Depression Nexus Letters: Secondary to Dermatological Conditions

Yes. Skin conditions can affect far more than the surface of the skin. For many veterans, chronic skin disease causes embarrassment, pain, itching, burning, drainage, odor, scarring, sleep disruption, social withdrawal, relationship strain, and reduced confidence in public or intimate settings. Over time, these daily burdens can contribute to depression, anxiety, irritability, low self-esteem, avoidance of social situations, and significant impairment in quality of life. This connection is well recognized in dermatology: dermatologists often refer patients to psychiatrists, psychologists, or other mental health professionals when the emotional toll of a skin condition becomes clinically significant. 

The field of psychodermatology exists to address these problems. Research has shown that at least one-third of dermatology patients may have a comorbid mood disorder, underscoring that depression and anxiety are common and clinically meaningful consequences of chronic skin disease. 

When these effects lead to persistent emotional suffering, a secondary mental health nexus letter may be appropriate.

Examples may include:

• A veteran with hidradenitis suppurativa who avoids social contact because of painful lesions, drainage, odor, and embarrassment.
• A veteran with pseudofolliculitis barbae who experiences anxiety and self-consciousness due to visible bumps, scarring, and shaving-related flare-ups.
• A veteran with eczema, psoriasis, or chronic rashes who develops depression because of constant itching, poor sleep, visible plaques, and frustration with recurrent symptoms.
• A veteran with burn scars, acne scarring, or disfigurement who struggles with low self-esteem, avoidance of photographs, intimacy issues, or social withdrawal.
• A veteran with recurrent herpes outbreaks who experiences anxiety, shame, relationship strain, and fear of future flare-ups.

The key issue is whether the evidence shows that the veteran’s mental health condition is at least as likely as not caused or worsened by the service-connected skin condition.

Secondary service connection occurs when a veteran develops a new disability because of an already service-connected condition, or when an already existing condition is made worse by a service-connected condition.

For example, if a veteran is already service-connected for a chronic skin condition and later develops depression or anxiety because of the pain, embarrassment, sleep disruption, social isolation, or functional limitations caused by that skin condition, the veteran may be able to file a claim for the mental health condition as secondary to the skin condition.

Secondary service connection may involve either causation or aggravation.

• Causation means the service-connected condition directly caused the secondary condition to develop.
• Aggravation means the service-connected condition made the secondary condition worse beyond its natural progression.

For VA purposes, a well-supported secondary claim usually needs three things:

1. A current diagnosis of a mental health condition.
2. An already service-connected skin condition.
3. A medical nexus explaining how the service-connected skin condition caused or aggravated the mental health condition.

A strong VA claim for depression or anxiety secondary to a skin condition usually includes medical, lay, and functional evidence. The goal is to show not only that the veteran has a diagnosed mental health condition, but also that the condition is connected to the service-connected skin disorder.

Helpful evidence may include:

• A current mental health diagnosis, such as major depressive disorder, generalized anxiety disorder, adjustment disorder, insomnia disorder, or another clinically recognized condition.
• VA or private treatment records documenting symptoms of depression, anxiety, sleep impairment, social withdrawal, low self-esteem, irritability, panic symptoms, or relationship strain.
• Dermatology records showing the severity, frequency, location, visibility, pain, itching, drainage, scarring, or chronic nature of the skin condition.
• Photographs showing visible skin symptoms, scars, lesions, plaques, rashes, or disfigurement, when appropriate.
• Personal statements describing how the skin condition affects mood, sleep, confidence, social life, work, relationships, and daily functioning.
• Buddy statements from spouses, family members, friends, coworkers, or supervisors describing observed changes in mood, social behavior, intimacy, work functioning, or emotional distress.
• Records showing missed work, workplace accommodations, shaving profiles, uniform problems, limitations during flare-ups, or difficulty performing job duties.
• A medical nexus opinion explaining how the service-connected skin condition caused or aggravated the veteran’s depression, anxiety, or other mental health condition.
• The strongest claims usually provide a clear timeline. For example, the evidence may show that the veteran developed worsening depression or anxiety after years of chronic skin symptoms, visible scarring, painful flare-ups, sleep disruption, embarrassment, or social withdrawal.

A nexus letter is a medical opinion that explains the relationship between a veteran’s service-connected condition and the claimed secondary disability. In this type of claim, the nexus letter should explain how the veteran’s skin condition caused or aggravated depression, anxiety, or another mental health condition.

A strong nexus letter may address:

• The veteran’s service-connected skin condition.
• The veteran’s current mental health diagnosis.
• The history and severity of skin symptoms.
• The emotional impact of visible lesions, scarring, pain, itching, drainage, odor, or disfigurement.
• The effect of the skin condition on sleep, social functioning, work, relationships, self-image, and quality of life.
• Whether the mental health condition is at least as likely as not caused or aggravated by the service-connected skin condition.

A nexus letter can be especially helpful when the VA acknowledges the skin condition but does not fully consider the emotional, social, and functional consequences of living with that condition. The letter can help connect the medical evidence, personal history, and psychiatric symptoms into a clear explanation for VA review.

At Brightview Psychiatry Solutions, Dr. Allen provides nexus letters for veterans pursuing mental health claims, including claims for depression and anxiety secondary to service-connected physical conditions such as chronic skin disease.