8.01
Category of
Impairments,
Skin Disorders
8.02
Ichthyosis
8.03
Bullous disease
8.04
Chronic infections
of the skin or mucous membranes
8.05
Dermatitis
8.06
Hidradenitis Suppurativa
8.07
Genetic photosensitivity disorders
8.08
Burns
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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.
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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.
We need evidence confirming the diagnosis of your XP or other genetic
photosensitivity disorder. The evidence must include a clinical
description of abnormal physical findings associated with the condition.
There must also be definitive genetic laboratory studies documenting
appropriate chromosomal damage, abnormal DNA repair, or other DNA
or genetic abnormality specific to your type of photosensitivity
disorder. However, we do not need a copy of the actual laboratory
report if we have medical evidence that is persuasive that a positive
diagnosis has been confirmed by laboratory testing.
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.
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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
by clinical and laboratory findings 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).
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