Psoriasis

Psoriasis is rated under 38 CFR § 4.118, diagnostic code 7816, and the interesting part of the code isn't the body-area percentages everyone fixates on. It's the second prong. DC 7816 rates psoriasis on the greater of two things: how much skin is affected, or how aggressive the treatment is. A veteran with plaques on five percent of the body and a biologic injection every eight weeks can reach a higher rating off the treatment than off the visible skin. Most claims I see in the BVA data get rated on the body-area prong and never develop the therapy prong at all.

That gap matters because the criteria changed. Effective August 13, 2018, VA amended DC 7816 to spell out that "systemic therapy" includes biologics and other immunosuppressive drugs, not just oral corticosteroids. Constant or near-constant systemic therapy over the past twelve months is the 60 percent criterion on its own, independent of body area. A veteran on adalimumab, ustekinumab, secukinumab, or methotrexate for a service-connected psoriasis is sitting on a 60 percent argument that has nothing to do with how clear the skin looks on exam day. The drug is the evidence.

This page walks through DC 7816's two-prong structure, the four body-area and systemic-therapy tiers, the post-2018 biologics lever, the alternative of rating by disfigurement under DC 7800 or scars under DC 7801 through 7805, the secondary chain into psoriatic arthritis under 38 CFR § 3.310, and the evidence patterns that show up across BVA psoriasis decisions. The dominant pattern in the data is inadequate skin exams, and the reason is structural: psoriasis flares and clears, and a single in-clinic snapshot rarely captures the disability.

TL;DR

• Psoriasis is rated under 38 CFR § 4.118, DC 7816. The criteria were amended effective August 13, 2018.
• DC 7816 rates on the greater of two prongs: body area affected (or exposed-area percentage), or the duration and intensity of systemic therapy over the past 12-month period.
• Tiers: 60% for more than 40% of the body or exposed areas, or constant/near-constant systemic therapy; 30% for 20 to 40%, or systemic therapy 6 weeks or more but not constant; 10% for 5 to less than 20%, or systemic therapy less than 6 weeks; 0% for less than 5% and topical therapy only.
• The post-2018 lever: biologics, other immunosuppressives, and phototherapy now count as systemic therapy. A veteran on a biologic can reach 60% on the therapy prong even with limited visible body area.
• DC 7816 also lets you rate by disfigurement of the head, face, or neck under DC 7800, or by scars under DC 7801 through 7805, when that produces a higher evaluation.
• Psoriatic arthritis frequently accompanies psoriasis and is separately ratable as an inflammatory arthritis under § 3.310.
• Document the drug name, the dosing schedule, and the total duration over the past twelve months. That is what the therapy prong turns on.
• In Claim Raven's analysis of 505 BVA psoriasis cases, 44.6% were remanded, 23.0% granted, and 26.3% denied. Of the 380 cases with a C&P adequacy determination, 63.7% had the exam flagged as inadequate.

DC 7816 and the Two-Prong Structure

The thing to understand about DC 7816 is that it gives you two independent ways to reach each rating level, and you take the higher one. The regulation rates psoriasis on body area or systemic therapy, whichever produces the greater evaluation, and separately permits rating by disfigurement or scars if that path is higher still.

Here are the body-area and systemic-therapy tiers under the post-2018 criteria:

60%: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected, OR constant or near-constant systemic therapy such as corticosteroids, other immunosuppressive drugs, biologics, or phototherapy during the past 12-month period. 30%: 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, OR systemic therapy such as corticosteroids, other immunosuppressive drugs, biologics, or phototherapy required for a total duration of 6 weeks or more, but not constantly, during the past 12-month period. 10%: at least 5 percent but less than 20 percent of the entire body or exposed areas affected, OR systemic therapy such as corticosteroids, other immunosuppressive drugs, biologics, or phototherapy required for a total duration of less than 6 weeks during the past 12-month period. 0%: less than 5 percent of the entire body or exposed areas affected, and no more than topical therapy required during the past 12-month period.

Each level reads as an "or." You qualify by hitting either the body-area number or the therapy criterion. That structure is the whole game. A veteran can be at 60 percent on therapy and 10 percent on body area, and the rating is 60 percent.

The body-area measurement separates "entire body" from "exposed areas." Exposed areas are the parts visible in ordinary clothing, generally the head, face, neck, and hands. A veteran with concentrated plaques on the scalp, face, and hands can hit the exposed-area percentage even when the whole-body percentage is lower, because the denominator is smaller. The examiner is supposed to record both.

The Post-2018 Lever: Biologics Count as Systemic Therapy

The August 13, 2018 amendment is the most important development in psoriasis rating, and it cuts in the veteran's favor. Before the amendment, the relationship between newer biologic drugs and the phrase "systemic therapy" was litigated and inconsistent. After the amendment, the regulation lists "biologics" and "other immunosuppressive drugs" explicitly alongside corticosteroids and phototherapy. There is no longer an argument that a biologic is not systemic therapy.

This matters because of how psoriasis is actually treated in 2026. The standard of care for moderate-to-severe plaque psoriasis is a biologic: a TNF inhibitor like adalimumab or etanercept, an IL-17 inhibitor like secukinumab or ixekizumab, an IL-23 inhibitor like guselkumab or risankizumab, or an IL-12/23 inhibitor like ustekinumab. Methotrexate and other oral immunosuppressives are also common. Phototherapy is systemic therapy under the regulation as well.

The clinical reality and the rating consequence collide here. Biologics work. A veteran on an effective biologic often has clear or nearly clear skin. If the rater looks only at the body-area prong, that veteran might rate at 0 or 10 percent because the visible disease is minimal. But the drug that produced the clear skin is constant or near-constant systemic therapy, which is the 60 percent criterion on its own. The treatment that suppresses the disease is itself the basis for the higher rating.

The dosing schedule determines which therapy tier applies. A biologic dosed every eight or twelve weeks, taken throughout the year, supports a "constant or near-constant" argument for 60 percent, because the drug is continuously in effect even if the injections are intermittent. A short course of oral steroids during a single flare might only support the less-than-six-weeks tier at 10 percent. The total duration over the past twelve-month period is the measurement that the regulation cares about.

What this means practically: the pharmacy record is rating evidence. The prescription, the refill history, the infusion or injection log, the duration of the prescription over the past twelve months, all of it goes in the file. A claim built only on photographs of skin and a dermatologist's body-area estimate leaves the strongest prong of the code undeveloped.

The Alternative Paths: Disfigurement and Scars

DC 7816 does not lock you into the body-area-and-therapy framework. The code directs that psoriasis be rated on the greater of that framework or disfigurement of the head, face, or neck under DC 7800, or scarring under DC 7801 through 7805. When psoriasis has produced visible disfigurement or scarring, you compare the two paths and take the higher rating.

DC 7800 rates disfigurement of the head, face, or neck on a set of eight characteristics, things like a scar five or more inches long, surface contour elevation or depression, hypo- or hyper-pigmentation over a defined area, and texture abnormality. The more characteristics present, the higher the rating, up to 80 percent for the most severe disfigurement affecting multiple features. Psoriasis on the face and scalp that has produced pigment changes, scaling, or texture abnormality across a defined area can rate under DC 7800 if that produces a higher number than the body-area or therapy prong.

DC 7801 through 7805 rate scars: deep and nonlinear scars by area, superficial nonlinear scars by area, unstable or painful scars by count, and other scar effects. Psoriasis that has caused fixed scarring rather than active plaques may rate under these codes.

In most active psoriasis claims, the therapy prong is the higher path, because biologics push toward 60 percent regardless of appearance. The disfigurement and scar paths matter more for facial and scalp disease with cosmetic residuals, or for cases where systemic therapy is not in use. The point is to run all three and rate on the greatest, which is what the code instructs.

Psoriatic Arthritis: The Secondary Chain

Psoriatic arthritis is an inflammatory arthritis that frequently accompanies psoriasis, and it is separately ratable. Under 38 CFR § 3.310, a condition that is caused or aggravated by a service-connected condition can be service-connected on a secondary basis (Allen v. Brown for the aggravation prong). A veteran service-connected for psoriasis who develops psoriatic arthritis has a secondary-connection argument for the joint disease.

This is a meaningful rating expansion because the skin and the joints rate separately. Psoriasis rates under DC 7816 on the skin and therapy prongs. Psoriatic arthritis rates under the arthritis framework in § 4.71a, generally as an active inflammatory arthritis or by analogy to limitation of motion of the affected joints, with the joint-by-joint rating math that musculoskeletal claims follow. The two ratings combine. A veteran with a 60 percent psoriasis rating on the therapy prong and a separate rating for psoriatic arthritis of the hands, spine, or other joints can build a substantially higher combined evaluation than the skin alone.

The nexus opinion for the secondary chain has to do the usual work: identify that the arthritis is psoriatic in type rather than ordinary osteoarthritis, connect it to the service-connected psoriasis, and address the medical mechanism. Psoriatic arthritis is a recognized comorbidity of psoriasis in the rheumatology literature, which makes the medical relationship easier to establish than many secondary chains, but the opinion still has to articulate it rather than assume it. A rheumatology workup distinguishing psoriatic arthritis from other arthritides is the strongest evidence.

C&P Exam Mechanics: What the Examiner Has to Capture

The psoriasis C&P exam follows the DBQ for skin conditions. The examiner is supposed to record several things, and the inadequacy rate in the data tracks closely with which of these get skipped:

• The percentage of the entire body affected by characteristic lesions.
• The percentage of exposed areas affected, measured separately from the entire-body figure.
• The specific systemic therapy used, the drug name, and the total duration over the past twelve-month period.
• Whether the therapy is constant, near-constant, or intermittent.
• Any disfigurement of the head, face, or neck, with the DC 7800 characteristics noted.
• Any scarring, with location, type, and measurement.

The structural problem with psoriasis exams is timing. Psoriasis is a relapsing-remitting disease. It flares and it clears. An exam scheduled during a clear or treated period captures a body-area percentage that does not reflect the disability across the year. The body-area prong is a snapshot, and the snapshot is often misleading.

This is exactly why the therapy prong matters so much, and why developing it protects the claim against a bad exam date. The therapy prong is measured over the past twelve-month period, not on exam day. A veteran whose skin happens to be clear at the exam because the biologic is working still qualifies on the constant-therapy criterion. When the examiner records the body area but not the therapy, the rating defaults to the snapshot and the over-the-year picture falls out. That is the single most common way these cases go wrong.

Common Evidence Gaps in Psoriasis Claims

A few patterns I've noticed across BVA decisions involving psoriasis.

The exam was scheduled during a clear or treated period. Psoriasis flares and remits. A veteran with severe disease for nine months of the year can have a clear-looking exam in the off month. The body-area percentage recorded at that exam understates the disability, and without the therapy prong or flare documentation, the rating tracks the snapshot. This is the core driver behind the high inadequacy rate in the data.

The therapy prong is never developed. This is the big one. The claim gets built around photographs and a body-area estimate, and the systemic therapy goes unmentioned or under-documented. The drug name, the dosing schedule, and the total duration over the past twelve months are missing from the record, so the 60 percent therapy criterion never gets evaluated. The pharmacy printout, the prescription history, and the dermatology or rheumatology notes documenting the biologic are the fix.

Exposed-area percentage not measured separately. The examiner records only the whole-body figure. A veteran with concentrated facial, scalp, and hand involvement can hit the exposed-area tier even when the whole-body number is lower, because the denominator is smaller. When the exam collapses both into one number, the higher exposed-area path disappears.

Psoriatic arthritis joint complaints not worked up. The veteran reports joint pain and stiffness, but no rheumatology referral distinguishes psoriatic arthritis from ordinary wear, so the separate joint rating under the arthritis framework never gets claimed. The skin rates and the joints don't.

No documentation of disfigurement or scarring residuals. Facial and scalp psoriasis can produce pigment changes and texture abnormality that would rate under DC 7800, but if the exam doesn't catalog the disfigurement characteristics, the alternative path the code provides goes unused.

I don't know exactly what percentage of psoriasis claims have one or more of these gaps. What I can say from Claim Raven's analysis of 505 BVA psoriasis cases is that, of the 380 cases with a C&P adequacy determination, 63.7% had the examination flagged as inadequate, and remands ran at 44.6%, the largest share of any outcome in the psoriasis subset. That pattern is consistent with the exam-timing and therapy-documentation dynamics described here: the Board is sending psoriasis cases back for proper development more often than it is granting or denying them outright, and the inadequate exam is usually the reason. The cases that succeed tend to have the systemic therapy documented over the twelve-month period rather than relying on a single body-area snapshot.

What to Push For

Build the therapy prong first. The body-area prong is a snapshot that a bad exam date can sink. The therapy prong is measured over the past twelve months and survives an exam where the skin happens to be clear. Get the pharmacy record, the prescription history, and the treating dermatologist or rheumatologist notes that name the drug, state the dosing schedule, and establish the duration. A biologic taken throughout the year supports the "constant or near-constant systemic therapy" criterion at 60 percent regardless of how the skin looks on exam day.

When the exam was scheduled during a clear period, that is grounds to argue the exam is not adequate to rate a relapsing-remitting condition. Your own documentation fills the gap: photographs of flares with dates, a symptom log tracking how much of the year the disease was active and how much skin was involved at its worst, and records of the systemic therapy. A symptom tracker for psoriasis flares with dated flare photos and a treatment log gives the rater the over-the-year picture the single exam misses.

Run all three rating paths and claim the highest. Body area or therapy under DC 7816, disfigurement under DC 7800, scars under DC 7801 through 7805. The code instructs the rater to rate on the greater, so the evidence has to support each path you want considered. And if there are joint symptoms, get a rheumatology workup to establish psoriatic arthritis as a separate, secondary-connected rating. An evidence checklist for skin claims should separate the body-area proof, the therapy proof, and the disfigurement proof into their own lanes.

What to Ask the C&P Examiner to Document

The skin exam should record the percentage of the entire body affected and the percentage of exposed areas affected as two separate figures. It should name the specific systemic therapy, state whether it is constant, near-constant, or intermittent, and quantify the total duration over the past twelve-month period. It should catalog any disfigurement of the head, face, or neck against the DC 7800 characteristics, and measure any scarring.

The exam is the rating engine, but for psoriasis the exam alone is structurally incomplete because it captures one day of a disease that fluctuates. If the examiner does not document the systemic therapy over the year, the 60 percent therapy criterion becomes an appeal issue instead of evidence in the initial decision. If the examiner records only a whole-body percentage, the exposed-area path is lost.

Use C&P exam prep for the skin DBQ and a flare log before the exam. Bring the pharmacy printout, dated photographs of active disease, and the treatment history so the examiner has the facts to record about therapy duration rather than relying on what the skin looks like that day. The secondary conditions tool helps map the psoriatic-arthritis chain before the exam.

Bottom Line

Psoriasis ratings under DC 7816 turn on a prong most claims never develop. The body-area percentage is the obvious path, and it is the path most exams measure, but it is a snapshot of a disease that flares and clears. The systemic-therapy prong is measured over the full year, and after the August 13, 2018 amendment, biologics and other immunosuppressives count toward it explicitly. A veteran on a biologic for service-connected psoriasis has a 60 percent argument that does not depend on how the skin looks on exam day, because the drug itself is the constant systemic therapy the criterion describes. Add the alternative disfigurement and scar paths the code provides, plus a separately ratable psoriatic arthritis under § 3.310, and a single skin condition can support a substantially higher combined rating than a body-area snapshot would suggest. Same disease, different paper trail, different outcome.

Related Conditions

Psoriasis shares rating logic and proof patterns with eczema, which is rated under the same § 4.118 framework on body area and therapy, and with scars and skin cancer where disfigurement and scarring residuals come into play. Veterans with joint symptoms should review the arthritis page and the secondary conditions tool, because psoriatic arthritis is a separately ratable inflammatory arthritis that frequently accompanies psoriasis. The common thread across these skin claims is that the C&P exam has to capture the disease across the year and document the systemic therapy, not just the appearance of the skin on a single day.

Methodology and Limitations

• Data source: Rating criteria quoted from 38 CFR § 4.118, DC 7816, as amended effective August 13, 2018. Alternative rating paths from DC 7800 (disfigurement of the head, face, or neck) and DC 7801 through 7805 (scars). Secondary service connection from § 3.310, with aggravation under Allen v. Brown. Psoriatic arthritis rating framework from § 4.71a.
• Sample size: Patterns in this post are drawn from Claim Raven's analysis of 101,518 condition records drawn from the analyzed subset of Claim Raven's 501,000+ Board-decision library, including 505 psoriasis cases. Within that psoriasis subset, outcomes ran 44.6% remanded, 23.0% granted, and 26.3% denied. Of the 380 cases with a C&P adequacy determination, 63.7% had the examination flagged as inadequate. The dataset captures overall outcome rather than per-prong (body-area versus systemic-therapy) breakdown.
• Classification approach: Rating-prong definitions drawn from the regulatory text. The systemic-therapy analysis follows the post-2018 amended criteria. Outcome and adequacy figures are queries against the BVA decision dataset.
• Limitations:
• The body-area-versus-therapy framework reflects the criteria amended effective August 13, 2018. Claims with effective dates spanning the amendment can implicate both the prior and current versions of DC 7816, and the rater applies whichever is more favorable for the relevant period.
• Whether a given dosing schedule supports "constant or near-constant" versus a shorter-duration therapy tier is a fact-specific determination that varies by case.
• The therapy prong is measured over the past twelve-month period, so the relevant evidence is the treatment history rather than the exam-day skin findings.
• Selection bias: BVA-level patterns reflect cases that appealed. Most psoriasis claims resolve at the RO level and aren't in any BVA dataset.
• The adequacy figure is drawn from the 380 cases in the subset that carried a C&P adequacy determination, not all 505 cases.
• These observations reflect patterns from the regulatory text, case law, and BVA decisions. They are not predictions of individual outcomes.