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VA Rating Assistant

DC 7816 · 38 CFR 4.118

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

To document the current severity, extent, and treatment of your skin condition for VA disability rating purposes under 38 CFR - 4.118 using the General Rating Formula for the Skin. The examiner will determine what percentage of your total body surface area (TBSA) and exposed body surface area (EBSA) is affected, whether your condition is active or in remission, and what treatments you require.

Format:
Interview + Physical
Typical duration:
15-30 minutes
DBQ form:
Skin_Diseases (Skin_Diseases)
Examiner:
Dermatologist or appropriate clinician

What the examiner evaluates

  • Specific diagnosis and ICD code for your skin condition(s)
  • Total body surface area (TBSA) affected, expressed as a percentage
  • Exposed body surface area (EBSA) affected, expressed as a percentage
  • Whether the condition is currently active or in remission
  • Current and past treatments including medications, phototherapy, biologics, and procedures
  • Severity descriptors: superficial vs. deep lesions, nodules, cysts, plaques
  • Location of involvement: face/neck, intertriginous areas, palmar/plantar surfaces, mucosal involvement
  • Presence of complications such as psoriatic arthritis, nail involvement, or oral mucosal involvement
  • Impact on daily activities, work, and quality of life
  • History of the condition including onset, course, flare-ups, and remissions
  • Whether the veteran has previously had skin conditions that have since resolved

The examiner will conduct a physical inspection of your skin. Be prepared to undress partially so all affected areas can be visually examined. The exam typically includes a structured interview about your symptoms, treatment history, and functional impact. Photographs may be taken to document lesion distribution and severity. Under M21-1 guidance, the DBQ must identify both TBSA and EBSA percentages for the rating to be sufficient.

Measurements and tests

Total Body Surface Area (TBSA) Assessment

What it measures: The percentage of your entire body surface covered by the skin condition. This is a core rating factor under the General Rating Formula for the Skin.

What to expect: The examiner will visually inspect your entire body and estimate the percentage of skin affected by your condition. The Rule of Nines or similar dermatological estimation methods may be used. You should expose all affected areas, including scalp, trunk, extremities, and intertriginous zones.

Critical thresholds

  • Less than 5% TBSA May support 0% or 10% rating depending on treatment requirements
  • 5%-19% TBSA or requiring systemic therapy May support 30% rating
  • 20%-39% TBSA May support 30% rating
  • 40%-59% TBSA May support 50% rating
  • 60% or more TBSA or incapacitating episodes requiring systemic therapy -6 weeks/year May support 60% rating

Tips

  • Point out ALL affected areas before the exam ends, including areas currently in remission that still scar or discolor
  • Mention scalp involvement separately as it is often overlooked
  • Describe your worst flare-up if your skin looks better on exam day than usual
  • Ask the examiner to document both TBSA and EBSA - the DBQ requires both for a sufficient rating

Pain considerations: Describe any pain, burning, or stinging associated with skin lesions, especially during flares. Note if touching or pressure on plaques or lesions causes pain, as this can support additional functional limitations.

Exposed Body Surface Area (EBSA) Assessment

What it measures: The percentage of normally exposed body surface area (face, neck, hands, forearms, lower legs, feet) affected by your condition. EBSA is critical because involvement of visible areas may affect employment and social functioning.

What to expect: The examiner will specifically note lesions on your face, neck, hands, forearms, and other areas typically visible in daily life. Some rating decisions give additional weight to visible or exposed-area involvement.

Critical thresholds

  • Less than 40% of face and neck affected Lower severity tier for facial/neck involvement
  • 40% or more of face and neck affected Higher severity tier; may support higher rating and employability considerations
  • Intertriginous areas affected (axilla, anogenital, under breasts) Elevated severity; these areas are especially debilitating and painful

Tips

  • Do not wear concealing makeup or clothing to hide lesions on exam day
  • If lesions on face/neck are worse during flares, describe that verbally even if less visible at exam time
  • Mention hand and foot involvement explicitly - palmar and plantar involvement is tracked separately on the DBQ
  • Note whether facial involvement has caused social withdrawal, employment issues, or psychological distress

Pain considerations: Facial and hand lesions can cause significant functional impairment. Describe difficulty with tasks requiring fine motor skills when hands are affected, or how facial involvement impacts daily interactions.

Acne Severity Classification

What it measures: For acne, the examiner classifies whether lesions are superficial (comedones, papules, pustules) or deep (inflamed nodules, pus-filled cysts) and determines body area distribution. Under DC 7828, severity drives the rating.

What to expect: The examiner will look for comedones, papules, pustules, inflamed nodules, and cysts. They will note the location (face/neck vs. body) and percentage of affected area. For chloracne (DC 7822), the exam is particularly detailed given its association with toxic exposures.

Critical thresholds

  • Superficial acne (comedones, papules, pustules only) Typically 0% unless affecting 40%+ of face/neck
  • Deep acne (nodules and cysts) affecting body areas other than face/neck Supports 10% rating
  • Deep acne affecting less than 40% of face and neck Supports 30% rating
  • Deep acne affecting 40% or more of face and neck, OR affecting intertriginous areas Supports 60% rating

Tips

  • If your acne fluctuates, describe your typical worst presentation, not just what is visible today
  • Note any scarring from past cysts or nodules as evidence of prior severity
  • Clearly distinguish between superficial and deep lesions when describing your condition
  • For chloracne, document any toxic or chemical exposure in service explicitly

Pain considerations: Deep acne nodules and cysts can be extremely painful. Describe pain level, tenderness to touch, and any impact on wearing clothing, using equipment, or physical contact in your military occupational specialty.

Rating criteria by percentage

0%

No disability, or the skin condition is controlled with no more than topical therapy. Condition is in remission or causes minimal symptoms that do not require ongoing treatment.

Key symptoms

  • Skin condition fully or largely in remission
  • Controlled with over-the-counter or basic topical creams only
  • No significant area of skin involvement
  • No functional impairment

From 38 CFR: Under the General Rating Formula for the Skin (38 CFR - 4.118), a 0% rating reflects a condition present but causing no disability warranting compensation.

10%

At least one of the following: topical therapy required over past 12-month period, or area of skin involved is less than 5% of total body surface area (TBSA). Condition requires ongoing management but is not severely disabling.

Key symptoms

  • Requires prescription topical corticosteroids, calcineurin inhibitors, or other prescription topical agents
  • Less than 5% TBSA affected
  • Periodic flares requiring topical treatment
  • Minimal impact on daily functioning

From 38 CFR: Under the General Rating Formula for the Skin, 10% reflects a condition requiring at least topical therapy or involving a small body surface area.

30%

At least one of the following: systemic therapy required for a total of at least six weeks during the past 12-month period, or 5%-19% of the total body surface area is affected during the past 12-month period.

Key symptoms

  • 5% to 19% TBSA affected
  • Requires systemic therapy (oral corticosteroids, methotrexate, cyclosporine, etc.) for -6 weeks in the past year
  • Significant itching, scaling, or inflammation
  • Moderate impact on daily activities and sleep
  • Condition requires monitoring by a dermatologist

From 38 CFR: Under the General Rating Formula for the Skin, 30% reflects moderate skin involvement or a treatment burden requiring systemic therapy for at least 6 weeks per year.

60%

At least one of the following: systemic therapy required for a total of at least 12 weeks during the past 12-month period, or 20%-39% of the total body surface area is affected during the past 12-month period.

Key symptoms

  • 20% to 39% TBSA affected
  • Requires systemic therapy (oral agents or biologics) for -12 weeks per year
  • Severe itching, pain, scaling, and inflammation
  • Significant impact on sleep, work, and social functioning
  • Multiple medication regimens required
  • Frequent dermatologist visits

From 38 CFR: Under the General Rating Formula for the Skin, 60% reflects severe skin involvement or high treatment burden requiring systemic therapy for at least 12 weeks per year.

Describing your symptoms accurately

Body Surface Area and Lesion Distribution

How to describe it: Describe the extent of your skin involvement using percentages where possible (e.g., 'My plaques cover roughly my entire back, both arms, and parts of my legs - I'd estimate about 30-40% of my body'). Name specific body regions: scalp, face, neck, trunk, extremities, palms, soles, and intertriginous areas (groin, armpits, under breasts). Distinguish between active lesions, healing areas, and post-inflammatory pigmentation or scarring.

Example: On my worst days, my psoriatic plaques cover nearly my entire back, both arms, and my scalp. The skin is cracked, bleeding in spots, and extremely tender. Even wearing a shirt is painful. I estimate about 35% of my body is covered at peak flares, which happen about monthly and last 2-3 weeks.

Examiner listens for: Specific body regions affected, percentage estimates, chronicity of involvement, whether current exam day represents typical presentation or a better-than-usual day, presence of involvement in high-severity locations (face, hands, intertriginous areas).

Avoid: Do not say 'it's not that bad right now' without also describing your worst presentation. Do not minimize scalp involvement or facial lesions. Do not forget to mention areas covered by clothing during the exam.

Treatment Burden and Systemic Therapy

How to describe it: List every medication you use for your skin condition - topical and systemic. Include the name, dose, how long you have been on it, and how many weeks per year you require it. For biologics or systemic agents, specify the exact therapy (e.g., methotrexate 15mg weekly, adalimumab every 2 weeks). Note any treatments you have tried and discontinued due to side effects or inadequate control.

Example: I have been on methotrexate for two years and also use high-potency topical steroids daily. I also completed a 12-week course of phototherapy last year. Despite all of this, I still have significant flares. The methotrexate requires monthly blood tests and causes fatigue and nausea.

Examiner listens for: Whether systemic therapy has been required, total weeks per year on systemic agents, escalation of treatment over time, side effects of treatment (which reflect treatment burden), and whether the condition is controlled or refractory despite treatment.

Avoid: Do not say you 'just use a cream' if you also take systemic medications. Do not underreport how many weeks per year you are on oral or injectable agents. Do not fail to mention biologics, immunosuppressives, or phototherapy.

Flares, Remissions, and Episodic Nature

How to describe it: Describe the frequency, duration, and severity of your flares. Note what triggers them (stress, cold weather, certain soaps, food, etc.). State how many weeks per year you experience active disease versus remission. Be explicit about whether today's exam reflects your typical condition or a period of relative improvement.

Example: I typically have 4-6 major flares per year, each lasting 3-4 weeks. During flares, I cannot sleep due to itching and pain, I miss work 1-2 days per week, and I avoid social situations due to embarrassment. I am currently in a partial remission, but this is not typical - most of the year I am dealing with active disease.

Examiner listens for: Frequency and duration of flares, impact of flares on function and work, whether remissions are complete or partial, triggers, and whether the exam-day appearance is representative of the year-round condition.

Avoid: Do not let a good exam day define your rating. If you have active disease most of the year, say so clearly. Do not forget to mention that your condition is episodic and today may not reflect your worst or typical presentation.

Functional and Occupational Impact

How to describe it: Explain how your skin condition affects your ability to work, perform daily tasks, sleep, and maintain social relationships. Mention specific limitations: inability to wear certain uniforms or clothing, difficulty using tools or equipment due to hand involvement, need to avoid sun exposure, inability to participate in physical training, and impact on mental health.

Example: During bad flares, I cannot grip tools because my palms are cracked and bleeding. I miss work because I cannot wear my uniform without severe skin irritation. I sleep only 2-3 hours a night due to intense itching. I have stopped socializing because of my appearance, which has contributed to depression.

Examiner listens for: Specific functional limitations tied to the skin condition, impact on employment and employability, sleep disruption, psychological effects, and any secondary conditions caused or worsened by the skin disease.

Avoid: Do not say you 'manage fine' without describing the accommodations required to do so. Do not omit psychological impact or social withdrawal. Do not downplay sleep disruption, which is a major functional consequence of severe skin conditions.

Complications and Associated Conditions

How to describe it: For psoriasis specifically, report any joint pain, stiffness, or swelling (psoriatic arthritis), nail changes (pitting, onycholysis, discoloration), or oral mucosal involvement. These complications are rated separately under additional diagnostic codes. Clearly describe each complication so the examiner can note it in the appropriate DBQ section.

Example: In addition to skin plaques, I have significant pain and swelling in my finger joints and both knees, which my doctor believes is psoriatic arthritis. My fingernails are pitted and partially separated from the nail bed. These joint problems make it difficult to walk more than one block and prevent me from doing most manual tasks.

Examiner listens for: Joint symptoms suggesting psoriatic arthritis, nail dystrophy, mucosal involvement, presence of erythroderma or exfoliative dermatitis, vasculitis, scarring alopecia, and any systemic manifestations.

Avoid: Do not assume joint pain is unrelated to your skin condition. Do not fail to mention nail changes, which are separately ratable. Do not overlook oral lesions or mucosal involvement if present.

Common mistakes to avoid

Presenting at exam during a period of remission without disclosing typical severity

Why: Skin conditions are episodic. The examiner can only see what is present on exam day. If today is a good day, the DBQ will reflect minimal involvement and your rating may be significantly lower than warranted.

Do this instead: Explicitly tell the examiner: 'Today is not representative of my typical condition. My worst flares look like [description] and occur [frequency]. I am in a partial remission today.' Bring photos of your skin during active flares.

Impact: All levels - this mistake most commonly causes 0% or 10% ratings when 30% or higher is warranted

Failing to report all treatments including systemic agents and biologics

Why: The number of weeks per year on systemic therapy is a key rating threshold under the General Rating Formula for the Skin. Failing to disclose all treatments (especially oral or injectable agents used for 6+ or 12+ weeks per year) can cause the rating to be scored at a lower tier.

Do this instead: Prepare a complete medication list including all topical and systemic treatments, the duration of each, and why they were prescribed. Include discontinued treatments that demonstrate the condition's severity over time.

Impact: 30% and 60% rating thresholds are directly tied to systemic therapy duration

Not mentioning complications such as psoriatic arthritis or nail involvement

Why: Complications of psoriasis are rated separately and can significantly increase your overall combined rating. If you do not report them, the examiner will not document them in the DBQ, and VA will not know to rate them.

Do this instead: Proactively describe all complications: joint pain, stiffness, nail changes, oral lesions. Ask the examiner to note each one in the DBQ and request referral to appropriate specialists if needed.

Impact: Can prevent separate ratings for psoriatic arthritis (DC 5002) and nail conditions

Minimizing the percentage of body surface area affected

Why: The TBSA percentage is one of the two primary quantitative criteria driving your rating tier. Veterans often downplay the extent of their condition or only reference areas visible on exam day.

Do this instead: Before the exam, use the Rule of Nines to estimate your typical affected area during active disease. Bring photos. Verbally describe your scalp, trunk, extremities, and hidden areas (groin, armpits, under breasts) in detail.

Impact: Directly determines whether you reach 10%, 30%, or 60% thresholds

Focusing only on appearance and not on functional limitations

Why: The impact on your ability to work, sleep, and function in daily life is critical context that supports the rating and any secondary conditions (like PTSD, depression, or musculoskeletal conditions). Examiners are required to document functional impact.

Do this instead: Prepare specific examples of how your skin condition limits you: 'I cannot wear a collared shirt during flares,' 'I miss 1-2 days of work per month,' 'I have not slept more than 4 hours on nights with active flares.' Tie limitations to specific activities.

Impact: All levels - functional impact documentation supports rating accuracy and secondary condition claims

Not disclosing resolved or historical conditions

Why: The DBQ has a section asking whether the veteran previously had skin conditions that have since resolved. A history of severe episodes, hospitalizations, or prior systemic treatment is relevant evidence of condition severity even if currently in remission.

Do this instead: Describe the full history of your condition: when it started, previous treatments including any hospitalizations, courses of systemic therapy, or procedures. Mention any periods of particularly severe disease even if they resolved.

Impact: Affects historical context and may support higher ratings or continuity of service-connection

Prep checklist

  • critical

    Compile a complete medication list

    List every medication used for your skin condition: topical corticosteroids (name and potency class), calcineurin inhibitors (tacrolimus, pimecrolimus), retinoids, antihistamines, oral corticosteroids (prednisone), immunosuppressives (methotrexate, cyclosporine, azathioprine), biologics (adalimumab/Humira, secukinumab/Cosentyx, ustekinumab/Stelara, dupilumab/Dupixent, etc.), and any other prescription agents. Note the start date, dose, frequency, and approximate number of weeks per year used. Include discontinued medications.

    before exam

  • critical

    Photograph your skin during active flares

    Take dated photos of all affected areas during your next flare or pull existing photos from your phone showing worst-day presentation. Include scalp, face, neck, trunk, arms, hands, legs, feet, and any intertriginous areas. Under M21-1, photographs may be considered in rating decisions and can document severity that is not visible on exam day.

    before exam

  • critical

    Estimate your total body surface area (TBSA) affected

    Use the Rule of Nines to estimate your typical TBSA during active disease: head/neck = 9%, each arm = 9%, chest = 9%, abdomen = 9%, upper back = 9%, lower back/buttocks = 9%, each thigh = 9%, each lower leg = 7%, genitalia = 1%. Add up your affected areas and note both your typical active-disease percentage and your worst-flare percentage.

    before exam

  • critical

    Document flare frequency and duration over the past 12 months

    Create a written timeline of your flares over the past year: start date, end date, approximate TBSA affected, treatment required, and functional impact during each episode. Twelve months of history is the standard reference period for the rating formula. Note total weeks on systemic therapy.

    before exam

  • critical

    Gather supporting medical records

    Collect records from your dermatologist, primary care provider, and any specialists. Include records documenting diagnosis, prescription history, phototherapy treatment logs, lab results (CBC, LFTs from methotrexate monitoring), and any hospitalizations for skin conditions. Submit these to VA prior to the exam or bring copies.

    before exam

  • critical

    Identify and document all complications

    For psoriasis: note any joint pain, swelling, morning stiffness (psoriatic arthritis), nail pitting or onycholysis, or oral lesions. For any skin condition: note scarring, alopecia, hyperhidrosis, or mucosal involvement. These are separately ratable and must be documented by the examiner.

    before exam

  • recommended

    Prepare a written statement or buddy statement

    Write a personal statement describing your condition's history, typical severity, flare patterns, treatment burden, and functional impact. Ask a family member, spouse, or close friend to write a buddy statement describing what they have observed. Submit these to VA before your exam.

    before exam

  • recommended

    Review the General Rating Formula for the Skin

    Familiarize yourself with the rating thresholds: topical therapy only or less than 5% TBSA = 10%; systemic therapy -6 weeks/year or 5-19% TBSA = 30%; systemic therapy -12 weeks/year or 20-39% TBSA = 60%. Understanding these thresholds helps you communicate your condition accurately.

    before exam

  • critical

    Do NOT conceal or treat affected areas before the exam

    Do not apply extra moisturizer, use makeup to cover facial lesions, or wear compression garments to hide plaques on the day of the exam. The examiner needs to see your condition as it typically appears. Do continue your normal medication routine, but do not take steps specifically designed to make your skin appear better.

    day of

  • recommended

    Wear easy-to-remove clothing for full examination

    Wear loose, easily removable clothing so the examiner can inspect all affected body areas including your scalp, trunk, back, axillae, groin, hands, and feet. Bring or wear a sports bra or tank top if you have chest or upper back involvement.

    day of

  • critical

    Bring your medication list and photos

    Bring your prepared medication list and flare photos to the exam. Offer these to the examiner at the start of the appointment. Ask that photos be included in or attached to the exam report.

    day of

  • optional

    Bring a trusted support person if permitted

    Consider bringing a spouse, family member, or VSO representative to help you remember important details and ensure you communicate your full symptom picture. Confirm with the exam facility whether support persons are permitted.

    day of

  • critical

    Disclose that today may not represent your typical condition

    At the start of the exam, clearly state whether your skin is better, worse, or typical compared to your usual condition. If you are in a relative remission, say so explicitly and describe what your skin looks like during active disease. Reference your photos.

    during exam

  • critical

    Name all affected body regions including hidden areas

    Proactively mention and show all affected areas including scalp (part your hair to show scalp plaques), ears, nail beds, palms, soles, groin, axillae, umbilicus, and gluteal cleft. These areas are often missed if you do not bring them to the examiner's attention.

    during exam

  • critical

    Report functional impact in specific terms

    Describe exactly how your condition limits you: 'I cannot grip a steering wheel during hand flares,' 'I wake up 3-4 times per night scratching,' 'I have called in sick to work 8 days in the past year due to my skin,' 'I stopped wearing shorts or short sleeves in public because of my lesions.' Specific, concrete examples are more useful than general statements.

    during exam

  • critical

    Report all complications separately

    Specifically ask the examiner to note psoriatic arthritis, nail involvement, oral mucosal lesions, scarring alopecia, hyperhidrosis, or any other complications in the DBQ. Ask whether a separate DBQ will be completed for joint complications.

    during exam

  • critical

    Confirm the examiner is documenting both TBSA and EBSA

    Under M21-1, a skin DBQ that does not identify both total body surface area and exposed body surface area percentages may be considered insufficient for rating. Politely confirm with the examiner that both are being documented.

    during exam

  • recommended

    Request exam recording if permitted in your state

    Veterans have the right to request that their C&P exam be recorded in most states (check your state's one-party or two-party consent laws). Notify the examiner at the start of the appointment if you wish to record. Recording can provide an accurate record if you later need to challenge an inadequate examination.

    during exam

  • recommended

    Request a copy of the completed DBQ

    You have the right to request a copy of the completed DBQ through your VA MyHealtheVet account or by submitting a records request. Review it for accuracy, especially the TBSA/EBSA percentages, treatment documentation, and functional impact description.

    after exam

  • recommended

    File a Nexus letter or supplemental statement if the DBQ is inaccurate

    If the exam report understates your condition, misses affected areas, or fails to document your treatment burden accurately, obtain a private nexus letter from your treating dermatologist or submit a supplemental statement with additional evidence before VA makes its rating decision.

    after exam

  • optional

    Consider filing for secondary conditions

    Skin conditions can cause or worsen depression, anxiety, sleep disorders, and social isolation. If your skin condition has contributed to a mental health condition, consider filing a secondary service connection claim supported by a medical opinion.

    after exam

Your rights during a C&P exam

  • You have the right to request that your C&P examination be recorded in most states, subject to applicable one-party or two-party consent laws. Notify the examiner at the beginning of the appointment.
  • You have the right to review the completed DBQ and all exam records through your VA MyHealtheVet account or by submitting a formal records request.
  • You have the right to submit a personal statement, buddy statements, and private medical opinions (nexus letters) to supplement the C&P exam evidence before VA issues its rating decision.
  • You have the right to request a new or additional C&P examination if you believe the original exam was inadequate, incomplete, or failed to document your condition accurately.
  • You have the right to bring a support person (spouse, family member, VSO representative) to your C&P exam, subject to facility rules. Confirm with the exam facility in advance.
  • You have the right to be rated based on your worst-day or typical presentation, not solely on what the examiner observes on a single exam day. You should verbally describe your condition during flares if today is not representative.
  • Under M21-1, a skin DBQ that does not identify both TBSA and EBSA percentages is considered insufficient for rating purposes. You can notify VA if these fields were not completed.
  • You have the right to appeal any rating decision you believe is inaccurate by filing a Higher-Level Review (HLR), Supplemental Claim with new evidence, or Board of Veterans Appeals (BVA) appeal.
  • Psoriasis complications such as psoriatic arthritis, nail involvement, and oral mucosal disease are separately ratable under additional diagnostic codes. You have the right to claim each complication separately.
  • You are not required to accept the first rating assigned. If your condition worsens or new evidence becomes available, you may file for an increased rating at any time.

Related conditions

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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.