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DC 7822 · 38 CFR 4.118

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

To document the nature, severity, and extent of your skin condition for VA disability rating purposes under 38 CFR - 4.118. The examiner will determine the diagnosis, the total body surface area (TBSA) and exposed body surface area (EBSA) affected, treatment history, frequency of flare-ups, and functional impact on daily life and work.

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

What the examiner evaluates

  • Specific skin diagnosis (e.g., papulosquamous disorder, 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 condition is active or in remission at time of exam
  • Frequency, duration, and severity of flare-ups
  • Involvement of special body areas: palmar, plantar, mucosal, intertriginous zones, face and neck
  • Current and historical treatments including corticosteroids, biologics, retinoids, antihistamines, phototherapy, immunosuppressives
  • Treatment-line history (first-line, second-line, third-line)
  • Impact on daily activities, employment, and quality of life
  • Presence of erythroderma or exfoliative dermatitis
  • Scarring, alopecia, hyperhidrosis, or vitiligo as related complications
  • Whether any complications warrant separate diagnostic codes (e.g., psoriatic arthritis)

The examiner will visually inspect affected skin areas and conduct a clinical interview. You may be asked to undress partially to allow full assessment. Bring all medications and a written symptom history. The exam often occurs at a VA medical center, CBOC, or contractor facility (e.g., VES, LHI, QTC). You have the right to request the exam be recorded in most states - check your state's one-party or two-party consent law beforehand.

Measurements and tests

Total Body Surface Area (TBSA) Affected

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

What to expect: The examiner will visually estimate the percentage of your skin affected using the Rule of Nines or similar clinical estimation. They may measure or estimate areas on your trunk, extremities, scalp, face, and neck. This measurement must appear in the DBQ for the exam to be sufficient for rating purposes.

Critical thresholds

  • Less than 5% TBSA May support 0% if well-controlled or 10% with constant symptoms
  • 5-20% TBSA or 20-40% EBSA Supports 30% rating under General Formula
  • More than 20% TBSA, or more than 40% EBSA, or systemic therapy required Supports 60% rating under General Formula

Tips

  • Do not apply medications, cover up lesions, or use heavy cosmetics before the exam - the examiner must see your condition at its representative state.
  • If your condition fluctuates, inform the examiner about your worst presentation even if the exam day is a better day.
  • Ask the examiner to document both TBSA and EBSA explicitly - both are required for a sufficient rating exam per M21-1.
  • Bring photographs taken during flare-ups to show the examiner the full extent of disease when active.

Pain considerations: Pain, burning, and pruritus associated with active lesions should be verbally reported to the examiner. Skin pain is not a separate DeLuca-type musculoskeletal factor but must be documented because it drives functional impairment used in the occupational and social impact section of the DBQ.

Exposed Body Surface Area (EBSA) Affected

What it measures: The percentage of exposed (visible) body surface areas - such as the face, neck, and hands - that are affected. Involvement of exposed areas carries additional rating weight because of the social and occupational impact of visible lesions.

What to expect: The examiner will separately assess what percentage of normally exposed skin is involved. Exposure of areas like face, neck, forearms, and hands may trigger higher rating criteria even if TBSA is lower.

Critical thresholds

  • 20-40% of exposed areas Supports 30% rating
  • More than 40% of exposed areas Supports 60% rating

Tips

  • Clearly identify to the examiner which areas are regularly exposed in your daily life and occupation.
  • Face and neck involvement at 40% or more is explicitly noted on the DBQ and raises rating consideration.
  • If you work outdoors or in a public-facing role, the functional impact of exposed-area involvement is amplified - communicate this.

Pain considerations: Lesions on exposed areas, particularly the face and hands, often cause social anxiety, avoidance behavior, and occupational limitations. Describe these impacts explicitly.

Special Area Involvement Assessment

What it measures: Whether the condition affects functionally and clinically significant body areas including palms (palmar), soles (plantar), mucous membranes (mucosal), and skin folds (intertriginous areas such as axilla, groin, and anogenital region).

What to expect: The examiner will check specific body sites. Palmar and plantar involvement are noted on DBQ checkboxes with episode frequency. Mucosal and intertriginous involvement are also separately recorded. These findings can affect rating level and may support analogous rating under higher criteria.

Critical thresholds

  • Palmar or plantar involvement present Can support 60% rating or higher analogous codes depending on frequency and severity
  • Mucosal involvement present Relevant to erythema multiforme, bullous disorders, and may trigger separate rating considerations
  • Intertriginous involvement present Noted in DBQ and supports higher severity documentation

Tips

  • Report all areas affected, including areas you might consider minor, such as inside your mouth, palms, or between skin folds.
  • For palmar/plantar involvement, describe how many episodes per year you experience and how long each lasts.
  • Intertriginous involvement (skin folds) is often underreported - describe any rashes, maceration, or secondary infections in these areas.

Pain considerations: Palmar and plantar psoriasis or eczema can be severely disabling due to cracking, bleeding, and pain with weight-bearing or manual tasks. Describe functional limitations such as inability to grip, walk, or perform daily tasks during flare-ups.

Flare-Up Frequency and Duration Assessment

What it measures: How often your skin condition flares, how long flares last, what triggers them, and what the condition looks like during a flare versus remission.

What to expect: The examiner will ask about frequency of active episodes, duration of remissions, and what treatments are required during flares. The DBQ captures whether the condition is currently active or in remission, and this is a critical rating driver.

Critical thresholds

  • Constant or near-constant symptoms requiring ongoing systemic treatment Supports 60% rating
  • Frequent flares with intermittent remission Supports 30% rating depending on area affected
  • Infrequent flares, well-controlled with topical treatment only May support 10% or 0% rating

Tips

  • Keep a symptom diary for the 60 days before your exam noting flare dates, severity, duration, and triggers.
  • Do not describe only your average day - describe your worst days per M21-1 guidance.
  • If the exam falls during a remission, explicitly tell the examiner: 'Today is a relatively controlled day; my condition is typically much worse.'
  • Describe all known triggers: stress, temperature changes, dietary factors, occupational exposures, soaps/chemicals.

Pain considerations: During flares, describe all associated symptoms: pain, burning, pruritus, weeping lesions, bleeding cracks, and any systemic symptoms such as fatigue or joint pain (especially relevant for psoriasis).

Rating criteria by percentage

0%

No characteristic lesions, or only residual skin damage with no active disease, no treatment required, and no functional impairment. Condition is in complete, sustained remission.

Key symptoms

  • Complete remission with no active lesions
  • No ongoing treatment required
  • No functional limitations from skin condition

From 38 CFR: Under the General Rating Formula for the Skin (38 CFR - 4.118), 0% is assigned when the condition requires no treatment and produces no disability.

10%

At least one characteristic lesion present, OR condition requires topical therapy only (creams, ointments), with less than 5% of total body surface area affected. Condition is controlled but not absent.

Key symptoms

  • Active lesions present but limited in extent
  • Controlled with topical medications only
  • Less than 5% TBSA affected
  • Minimal functional impairment

From 38 CFR: General Rating Formula for the Skin: at least one of the following: characteristic lesions involving less than 5% of entire body, or less than 5% of exposed areas, and; no more than topical therapy required during the past 12-month period.

30%

Characteristic lesions involving 5-20% of the entire body surface OR 20-40% of exposed body surface areas, OR requiring intermittent systemic therapy (oral steroids, immunosuppressives, retinoids, biologics) for a total duration of less than 6 weeks during the past 12-month period.

Key symptoms

  • 5-20% TBSA affected
  • 20-40% of exposed body surface affected
  • Intermittent use of systemic medications
  • Requires oral steroids or second-line agents less than 6 weeks per year
  • Moderate flare-up frequency with partial remission between episodes

From 38 CFR: General Rating Formula for the Skin at 30%: At least one of the following: characteristic lesions involving 5% to 20% of entire body or 20% to 40% of exposed areas, OR systemic therapy such as corticosteroids or other immunosuppressives required for a total duration of less than six weeks over the past 12-month period.

60%

Characteristic lesions involving more than 20% of the entire body surface OR more than 40% of exposed body surface areas, OR requiring systemic therapy (oral or injectable steroids, biologics, immunosuppressives, retinoids) for a total duration of 6 weeks or more during the past 12-month period.

Key symptoms

  • More than 20% TBSA affected
  • More than 40% of exposed body surface affected
  • Systemic therapy required 6 or more weeks per year
  • Biologic medications in use
  • Significant functional impairment, occupational limitations
  • Frequent or prolonged flare-ups
  • Palmar or plantar involvement with functional limitation
  • Intertriginous, mucosal, or facial involvement

From 38 CFR: General Rating Formula for the Skin at 60%: At least one of the following: characteristic lesions involving more than 20% of the entire body or more than 40% of exposed areas, OR systemic therapy such as corticosteroids or other immunosuppressives required for a total duration of six weeks or more over the past 12-month period.

Describing your symptoms accurately

Extent and Location of Active Lesions

How to describe it: Describe which body areas are currently affected and estimate what percentage of your body is covered. Use reference points: 'Both arms from wrist to elbow are fully involved, both lower legs are covered, and patches on my back and abdomen together cover roughly 25-30% of my body.' Specify face, neck, hands, and other exposed areas separately.

Example: On my worst days, the plaques cover both legs entirely from knee to ankle, spread across my lower back and abdomen, and I have patches on both arms. My palms crack and bleed, and I cannot make a full fist. I estimate 25-30% of my body is affected during a full flare, including visible areas on my face and forearms that I cannot hide at work.

Examiner listens for: Specific body locations, percentage estimates, involvement of exposed versus non-exposed areas, and whether special sites (palms, soles, face, mucous membranes) are affected.

Avoid: Do not say 'a few spots here and there' if your condition covers large areas during flares. Do not minimize involvement of the face or hands. Do not fail to mention mucosal or genital involvement if present.

Treatment Intensity and Duration

How to describe it: List every medication you use or have used, whether topical or systemic, and for how long you used it in the past 12 months. Include: corticosteroid creams, biologic injections (e.g., Humira, Skyrizi, Dupixent), oral retinoids, methotrexate, cyclosporine, antihistamines, and any phototherapy. State total weeks of use per year for systemic treatments.

Example: I have been on a biologic injection every two weeks for the past 14 months because topical steroids and oral methotrexate were no longer adequate. I also use high-potency topical steroids daily on resistant patches. I have been on systemic therapy continuously for more than 6 weeks in the past 12 months.

Examiner listens for: Escalation of treatment over time, use of systemic or biologic agents, total duration of systemic therapy in the past year (the 6-week threshold is the key dividing line for 30% vs. 60% rating), and whether treatment has failed.

Avoid: Do not omit any medication - even over-the-counter antihistamines or prescription topical calcineurin inhibitors. Do not understate total weeks of systemic treatment. Bring a medication list with start/stop dates.

Flare-Up Frequency, Triggers, and Severity

How to describe it: Describe how many times per year you have significant flares, how long they last, what triggers them, and what the skin looks like during a flare (plaques, scaling, oozing, cracking, pustules, erythema). Also describe periods of remission and how complete the remission is.

Example: I flare severely 4-6 times per year, with each flare lasting 3-6 weeks before partial control is achieved. During a flare, my skin is bright red, thickly scaled, extremely itchy, and bleeds if I scratch. I have never achieved complete clearance - even in remission I have at least 5-10% of my body still showing plaques.

Examiner listens for: Frequency and duration of flares, whether remission is complete or partial, what the skin looks like at its worst, and whether there are any systemic symptoms during flares such as joint pain, fatigue, or fever.

Avoid: Do not describe only your current state if today is a good day. Explicitly state: 'Today is better than average - my typical presentation is more severe.' Do not omit triggers such as stress, infection, or occupational exposures.

Functional and Occupational Impact

How to describe it: Describe how your skin condition limits your ability to work, perform daily tasks, socialize, exercise, or sleep. Mention any missed work days, limitations on lifting or gripping due to hand involvement, inability to wear certain clothing or equipment, or psychological effects such as social avoidance or depression.

Example: During flares, I cannot wear my work uniform because it irritates the plaques. I have missed an average of 2-3 days of work per month. My hand involvement prevents me from using tools or shaking hands. I avoid social situations because of the appearance of my skin on my face and arms, and I have been diagnosed with depression linked to my skin condition.

Examiner listens for: Specific occupational limitations, missed work, impact on activities of daily living, psychological effects, and any assistive measures or accommodations required because of the skin condition.

Avoid: Do not say 'it bothers me a little' if your condition significantly affects your work or social life. Be specific about missed days, tasks you cannot perform, and how the condition has changed your life over time.

Associated Symptoms and Complications

How to describe it: For psoriasis specifically, mention any joint pain (psoriatic arthritis), nail changes (pitting, onycholysis), scalp involvement, or eye conditions. For eczema/dermatitis, mention secondary bacterial infections, lichenification (thickening of skin), sleep disruption from itching, and any history of infections requiring antibiotics. These complications may warrant separate diagnostic codes and additional ratings.

Example: In addition to the skin plaques, I have joint pain and stiffness in both wrists and my lower back that my rheumatologist has diagnosed as psoriatic arthritis. My nails are pitted and one has separated from the nail bed. I have had three separate bacterial skin infections in the past 18 months requiring oral antibiotics.

Examiner listens for: Evidence of systemic involvement, psoriatic arthritis, secondary infections, nail or scalp involvement, and any conditions that could be separately rated under other diagnostic codes per the note in DC 7816.

Avoid: Do not omit joint pain, nail changes, or eye symptoms when claiming psoriasis. Do not fail to mention secondary infections - these may support a separate claim under DC 7820 or an increased rating.

Common mistakes to avoid

Applying heavy moisturizer, covering lesions with makeup, or treating skin aggressively immediately before the exam

Why: This artificially minimizes the visible extent of your condition and can cause the examiner to underestimate TBSA and EBSA, directly lowering your rating.

Do this instead: Allow your skin to present in its representative state. You may use your normal medications but avoid cosmetic coverup of lesions on the day of the exam. Bring photographs showing your skin during typical or worst-day presentations.

Impact: All levels, particularly the difference between 10% and 30%

Describing only the current day's condition without mentioning your worst-day presentation

Why: VA ratings under M21-1 guidance consider the condition as it exists across its full range of severity. If the exam falls on a good day, the examiner may document only the mild presentation they observe.

Do this instead: Proactively tell the examiner: 'Today is one of my better days. During a typical flare my skin looks like [description], affecting approximately [X]% of my body.' Provide photographs taken during flares.

Impact: 30% vs. 60% - the TBSA threshold is the primary determiner

Failing to bring a complete, accurate medication list with duration of use

Why: The DBQ specifically records which medications were used and for how long. The critical rating threshold between 30% and 60% depends on whether systemic therapy was used for more or fewer than 6 weeks in the past 12 months. If you cannot document this, the examiner may record it as less than 6 weeks.

Do this instead: Bring a written medication log with drug names, doses, start and stop dates, and the reason each was prescribed. Obtain pharmacy printouts if possible. Calculate total weeks of systemic treatment use in the past year before the exam.

Impact: 30% vs. 60%

Not mentioning palmar, plantar, mucosal, or intertriginous involvement

Why: These special body areas are explicitly captured on the DBQ and can support higher rating levels or analogous codes. Veterans often omit involvement of palms, soles, genitals, or mouth because they consider these embarrassing or minor.

Do this instead: Disclose all affected areas completely, including sensitive areas. These findings directly influence the examiner's documentation and rating recommendation.

Impact: 30% vs. 60%, and may unlock separate rating codes

Failing to report complications such as psoriatic arthritis, nail changes, or secondary infections

Why: Under DC 7816, complications such as psoriatic arthritis are rated separately under the appropriate diagnostic code. If you do not report joint pain, nail changes, or recurrent infections, these conditions will not be documented for separate rating consideration.

Do this instead: Report all related conditions including joint pain, stiffness, nail pitting, eye inflammation, and any infections. Ask whether a separate DBQ for arthritis or other complications should be completed.

Impact: Affects total combined disability rating through additional separate claims

Not mentioning psychological or occupational impact

Why: The DBQ has a specific functional impact section. If you do not describe how the condition affects your work, social life, and daily activities, the examiner may leave this section blank or minimize it, reducing documentation supporting TDIU or secondary psychiatric claims.

Do this instead: Describe specific functional limitations: missed work days, inability to perform job duties, social avoidance, sleep disruption from itching, depression or anxiety diagnosis, and any workplace accommodations required.

Impact: Supports TDIU, secondary psychiatric claims, and highest rating levels

Prep checklist

  • critical

    Obtain and review your complete medical records related to your skin condition

    Gather all dermatology records, primary care notes, pharmacy records, and any biopsy or lab results. Ensure the records document your diagnosis, treatment history, and prior flare-ups. Submit these to your VA claims file before the exam if possible.

    before exam

  • critical

    Calculate total weeks of systemic therapy used in the past 12 months

    The single most important threshold for a 30% vs. 60% rating is whether you used systemic medications (oral steroids, biologics, methotrexate, cyclosporine, retinoids, immunosuppressives) for more or fewer than 6 weeks in the past 12-month period. Count the total days/weeks, convert to weeks, and write it down.

    before exam

  • critical

    Photograph your skin during a flare-up before the exam

    Take clear, well-lit photographs of all affected body areas during an active flare. Include close-ups of significant lesions and wide shots showing total extent. Date the photographs. Print copies to bring to the exam and keep digital backups. Per M21-1, photographs are considered evidence for rating.

    before exam

  • critical

    Prepare a written medication history

    List every medication - topical and systemic - used for your skin condition, including name, dose, start date, stop date, and condition treated. Include OTC antihistamines, prescription topicals, oral medications, biologics, and any phototherapy. Obtain pharmacy printouts for accuracy.

    before exam

  • recommended

    Write a symptom journal covering the past 60 days

    Record flare dates, severity (scale of 1-10), body areas affected, triggers, treatment used, and functional limitations. Note any missed work days, social activities avoided, or sleep disruption. Bring this journal to the exam.

    before exam

  • recommended

    Identify and document all affected body areas with percentage estimates

    Before the exam, estimate what percentage of your total body surface and exposed body surface are affected during a typical flare. Use the Rule of Nines as a reference: each arm = 9%, each leg = 18%, front torso = 18%, back torso = 18%, head = 9%.

    before exam

  • recommended

    Check your state's recording consent law

    Veterans have the right to record their C&P exam in most states. Some states require one-party consent (you can record without telling the examiner), others require two-party consent. Research your state's law and consider bringing a small digital recorder or using your smartphone.

    before exam

  • recommended

    Research whether complications should be separately claimed

    If you have psoriatic arthritis, nail changes, eye symptoms, or recurrent secondary infections, consider filing separate claims for these conditions. Under DC 7816, psoriasis complications are rated separately under appropriate diagnostic codes.

    before exam

  • critical

    Do not apply cosmetic makeup or coverup products to affected skin

    Allow your skin to present naturally. Normal moisturizing lotions and prescribed medications may be applied, but do not use foundation, concealer, or other products that obscure the extent or appearance of lesions.

    day of

  • critical

    Bring your medication list, photographs, and symptom journal

    Bring physical copies of your medication history, flare-up photographs with dates, symptom journal, and any relevant medical records. The examiner may review them and they become part of the record.

    day of

  • recommended

    Wear loose, easily removed clothing

    The examiner will need to inspect your skin. Wear clothing that is easy to remove partially for inspection of the trunk, extremities, and any involved areas. Avoid tight clothing that may irritate your skin.

    day of

  • recommended

    Arrive early and mentally prepare your worst-day narrative

    Before entering the exam room, review your notes and be ready to clearly describe your worst-day symptoms, the extent of your condition during flares, and the impact on your daily life and work.

    day of

  • critical

    Proactively state if today is a better-than-average day

    If your skin is relatively controlled on exam day, immediately tell the examiner: 'Today is a better day than usual. My condition typically presents as [description] with [X]% of my body affected during a flare.' Do not let the examiner assume today's presentation is representative.

    during exam

  • critical

    Report ALL affected body areas including sensitive sites

    Disclose involvement of palms, soles, genitals, mucous membranes, axilla, groin, scalp, face, and nail changes. These are specifically captured on the DBQ and affect your rating. Do not omit any area due to embarrassment.

    during exam

  • critical

    Describe functional and occupational limitations clearly

    Tell the examiner specifically how your skin condition limits work, daily activities, and social functioning. Give concrete examples: 'I missed 8 days of work last year due to flares,' 'I cannot grip tools when my palms are cracked,' 'I avoid public situations because of the appearance of lesions on my face.'

    during exam

  • critical

    Ask the examiner to document both TBSA and EBSA

    Per M21-1, the DBQ must identify total body surface area and exposed body surface area as percentages for the exam to be sufficient for rating purposes. If the examiner does not appear to be recording this, politely ask: 'Can you note the percentage of my total and exposed body surface area that is affected?'

    during exam

  • recommended

    Present your photographs to the examiner

    Show the examiner dated photographs of your worst flare-up presentations and ask that they note reviewing the photographs. This establishes the full severity of your condition beyond what is visible on exam day.

    during exam

  • recommended

    Report all complications including joint pain, nail changes, and secondary infections

    Inform the examiner of any psoriatic arthritis symptoms, nail pitting, eye inflammation, or secondary bacterial infections. These may trigger completion of additional DBQs and separate rating claims.

    during exam

  • critical

    Request a copy of the C&P exam report

    After the exam is completed and uploaded, you have the right to request a copy through your VA MyHealtheVet account, by contacting your Regional Office, or through your VSO. Review the report carefully for accuracy, particularly the documented TBSA, EBSA, treatment duration, and functional impact.

    after exam

  • critical

    Review the DBQ for errors and file a rebuttal if inaccurate

    If the examiner's report contains factual errors - such as underestimating TBSA, incorrectly recording systemic therapy duration, or omitting special area involvement - you have the right to submit a written rebuttal or request a new exam. Work with your VSO or accredited attorney.

    after exam

  • recommended

    File for secondary conditions if applicable

    If the exam report documents psoriatic arthritis, secondary infections, nail changes, or psychological conditions related to your skin disease, consult your VSO about filing separate secondary claims for these conditions.

    after exam

  • optional

    Continue documenting your condition after the exam

    Continue keeping a symptom journal and photographing flare-ups. If your condition worsens after the rating decision, this documentation supports a future claim for increased rating.

    after exam

Your rights during a C&P exam

  • You have the right to a thorough, in-person examination unless a records-only review is appropriate - if your skin condition requires visual inspection for accurate assessment, you may request an in-person exam.
  • You have the right to record your C&P examination in most states - check your state's recording consent laws before the exam.
  • You have the right to submit a written rebuttal or request a supplemental exam if the C&P report contains factual inaccuracies or is insufficient for rating purposes under M21-1.
  • Per M21-1, a skin examination report that fails to identify both total body surface area (TBSA) and exposed body surface area (EBSA) as percentages is considered insufficient for rating purposes - you may request a new exam if these are missing.
  • You have the right to submit buddy statements, personal statements, and photographic evidence in support of your claim - these are part of the evidence of record.
  • You have the right to have your condition rated based on your worst-day presentation, not solely the condition observed on exam day, per M21-1 guidance.
  • You have the right to representation by an accredited VSO, attorney, or claims agent at no cost to you for initial claims.
  • You have the right to appeal a rating decision through the Supplemental Claim, Higher-Level Review, or Board of Veterans' Appeals lanes under the AMA framework.
  • If the examiner fails to examine you in person and conducts only a records review, you have the right to a statement explaining how the exam was conducted - this is documented on the DBQ.
  • Psoriasis complications (such as psoriatic arthritis) must be rated separately under appropriate diagnostic codes per the note in 38 CFR - 4.118, DC 7816 - you have the right to separate ratings for each ratable complication.

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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.