Chapter 22 - Skin Impairment

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Table of Contents PDF Version

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Introduction

This chapter provides criteria for assessing permanent impairment from entitled skin conditions.

Skin conditions vary widely in severity over periods of time; therefore, when assessing a permanent impairment of the skin, consideration must be given to the pattern of the signs and symptoms of the skin condition.

Various factors are used to determine the level of skin impairment. These factors include:

• The nature of the skin condition(s). Skin conditions that scale, weep, crust, bleed or that cause fissures or erosions warrant a higher impairment rating.
• The symptoms presented. Skin conditions that are pruritic and/or cause discomfort/pain warrant a higher impairment rating.
• The extent of skin involved. In general, the greater the surface area involved, the greater the impairment rating.
• The location of the lesion(s). In general, skin conditions of the face and hands warrant a higher impairment rating than those elsewhere on the body.
• The treatment required. In general, skin conditions that require continuous treatment warrant a higher rating than those that require only intermittent or no treatment. Skin conditions that require systemic treatment instead of or in addition to topical treatment warrant a higher rating than those requiring topical treatment alone.

When assessing a permanent impairment of the skin, the functional loss includes disfigurement.

Skin conditions with complications of severe systemic or life threatening infections are rated on individual merits.

An additional rating may be obtained from Chapter 17, Musculoskeletal Impairment in cases where skin conditions result in scarring and contractures causing a loss of joint function.

A rating is not given from this chapter for the conditions listed below. Each bullet indicates the appropriate chapter to be used.

• Impairment from skin conditions caused by varicose veins, peripheral vascular arterial disease and deep vein thrombosis is rated within Chapter 13, Hypertension and Vascular Impairment.
• Impairment from diabetic foot ulcers is rated within Chapter 15, Endocrine and Metabolic Impairment.
• Impairment from skin conditions as a result of osteomyelitis is rated within Chapter 17, Musculoskeletal Impairment.

Impairment from malignant skin conditions is rated within Chapter 18

, Malignant Impairment. Follow the steps contained within the Malignant Impairment chapter.

Rating Tables

This chapter contains six "Loss of Function" tables, three "Other Impairment" tables and one diagram, the "Rule of Nines" which may be used to rate entitled skin conditions.

Loss of Function - Skin - Face and Scalp

Table 22.1 is used to rate impairment from skin conditions of the face and scalp. This table has three columns. One rating is chosen from each of the three columns. All three ratings are added to arrive at the Table 22.1 rating.

When entitled skin conditions of the face and scalp result in permanent impairment of other organ systems, a consequential entitlement decision is required. If awarded, the resulting impairment of that organ system(s) will be rated using the applicable body system specific table(s).

If non-entitled conditions or conditions rated within another chapter/table of the Table of Disabilities are contributing to the overall impairment, then the Partially Contributing Table (PCT) must be applied to arrive at the rating which is due to the entitled condition(s) rated within this table.

Loss of Function - Skin - Hands

Table 22.2 is used to rate impairment from skin conditions of the hands. The hands are rated together. This table has three columns. One rating is chosen from each of the three columns. All three ratings are added to arrive at the Table 22.2 rating.

When entitled skin conditions of the hands result in permanent impairment of other organ systems, a consequential entitlement decision is required. If awarded, the resulting impairment of that organ system(s) will be rated using the applicable body system specific table(s).

If non-entitled conditions or conditions rated within another chapter/table of the Table of Disabilities are contributing to the overall impairment, then the Partially Contributing Table (PCT) must be applied to arrive at the rating which is due to the entitled condition(s) rated within this table.

Loss of Function - Skin - Feet

Table 22.3 is used to rate impairment from skin conditions of the feet. The feet are rated together. This table has three columns. One rating is chosen from each of the three columns. All three ratings are added to arrive at the Table 22.3 rating.

When entitled skin conditions of the feet result in permanent impairment of other organ systems, a consequential entitlement decision is required. If awarded, the resulting impairment of that organ system(s) will be rated using the applicable body system specific table(s).

If non-entitled conditions or conditions rated within another chapter/table of the Table of Disabilities are contributing to the overall impairment, then the Partially Contributing Table (PCT) must be applied to arrive at the rating which is due to the entitled condition(s) rated within this table.

Loss of Function - Skin - Genitalia

Table 22.4 is used to rate impairment from skin conditions of the genitalia/perineum. This table has three columns. One rating is chosen from each of the three columns. All three ratings are then added to arrive at the Table 22.4 rating.

When entitled skin conditions of the genitalia result in permanent impairment of other organ systems, a consequential entitlement decision is required. If awarded, the resulting impairment of that organ system(s) will be rated using the applicable body system specific table(s).

If non-entitled conditions or conditions rated within another chapter/table of the Table of Disabilities are contributing to the overall impairment, then the Partially Contributing Table (PCT) must be applied to arrive at the rating which is due to the entitled condition(s) rated within this table.

Loss of Function - Skin - Generalized

Table 22.5 is used to rate impairment from generalized skin conditions. This table has three columns. One rating is chosen from each of the three columns. All three ratings areadded to arrive at the Table 22.5 rating.

This table is used to determine an impairment rating in the following circumstances:

• The entitled skin condition affects an area not rated by a site specific table within this chapter; and/or
• Two or more specific body areas (excluding the nails) are affected by the same entitled skin condition.

To determine the extent of skin involvement for Table 22.5, Diagram 22A, the "Rule of Nines", is utilized. The "Rule of Nines" figure divides the entire body skin surface into sections where each section equals a percentage of total body surface area, as noted below:

• head and neck - 9%
• each hand and arm - 9%
• palmar surface of hand - 1%
• each foot and leg - 18% (9% anterior foot and leg; 9% posterior foot and leg)
• anterior trunk - 18%
• posterior trunk (including buttocks) - 18%
• perineum - 1%.

Note: Approximations must be carried out when applying the "Rule of Nines" when only a portion of a body surface area is involved.

When entitled generalized skin conditions result in permanent impairment of other organ systems, a consequential entitlement decision is required. If awarded, the resulting impairment of that organ system(s) will be rated using the applicable body system specific table(s).

If non-entitled conditions or conditions rated within another chapter/table of the Table of Disabilities are contributing to the overall impairment, then the Partially Contributing Table (PCT) must be applied to arrive at the rating which is due to the entitled condition(s) rated within this table.

Loss of Function - Nails

Table 22.6 is used to rate impairment from nail conditions on the hands and the feet. This table has two columns. One rating is chosen from each of the two columns. Both ratings are added to arrive at the Table 22.6 rating.

When entitled nail conditions result in permanent impairment of other organ systems, a consequential entitlement decision is required. If awarded, the resulting impairment of that organ system(s) will be rated using the applicable body system specific table(s).

If non-entitled conditions or conditions rated within another chapter/table of the Table of Disabilities are contributing to the overall impairment, then the Partially Contributing Table (PCT) must be applied to arrive at the rating which is due to the pensioned condition(s) rated within this table.

Other Impairment - Superficial Gunshot Wounds and Scars - Face

Table 22.7 is used to rate impairment from superficial gunshot wounds and scars of the face. Total surface area of all scars on the face is used to determine the extent of skin involvement. This table has two columns. One rating is chosen from each of the two columns. Both ratings are added to arrive at the Table 22.7 rating.

* Burn scars are rated from the site specific tables and/or Table 22.5 - Skin - Generalized within this chapter. Burn scars are not rated from Table 22.7.

When entitled superficial gunshot wounds and scars of the face and scalp result in permanent impairment of other organ systems, a consequential entitlement decision is required. If awarded, the resulting impairment of that organ system(s) will be rated using the applicable body system specific table(s).

If non-entitled conditions or conditions rated within another chapter/table of the Table of Disabilities are contributing to the overall impairment, then the Partially Contributing Table (PCT) must be applied to arrive at the rating which is due to the entitled condition(s) rated within this table.

Other Impairment - Superficial Gunshot Wounds and Scars - Hands

Table 22.7 is used to rate impairment from superficial gunshot wounds and scars of the hands. Total surface area of all scars on the hands is used to determine the extent of skin involvement. This table has two columns. One rating is chosen from each of the two columns. Both ratings are added to arrive at the Table 22.8 rating.

* Burn scars are rated from the site specific tables and/or Table 22.5 - Skin - Generalized within this chapter. Burn scars are not rated from Table 22.8.

When entitled superficial gunshot wounds and scars of the hands result in permanent impairment of other organ systems, a consequential entitlement decision is required. If awarded, the resulting impairment of that organ system(s) will be rated using the applicable body system specific table(s).

If non-entitled conditions or conditions rated within another chapter/table of the Table of Disabilities are contributing to the overall impairment, then the Partially Contributing Table (PCT) must be applied to arrive at the rating which is due to the entitled condition(s) rated within this table.

Other Impairment - Superficial Gunshot Wounds and Scars - Other

Table 22.9 is used to rate impairment from superficial gunshot wounds and scars other than of the face and hands. Total surface area of all scars other than of the face and hands is used to determine the extent of skin involvement. This table has two columns. One rating is chosen from each of the two columns. Both ratings are added to arrive at the Table 22.9 rating.

* Graft and skin donor site conditions are rated from this table.

* Scars of the scalp are rated in Table 22.9.

* Burn scars are rated from the site specific tables and/or Table 22.5 - Skin - Generalized within this chapter. Burn scars are not rated from Table 22.9.

When entitled superficial gunshot wounds and scars of areas, other than the face and hands, result in permanent impairment of other organ systems, a consequential entitlement decision is required. If awarded, the resulting impairment of that organ system(s) will be rated using the applicable body system specific table(s).

If non-entitled conditions or conditions rated within another chapter/table of the Table of Disabilities are contributing to the overall impairment, then the Partially Contributing Table (PCT) must be applied to arrive at the rating which is due to the entitled condition(s) rated within this table.

Table 22.1 - Loss of Function - Skin - Face and Scalp

Only one rating may be given from a column in Table 22.1 for each entitled condition. If more than one rating is applicable for an entitled condition within a column, the highest is selected. The ratings from each column are added for each entitled condition.

Male pattern baldness is assessed at nil.

Steps to Determine Skin (Face and Scalp) Impairment Assessment

• Step 1: Determine the rating from Table 22.1 (Loss of Function - Skin - Face and Scalp).
• Step 2: Does the Partially Contributing Table apply? If yes, then apply to rating at Step 1.
• Step 3: Determine the Quality of Life rating.
• Step 4: Add the ratings at Step 2 and Step 3.
• Step 5: If partial entitlement exists, apply to rating at Step 4.

This is the Disability Assessment.

Table 22.2 - Loss of Function - Skin - Hands

Only one rating may be given from a column in Table 22.2 for each entitled condition. The hands are rated together. If more than one rating is applicable for an entitled condition within a column, the highest is selected. The ratings from each column are added for each entitled condition.

Steps to Determine Skin (Hands) Impairment Assessment

• Step 1: Determine the rating from Table 22.2 (Loss of Function - Skin - Hands).
• Step 2: Does the Partially Contributing Table apply? If yes, then apply to rating at Step 1.
• Step 3: Determine the Quality of Life rating.
• Step 4: Add the ratings at Step 2 and Step 3.
• Step 5: If partial entitlement exists, apply to Step 4 rating.

This is the Disability Assessment.

Table 22.3 - Loss of Function - Skin - Feet

Only one rating may be given from a column in Table 22.3 for each entitled condition. The feet are rated together. If more than one rating is applicable for an entitled condition within a column, the highest is selected. The ratings from each column are added for each entitled condition.

Steps to Determine Skin (Feet) Impairment Assessment

• Step 1: Determine the rating from Table 22.3 (Loss of Function - Feet).
• Step 2: Does the Partially Contributing Table apply? If yes, then apply to rating at Step 1.
• Step 3: Determine the Quality of Life rating.
• Step 4: Add the ratings at Step 2 and Step 3.
• Step 5: If partial entitlement exists, apply to Step 4 rating.

This is the Disability Assessment.

Table 22.4 - Loss of Function - Skin - Genitalia

Only one rating may be given from a column in Table 22.4 for each entitled condition. If more than one rating is applicable for an entitled condition within a column, the highest is selected. The ratings from each column are added for each entitled condition.

Steps to Determine Skin (Genitalia) Impairment Assessment

• Step 1: Determine rating from Table 22.4 (Loss of Function - Genitalia).
• Step 2: Does the Partially Contributing Table apply? If yes, then apply to rating at Step 1.
• Step 3: Determine the Quality of Life rating.
• Step 4: Add the ratings at Step 2 and Step 3.
• Step 5: If partial entitlement exists, apply to rating at Step 4.

This is the Disability Assessment.

Table 22.5 - Loss of Function - Skin - Generalized

Only one rating may be given from a column in Table 22.5 for each entitled condition. If more than one rating is applicable for an entitled condition within a column, the highest is selected. The ratings from each column are added for each entitled condition.

Diagram 22A, the "Rule of Nines" is used to determine the extent of skin involvement in Table 22.5. Approximations may be necessary when using the "Rule of Nines" when only a portion of body surface area is involved.

Steps to Determine Skin (Generalized) Impairment Assessment

• Step 1: Determine the rating from Table 22.5 (Loss of Function - Skin - Generalized).
• Step 2: Does the Partially Contributing Table apply? If yes, then apply to rating at Step 1.
• Step 3: Determine the Quality of Life rating.
• Step 4: Add the ratings at Step 2 and Step 3.
• Step 5: If partial entitlement exists, apply to rating at Step 4.

This is the Disability Assessment.

Table 22.6 - Loss of Function - Nails

Only one rating may be given from each column in Table 22.6 regardless of the number of entitled conditions to be rated. If more than one rating is applicable within a column, the highest is selected as the column rating. The ratings from each column are added.

Steps to Determine Nail Impairment Assessment

• Step 1: Determine the rating from Table 22.6 (Loss of Function - Nails).
• Step 2: Does the Partially Contributing Table apply? If yes, then apply to rating at Step 1.
• Step 3: Determine the Quality of Life rating.
• Step 4: Add the ratings at Step 2 and Step 3.
• Step 5: If partial entitlement exists, apply to rating at Step 4.

This is the Disability Assessment.

Table 22.7 - Other Impairment - Superficial Gunshot Wounds and Scars - Face

Only one rating may be given from each column in Table 22.7 regardless of the number of entitled conditions to be rated. If more than one rating is applicable within a column, the highest is selected as the column rating. The ratings from each column are added.

Cases of severe disfigurement are rated on individual merits.

Steps to Determine Superficial Gunshot Wounds and Scars (Face) Impairment Assessment

• Step 1: Determine the rating from Table 22.7 (Other Impairment - Superficial Gunshot Wounds and Scars - Face).
• Step 2: Does the Partially Contributing Table apply? If yes, then apply to rating at Step 1.
• Step 3: Determine the Quality of Life rating.
• Step 4: Add the ratings at Step 2 and Step 3.
• Step 5: If partial entitlement exists, apply to rating at Step 4.

This is the Disability Assessment.

Table 22.8 - Other Impairment - Superficial Gunshot Wounds and Scars - Hands

Only one rating may be given from each column in Table 22.8 regardless of the number of entitled conditions to be rated. If more than one rating is applicable within a column, the highest is selected as the column rating. The ratings from each column are added.

Steps to Determine Superficial Gunshot Wounds and Scars (Hands) Impairment Assessment

• Step 1: Determine the rating from Table 22.7 (Other Impairment Superficial Gunshot Wounds and Scars - Hands).
• Step 2: Does the Partially Contributing Table apply? If yes, then apply to rating at Step 1.
• Step 3: Determine the Quality of Life rating.
• Step 4: Add the ratings at Step 2 and Step 3.
• Step 5: If partial entitlement exists, apply to rating at Step 4.

This is the Disability Assessment.

Table 22.9 - Other Impairment - Superficial Gunshot Wounds and Scars - Other

Only one rating may be given from each column in Table 22.9 regardless of the number of entitled conditions to be rated. If more than one rating is applicable within a column, the highest is selected as the column rating. The ratings from each column are added.

Steps to Determine Superficial Gunshot Wounds and Scars (Other) Impairment Assessment

• Step 1: Determine the rating from Table 22.9 (Other Impairment - Superficial Gunshot Wounds and Scars - Other).
• Step 2: Does the Partially Contributing Table apply? If yes, then apply to rating at Step 1.
• Step 3: Determine the Quality of Life rating.
• Step 4: Add the ratings at Step 2 and Step 3.
• Step 5: If partial entitlement exists, apply to rating at Step 4.

This is the Disability Assessment.

Diagram 22A - Estimating Percent of Affected Body