cutaneous involvement or systemic manifestations and 
intermittent systemic medication, such as immunosuppressive retinoids, 
for a total duration of six weeks or more, but not constantly, during 
the past 12-month period. A 10-percent evaluation requires localized or 
episodic cutaneous involvement and intermittent systemic medication, 
such as immunosuppressive retinoids, for a total duration of less than 
six weeks during the past 12-month period. A zero-percent evaluation is 
assigned if no more than topical therapy was required during the past 
12-month period. These criteria are more appropriate for the evaluation 
of diseases of keratinization. In addition, we have added to the title 
some of the specific diseases that make

[[Page 49594]]

up the category of diseases of keratinization-icthyoses, Darier's 
disease, and palmoplantar keratoderma.
    Under the former schedule, leishmaniasis, both American (DC 7807) 
and Old World (DC 7808), were ordinarily evaluated under the same 
criteria as DC 7806 (eczema). We proposed to evaluate leishmaniasis as 
disfigurement, scars, or dermatitis, depending upon the predominant 
disability. One commenter suggested that we include evaluation criteria 
for systemic manifestations of the disease under these codes. In our 
judgment, there is no need to include criteria for the systemic forms 
of leishmaniasis here, because evaluation criteria for visceral 
leishmaniasis are provided under DC 6301, in the section of the rating 
schedule on infectious diseases, immune disorders and nutritional 
deficiencies (38 CFR 4.88b). However, as a reminder to rating 
specialists, we have added a note under each of these codes directing 
that non-cutaneous (visceral) leishmaniasis be evaluated under DC 6301 
(visceral leishmaniasis).
    In the former schedule and in the proposed rule, DC 7811 
(tuberculosis luposa (lupus vulgaris), active or inactive) was directed 
to be rated under Secs. 4.88b or 4.89. Section 4.88b was redesignated 
Sec. 4.88c in a separate rulemaking, so we have corrected the reference 
under DC 7811 to codes to be used for the evaluation of tuberculosis of 
the skin to Secs. 4.88c and 4.89.
    Malignant neoplasms of the skin (DC 7818) were evaluated on scars, 
disfigurement, etc., on the extent of constitutional symptoms, and on 
physical impairment, in the former schedule. We proposed to evaluate 
based on impairment of function, disfigurement, or scars. One commenter 
stated that these criteria are inadequate for malignant melanoma 
because the condition is potentially lethal.
    On further consideration, we have added a separate diagnostic code, 
7833, to the rating schedule for malignant melanoma of the skin because 
it is a common malignancy and often behaves differently, particularly 
more aggressively, than other skin malignancies. All residuals that 
might occur from any skin malignancy can be evaluated under the 
proposed criteria for malignant neoplasms of the skin because 
``impairment of function'' covers virtually any disability that might 
result, and we propose to provide the same evaluation criteria for 
malignant melanoma as for other skin malignancies. However, malignant 
melanoma, and at times other malignancies of the skin, may require a 
level of antineoplastic treatment that is similar to that used for 
internal malignancies. We have therefore added a note under DC's 7818 
and 7833 stating that if a skin malignancy requires therapy that is 
comparable to that used for internal malignancies, i.e., systemic 
chemotherapy, X-ray therapy more extensive than to the skin, or surgery 
more extensive than wide local excision, a 100-percent evaluation will 
be assigned from the date of onset of treatment, and will continue, 
with a mandatory VA examination six months following the completion of 
such antineoplastic treatment, and any change in evaluation based upon 
that or any subsequent examination subject to the provisions of 38 CFR 
3.105(e). Those provisions require a 60-day notice before VA reduces an 
evaluation and an additional 60-day notice before the reduced 
evaluation takes effect. The revision requires a current examination to 
assure that all residuals are documented, and also offers the veteran 
more contemporaneous notice of any proposed action and expands the 
veteran's opportunity to present evidence showing that the proposed 
action should not be taken. If there has been no local recurrence or 
metastasis, evaluation will then be made on residuals. This will assure 
that the evaluation of these neoplasms, when they require treatment 
that is comparable to the treatment of internal malignancies, is 
commensurate with that type of treatment and is consistent with the 
method of evaluating malignancies in other systems. If treatment is 
confined to the skin, the provisions for a 100-percent evaluation do 
not apply. Since we have provided a separate diagnostic code for 
malignant melanoma, we added to the title of malignant skin neoplasms 
(DC 7818) for clarity, ``other than malignant melanoma.''
    We proposed to add urticaria to the rating schedule as DC 7825, 
with evaluation levels of 40, 20, and zero percent. We proposed to call 
for a 40-percent evaluation if there is either a need for regular 
immunosuppressive therapy or the presence of uncontrollable episodes 
despite therapy; a 20-percent evaluation if there is a need for 
frequent immunosuppressive therapy; and a zero-percent evaluation if 
the condition is occasional or asymptomatic. We received two comments 
about these criteria. One commenter said that urticaria should be 
evaluated at 60 percent if it is uncontrollable despite any therapy, 
and at 50 percent if it requires frequent treatment. The other said 
that urticaria should be evaluated higher than 40 percent if it is 
uncontrolled by systemic immunosuppressive therapy and that we should 
replace the words ``frequent,'' ``regular,'' and ``occasional'' with 
more objective criteria.
    We agree that a higher level of evaluation is warranted and have 
therefore added a 60-percent evaluation level for urticaria when there 
are at least four debilitating episodes during the past 12-month period 
despite continuous immunosuppressive therapy. In conjunction with this 
change, we made the next lower evaluation level 30 percent instead of 
40 percent, and based it on debilitating episodes occurring at least 
four times during the past 12-month period but requiring only 
intermittent systemic immunosuppressive therapy for control, and made 
the level below that 10 percent instead of 20 percent, and based it on 
recurrent episodes occurring at least four times during the past 12-
month period and that respond to treatment with antihistamines or 
sympathomimetics. These evaluation levels are consistent with the 
ranges for other skin diseases, and these criteria respond to the 
comments by providing a higher evaluation level for the most severe 
cases of urticaria, and by providing more objective criteria. The more 
objective criteria will assure more consistent evaluations.
    We proposed to add primary cutaneous vasculitis as DC 7826, to be 
evaluated on the basis of disfigurement, scars, or urticaria, depending 
upon the predominant disability. Because the revised evaluation 
criteria for disfigurement (DC 7800) and urticaria (DC 7825) are more 
specific to those conditions than the proposed criteria were, they are 
less appropriate for the evaluation of primary cutaneous vasculitis, 
which is a chronic, but episodic, condition. We have therefore provided 
a separate set of more objective criteria with evaluation levels of 60, 
30, and 10 percent for primary cutaneous vasculitis, based on the 
frequency of debilitating episodes and the type and frequency of 
treatment. A 60-percent evaluation calls for recurrent debilitating 
episodes occurring at least four times during the past 12-month period 
despite continuous immunosuppressive therapy; a 30-percent evaluation 
calls for recurrent debilitating episodes occurring at least four times 
during the past 12-month period and requiring intermittent systemic 
immunosuppressive therapy for control; and a ten-percent evaluation 
calls for recurrent episodes occurring one to three times during the 
past 12-month period and requiring intermittent systemic 
immunosuppressive therapy

[[Page 49595]]

for control. These criteria are more specific to this condition and 
will result in more consistent evaluations. We have also provided an 
alternative direction to rate as disfigurement of the head, face, or 
neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), 
depending upon the predominant disability. These are consistent with 
the criteria recommended by our consultants.
    Similarly, we proposed to add erythema multiforme (toxic epidermal 
necrolysis) as DC 7827, with evaluation based on disfigurement, scars, 
or urticaria, depending upon the predominant disability. Because the 
revised evaluation criteria for disfigurement (DC 7800) and urticaria 
(DC 7825) are more specific to those conditions than the proposed 
criteria were, they are less appropriate for the evaluation of erythema 
multiforme. We have therefore provided a separate set of more objective 
criteria for erythema multiforme, which is an episodic condition, with 
levels of 60, 30, and 10 percent, based on the frequency of 
debilitating episodes and the type and frequency of treatment. A 60-
percent evaluation calls for recurrent debilitating episodes at least 
four times during the past 12-month period despite ongoing 
immunosuppressive therapy; a 30-percent evaluation calls for recurrent 
debilitating episodes at least four times during the past 12-month 
period despite ongoing immunosuppressive therapy; and a ten-percent 
evaluation calls for recurrent episodes that respond to treatment with 
antihistamines or sympathomimetics. We also provided an alternative 
direction to rate as disfigurement of the head, face, or neck (DC 7800) 
or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending upon the 
predominant disability. These criteria are identical to the criteria 
for DC 7826, since both conditions are episodic and require similar 
treatment, and they are consistent with the criteria recommended by our 
consultants.
    We proposed that acne (DC 7828) and chloracne (DC 7829), which have 
similar manifestations, be evaluated under the same criteria as DC 7800 
(disfigurement of the head, face, or neck). One commenter suggested 
that acne on nonexposed areas may warrant a compensable evaluation if 
there are extensive painful cysts. The proposed criteria did not 
provide for a compensable evaluation for such manifestations.
    We agree that acne involving nonexposed areas may be disabling, 
more because of the inflammatory aspects than the disfiguring aspects. 
We have therefore established evaluation criteria for acne and 
chloracne that are based on the extent of involvement by acne, its 
location, and whether it is deep or superficial. We have provided a 30-
percent evaluation for deep acne (meaning deep inflamed nodules and 
pus-filled cysts) affecting 40 percent or more of the face and neck; a 
10-percent evaluation for deep acne affecting less than 40 percent of 
the face and neck, or deep acne other than on the face and neck; and a 
zero-percent evaluation for superficial acne (comedones, papules, 
pustules, superficial cysts) of any extent. We have provided an 
alternative direction to rate acne and chloracne as disfigurement of 
the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 
7804, or 7805), depending upon the predominant disability. This change 
will allow more leeway in assessing which type of disability best 
represents the findings in a particular case of acne or chloracne.
    We proposed to evaluate scarring alopecia (DC 7830) and alopecia 
areata (DC 7831) on the basis of disfigurement. One commenter suggested 
that the criteria for DC's 7830 and 7831 take into account the ability 
or inability to improve appearance with a hairpiece or wig. We have 
reconsidered the criteria for these types of alopecia in view of our 
changed disfigurement criteria, which are not appropriate for these 
conditions, and have provided evaluation criteria based instead on the 
extent of involvement by alopecia. We have provided evaluation levels 
of 20, 10, and zero percent for scarring alopecia and ten and zero 
percent for alopecia areata. These levels are commensurate with the 
range of disability these conditions produce, according to our contract 
consultant specialists, who reviewed the rating schedule and made 
recommendations for changes to help fulfill the goals of revising and 
updating the medical criteria. For scarring alopecia, which usually 
follows injury, infection, burns, etc., and shows tissue loss and 
scarring, we have provided a 20-percent evaluation if the condition 
affects more than 40 percent of the scalp; a 10-percent evaluation if 
it affects 20 to 40 percent of the scalp; and a zero-percent evaluation 
if it affects less than 20 percent of the scalp. For alopecia areata, 
where scarring and atrophic changes are not present, we have provided a 
10-percent evaluation for generalized involvement of the body, and a 
zero-percent evaluation if the condition is limited to the scalp and 
face. These criteria are clear and objective and will assure 
consistency in evaluation. They do not take into account the potential 
improvement of appearance with a hairpiece or wig, which would require 
a subjective assessment, but are based instead on the objectively 
determinable effects of the condition and are consistent with the 
recommendations of our consultants.
    We edited the language of the note regarding under painful 
superficial scars (DC 7804) for clarity, and the notes under DC's 7801 
and 7802 regarding scars in widely separated areas for the same reason, 
but these are not substantive changes.
    For more clarity and objectivity, we have revised the language in 
DC 7802 from ``area or areas approximating 144 square inches (929 sq. 
cm.)'' to ``area or areas of 144 square inches (929 sq. cm.) or 
greater.'' We revised the title of DC 7813, Dermatophytosis, to include 
``(ringworm: of body, tinea corporis; of head, tinea capitis; of feet, 
tinea pedis; of beard area, tinea barbae; of nails, tinea unguium; of 
inguinal area (jock itch), tinea cruris)'' to clarify what is included.
    VA appreciates the comments submitted in response to the proposed 
rule, which is now adopted with the amendments noted above.

Unfunded Mandates

    The Unfunded Mandates Reform Act requires, at 2 U.S.C. 1532, that 
agencies prepare an assessment of anticipated costs and benefits before 
developing any rule that may result in an expenditure by State, local, 
or tribal governments, in the aggregate, or by the private sector of 
$100 million or more in any given year. This rule would have no 
consequential effect on State, local or tribal governments.

Paperwork Reduction Act

    This document contains no provisions constituting a collection of 
information under the Paperwork Reduction Act (44 U.S.C. 3501-3520).

Regulatory Flexibility Act

    The Secretary hereby certifies that this regulatory amendment will 
not have a significant economic impact on a substantial number of small 
entities as they are defined in the Regulatory Flexibility Act (RFA), 5 
U.S.C. 601-612. The reason for this certification is that this 
amendment would not directly affect any small entities. Only VA 
beneficiaries could be directly affected. Therefore, pursuant to 5 
U.S.C. 605(b), this amendment is exempt from the initial and final 
regulatory flexibility analysis requirements of sections 603 and 604.

Executive Order 12866

    This regulatory amendment has been reviewed by the Office of 
Management

[[Page 49596]]

and Budget under the provisions of Executive Order 12866, Regulatory 
Planning and Review, dated September 30, 1993.

    The Catalog of Federal Domestic Assistance program numbers are 
64.104 and 64.109.

List of Subjects in 38 CFR Part 4

    Disability benefits, Individuals with disabilities, Pensions, 
Veterans.

    Approved: May 17, 2002.
Anthony J. Principi,
Secretary of Veterans Affairs.


    For the reasons set out in the preamble, 38 CFR part 4, subpart B, 
is amended as set forth below:

PART 4--SCHEDULE FOR RATING DISABILITIES

    1. The authority citation for part 4 continues to read as follows:

    Authority: 38 U.S.C. 1155, unless otherwise noted.

Subpart B--Disability Ratings

    2. Section 4.118 is revised to read as follows:


Sec. 4.118  Schedule of ratings--skin.

------------------------------------------------------------------------
                                                                Rating
------------------------------------------------------------------------
7800  Disfigurement of the head, face, or neck:
    With visible or palpable tissue loss and either gross             80
     distortion or asymmetry of three or more features or
     paired sets of features (nose, chin, forehead, eyes
     (including eyelids), ears (auricles), cheeks, lips),
     or; with six or more characteristics of disfigurement.
    With visible or palpable tissue loss and either gross             50
     distortion or asymmetry of two features or paired sets
     of features (nose, chin, forehead, eyes (including
     eyelids), ears (auricles), cheeks, lips), or; with
     four or five characteristics of disfigurement.........
    With visible or palpable tissue loss and either gross             30
     distortion or asymmetry of one feature or paired set
     of features (nose, chin, forehead, eyes (including
     eyelids), ears (auricles), cheeks, lips), or; with two
     or three characteristics of disfigurement.............
    With one characteristic of disfigurement...............           10
    Note (1):The 8 characteristics of disfigurement, for
     purposes of evaluation under Sec.  4.118, are:
    Scar 5 or more inches (13 or more cm.) in length.
    Scar at least one-quarter inch (0.6 cm.) wide at widest
     part.
    Surface contour of scar elevated or depressed on
     palpation.
    Scar adherent to underlying tissue.
    Skin hypo-or hyper-pigmented in an area exceeding six
     square inches (39 sq. cm.).
    Skin texture abnormal (irregular, atrophic, shiny,
     scaly, etc.) in an area exceeding six square inches
     (39 sq. cm.).
    Underlying soft tissue missing in an area exceeding six
     square inches (39 sq. cm.).
    Skin indurated and inflexible in an area exceeding six
     square inches (39 sq. cm.).
    Note (2): Rate tissue loss of the auricle under DC 6207
     (loss of auricle) and anatomical loss of the eye under
     DC 6061 (anatomical loss of both eyes) or DC 6063
     (anatomical loss of one eye), as appropriate.
    Note (3): Take into consideration unretouched color
     photographs when evaluating under these criteria.
7801  Scars, other than head, face, or neck, that are deep
 or that cause limited motion:
    Area or areas exceeding 144 square inches (929 sq.cm.).           40
    Area or areas exceeding 72 square inches (465 sq. cm.).           30
    Area or areas exceeding 12 square inches (77 sq. cm.)..           20
    Area or areas exceeding 6 square inches (39 sq. cm.)...           10
    Note (1): Scars in widely separated areas, as on two or
     more extremities or on anterior and posterior surfaces
     of extremities or trunk, will be separately rated and
     combined in accordance with Sec.  4.25 of this part.
    Note (2): A deep scar is one associated with underlying
     soft tissue damage.
7802  Scars, other than head, face, or neck, that are                 10
 superficial and that do not cause limited motion: Area or
 areas of 144 square inches (929 sq. cm.) or greater.......
    Note (1): Scars in widely separated areas, as on two or
     more extremities or on anterior and posterior surfaces
     of extremities or trunk, will be separately rated and
     combined in accordance with Sec.  4.25 of this part.
    Note (2): A superficial scar is one not associated with
     underlying soft tissue damage.
7803  Scars, superficial, unstable.........................           10
    Note (1): An unstable scar is one where, for any
     reason, there is frequent loss of covering of skin
     over the scar.
    Note (2): A superficial scar is one not associated with
     underlying soft tissue damage.
7804  Scars, superficial, painful on examination...........           10
    Note (1): A superficial scar is one not associated with
     underlying soft tissue damage.
    Note (2): In this case, a 10-percent evaluation will be
     assigned for a scar on the tip of a finger or toe even
     though amputation of the part would not warrant a
     compensable evaluation.
    (See Sec.  4.68 of this part on the amputation rule.)
7805  Scars, other; Rate on limitation of function of
 affected part.
7806  Dermatitis or eczema.
    More than 40 percent of the entire body or more than 40           60
     percent 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..................................
    20 to 40 percent of the entire body or 20 to 40 percent           30
     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...
    At least 5 percent, but less than 20 percent, of the              10
     entire body, or at least 5 percent, but less than 20
     percent, of exposed areas affected, or; intermittent
     systemic therapy such as corticosteroids or other
     immunosuppressive drugs required for a total duration
     of less than six weeks during the past 12-month period
    Less than 5 percent of the entire body or less than 5              0
     percent of exposed areas affected, and; no more than
     topical therapy required during the past 12-month
     period................................................
    Or rate as disfigurement of the head, face, or neck (DC
     7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805),
     depending upon the predominant disability.
7807  American (New World) leishmaniasis (mucocutaneous,
 espundia): Rate as disfigurement of the head, face, or
 neck (DC 7800), scars (DC's 7801, 7802, 7803, 7804, or
 7805), or dermatitis (DC 7806), depending upon the
 predominant disability.

[[Page 49597]]

 
    Note: Evaluate non-cutaneous (visceral) leishmaniasis
     under DC 6301 (visceral leishmaniasis).
7808  Old World leishmaniasis (cutaneous, Oriental sore):
 Rate as disfigurement of the head, face, or neck (DC
 7800), scars (DC's 7801, 7802, 7803, 7804, or 7805), or
 dermatitis (DC 7806), depending upon the predominant
 disability.
    Note: Evaluate non-cutaneous (visceral) leishmaniasis
     under DC 6301 (visceral leishmaniasis).
7809  Discoid lupus erythematosus or subacute cutaneous
 lupus erythematosus: Rate as disfigurement of the head,
 face, or neck (DC 7800), scars (DC's 7801, 7802, 7803,
 7804, or 7805), or dermatitis (DC 7806), depending upon
 the predominant disability. Do not combine with ratings
 under DC 6350.
7811  Tuberculosis luposa (lupus vulgaris), active or
 inactive: Rate under Secs.  4.88c or 4.89, whichever is
 appropriate.
7813  Dermatophytosis (ringworm: of body, tinea corporis;
 of head, tinea capitis; of feet, tinea pedis; of beard
 area, tinea barbae; of nails, tinea unguium; of inguinal
 area (jock itch), tinea cruris): Rate as disfigurement of
 the head, face, or neck (DC 7800), scars (DC's 7801, 7802,
 7803, 7804, or 7805), or dermatitis (DC 7806), depending
 upon the predominant disability.
7815  Bullous disorders (including pemphigus vulgaris,
 pemphigus foliaceous, bullous pemphigoid, dermatitis
 herpetiformis, epidermolysis bullosa acquisita, benign
 chronic familial pemphigus (Hailey-Hailey), and porphyria
 cutanea tarda):
    More than 40 percent of the entire body or more than 40           60
     percent 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..................................
    20 to 40 percent of the entire body or 20 to 40 percent           30
     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...
    At least 5 percent, but less than 20 percent, of the              10
     entire body, or at least 5 percent, but less than 20
     percent, of exposed areas affected, or; intermittent
     systemic therapy such as corticosteroids or other
     immunosuppressive drugs required for a total duration
     of less than six weeks during the past 12-month period
    Less than 5 percent of the entire body or exposed areas            0
     affected, and; no more than topical therapy required
     during the past 12-month period.......................
    Or rate as disfigurement of the head, face, or neck (DC
     7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805),
     depending upon the predominant disability.
7816  Psoriasis:
    More than 40 percent of the entire body or more than 40           60
     percent 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..................................
    20 to 40 percent of the entire body or 20 to 40 percent           30
     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...
    At least 5 percent, but less than 20 percent, of the              10
     entire body, or at least 5 percent, but less than 20
     percent, of exposed areas affected, or; intermittent
     systemic therapy such as corticosteroids or other
     immunosuppressive drugs required for a total duration
     of less than six weeks during the past 12-month period
    Less than 5 percent of the entire body or exposed areas            0
     affected, and; no more than topical therapy required
     during the past 12-month period.......................
    Or rate as disfigurement of the head, face, or neck (DC
     7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805),
     depending upon the predominant disability.
7817  Exfoliative dermatitis (erythroderma):
    Generalized involvement of the skin, plus systemic               100
     manifestations (such as fever, weight loss, and
     hypoproteinemia), and; constant or near-constant
     systemic therapy such as therapeutic doses of
     corticosteroids, immunosuppressive retinoids, PUVA
     (psoralen with long-wave ultraviolet-A light) or UVB
     (ultraviolet-B light) treatments, or electron beam
     therapy required during the past 12-month period......
    Generalized involvement of the skin without systemic              60
     manifestations, and; constant or near-constant
     systemic therapy such as therapeutic doses of
     corticosteroids, immunosuppressive retinoids, PUVA
     (psoralen with long-wave ultraviolet-A light) or UVB
     (ultraviolet-B light) treatments, or electron beam
     therapy required during the past 12-month period......
    Any extent of involvement of the skin, and; systemic              30
     therapy such as therapeutic doses of corticosteroids,
     immunosuppressive retinoids, PUVA (psoralen with long-
     wave ultraviolet-A light) or UVB (ultraviolet-B light)
     treatments, or electron beam therapy required for a
     total duration of six weeks or more, but not
     constantly, during the past 12-month period...........
    Any extent of involvement of the skin, and; systemic              10
     therapy such as therapeutic doses of corticosteroids,
     immunosuppressive retinoids, PUVA (psoralen with long-
     wave ultraviolet-A light) or UVB (ultraviolet-B light)
     treatments, or electron beam therapy required for a
     total duration of less than six weeks during the past
     12-month period.......................................
    Any extent of involvement of the skin, and; no more                0
     than topical therapy required during the past 12-month
     period................................................
7818  Malignant skin neoplasms (other than malignant
 melanoma): Rate as disfigurement of the head, face, or
 neck (DC 7800), scars (DC's 7801, 7802, 7803, 7804, or
 7805), or impairment of function.
    Note: If a skin malignancy requires therapy that is
     comparable to that used for systemic malignancies,
     i.e., systemic chemotherapy, X-ray therapy more
     extensive than to the skin, or surgery more extensive
     than wide local excision, a 100-percent evaluation
     will be assigned from the date of onset of treatment,
     and will continue, with a mandatory VA examination six
     months following the completion of such antineoplastic
     treatment, and any change in evaluation based upon
     that or any subsequent examination will be subject to
     the provisions of Sec.  3.105(e) of this chapter. If
     there has been no local recurrence or metastasis,
     evaluation will then be made on residuals. If
     treatment is confined to the skin, the provisions for
     a 100-percent evaluation do not apply.
7819  Benign skin neoplasms: Rate as disfigurement of the
 head, face, or neck (DC 7800), scars (DC's 7801, 7802,
 7803, 7804, or 7805), or impairment of function.
7820  Infections of the skin not listed elsewhere
 (including bacterial, fungal, viral, treponemal and
 parasitic diseases): Rate as disfigurement of the head,
 face, or neck (DC 7800), scars (DC's 7801, 7802, 7803,
 7804, or 7805), or dermatitis (DC 7806), depending upon
 the predominant disability.
7821  Cutaneous manifestations of collagen-vascular
 diseases not listed elsewhere (including scleroderma,
 calcinosis cutis, and dermatomyositis):
    More than 40 percent of the entire body or more than 40           60
     percent 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..................................
    20 to 40 percent of the entire body or 20 to 40 percent           30
     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...

[[Page 49598]]

 
    At least 5 percent, but less than 20 percent, of the              10
     entire body, or at least 5 percent, but less than 20
     percent, of exposed areas affected, or; intermittent
     systemic therapy such as corticosteroids or other
     immunosuppressive drugs required for a total duration
     of less than six weeks during the past 12-month period
    Less than 5 percent of the entire body or exposed areas            0
     affected, and; no more than topical therapy required
     during the past 12-month period.......................
    Or rate as disfigurement of the head, face, or neck (DC
     7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805),
     depending upon the predominant disability.
7822  Papulosquamous disorders not listed elsewhere
 (including lichen planus, large or small plaque
 parapsoriasis, pityriasis lichenoides et varioliformis
 acuta (PLEVA), lymphomatoid papulosus, and pityriasis
 rubra pilaris (PRP)):
    More than 40 percent of the entire body or more than 40           60
     percent of exposed areas affected, and; constant or
     near-constant systemic medications or intensive light
     therapy required during the past 12-month period......
    20 to 40 percent of the entire body or 20 to 40 percent           30
     of exposed areas affected, or; systemic therapy or
     intensive light therapy required for a total duration
     of six weeks or more, but not constantly, during the
     past 12-month period..................................
    At least 5 percent, but less than 20 percent, of the              10
     entire body, or at least 5 percent, but less than 20
     percent, of exposed areas affected, or; systemic
     therapy or intensive light therapy required for a
     total duration of less than six weeks during the past
     12-month period.......................................
    Less than 5 percent of the entire body or exposed areas            0
     affected, and; no more than topical therapy required
     during the past 12-month period.......................
    Or rate as disfigurement of the head, face, or neck (DC
     7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805),
     depending upon the predominant disability.
7823  Vitiligo:
    With exposed areas affected............................           10
    With no exposed areas affected.........................            0
7824 Diseases of keratinization (including icthyoses,
 Darier's disease, and palmoplantar keratoderma):
    With either generalized cutaneous involvement or                  60
     systemic manifestations, and; constant or near-
     constant systemic medication, such as
     immunosuppressive retinoids, required during the past
     12-month period.......................................
    With either generalized cutaneous involvement or                  30
     systemic manifestations, and; intermittent systemic
     medication, such as immunosuppressive retinoids,
     required for a total duration of six weeks or more,
     but not constantly, during the past 12-month period...
    With localized or episodic cutaneous involvement and              10
     intermittent systemic medication, such as
     immunosuppressive retinoids, required for a total
     duration of less than six weeks during the past 12-
     month period..........................................
    No more than topical therapy required during the past              0
     12-month period.......................................
7825  Urticaria:
    Recurrent debilitating episodes occurring at least four           60
     times during the past 12-month period despite
     continuous immunosuppressive therapy..................
    Recurrent debilitating episodes occurring at least four           30
     times during the past 12-month period, and; requiring
     intermittent systemic immunosuppressive therapy for
     control...............................................
    Recurrent episodes occurring at least four times during           10
     the past 12-month period, and; responding to treatment
     with antihistamines or sympathomimetics...............
7826  Vasculitis, primary cutaneous:
    Recurrent debilitating episodes occurring at least four           60
     times during the past 12-month period despite
     continuous immunosuppressive therapy..................
    Recurrent debilitating episodes occurring at least four           30
     times during the past 12-month period, and; requiring
     intermittent systemic immunosuppressive therapy for
     control...............................................
    Recurrent episodes occurring one to three times during            10
     the past 12-month period, and; requiring intermittent
     systemic immunosuppressive therapy for control........
    Or rate as disfigurement of the head, face, or neck (DC
     7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805),
     depending upon the predominant disability.
7827  Erythema multiforme; Toxic epidermal necrolysis:
    Recurrent debilitating episodes occurring at least four           60
     times during the past 12-month period despite ongoing
     immunosuppressive therapy.............................
    Recurrent episodes occurring at least four times during           30
     the past 12-month period, and; requiring intermittent
     systemic immunosuppressive therapy....................
    Recurrent episodes occurring during the past 12-month             10
     period that respond to treatment with antihistamines
     or sympathomimetics, or; one to three episodes
     occurring during the past 12-month period requiring
     intermittent systemic immunosuppressive therapy.......
    Or rate as disfigurement of the head, face, or neck (DC
     7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805),
     depending upon the predominant disability.
7828  Acne:
    Deep acne (deep inflamed nodules and pus-filled cysts)            30
     affecting 40 percent or more of the face and neck.....
    Deep acne (deep inflamed nodules and pus-filled cysts)            10
     affecting less than 40 percent of the face and neck,
     or; deep acne other than on the face and neck.........
    Superficial acne (comedones, papules, pustules,                    0
     superficial cysts) of any extent......................
    Or rate as disfigurement of the head, face, or neck (DC
     7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805),
     depending upon the predominant disability.
7829  Chloracne:
    Deep acne (deep inflamed nodules and pus-filled cysts)            30
     affecting 40 percent or more of the face and neck.....
    Deep acne (deep inflamed nodules and pus-filled cysts)            10
     affecting less than 40 percent of the face and neck,
     or; deep acne other than on the face and neck.........
    Superficial acne (comedones, papules, pustules,                    0
     superficial cysts) of any extent......................
    Or rate as disfigurement of the head, face, or neck (DC
     7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805),
     depending upon the predominant disability.
7830  Scarring alopecia:
    Affecting more than 40 percent of the scalp............           20

[[Page 49599]]

 
    Affecting 20 to 40 percent of the scalp................           10
    Affecting less than 20 percent of the scalp............            0
7831  Alopecia areata:
    With loss of all body hair.............................           10
    With loss of hair limited to scalp and face............            0
7832  Hyperhidrosis:
    Unable to handle paper or tools because of moisture,              30
     and unresponsive to therapy...........................
    Able to handle paper or tools after therapy............            0
7833  Malignant melanoma: Rate as scars (DC's 7801, 7802,
 7803, 7804, or 7805), disfigurement of the head, face, or
 neck (DC 7800), or impairment of function (under the
 appropriate body system).
    Note: If a skin malignancy requires therapy that is
     comparable to that used for systemic malignancies,
     i.e., systemic chemotherapy, X-ray therapy more
     extensive than to the skin, or surgery more extensive
     than wide local excision, a 100-percent evaluation
     will be assigned from the date of onset of treatment,
     and will continue, with a mandatory VA examination six
     months following the completion of such antineoplastic
     treatment, and any change in evaluation based upon
     that or any subsequent examination will be subject to
     the provisions of Sec.  3.105(e). If there has been no
     local recurrence or metastasis, evaluation will then
     be made on residuals. If treatment is confined to the
     skin, the provisions for a 100-percent evaluation do
     not apply.
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(Authority: 38 U.S.C. 1155)

[FR Doc. 02-19331 Filed 7-30-02; 8:45 am]
BILLING CODE 8320-01-P