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A.
What skin disorders do we evaluate with these listings?
We use these listings to evaluate skin disorders
that may result from hereditary, congenital, or acquired pathological processes. The kinds of impairments covered by these
listings are: Ichthyosis, bullous diseases, chronic infections of the skin or mucous membranes, dermatitis, hidradenitis suppurativa,
genetic photosensitivity disorders, and burns.
B. What documentation
do we need?
When we evaluate the existence and severity of your skin disorder, we generally need information
about the onset, duration, frequency of flare-ups, and prognosis of your skin disorder; the location, size, and appearance
of lesions; and, when applicable, history of exposure to toxins, allergens, or irritants, familial incidence, seasonal variation,
stress factors, and your ability to function outside of a highly protective environment. To confirm the diagnosis, we may
need laboratory findings (for example, results of a biopsy obtained independently of Social Security disability evaluation
or blood tests) or evidence from other medically acceptable methods consistent with the prevailing state of medical knowledge
and clinical practice.
C. How do we assess the severity of your skin disorder(s)?
We generally
base our assessment of severity on the extent of your skin lesions, the frequency of flare-ups of your skin lesions, how your
symptoms (including pain) limit you, the extent of your treatment, and how your treatment affects you.
1. Extensive skin lesions.
Extensive skin lesions are those that involve multiple body sites
or critical body areas, and result in a very serious limitation. Examples of extensive skin lesions that result in a very
serious limitation include but are not limited to: a. Skin lesions that interfere
with the motion of your joints and that very seriously limit your use of more than one extremity; that is, two upper extremities,
two lower extremities, or one upper and one lower extremity. b. Skin lesions on the
palms of both hands that very seriously limit your ability to do fine and gross motor movements. c. Skin lesions on the soles of both feet, the perineum, or both inguinal areas that very seriously limit your
ability to ambulate.
2. Frequency of flare-ups.
If you
have skin lesions, but they do not meet the requirements of any of the listings in this body system, you may still have an
impairment that prevents you from doing any gainful activity when we consider your condition over time, especially if your
flare-ups result in extensive skin lesions, as defined in C1 of this section. Therefore, if you have frequent flare-ups, we
may find that your impairment(s) is medically equal to one of these listings even though you have some periods during which
your condition is in remission. We will consider how frequent and serious your flare-ups are, how quickly they resolve, and
how you function between flare-ups to determine whether you have been unable to do any gainful activity for a continuous period
of at least 12 months or can be expected to be unable to do any gainful activity for a continuous period of at least 12 months.
We will also consider the frequency of your flare-ups when we determine whether you have a severe impairment and when we need
to assess your residual functional capacity.
3. Symptoms (including pain).
Symptoms (including
pain) may be important factors contributing to the severity of your skin disorder(s). We assess the impact of symptoms as
explained in §§ 404.1528, 404.1529, 416.928, and 416.929 of this chapter. 4.
Treatment.
We assess the effects of medication, therapy, surgery, and any other form of treatment you
receive when we determine the severity and duration of your impairment(s). Skin disorders frequently respond to treatment;
however, response to treatment can vary widely, with some impairments becoming resistant to treatment. Some treatments can
have side effects that can in themselves result in limitations.
a. We
assess the effects of continuing treatment as prescribed by determining if there is improvement in the symptoms, signs, and
laboratory findings of your disorder, and if you experience side effects that result in functional limitations. To assess
the effects of your treatment, we may need information about: i. The
treatment you have been prescribed (for example, the type, dosage, method, and frequency of administration of medication or
therapy); ii. Your response to the treatment; iii.
Any adverse effects of the treatment; and
iv. The expected duration of the treatment.
b. Because treatment itself or the effects of treatment may be temporary, in most cases sufficient time must
elapse to allow us to evaluate the impact and expected duration of treatment and its side effects. Except under 8.07 and 8.08,
you must follow continuing treatment as prescribed for at least 3 months before your impairment can be determined to meet
the requirements of a skin disorder listing. (See 8.00H if you are not undergoing treatment or did not have treatment for
3 months.) We consider your specific response to treatment when we evaluate the overall severity of your impairment.
D. How do we assess impairments that may affect the skin and other body systems?
When your impairment affects your skin and has effects in other body systems, we first evaluate the predominant
feature of your impairment under the appropriate body system. Examples include, but are not limited to the following. 1. Tuberous sclerosis primarily affects the brain. The predominant features are
seizures, which we evaluate under the neurological listings in 11.00, and developmental delays or other mental disorders,
which we evaluate under the mental disorders listings in 12.00. 2. Malignant
tumors of the skin (for example, malignant melanomas) are cancers, or neoplastic diseases, which we evaluate under the
listings in 13.00. 3. Connective tissue disorders and other immune system disorders
(for example, systemic lupus erythematosus, scleroderma, human immunodeficiency virus (HIV) infection, and Sjögren's
syndrome) often involve more than one body system. We first evaluate these disorders under the immune system listings in 14.00.
We evaluate lupus erythematosus under 14.02, scleroderma under 14.04, symptomatic HIV infection under 14.08, and Sjögren's
syndrome under 14.03, 14.09, or any other appropriate listing in section 14.00. 4.
Disfigurement or deformity resulting from skin lesions may result in loss of sight, hearing, speech, and the ability
to chew (mastication). We evaluate these impairments and their effects under the special senses and speech listings in 2.00
and the digestive system listings in 5.00. Facial disfigurement or other physical deformities may also have effects we evaluate
under the mental disorders listings in 12.00, such as when they affect mood or social functioning. E. How do we evaluate genetic photosensitivity disorders? 1.
Xeroderma pigmentosum (XP). When you have XP, your impairment meets the requirements of 8.07A if you have clinical and laboratory
findings showing that you have the disorder. (See 8.00E3.) People who have XP have a lifelong hypersensitivity to all forms
of ultraviolet light and generally lead extremely restricted lives in highly protective environments in order to prevent skin
cancers from developing. Some people with XP also experience problems with their eyes, neurological problems, mental disorders,
and problems in other body systems. 2. Other genetic photosensitivity disorders.
Other genetic photosensitivity disorders may vary in their effects on different people, and may not result
in an inability to engage in any gainful activity for a continuous period of at least 12 months. Therefore, if you have a
genetic photosensitivity disorder other than XP (established by clinical and laboratory findings as described in 8.00E3),
you must show that you have either extensive skin lesions or an inability to function outside of a highly protective environment
to meet the requirements of 8.07B.
You must also show that your impairment meets the duration requirement. By
inability to function outside of a highly protective environment we mean that you must avoid exposure to ultraviolet light
(including sunlight passing through windows and light from unshielded fluorescent bulbs), wear protective clothing and eyeglasses,
and use opaque broad spectrum sunscreens in order to avoid skin cancer or other serious effects. Some genetic photosensitivity
disorders can have very serious effects in other body systems, especially special senses and speech (2.00), neurological (11.00),
mental (12.00), and neoplastic (13.00). We will evaluate the predominant feature of your impairment under the appropriate
body system, as explained in 8.00D. 3. Clinical and laboratory findings.
a. General. We need documentation from an acceptable medical source, as defined in §§404.1513(a)
and 416.913(a), to establish that you have a medically determinable impairment. In general, we must have evidence of appropriate
laboratory testing showing that you have XP or another genetic photosensitivity disorder. We will find that you have XP or
another genetic photosensitivity disorder based on a report from an acceptable medical source indicating that you have the
impairment, supported by definitive genetic laboratory studies documenting appropriate chromosomal changes, including abnormal
DNA repair or another DNA or genetic abnormality specific to your type of photosensitivity disorder. b. What we will accept as medical evidence instead of the actual laboratory report. When we do not have
the actual laboratory report, we need evidence from an acceptable medical source that includes appropriate clinical findings
for your impairment and that is persuasive that a positive diagnosis has been confirmed by appropriate laboratory testing
at some time prior to our evaluation. To be persuasive, the report must state that the appropriate definitive genetic laboratory
study was conducted and that the results confirmed the diagnosis. The report must be consistent with other evidence in your
case record. F. How do we evaluate burns?
Electrical, chemical,
or thermal burns frequently affect other body systems; for example, musculoskeletal, special senses and speech, respiratory,
cardiovascular, renal, neurological, or mental. Consequently, we evaluate burns the way we evaluate other disorders that can
affect the skin and other body systems, using the listing for the predominant feature of your impairment. For example, if
your soft tissue injuries are under continuing surgical management (as defined in 1.00M), we will evaluate your impairment
under 1.08. However, if your burns do not meet the requirements of 1.08 and you have extensive skin lesions that result in
a very serious limitation (as defined in 8.00C1) that has lasted or can be expected to last for a continuous period of at
least 12 months, we will evaluate them under 8.08. G. How do we determine if
your skin disorder(s) will continue at a disabling level of severity in order to meet the duration requirement?
For all of these skin disorder listings except 8.07 and 8.08, we will find that your impairment meets the duration requirement
if your skin disorder results in extensive skin lesions that persist for at least 3 months despite continuing treatment as
prescribed. By persist, we mean that the longitudinal clinical record shows that, with few exceptions, your lesions have been
at the level of severity specified in the listing. For 8.07A, we will presume that you meet the duration requirement. For
8.07B and 8.08, we will consider all of the relevant medical and other information in your case record to determine whether
your skin disorder meets the duration requirement. H. How do we assess your
skin disorder(s) if your impairment does not meet the requirements of one of these listings? 1. These listings are only examples of common skin disorders that we consider severe enough to prevent you from
engaging in any gainful activity. For most of these listings, if you do not have continuing treatment as prescribed, if your
treatment has not lasted for at least 3 months, or if you do not have extensive skin lesions that have persisted for at least
3 months, your impairment cannot meet the requirements of these skin disorder listings. (This provision does not apply to
8.07 and 8.08.) However, we may still find that you are disabled because your impairment(s) meets the requirements of a listing
in another body system or medically equals the severity of a listing. (See §§ 404.1526 and 416.926 of this chapter.)
We may also find you disabled at the last step of the sequential evaluation process.
2. If you have not received
ongoing treatment or do not have an ongoing relationship with the medical community despite the existence of a severe impairment(s),
or if your skin lesions have not persisted for at least 3 months but you are undergoing continuing treatment as prescribed,
you may still have an impairment(s) that meets a listing in another body system or that medically equals a listing. If you
do not have an impairment(s) that meets or medically equals a listing, we will assess your residual functional capacity and
proceed to the fourth and, if necessary, the fifth step of the sequential evaluation process in §§ 404.1520 and
416.920 of this chapter. When we decide whether you continue to be disabled, we use the rules in §§ 404.1594 and
416.994 of this chapter.
8.01 Category of Impairments, Skin Disorders 8.02 Ichthyosis, with extensive skin lesions that persist for at least 3 months despite continuing treatment
as prescribed. 8.03 Bullous disease (for example, pemphigus, erythema multiforme bullosum, epidermolysis bullosa, bullous
pemphigoid, dermatitis herpetiformis), with extensive skin lesions that persist for at least 3 months despite continuing treatment
as prescribed. . 8.04 Chronic infections of the skin or mucous membranes, with extensive fungating or extensive ulcerating
skin lesions that persist for at least 3 months despite continuing treatment as prescribed. 8.05 Dermatitis (for example, psoriasis, dyshidrosis, atopic dermatitis, exfoliative dermatitis, allergic
contact dermatitis), with extensive skin lesions that persist for at least 3 months despite continuing treatment as prescribed. 8.06 Hidradenitis suppurativa, with extensive skin lesions involving both axillae, both
inguinal areas or the perineum that persist for at least 3 months despite continuing treatment as prescribed.
8.07 Genetic photosensitivity disorders, established as described in 8.00E.
A. Xeroderma
pigmentosum. Consider the individual disabled from birth. B. Other genetic photosensitivity
disorders, with: 1. Extensive skin lesions that have lasted or can be expected to
last for a continuous period of at least 12 months, OR 2. Inability to function outside of a highly protective environment for a continuous period of at least 12 months
(see 8.00E2). 8.08 Burns, with extensive skin lesions that have lasted or can be expected to last for a continuous
period of at least 12 months (see 8.00F). |
