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C&P Exam Prep: Skin Diseases (Dermatitis / Psoriasis / Acne)
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 evaluate the nature, severity, and extent of your skin condition(s) for VA disability rating purposes under 38 CFR - 4.118. The examiner will assess diagnosis, treatment history, and the percentage of total and exposed body surface area (BSA) affected, which directly determines your rating percentage under the General Rating Formula for the Skin.
What the examiner evaluates:
- Specific diagnosis and ICD code of the skin condition(s)
- Total body surface area (BSA) affected, expressed as a percentage
- Exposed body surface area (e.g., face, neck, hands, forearms) affected, expressed as a percentage
- Whether the condition is in an active or remission phase
- Current and past treatment regimen including topical agents, systemic medications, biologics, phototherapy, and immunosuppressives
- Severity, frequency, and duration of flare-ups
- Presence of disfigurement, scarring, mucosal involvement, palmar or plantar involvement
- Whether the condition causes social or occupational impairment
- Nexus (connection) between the skin condition and military service
- Any secondary or associated conditions such as psoriatic arthritis, nail involvement, or systemic manifestations
The examiner will conduct a visual inspection of affected skin areas. You should be prepared to undress to allow inspection of all affected body areas. Wear comfortable, loose-fitting clothing for easy access. Bring a list of all current and past skin medications. Be prepared to describe your condition on your worst days, not just how you feel on the day of the exam.
Typical duration: 15-30 minutes
Total Body Surface Area (BSA) Affected
The percentage of your entire body skin surface covered by the skin condition. This is a critical rating driver under the General Rating Formula for the Skin.
What to expect:
The examiner will visually inspect your entire body and estimate the percentage of total BSA affected. The common 'rule of nines' or palm method may be used. Each palm equals approximately 1% BSA.
Key thresholds:
- Less than 5% of total BSA OR less than 5% of exposed BSA — Typically supports a 10% rating if requiring intermittent treatment
- 5-20% of total BSA OR 5-20% of exposed BSA — Typically supports a 30% rating if requiring intermittent systemic therapy
- 20-40% of total BSA — Typically supports a 60% rating if requiring systemic therapy
- More than 40% of total BSA OR incapacitating episodes requiring hospitalization — Typically supports a 60% rating at the highest level under the General Formula
Tips:
- Do NOT apply heavy moisturizers, camouflage makeup, or thick topical treatments to affected areas on exam day - the examiner must see your skin as it actually is.
- If your condition fluctuates, inform the examiner that exam-day presentation may not reflect worst-day severity.
- Bring photos of your skin during severe flare-ups to demonstrate typical presentation.
- Point out every affected area, including scalp, behind ears, in skin folds, groin, and under nails - these are easy to miss.
Pain considerations: If affected areas are painful, cracked, bleeding, or tender, verbally state this during inspection so the examiner documents it accurately.
Exposed Body Surface Area (Exposed BSA) Affected
The percentage of exposed body surface areas - primarily the face, neck, hands, forearms, and lower legs - affected by the skin condition. Exposed BSA involvement can independently support higher ratings.
What to expect:
The examiner will specifically assess whether your condition affects visible, exposed areas of skin. For acne-type conditions, the examiner will note whether the face/neck is affected and to what degree (less than 40% or 40% or more).
Key thresholds:
- Acne affecting less than 40% of face and neck — Supports lower rating level for acne under the formula
- Acne affecting 40% or more of face and neck — Supports higher rating level for acne
- Chloracne affecting less than 40% of face and neck — Supports a 10% rating
- Chloracne affecting 40% or more of face and neck — Supports a higher rating
Tips:
- Describe any involvement on the face, neck, and backs of hands clearly - these are 'exposed' areas that directly affect rating.
- Mention any social isolation or avoidance of public activity due to visible skin involvement.
- If your condition affects your scalp and is visible, point this out explicitly.
- For psoriasis, note involvement of nails, oral mucosa, and intertriginous areas (armpits, groin, under breasts) as these are separately documented on the DBQ.
Pain considerations: Painful or bleeding fissures on hands or feet (palmar/plantar involvement) are specifically tracked on the DBQ and directly affect your rating. Describe any functional limitations from palmar or plantar involvement.
Treatment Intensity Assessment
The type, frequency, and duration of treatment required to manage your skin condition. Treatment intensity is a primary driver of VA skin ratings - requiring systemic therapy, biologics, or hospitalization elevates your rating.
What to expect:
The examiner will review your current medications and treatment history and document them on the DBQ, including topical corticosteroids, systemic corticosteroids, antihistamines, retinoids, biologics (e.g., adalimumab, secukinumab), immunosuppressives (e.g., methotrexate, cyclosporine), phototherapy (UVB), photochemotherapy (PUVA), and electron beam therapy.
Key thresholds:
- Topical therapy only (no systemic medications) — Generally supports lower rating levels (0-10%)
- Intermittent systemic therapy (oral steroids, antihistamines, retinoids as needed) — Supports 30% rating under the General Formula
- Constant systemic therapy including immunosuppressives or biologics — Supports 60% rating under the General Formula
- Hospitalization required due to incapacitating episodes — Supports highest rating levels
Tips:
- Bring a complete, up-to-date medication list including names, dosages, and how long you have been taking each medication.
- If you have ever required hospitalization for your skin condition, bring documentation of all hospitalizations.
- If you use biologics or receive phototherapy, bring records showing frequency of treatments.
- Report any medications you had to stop due to side effects - this demonstrates treatment burden and severity.
- If you have no current treatment but have a documented history of needing it, make sure this is clearly stated.
Pain considerations: If your skin condition causes you to avoid or stop working due to pain, itching, or appearance, this should be stated clearly as it demonstrates functional impact.
Rating Criteria Breakdown
| Rating % | Criteria | Key Symptoms |
|---|---|---|
| 60% | More than 40% of the entire body, or more than 40% of exposed areas affected; or constant or near-constant systemic therapy including immunosuppressives or biologics required during the past 12-month period. |
CFR: General Rating Formula for the Skin: 60% - 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. Note (DC 7816): For psoriasis, rate complications such as psoriatic arthritis and other clinical manifestations (e.g., oral mucosa, nails) separately under the appropriate diagnostic code. |
| 30% | 20% to 40% of the entire body, or 20% to 40% of exposed areas affected; or systemic therapy required for a total duration of 6 weeks or more, but not constantly, during the past 12-month period. |
CFR: General Rating Formula for the Skin: 30% - 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% of the entire body, or at least 5% but less than 20% of exposed areas, affected; or intermittent systemic therapy required for a total of less than 6 weeks during the past 12-month period. |
CFR: General Rating Formula for the Skin: 10% - 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% | No characteristic skin symptoms, or skin condition is well-controlled with topical therapy alone and causes no functional impairment. Condition may be present but does not meet the threshold for a compensable rating. |
CFR: Under the General Rating Formula for the Skin (38 CFR - 4.118), a 0% rating is assigned when the condition is present but does not rise to the level of requiring at least intermittent systemic therapy or causing at least 5% BSA involvement requiring constant topical therapy. |
60% More than 40% of the entire body, or more than 40% of expose ...
More than 40% of the entire body, or more than 40% of exposed areas affected; or constant or near-constant systemic therapy including immunosuppressives or biologics required during the past 12-month period.
Key Symptoms
- Widespread skin involvement covering more than 40% of total BSA
- Extensive exposed area involvement (face, neck, and hands severely affected)
- Daily use of immunosuppressive agents, biologics, or oral corticosteroids
- Regular phototherapy (UVB) or photochemotherapy (PUVA) treatments
- Erythroderma or exfoliative dermatitis with generalized skin involvement
- Significant systemic manifestations (e.g., erythrodermic psoriasis)
- Hospitalizations due to incapacitating episodes
- Severe functional impairment in daily activities, sleep, employment
CFR: General Rating Formula for the Skin: 60% - 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. Note (DC 7816): For psoriasis, rate complications such as psoriatic arthritis and other clinical manifestations (e.g., oral mucosa, nails) separately under the appropriate diagnostic code.
30% 20% to 40% of the entire body, or 20% to 40% of exposed area ...
20% to 40% of the entire body, or 20% to 40% of exposed areas affected; or systemic therapy required for a total duration of 6 weeks or more, but not constantly, during the past 12-month period.
Key Symptoms
- Moderate-to-large patches of psoriasis, dermatitis, or eczema covering 20-40% of body
- Significant exposed area involvement (face, neck, hands, forearms)
- Multiple courses of systemic steroids, antihistamines, or retinoids per year totaling 6+ weeks
- Significant itching, pain, scaling, or weeping skin
- Impact on sleep, work, or daily activities
- Palmar or plantar involvement affecting hand or foot function
CFR: General Rating Formula for the Skin: 30% - 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% of the entire body, or at leas ...
At least 5% but less than 20% of the entire body, or at least 5% but less than 20% of exposed areas, affected; or intermittent systemic therapy required for a total of less than 6 weeks during the past 12-month period.
Key Symptoms
- Patches of dermatitis, psoriasis, or eczema affecting less than 20% of total or exposed BSA
- Occasional flare-ups requiring short courses of oral steroids or antihistamines
- Skin lesions causing mild itching, scaling, or redness
- Intermittent topical and/or brief systemic treatment
- Some social or cosmetic impact but manageable
CFR: General Rating Formula for the Skin: 10% - 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% No characteristic skin symptoms, or skin condition is well-c ...
No characteristic skin symptoms, or skin condition is well-controlled with topical therapy alone and causes no functional impairment. Condition may be present but does not meet the threshold for a compensable rating.
Key Symptoms
- Minimal or no active lesions
- Controlled with over-the-counter topicals
- No systemic treatment required
- No functional limitations
CFR: Under the General Rating Formula for the Skin (38 CFR - 4.118), a 0% rating is assigned when the condition is present but does not rise to the level of requiring at least intermittent systemic therapy or causing at least 5% BSA involvement requiring constant topical therapy.
How to Describe Your Symptoms
Extent and Location of Skin Involvement
How to describe:
Describe every area of your body affected by your skin condition. Be specific: 'My psoriasis covers both forearms, the back of my scalp, behind both ears, my lower back, both shins, and my groin area.' Estimate how much of your body is covered during a bad flare.
Worst-day example:
“On my worst days, the plaques on my arms and legs are so thick and inflamed that they crack and bleed when I bend my elbows or knees. The patches cover easily half my body from my scalp down to my feet, and I cannot sleep because the itching is constant.”
What the examiner listens for:
Specific body locations affected, whether exposed areas (face, neck, hands) are involved, whether intertriginous areas (armpits, groin) are involved, and an estimate of total BSA coverage.
Understatements to avoid:
Do not say 'just a little rash here and there.' Do not minimize coverage. The examiner needs to understand your full pattern of involvement, especially on your worst days.
Treatment Burden and Systemic Therapy Use
How to describe:
Describe every medication you take for your skin, how often you take it, and how long during the year you need it. 'I take oral prednisone about 3 to 4 times a year for 2 weeks each time when my eczema flares severely. I am on methotrexate weekly. I receive biologic injections every 8 weeks.'
Worst-day example:
“During my worst flares I need oral steroids, which I take for two weeks at a time. I have been on methotrexate continuously for two years, and even with that my skin never fully clears. I also use high-potency topical steroids every day.”
What the examiner listens for:
Whether systemic therapy (oral steroids, immunosuppressives, biologics) is used, how many weeks per year it is needed, whether it is constant or intermittent, and whether it controls the condition effectively.
Understatements to avoid:
Do not just list topical creams and forget to mention your oral or injectable medications. Do not say 'I manage with creams' if you also take systemic medications - both are important.
Flare-Up Frequency and Duration
How to describe:
Describe how often your condition flares and how long each flare lasts. 'I have a moderate flare about every 6-8 weeks that lasts 2-3 weeks. During that time my skin is actively inflamed, itching, and scaling, and I often have to call out of work.'
Worst-day example:
“My worst flares happen 4-5 times a year and last 3-4 weeks each. During those periods I cannot wear normal clothing because the fabric irritates my skin, I cannot sleep more than 2-3 hours at a time due to itching, and I avoid going out in public because of how my skin looks.”
What the examiner listens for:
How frequently flares occur, how long they last, what triggers them, and how they impact your daily life, work, and sleep.
Understatements to avoid:
Do not say 'it comes and goes' without quantifying how often and how severely. Vague descriptions result in the examiner defaulting to minimal documentation.
Pain, Itching, and Physical Impact
How to describe:
Describe your daily symptoms in concrete terms. 'The itching is constant - I rate it a 7 out of 10 most days. My skin on my hands cracks and bleeds when the weather is dry. The pain in my palms makes it hard to grip tools or open jars.'
Worst-day example:
“On my worst days I am scratching until I bleed, and the bleeding and crusting keep me from using my hands normally. The pain from fissures on my palms is a 9 out of 10 - I cannot work with tools, type on a keyboard, or even shake hands.”
What the examiner listens for:
Whether the condition causes pain (not just itching), whether palmar or plantar involvement limits hand or foot function, and how symptoms affect the ability to perform daily activities and work.
Understatements to avoid:
Do not only mention itching - also describe any pain, burning, stinging, bleeding, or skin cracking. Do not fail to mention hand or foot involvement if present, as these are specifically tracked on the DBQ.
Social, Occupational, and Psychological Impact
How to describe:
Describe how your skin condition affects your work, relationships, and mental health. 'I avoid social situations because of my visible psoriasis on my face and arms. I have turned down job opportunities that require client-facing interactions. My skin condition has caused significant depression and anxiety.'
Worst-day example:
“I called out of work 8 times in the past year due to severe flares. I stopped going to the gym, swimming, or wearing short sleeves in public. My relationship with my partner has been strained because my condition affects intimacy and my mood.”
What the examiner listens for:
Any occupational limitations (missed work, job changes, inability to perform job duties), social avoidance, and mental health impact - particularly relevant for the functional impact section of the DBQ.
Understatements to avoid:
Do not minimize psychological or social impact. The DBQ specifically asks about the impact of skin conditions on the veteran's life. Failure to describe this may result in the examiner leaving this field blank or under-documenting.
Disfigurement, Scarring, and Visible Manifestations
How to describe:
Describe any permanent changes to your skin, including scarring, hyperpigmentation, hypopigmentation, nail changes, or disfigurement. 'My psoriasis has left large areas of permanent discoloration on my arms and legs. My fingernails are pitted and thickened. I have scarring on my face from cystic acne.'
Worst-day example:
“Even when my skin is not actively flaring, the scarring and discoloration from years of severe acne are permanently visible on my face, jaw, and neck. People regularly comment on my skin and it causes me significant distress.”
What the examiner listens for:
Presence of scarring, disfigurement, nail involvement (for psoriasis), mucosal involvement, and any permanent changes to skin appearance that persist even during remission.
Understatements to avoid:
Do not assume the examiner will notice all areas of scarring or disfigurement. Actively point out every affected or permanently changed area, including nail pitting, scalp scarring, or facial scarring.
Common Mistakes to Avoid
Only describing your skin on the day of the exam rather than on your worst days
Skin conditions are highly variable. If you are in partial remission on exam day, the examiner may document minimal findings and the rating will reflect only what they observe, not your typical worst-day presentation.
Instead: Explicitly tell the examiner: 'My skin today does not represent my worst days. Here are photos of my skin during a severe flare.' Bring photographs taken during active flares.
Impact: Could result in a 0-10% rating instead of a 30-60% rating
Failing to mention all systemic medications, especially biologics and immunosuppressives
The treatment intensity you require is one of the most important rating drivers for skin conditions. If only topical creams are documented, the examiner may assign a lower rating regardless of actual severity.
Instead: Bring a complete printed medication list including all systemic treatments, their dosages, and how long you have been taking them. Verbally confirm each medication with the examiner.
Impact: Could result in a 10% rating instead of a 30-60% rating
Not exposing all affected skin areas during the examination
The examiner can only document and measure what they can see. BSA calculations depend on a complete visual inspection. Areas under clothing, on the scalp, or in skin folds are commonly missed.
Instead: Prepare to undress fully for the exam. Point out every affected area including scalp, behind ears, armpits, groin, between fingers, under nails, and on the soles of your feet.
Impact: Directly reduces documented BSA percentage, lowering rating from 30-60% to 10%
Minimizing the impact on daily activities, work, and social life
The DBQ includes a specific section on functional impact. If you understate how your condition affects your life, the examiner will document minimal impact, which weakens your claim.
Instead: Prepare specific examples of how your skin condition has affected your work, relationships, sleep, physical activities, and mental health. Use concrete numbers (days missed from work, hours of sleep lost, events avoided).
Impact: Affects overall documentation quality and can undermine ratings at all levels
Not mentioning palmar or plantar involvement if present
Palmar (palm of hand) and plantar (sole of foot) involvement are specifically documented on the DBQ and can support higher ratings. They also indicate functional limitation in gripping, standing, and walking.
Instead: If you have skin involvement on your palms or the soles of your feet, explicitly point this out, describe the pain and functional limitation it causes, and show the examiner directly.
Impact: Can affect 30% vs. 60% rating determination
Failing to disclose prior treatment history if not currently on treatment
The DBQ specifically accounts for veterans who have a documented history of treatment even if not currently receiving it. Not disclosing prior systemic therapy may result in a lower rating.
Instead: Describe your full treatment history. If you stopped a medication due to side effects, cost, or temporary improvement, explain this. Bring medical records showing prior prescriptions.
Impact: Could result in 0-10% instead of 30%
Not mentioning associated conditions like psoriatic arthritis, nail changes, or mucosal involvement
Under DC 7816, psoriasis complications such as psoriatic arthritis and nail/oral mucosal involvement must be rated separately. If you do not mention these, they will not be captured and you will miss separate rating opportunities.
Instead: Describe all manifestations of your psoriasis including joint pain, nail pitting or thickening, and any oral lesions. These may qualify for separate diagnostic codes and additional disability ratings.
Impact: Missing secondary conditions that could each receive 10-60% ratings
Prep Checklist
Before Your Exam
Day Of
During the Exam
After the Exam
Your Rights During a C&P Exam
- You have the right to a thorough and contemporaneous examination under 38 U.S.C. - 5103A. If the examiner does not physically examine your skin, does not document BSA percentages, or does not inquire about your treatment history, the examination may be considered inadequate for rating purposes.
- You have the right to submit a personal statement (VA Form 21-4138) describing your symptoms, functional impact, and worst-day presentation. This statement becomes part of your claims file and must be considered.
- You have the right to submit buddy statements (VA Form 21-10210) from family members, coworkers, or friends who have observed your skin condition and its impact on your daily life.
- You have the right to submit lay evidence, including your own written statement and dated photographs, describing your condition. Lay evidence is competent evidence for observable symptoms like visible skin lesions.
- You have the right to request a copy of your C&P examination report (DBQ) from your VA regional office and to review it for accuracy before a rating decision is issued.
- In many states, you have the right to audio or video record your C&P examination. Check your state's recording consent laws and notify the examiner at the start of the exam if you choose to record.
- If you believe your C&P examination was inadequate - for example, the examiner did not examine you in person, did not document BSA percentages, or failed to ask about medications - you have the right to challenge the examination and request a new one. Under M21-1, Part IV, Subpart i, 3.C, VA must obtain clarification or a new examination if the existing one is insufficient for rating purposes.
- You have the right to seek an independent medical opinion (IMO) or nexus letter from a private dermatologist if you disagree with the C&P examiner's findings. This can be submitted as new and relevant evidence.
- Under 38 CFR - 4.7 (benefit of the doubt), when there is an approximate balance of positive and negative evidence, the benefit of the doubt must be given to the veteran. If the examiner's findings could support more than one rating level, you are entitled to the higher rating.
- For psoriasis (DC 7816), you have the right to have complications such as psoriatic arthritis and nail or oral mucosal involvement evaluated separately under appropriate diagnostic codes, potentially resulting in multiple separate ratings.
- You have the right to have your claim adjudicated based on your worst-day presentation, not only on your condition as observed on the exam date. Per M21-1 guidance, examiners should consider the full range of the veteran's symptoms over time.
Related Conditions
- Psoriatic Arthritis A direct complication of psoriasis (DC 7816). Per 38 CFR 4.118 Note for DC 7816, psoriatic arthritis must be rated separately under the appropriate diagnostic code (typically DC 5002 or DC 5009) in addition to the skin rating.
- Scarring (Non-Superficial) Skin conditions such as cystic acne, severe psoriasis, or chronic dermatitis may result in permanent scarring. Scars are rated separately under 38 CFR 4.118 DCs 7800 7805 depending on location, size, and whether they are painful or unstable.
- Anxiety Disorder / Depression Chronic, visible skin conditions are strongly associated with secondary mental health conditions including depression, social anxiety disorder, and PTSD related avoidance behaviors. These may be ratable as secondary conditions under 38 CFR 3.310.
- Sleep Apnea / Sleep Disturbance Chronic pruritus (severe itching) from dermatitis, eczema, and psoriasis commonly causes significant sleep disruption. If sleep disturbance is severe enough, a separate claim for sleep impairment secondary to the skin condition may be warranted.
- Nail Disorders (Psoriatic Nail Disease) Psoriatic nail involvement including pitting, onycholysis, and subungual hyperkeratosis is a direct manifestation of psoriasis. Under DC 7816, this should be separately documented and may support a separate rating.
- Eczema / Atopic Dermatitis Often rated under DC 7806 (dermatitis or eczema) within the same General Rating Formula for the Skin framework. If claimed separately from other skin conditions, it receives its own evaluation under 4.118.
- Chloracne (Toxic Acne from Agent Orange / TCDD Exposure) Chloracne is a presumptive condition associated with herbicide exposure under 38 CFR 3.309(e) for Vietnam era veterans. It is rated under DC 7828 under the General Rating Formula for the Skin, with specific location criteria for the face and neck.
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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.