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C&P Exam Prep: Skin Diseases (Dermatitis / Psoriasis / Acne)

DC 7813 skin 38 CFR 4.118

DBQ Overview

Interview + Physical
Form Name
Skin_Diseases
Form Code
Skin_Diseases
Page Count
12
Examiner Type
Dermatologist or appropriate clinician
Estimated Duration
15-30 minutes
Exam Format
Interview + Physical

What to Expect During Your Exam

Exam Overview

To document the nature, severity, and extent of your skin condition for VA disability rating purposes under 38 CFR - 4.118. The examiner will assess the specific diagnosis, body surface area affected, treatment history, and functional impact to assign a rating under the General Rating Formula for the Skin.

What the examiner evaluates:

  • Specific diagnosis and ICD code (e.g., dermatitis, psoriasis, acne, eczema)
  • Total body surface area (TBSA) affected expressed as a percentage
  • Exposed body surface area (EBSA) affected expressed as a percentage
  • Whether the condition is active or in remission
  • Type and complexity of medications required (topical, systemic, biologics, retinoids, corticosteroids, antihistamines, immunosuppressives)
  • Treatment history including phototherapy, photochemotherapy, electron beam therapy, and intensive light therapy
  • Involvement of special areas: palmar, plantar, mucosal, intertriginous, face and neck
  • Presence of erythroderma or exfoliative dermatitis
  • Complications such as psoriatic arthritis, nail involvement, oral mucosa involvement
  • Acne severity classification (superficial vs. deep inflamed nodules and cysts)
  • Vitiligo extent and distribution
  • Hyperhidrosis severity
  • Alopecia type and extent
  • History of resolved conditions and prior treatments
  • Impact on daily activities and occupational functioning

The examination will include both an interview about your medical history and symptoms AND a direct visual inspection of all affected skin areas. Wear clothing that allows easy access to all affected body regions. Bring a list of all current medications. The examiner must document TBSA and EBSA percentages for the rating to be sufficient, per M21-1 guidance. Photographs may be taken as part of the documentation.

Typical duration: 15-30 minutes

Total Body Surface Area (TBSA) Assessment

The percentage of your entire skin surface that is currently affected by the skin condition. This is a critical rating factor under the General Rating Formula for the Skin.

What to expect:

The examiner will visually inspect all areas of your body, estimating the percentage of skin covered by lesions, plaques, rashes, or other manifestations. Common methods include the Rule of Nines or the palm method (each palm equals approximately 1% TBSA).

Key thresholds:

  • Less than 5% TBSA, or systemic therapy not required — 0% - Condition present but minimal impact; may still be service-connected at 0%
  • At least 5% but less than 20% TBSA, OR; at least 20% TBSA but not requiring systemic therapy — 10% - Moderate involvement with limited treatment requirements
  • 20% or more TBSA, 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 — 30% - Significant involvement or systemic treatment burden
  • More than 40% TBSA involved, OR; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period — 60% - Severe, widespread involvement or constant systemic treatment requirement

Tips:

  • Do NOT apply topical treatments, creams, or moisturizers on the day of the exam so lesions are fully visible.
  • If your condition fluctuates, come to the exam during or just after a flare-up if possible, or bring photographic documentation of your worst presentation.
  • Point out ALL affected areas to the examiner, including scalp, behind ears, groin, underarms, between toes, and other areas that might be overlooked.
  • Ask the examiner to confirm they have documented the TBSA and EBSA percentages - this is required for a sufficient rating exam.
  • The examiner should assess your typical or worst-day presentation, not only what is visible that specific day.

Pain considerations: Although skin conditions are not musculoskeletal, note any pain, burning, stinging, or pruritus (itching) associated with your skin lesions, as this affects functional impairment documentation.

Exposed Body Surface Area (EBSA) Assessment

The percentage of skin that is normally exposed to view (face, neck, hands, forearms, lower legs, feet) that is affected. EBSA is specifically referenced in M21-1 adjudication guidance as a required documentation element for skin condition DBQs.

What to expect:

The examiner will separately note what percentage of typically exposed body areas (face, neck, hands, arms below elbow, legs below knee) are affected. This is relevant because visible skin conditions can independently affect occupational and social functioning.

Key thresholds:

  • Any EBSA involvement documented — Supports higher rating when combined with TBSA thresholds; critical for demonstrating visibility-related occupational and social impact

Tips:

  • Explicitly tell the examiner which exposed areas are affected, particularly face, neck, and hands.
  • Describe how visible lesions have affected your employment, social interactions, or daily activities.
  • If you have chloracne affecting the face and neck, note whether it covers less than 40% or 40% or more of the face and neck - this determines the specific acne rating level.

Pain considerations: Note any cosmetically disfiguring effects and psychological impact of visible skin lesions, including anxiety, depression, or social withdrawal.

Systemic Treatment Duration Assessment

Whether your condition has required systemic therapy (oral or injectable corticosteroids, immunosuppressives, biologics, retinoids, antihistamines) and for how long during the past 12 months. Treatment duration is a primary rating driver under the General Rating Formula for the Skin.

What to expect:

The examiner will review your medication list and medical history to determine cumulative weeks of systemic therapy in the past 12-month period. They will document each medication class: corticosteroids, biologics, immunosuppressives, retinoids, antihistamines, sympathomimetics, and others.

Key thresholds:

  • No systemic therapy, or systemic therapy less than 6 weeks total in past 12 months — 10% range - treatment burden does not independently elevate rating above 10%
  • Systemic therapy 6 weeks or more but not constant in past 12 months — 30% - significant treatment burden even without TBSA threshold being met
  • Constant or near-constant systemic therapy required during past 12 months — 60% - maximum rating level supported by treatment burden alone

Tips:

  • Bring a complete medication list including all prescription and over-the-counter treatments, with start dates and dosages.
  • Track and document how many weeks per year you require systemic medications - keep a medication diary or calendar.
  • If you take corticosteroid tapers (burst and taper cycles), each cycle counts toward cumulative systemic therapy weeks.
  • Biologic injections (e.g., adalimumab, secukinumab, dupilumab) count as systemic therapy - document frequency and duration.
  • If you have historically required systemic therapy but not currently due to medication access issues or side effects, ask the examiner to document the prior treatment history.

Pain considerations: Note any side effects from systemic medications (e.g., steroid-induced weight gain, bone density loss, immunosuppression leading to infections) as these represent additional disability burden.

Estimate

Rating Criteria Breakdown

60% More than 40% total body surface area affected; OR constant ...

More than 40% total body surface area affected; OR constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. This is the maximum rating under the General Rating Formula for the Skin.

Key Symptoms

  • More than 40% TBSA with active disease
  • Constant systemic medication requirement (daily or near-daily use)
  • Severe, widespread plaques, weeping, or exfoliation
  • Erythroderma (generalized redness involving most of body surface)
  • Severely impaired ability to work, sleep, or perform self-care
  • Frequent hospitalizations or urgent care visits for skin condition
  • Biologic injections required continuously
  • Severe palmar and plantar involvement preventing occupational use of hands or normal ambulation
  • Mucosal involvement (oral, genital)
  • Significant scarring or permanent skin changes

CFR: Under 38 CFR - 4.118 General Rating Formula for the Skin: 60 percent - more than 40 percent of the entire body or more than 40 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.

30% 20% or more total body surface area affected; OR systemic th ...

20% or more total body surface area affected; OR systemic therapy (corticosteroids, immunosuppressives, biologics) required for 6 weeks or more but not constantly during the past 12-month period.

Key Symptoms

  • 20% or more TBSA with active lesions
  • Requires systemic treatment 6 or more weeks per year
  • Significant pruritus, scaling, cracking, or weeping lesions
  • Sleep disruption due to itching or pain
  • Involvement of functionally or cosmetically significant areas (hands, face, genitalia)
  • Palmar or plantar involvement limiting fine motor function or ambulation
  • Flare-ups requiring steroid burst/taper cycles multiple times per year

CFR: Under 38 CFR - 4.118 General Rating Formula for the Skin: 30 percent - 20 to 40 percent of the entire body or 20 to 40 percent 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.

10% At least 5% but less than 20% total body surface area affect ...

At least 5% but less than 20% total body surface area affected; OR; at least 20% TBSA but systemic therapy not required. Condition is manageable with topical or minimal treatment.

Key Symptoms

  • 5% to less than 20% TBSA involvement
  • OR 20% or more TBSA but controlled with topical treatments only
  • Periodic flare-ups requiring increased topical treatment
  • Pruritus, scaling, or erythema present but limited
  • Intermittent impact on sleep or daily activities

CFR: Under 38 CFR - 4.118 General Rating Formula for the Skin: 10 percent - 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 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.

0% Skin condition is diagnosed and service-connected but involv ...

Skin condition is diagnosed and service-connected but involves less than 5% total body surface area AND does not require systemic therapy. Minimal functional impact.

Key Symptoms

  • Small, localized lesions covering less than 5% TBSA
  • Managed with topical treatments only (no systemic medications)
  • Minimal or no impact on daily activities
  • Condition may be stable or in remission

CFR: Under 38 CFR - 4.118 General Rating Formula for the Skin: 0 percent - the condition is present and diagnosed but does not meet the 5% TBSA threshold and requires no systemic therapy. A 0% rating still establishes service connection, which is important for future increases.

How to Describe Your Symptoms

Extent of Skin Involvement

How to describe:

Describe affected body areas with specific location names and approximate surface coverage. Quantify using landmarks (e.g., 'plaques cover both forearms from wrist to elbow, both shins, and my entire lower back'). Mention whether involvement is constant or fluctuating.

Worst-day example:

“On my worst days, the plaques on my arms, legs, and back become inflamed, weeping, and cover what feels like half my body. I have measured by comparing to diagrams and estimate about 35-40% of my skin is affected during major flares, which happen 4-6 times per year and last 2-4 weeks each.”

What the examiner listens for:

Specific body regions, estimated percentages, whether the condition is currently active or in remission, duration and frequency of flare-ups, and whether today's exam presentation is representative of typical severity.

Understatements to avoid:

Do not say 'it comes and goes' without specifying how often and how severely. Do not minimize by saying 'it's not that bad right now' - explain that today may not represent your worst or average presentation.

Systemic Treatment Requirements

How to describe:

Provide a complete, chronological medication history. State each medication by name, dose, route (oral/injection), and how many weeks per year you use it. Distinguish between topical-only periods and periods requiring systemic treatment.

Worst-day example:

“I take oral prednisone approximately 3-4 times per year in 2-week tapers - that is about 6-8 weeks of systemic corticosteroids annually. I also receive biologic injections every two weeks year-round. Despite this, I continue to have significant flare-ups during high-stress periods.”

What the examiner listens for:

Whether systemic therapy has been used for less than 6 weeks, 6 or more weeks, or constantly in the past 12 months. The examiner will ask about each drug class separately. Be prepared to name all medications including biologics, retinoids, immunosuppressives, and antihistamines.

Understatements to avoid:

Do not forget to count all systemic treatments including injections, oral medications, and infusions. Do not omit short steroid tapers or 'burst' courses - each one counts toward your annual total.

Functional and Daily Life Impact

How to describe:

Describe specific activities you cannot perform or perform with difficulty due to your skin condition. Include work limitations, sleep disruption, social withdrawal, hygiene challenges, and limitations in use of hands or feet if palmar/plantar involvement is present.

Worst-day example:

“During flares my hands crack and bleed, making it impossible to grip tools or type at a computer for more than 20 minutes. The itching wakes me 3-4 times per night. I have missed work approximately 10-15 days per year due to severe flare-ups and have declined social invitations because of embarrassment about my visible skin lesions.”

What the examiner listens for:

Concrete examples of functional impairment, occupational limitations, sleep disturbance, social/psychological effects, and whether visible lesions on exposed areas affect employment or social functioning. The examiner will complete the functional impact field on the DBQ.

Understatements to avoid:

Do not say you 'manage fine' if you have made accommodations or sacrifices. Do not minimize psychological impacts such as depression, anxiety, or social isolation caused by your skin condition.

Flare-Up Pattern and Triggers

How to describe:

Describe how often flares occur, how long they last, what triggers them (stress, weather, chemicals, certain foods, infections), and how severe they become. Distinguish your 'baseline' presentation from your 'worst-day' presentation.

Worst-day example:

“I have major flares 4-6 times per year, each lasting 3-4 weeks. During these flares I cannot wear certain clothing because it sticks to weeping lesions. Minor flares occur more frequently, roughly monthly, lasting 1-2 weeks. My condition is never completely clear.”

What the examiner listens for:

Frequency, duration, and severity of flare-ups; whether the condition ever achieves complete remission; and what the condition looks like between flares. The examiner needs to understand that a 'good day' during the exam may not be representative.

Understatements to avoid:

Do not allow the examiner to assume that your condition looks the same year-round as it does on the day of the exam. Proactively state that today may be a relatively better day and describe your typical and worst presentations.

Special Area Involvement

How to describe:

Specifically call out involvement of palms, soles, face, neck, genitalia, intertriginous areas (armpits, groin, under breasts), oral mucosa, scalp, and nails. These areas carry special rating significance and functional implications.

Worst-day example:

“My psoriasis involves my palms and makes it painful to grip objects. The soles of my feet crack and bleed making it difficult to walk long distances. I have nail pitting on all ten fingers. I also have oral mucosal plaques that my dentist has noted.”

What the examiner listens for:

Whether palmar involvement (hands) or plantar involvement (feet) is present, as these are specifically noted on the DBQ. Mucosal involvement, nail changes, and facial/neck involvement percentage (less than 40% vs. 40% or more of face and neck for acne rating) are separately documented.

Understatements to avoid:

Do not omit areas that are covered by clothing during the exam. Proactively show or describe all affected areas including scalp, genitalia, and intertriginous zones.

Acne-Specific Severity (if applicable)

How to describe:

Distinguish between superficial acne (comedones, papules, pustules) and deep acne (inflamed nodules and pus-filled cysts). Specify what percentage of face and neck is affected and whether body areas beyond face and neck are involved.

Worst-day example:

“I have deep cystic acne with inflamed nodules covering more than 40% of my face and neck, extending to my chest and upper back. I have required multiple courses of oral antibiotics and isotretinoin (a retinoid) over the past three years.”

What the examiner listens for:

Whether acne is superficial or deep/cystic (nodular), what percentage of face and neck is involved (under 40% vs. 40% or more), whether body areas beyond face and neck are affected, and chloracne diagnosis if applicable.

Understatements to avoid:

Do not describe cystic nodular acne as just 'bad acne.' Use the clinical language: deep inflamed nodules and pus-filled cysts. Do not underreport face and neck surface area involvement.

Common Mistakes to Avoid

Prep Checklist

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Before Your Exam

Day Of

During the Exam

After the Exam

Your Rights During a C&P Exam

  • You have the right to record your C&P examination in most states - check your state's consent laws and your specific exam facility's policy before recording.
  • You have the right to request that the examiner review your complete medical records and claims file before conducting the examination.
  • You have the right to submit photographs, personal statements, buddy statements, and private medical opinions as supporting evidence for your claim.
  • You have the right to request a new C&P examination if the original exam report is insufficient - for skin conditions, the DBQ must document TBSA and EBSA percentages or it may be considered insufficient for rating purposes per M21-1 guidance.
  • You have the right to submit a Notice of Disagreement (NOD) or request a Higher-Level Review if you believe the rating decision does not accurately reflect the rating criteria.
  • You have the right to obtain a copy of your C-file (claims file) and all exam reports - request this through your VSO or by submitting VA Form 20-10206 (Freedom of Information Act Request).
  • You have the right to have a VSO representative present during your C&P examination in some circumstances - contact your VSO in advance to explore this option.
  • You have the right to receive a private independent medical examination and submit it as evidence, even if VA has already completed their C&P exam.
  • Under 38 CFR - 4.7, when there is reasonable doubt regarding the degree of disability, such doubt shall be resolved in the veteran's favor - this applies to determining TBSA percentages and treatment duration when records are ambiguous.
  • Under the benefit-of-the-doubt standard (38 CFR - 3.102), when there is an approximate balance of positive and negative evidence, the claim shall be resolved in favor of the veteran.
  • Complications of psoriasis (e.g., psoriatic arthritis per DC 7816 note) must be rated separately under appropriate diagnostic codes - you have the right to claim and be rated for all manifestations of a service-connected condition.
  • You have the right to claim secondary conditions caused or aggravated by your service-connected skin condition, such as depression, anxiety, or secondary infections, under 38 CFR - 3.310.

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This C&P exam preparation guide is for educational purposes only and does not constitute legal, medical, or claims advice. Always consult with a qualified Veterans Service Organization (VSO) representative or VA-accredited attorney for guidance specific to your claim. Never exaggerate, minimize, or fabricate symptoms during a C&P examination.