Bullous Disorders (Pemphigus, Pemphigoid) — VA Disability Rating (DC 7815)
Diagnostic Code 7815 · 38 CFR §4.118
What Is It?
Bullous disorders are autoimmune diseases in which the immune system attacks the proteins that hold skin cells together, causing the skin to blister and separate. DC 7815 covers the group: pemphigus vulgaris and pemphigus foliaceus, bullous pemphigoid, mucous membrane (cicatricial) pemphigoid, epidermolysis bullosa acquisita, dermatitis herpetiformis, and benign chronic familial pemphigus. They are serious conditions — pemphigus vulgaris was frequently fatal before corticosteroids — and they are managed with long-term systemic immunosuppression: prednisone, azathioprine, mycophenolate, and increasingly rituximab. The VA rates DC 7815 under the General Rating Formula for the Skin. For these diseases the systemic-therapy path is almost always the operative one, because treatment is continuous by design and the criteria at 30 and 60 percent are written around duration. A veteran maintained on year-round immunosuppression meets the constant-or-near-constant criterion for 60 percent even when the blistering itself is well controlled — which is exactly the point, since the control is purchased with the therapy.
Rating Criteria
| Rating | Criteria |
|---|---|
| 60% | Characteristic bullous 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 required over the past 12-month period. This is the maximum schedular evaluation under the General Rating Formula for the Skin. |
| 30% | Characteristic bullous lesions involving 20 to 40 percent of the entire body, or 20 to 40 percent of exposed areas affected; or, systemic therapy required for a total duration of six weeks or more, but not constantly, over the past 12-month period. |
| 10% | Characteristic bullous lesions involving at least 5 percent but less than 20 percent of the entire body, or at least 5 percent but less than 20 percent of exposed areas affected; or, intermittent systemic therapy — including but not limited to corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs — required for a total duration of less than six weeks over the past 12-month period. |
| 0% | No more than topical therapy required over the past 12-month period, and characteristic bullous lesions involving less than 5 percent of the entire body or less than 5 percent of exposed areas affected. |
Evidence Needed
The diagnosis needs to be pinned down precisely, because the bullous family contains several distinct diseases and the workup is specific: skin biopsy with direct immunofluorescence showing the pattern of antibody deposition, plus serologic testing for desmoglein or BP180/BP230 antibodies. For the rating, the treatment record is the centerpiece — every systemic agent, the dose, and above all the total duration over the past twelve months, because "constant or near-constant" is the 60 percent criterion and continuous maintenance therapy satisfies it. Hospital admissions for severe flares, wound-care records, and photographs of active blistering and erosions document severity. If mucous membranes are involved, ophthalmology and otolaryngology notes matter, since ocular pemphigoid scars the conjunctiva and can threaten sight.
C&P Exam Tips
Bring the complete immunosuppressive history and state it in terms the criteria use: continuous, or a specific number of weeks over the past twelve months. This is the single most important thing you will say at the exam. Make clear that maintenance therapy is not the same as being cured — the disease is controlled because of the drugs, and the criteria are explicitly written to compensate for the therapy burden. Bring photographs of active blistering; you may well be examined during a controlled period. Ask that mucosal involvement be documented, including the mouth, eyes, throat, and genitals, and mention any difficulty eating or swallowing. Report the side effects of long-term steroid and immunosuppressive therapy — bone loss, diabetes, cataracts, infections — because those are separately ratable.
How to File
File on VA Form 21-526EZ naming the specific disease — pemphigus vulgaris, bullous pemphigoid, epidermolysis bullosa acquisita — under DC 7815. Attach the biopsy with direct immunofluorescence, serology, the full systemic therapy history with durations, hospital records, and photographs. File the complications of long-term immunosuppression as separate secondary claims: steroid-induced osteoporosis, steroid-induced diabetes, cataracts, and recurrent infections are all consequences of treatment for a service-connected condition under 38 CFR §3.310. Claim residual scarring under DC 7800 through 7805 and ocular involvement under the eye codes.
Common Mistakes
The most consequential mistake is understating therapy because the disease is quiet. A veteran on maintenance rituximab or daily mycophenolate with no active blisters is on constant systemic therapy and meets the 60 percent criterion — but if the exam records only "skin clear, no active lesions," the rating comes back at 0 or 10. Say the therapy history out loud and put it in writing. The second mistake is leaving the treatment complications unclaimed: long-term corticosteroids cause osteoporosis, avascular necrosis, diabetes, and cataracts, and every one of those is a compensable secondary condition. The third is not documenting mucosal disease, which drives functional impairment and can produce separately ratable eye and throat findings. The fourth is being examined without flare photographs.
Frequently Asked Questions
Can I get 60 percent if my blisters are controlled?
Yes, if the control comes from constant or near-constant systemic therapy. The General Rating Formula provides 60 percent for more than 40 percent body involvement OR for constant or near-constant systemic therapy over the past twelve months — the two paths are alternatives, not requirements. Continuous immunosuppression for pemphigus or pemphigoid satisfies the therapy path on its own, and that is the intended reading: the criteria compensate the treatment burden as well as the disease.
Does rituximab count as systemic therapy?
Yes. 38 CFR §4.118(a) defines systemic therapy as treatment administered through any route other than the skin, and the General Rating Formula expressly names biologics and other immunosuppressive drugs among the qualifying agents. Rituximab is an infused biologic immunosuppressant. Because it is given in cycles, document the treatment plan and the intervals so the duration is assessed as ongoing therapy rather than as isolated infusion days.
What secondary conditions come from bullous disorder treatment?
Long-term systemic corticosteroids are the usual culprit: osteoporosis and fractures, avascular necrosis of the hip, steroid-induced diabetes, cataracts, glaucoma, hypertension, and weight gain. Broader immunosuppression brings recurrent and opportunistic infections. Each is separately compensable under 38 CFR §3.310 as a consequence of treatment for a service-connected condition, and together they frequently exceed the value of the skin rating itself.
How is mucous membrane involvement rated?
The skin evaluation under DC 7815 covers the disease process, but the damage mucosal disease causes is rated where it lands. Cicatricial pemphigoid scarring the conjunctiva is rated under the eye codes and can be sight-threatening; esophageal strictures are rated under the digestive codes; laryngeal involvement under the respiratory codes. Ask for the appropriate specialty examinations and claim those effects by name.