Understanding Skin Conditions and Medical Documentation Standards
Military service often exposes veterans to environmental conditions such as extreme climates, chemical substances, infectious agents, and physical trauma that can contribute to chronic skin issues. These disorders can significantly impact quality of life, employment opportunities, and psychological well-being.
According to the VA’s Fiscal Year 2024 Annual Benefits Report, skin conditions are ranked among the top five most common service-connected disabilities for new compensation recipients.
Medical Documentation Requirements for Common Skin Conditions
Below are detailed guidelines on what should be documented by your medical providers specific to various skin conditions.
Eczema/Dermatitis (DC 7806)
Essential Medical Documentation:
- Precise dermatological diagnosis (type: atopic, contact dermatitis, nummular, etc.).
- Percentage of total body surface area (BSA) affected.
- Separate percentage indicating extent on exposed areas (face, neck, hands).
- Types, frequency, dosage, and response to treatments (specifically documenting any systemic therapy such as oral corticosteroids).
- Characterization of symptoms: erythema, scaling, itching intensity, secondary infections.
- Impact on sleep, daily activities, employment, and social interactions.
- High-quality, dated photographs during flare-ups.
Psoriasis (DC 7816)
Medical Documentation Essentials:
- Exact diagnosis (plaque, guttate, pustular, inverse).
- Total BSA (Body Surface Area) affected and extent on exposed areas.
- Comprehensive treatment history (biologics, oral systemic medicine, phototherapy) clearly identifying treatment as systemic therapy.
- Documentation regarding joint involvement (if psoriatic arthritis is present).
- Functional limitations at home, work, or socially.
- Clinical photographic documentation indicating severity and distribution patterns during symptomatic phases.
- Psychological effects, if applicable.
Acne & Residual Scarring (DC 7828, DC 7800–7805)
Medical Overviews Required:
- Defined dermatological diagnosis with condition subtype (cystic, nodular, inflammatory).
- Record exact measurements (length, width, depth, area in square centimeters) of acne scars.
- Detailed evaluation note regarding pain, instability, pigmentation, or adherence of scars.
- Functional assessment for scars that result in limited movement or facial scars causing psychological effects.
- Clinical photographs demonstrating lesion severity and residual scarring clearly, with measurement scale for reference.
Burns & Scarring (DC 7801–7805)
Documentation Essential Points:
- Precise dimensional documentation of each scar (length, width, area).
- Evaluation of scar characteristics: painful/tender, instability (skin breakdown), adhesiveness to underlying tissues, texture, pigment variations.
- Functionality assessment noting impact on joint mobility or daily functioning.
- Facial scarring evaluation using medical criteria including defined characteristics such as width, elevation, depression, pigment variance, adherence.
- Photo documentation clearly depicting scars, dimensions, and characteristics, taken from multiple viewpoints.
Skin Cancer (DC 7818, DC 7833)
Medical Professional Documentation Needs:
- Pathology/biopsy confirmation (exact diagnosis, staging, and type).
- Precise treatment records: surgery dates, chemotherapy, radiation start and completion dates.
- Complete documentations of residual factors post-treatment: scarring characteristics, functionality impacts, psychological factors.
- Ongoing surveillance plans clearly documented.
- Any medically justifiable statements linking your skin cancer to military-related exposures (chemical, sunlight, etc.).
How Medical Documentation Should Reflect Body Surface Area (BSA) Calculation
Medical providers commonly use the ‘Rule of Nines’ to document percentage of body surface area affected:
| Body Region | Percentage of Total BSA |
| Head and Neck | 9% |
| Each Arm | 9% each (18% total) |
| Each Leg | 18% each (36% total) |
| Anterior Trunk | 18% |
| Posterior Trunk | 18% |
| Genitalia | 1% |
Medical providers should clearly document:
- Total BSA affected.
- Specific percentage of visible/exposed areas (face, neck, hands).
- Document variation in BSA involvement, noting flare vs. stable times.
Medical Documentation Essentials: Checklist for Providers
Medical records documenting skin conditions should clearly include:
- Clearly defined diagnostic information with ICD-10 code.
- Specialist (dermatologist) evaluation noting extent/severity, measurement of BSA affected.
- Clear documentation of exposed vs. total area percentage.
- Explicitly detailed treatment history (type, dosage, frequency, systemic vs. topical).
- Objective documentation tools: dated photos during symptom flares, biopsy, diagnostic test results.
- Functional impacts on employment, daily activities, sleep impairment, or psychosocial wellbeing clearly noted.
Understanding Clinical Assessments (C&P) for Skin Conditions
Examinations performed for evaluation of skin conditions typically involve:
- Medical record reviews by medical professionals familiar with dermatologic conditions.
- Physical examination and observation of skin condition severity.
- Documentation and measurements of condition extent.
- Review of symptoms, severity, and history of treatment.
- Professional documentation of the functional effect of skin condition.
Medical documentation provided by your treating providers significantly influences these clinical assessments and evaluations.
Documentation of Secondary Medical Conditions Linked to Skin Disorders
Skin disorders can sometimes create or exacerbate secondary health conditions. Medical providers should consider detailed documentation of secondary conditions including:
Mental Health Issues: Assessment of psychological impacts, using standardized diagnostic tools (PHQ-9, GAD-7). Document connections to visible skin conditions clearly.
Sleep Disruptions: Medical documentation regarding sleep quality reductions connected directly to physical symptoms such as severe itching or skin pain. Methodical logs or sleep assessments are medically advised.
Secondary Infections: Historical medical record of infections explicitly connected to skin impairments, with bacterial/fungal/viral culture reports and treatment history clearly noted.
Joint/Movement Limitations: Rheumatology examination notes, joint involvement clearly documented in connection with skin conditions like psoriasis, clinically measured range-of-motion limitations.
Lymphedema/Circulatory Issues: Functional impact notes, swelling pattern documented medically, connections to prior skin cancer treatments or chronic skin inflammation clearly specified in medical records.
Examples: Strong Medical Documentation
Eczema Example:
“Veteran exhibits severe chronic atopic dermatitis (ICD-10: L20.9), affecting approximately 40% total body surface area and 60% of exposed areas (face, hands). Severe itching (8/10) disrupts sleep consistently. Medical treatment history includes systemic therapies (prednisone) three times/year, topical treatments continuous use. Photographic documentation clearly illustrates extensive involvement during flare-ups. Significant occupational and social impact documented due to appearance, sleep deprivation, and consistent discomfort.”
Daily Skin Symptom Tracker Template
Keep a daily symptom log to provide clear, objective documentation for your claim:
| Date | Itching (0–10) | Pain (0–10) | Areas Affected | Treatments Used | Relief Level (0–10) | Sleep Impact | Activities Limited | Additional Notes |
Medical Questions Veterans Can Ask Providers Regarding Skin Condition Documentation
- “Could you medically document my exact condition including ICD-10 in your notes?”
- “Would you document accurately the percentage of my body—and specifically exposed areas—affected?”
- “Can you specify in your medical notes whether my treatments qualify as ‘systemic therapy’?”
- “Could you record all medications and treatments clearly, noting their effectiveness?”
- “Would you describe in your documentation the functional impact of my condition in daily life?”
- “Can you medically connect service-related exposures to my current diagnosis?”
You Can Take Control
Careful personal documentation, proactive medical record management, and clear communication with your healthcare providers significantly empower your disability claim. Ensure your providers understand how crucial clear, detailed documentation is for obtaining appropriate Department of Veterans Affairs (VA) evaluations.
Disclaimer
This guide is provided for educational purposes and does not constitute legal or medical advice. Always consult accredited VA representatives and qualified healthcare providers for personalized advice regarding your situation.
