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Chapter 12: Skin Secondary Conditions
Chapter 12
Skin Secondary Conditions
Introduction to Skin Secondary Connections
Skin conditions frequently develop as secondary effects of service-connected disabilities. The skin’s role as both a protective barrier and a reflection of internal health makes it particularly vulnerable to cascading effects from various primary conditions, whether through direct physiological impact, medication side effects, or immune system dysregulation.
Key Concepts
Skin secondary conditions typically develop through these pathways:
- Medication effects on skin integrity, pigmentation, or immune response
- Vascular changes affecting skin perfusion and healing
- Neurological effects on skin sensation and protection
- Immune system dysregulation affecting skin inflammation
- Metabolic changes affecting skin health and function
This chapter explores the most common skin conditions that develop secondary to service-connected disabilities and provides the medical evidence and documentation strategies needed to successfully claim these conditions.
Dermatitis Secondary to Medication Effects or Stress
Dermatitis—a general term for skin inflammation—frequently develops as a secondary condition to medications prescribed for service-connected conditions or as a result of stress from service-connected mental health conditions.
Medical Connection
The development of dermatitis as a secondary condition occurs through several established mechanisms:
Secondary to Medication Effects
Medications can cause dermatitis through:
- Allergic reactions: Immune-mediated hypersensitivity to medications
- Direct irritant effects: Topical or systemic medications damaging skin
- Photosensitivity: Increased sensitivity to sunlight from medications
- Altered immune function: Medications affecting skin immune responses
- Altered skin barrier: Medications affecting skin integrity
Secondary to Stress and Mental Health Conditions
Stress contributes to dermatitis through:
- Neuroinflammatory pathways: Stress hormones trigger skin inflammation
- Impaired barrier function: Stress affects skin barrier integrity
- Altered immune response: Stress affects skin immune function
- Increased scratching behavior: Stress exacerbates itch-scratch cycle
- Autonomic nervous system effects: Altered blood flow and sweating
Case Study: Contact Dermatitis Secondary to Medication
A veteran with service-connected hypertension (10% rating) was prescribed hydrochlorothiazide. Two weeks after starting the medication, he developed a widespread, itchy rash with redness and scaling. His successful secondary claim included:
- Dermatology evaluation diagnosing medication-induced dermatitis
- Pharmacy records documenting hydrochlorothiazide prescribed for service-connected hypertension
- Photographic evidence of the rash
- Dermatologist’s opinion stating that “the veteran’s dermatitis is at least as likely as not caused by hydrochlorothiazide prescribed for his service-connected hypertension, as evidenced by the characteristic distribution, timing of onset, and resolution after medication discontinuation”
- Documentation of resolution when medication was changed
- Evidence of recurrence when medication was briefly reintroduced
The VA granted service connection for medication-induced dermatitis as secondary to treatment for service-connected hypertension with a 10% rating.
Common Patterns of Secondary Dermatitis
| Primary Condition | Dermatitis Type | Characteristics |
|---|---|---|
| Conditions requiring antibiotics | Drug eruption, fixed drug eruption | Appears after medication initiation, may recur in same location with rechallenge |
| Hypertension treated with thiazides | Photosensitive dermatitis | Occurs in sun-exposed areas, worsens with sun exposure |
| PTSD, anxiety disorders | Stress-induced eczema | Flares during periods of increased stress, often affects hands, face |
| Diabetes mellitus | Diabetic dermopathy | Light brown, scaly patches on shins |
| Venous insufficiency | Stasis dermatitis | Affects lower legs, associated with swelling and discoloration |
Documentation Strategies
To establish dermatitis as a secondary condition, focus on documenting:
- Dermatology evaluation and diagnosis
- Detailed description of the rash:
- Location and distribution
- Appearance (redness, scaling, blistering)
- Symptoms (itching, burning, pain)
- Pattern of onset and progression
- Photographic evidence of the skin condition
- For medication-induced dermatitis:
- Complete medication history
- Temporal relationship to rash onset
- Challenge/dechallenge/rechallenge information
- Allergy testing results if performed
- For stress-related dermatitis:
- Correlation between stress levels and skin symptoms
- Mental health provider observations
- Symptom diary showing relationship
- Failed treatments and current management
- Impact on daily activities and quality of life
- Specialist opinions addressing the causal relationship
- Research literature supporting the specific connection
Rating Consideration
Dermatitis is typically rated under Diagnostic Code 7806, with ratings from 0% to 60% based on percentage of body area affected, exposed areas affected, and treatment requirements. Document the extent of skin involvement and all treatments, particularly if systemic therapy such as corticosteroids or immunosuppressive drugs are required.
Psoriasis Secondary to Stress or Medication Effects
Psoriasis—a chronic inflammatory skin condition characterized by red, scaly patches—can develop or worsen as a secondary condition to stress from service-connected mental health conditions or as a result of medications prescribed for service-connected conditions.
Medical Connection
The development or exacerbation of psoriasis as a secondary condition occurs through several mechanisms:
Secondary to Stress and Mental Health Conditions
Stress contributes to psoriasis through:
- Neuroimmune interactions: Stress hormones affect immune cells involved in psoriasis
- Increased inflammatory cytokines: Stress increases pro-inflammatory mediators
- Altered skin barrier function: Stress affects skin integrity
- Impaired wound healing: Stress delays repair processes
- Behavioral factors: Stress may lead to scratching, poor self-care
Secondary to Medication Effects
Various medications can trigger or worsen psoriasis:
- Beta-blockers: Can trigger or exacerbate psoriasis
- Lithium: Well-known trigger for psoriasis
- Antimalarials: May worsen existing psoriasis
- NSAIDs: Can trigger psoriasis in some individuals
- Rapid steroid withdrawal: Can cause rebound psoriasis
Case Study: Psoriasis Secondary to PTSD
A veteran with service-connected PTSD (50% rating) developed widespread psoriasis that flared significantly during periods of increased PTSD symptoms. His successful secondary claim included:
- Dermatology evaluation diagnosing plaque psoriasis
- Symptom diary showing correlation between PTSD symptom exacerbations and psoriasis flares
- Photographic evidence of psoriasis during stress-related flares
- Dermatologist’s opinion stating that “the veteran’s psoriasis is at least as likely as not aggravated by his service-connected PTSD, as evidenced by the clear temporal relationship between stress levels and disease activity, consistent with the well-established stress-psoriasis connection in medical literature”
- Mental health provider’s observations about skin worsening during therapy for trauma
- Research literature supporting the stress-psoriasis connection
The VA granted service connection for psoriasis as secondary to PTSD with a 30% rating based on body surface area affected and treatment requirements.
Common Patterns of Secondary Psoriasis
| Primary Condition | Mechanism for Psoriasis | Documentation Focus |
|---|---|---|
| PTSD/anxiety disorders | Stress-induced immune dysregulation | Correlation between mental health symptoms and psoriasis flares |
| Hypertension treated with beta-blockers | Medication-induced psoriasis | Temporal relationship to medication, improvement with alternative treatments |
| Bipolar disorder treated with lithium | Medication-induced psoriasis | Onset or worsening after lithium initiation |
| Inflammatory conditions requiring NSAIDs | Medication-triggered psoriasis | Pattern of flares related to medication use |
| Conditions requiring steroid treatment | Rebound psoriasis after steroid withdrawal | Timing relationship to steroid tapering |
Documentation Strategies
To establish psoriasis as a secondary condition, focus on documenting:
- Dermatology evaluation and diagnosis
- Detailed description of psoriasis:
- Location and distribution
- Percentage of body surface area affected
- Percentage of exposed areas affected
- Characteristics (plaque, guttate, pustular, etc.)
- Photographic evidence of the skin condition
- For stress-related psoriasis:
- Symptom diary correlating stress and flares
- Mental health provider observations
- Pattern of disease activity related to stress
- For medication-induced psoriasis:
- Complete medication history
- Temporal relationship to psoriasis onset or worsening
- Response to medication changes
- Treatment requirements:
- Topical treatments
- Phototherapy
- Systemic medications
- Biologics
- Impact on daily activities and quality of life
- Specialist opinions addressing the causal relationship
- Research literature supporting the specific connection
Skin Ulcers Secondary to Diabetes or Vascular Conditions
Skin ulcers—open wounds that develop when skin and underlying tissue break down—frequently develop as secondary conditions to service-connected diabetes mellitus, vascular conditions, and neurological disorders. These secondary skin ulcers can be persistent, painful, and lead to serious complications including infection and amputation.
Medical Connection
The development of skin ulcers as secondary conditions occurs through several mechanisms:
Secondary to Diabetes Mellitus
Diabetes contributes to skin ulcers through:
- Peripheral neuropathy: Loss of protective sensation
- Vascular disease: Reduced blood flow to extremities
- Immune dysfunction: Impaired infection control
- Altered collagen structure: Changes in skin integrity
- Delayed wound healing: Impaired cellular repair mechanisms
- Increased susceptibility to infection: Higher risk of wound complications
Case Study: Diabetic Foot Ulcers Secondary to Diabetes
A veteran with service-connected diabetes mellitus (40% rating) developed recurrent foot ulcers. His successful secondary claim included:
- Podiatry and wound care evaluations diagnosing diabetic neuropathic ulcers
- Monofilament testing showing severe loss of protective sensation
- Vascular studies showing reduced perfusion to feet
- Photographic evidence of ulcers
- Wound care specialist’s opinion stating that “the veteran’s foot ulcers are directly caused by his service-connected diabetes mellitus, as evidenced by the classic neuropathic pattern, location over pressure points, and associated diabetic neuropathy and vascular disease”
- Documentation of multiple hospitalizations for ulcer-related infections
- Evidence of required accommodative footwear and activity limitations
The VA granted service connection for diabetic foot ulcers as secondary to diabetes mellitus with a 30% rating based on recurrent ulceration and required care.
Common Types of Secondary Skin Ulcers
| Primary Condition | Ulcer Type | Characteristics |
|---|---|---|
| Diabetes mellitus | Neuropathic (diabetic) ulcers | Typically on pressure points of feet, painless, round with callused edges |
| Venous insufficiency | Venous stasis ulcers | Lower leg, especially medial ankle, shallow, irregular, painful |
| Peripheral arterial disease | Arterial ulcers | Toes, feet, or lateral ankle, deep, well-defined, extremely painful |
| Spinal cord injury, paralysis | Pressure ulcers (decubitus) | Over bony prominences, related to immobility, staged by depth |
| Vasculitis, autoimmune conditions | Vasculitic ulcers | Can occur anywhere, often multiple, painful, irregular borders |
Documentation Strategies
To establish skin ulcers as secondary conditions, focus on documenting:
- Specialist evaluation (dermatology, vascular, podiatry, wound care)
- Detailed description of ulcers:
- Location and distribution
- Size (length, width, depth)
- Appearance (edges, base, drainage)
- Pain level
- Recurrence pattern
- Photographic evidence of ulcers
- Objective testing related to cause:
- Vascular studies (ABI, duplex ultrasound)
- Neurological testing (monofilament, nerve conduction)
- Laboratory studies (glucose control, inflammatory markers)
- Treatment requirements:
- Wound care frequency
- Debridement procedures
- Dressing types and frequency
- Antibiotics for infections
- Hospitalizations
- Surgical interventions
- Preventive measures required:
- Special footwear
- Pressure-relieving devices
- Activity modifications
- Complications:
- Infections
- Osteomyelitis
- Need for amputation
- Impact on mobility and daily activities
- Specialist opinions addressing the causal relationship
Evidence Checklist & Documentation Strategies
Skin Secondary Conditions Evidence Checklist
- Medical diagnosis of the secondary skin condition
- Treatment records for the primary service-connected condition
- Dermatology specialist evaluations
- Photographic evidence of skin condition
- Detailed measurements and descriptions of affected areas
- Medication history showing drugs prescribed for service-connected conditions
- Medical opinion linking the skin condition to the primary condition
- Timeline showing primary condition preceded skin symptoms
- Biopsy results if performed
- Treatment records for the skin condition
- Documentation of functional limitations caused by skin condition
- Evidence of psychological impact if applicable
- Personal statement describing how the primary condition led to skin symptoms
- Relevant medical literature supporting the skin condition connection
Effective Documentation Approaches
For skin secondary conditions, these documentation strategies are particularly effective:
Visual Evidence
Skin conditions benefit greatly from visual documentation:
- Clear, well-lit photographs of affected areas
- Multiple angles to show extent and characteristics
- Close-up images showing detail of lesions
- Serial photographs showing progression or changes over time
- Comparison photographs of affected vs. unaffected areas
Precise Measurements
Detailed measurements strengthen claims:
- Exact dimensions of scars (length, width, depth)
- Percentage of body surface area affected
- Percentage of exposed areas affected
- Size and number of lesions
- Area measurements using transparent grids or digital tools
Functional Impact Documentation
Document how skin conditions affect function:
- Pain or tenderness (frequency, severity, triggers)
- Limitation of motion from scars or skin tightness
- Instability of skin (breakdown, bleeding)
- Impact on daily activities (dressing, bathing, sleeping)
- Work limitations and accommodations needed
- Social effects and psychological impact
Treatment Documentation
Detailed treatment records strengthen claims:
- All prescribed medications with dosages and frequency
- Duration of treatments
- Systemic vs. topical therapies
- Procedures performed (debridement, injections)
- Frequency of medical visits
- Failed treatments and side effects
Expert Tip
For medication-induced skin conditions, the “challenge/dechallenge/rechallenge” evidence can be particularly powerful. Document how symptoms developed after starting a medication (challenge), improved after stopping it (dechallenge), and potentially returned if the medication was tried again (rechallenge). This pattern strongly supports the causal relationship between the medication and the skin condition.