TN 29 (10-23)
8.00 Skin Disorders
A. Which skin disorders do we evaluate under these listings? We use these listings to evaluate skin disorders that result from hereditary, congenital,
or acquired pathological processes. We evaluate genetic photosensitivity disorders
(8.07), burns (8.08), and chronic conditions of the skin or mucous membranes such
as ichthyosis, bullous disease, dermatitis, psoriasis, and hidradenitis suppurativa
(8.09) under these listings.
B. What are our definitions for the following terms used in this body
system?
1. Assistive device(s): An assistive device, for the purposes of these listings, is any device used to improve
stability, dexterity, or mobility. An assistive device can be hand-held, such as a
cane(s), a crutch(es), or a walker; used in a seated position, such as a wheelchair,
rollator, or power operated vehicle; or worn, such as a prosthesis or an orthosis.
2. Chronic skin lesions: Chronic skin lesions can have recurrent exacerbations (see 8.00B7). They can occur
despite prescribed medical treatment. These chronic skin lesions can develop on any
part of your body, including upper extremities, lower extremities, palms of your hands,
soles of your feet, the perineum, inguinal (groin) region, and axillae (underarms).
Chronic skin lesions may result in functional limitations as described in 8.00D2.
3. Contractures: Contractures are permanent fibrous scar tissue resulting in tightening and thickening
of skin that prevents normal movement of the damaged area. They can develop on any
part of your musculoskeletal system, including upper extremities, lower extremities,
palms of your hands, soles of your feet, the perineum, inguinal (groin) region, and
axillae (underarms). Contractures may result in functional limitations as described
in 8.00D2.
4. Documented medical need: When we use the term “documented medical need,” we mean that there is evidence (see
§§ 404.1513 and 416.913 of this chapter) from your medical source(s) in the medical record that supports
your need for an assistive device (see 8.00B1) for a continuous period of at least
12 months. The evidence must include documentation from your medical source(s) describing
any limitation(s) in your upper or lower extremity functioning that supports your
need for the assistive device and describing the circumstances for which you need
it. The evidence does not have to include a specific prescription for the device.
5. Fine and gross movements: Fine movements, for the purposes of these listings, involve use of your wrists, hands,
and fingers; such movements include picking, pinching, manipulating, and fingering.
Gross movements involve use of your shoulders, upper arms, forearms, and hands; such
movements include handling, gripping, grasping, holding, turning, and reaching. Gross
movements also include exertional activities such as lifting, carrying, pushing, and
pulling.
6. Surgical management: For the purposes of these listings, surgical management includes the surgery(ies)
itself, as well as various post-surgical procedures, surgical complications, infections
or other medical complications, related illnesses, or related treatments that delay
a person's attainment of maximum benefit from surgery.
7. Exacerbation: For the purposes of these listings, exacerbation means an increase in the signs or
symptoms of the skin disorder. Exacerbation may also be referred to as flare, flare-up,
or worsening of the skin disorder.
C. What evidence do we need to evaluate your skin
disorder?
1. To establish the presence of a skin disorder as a medically determinable impairment,
we need objective medical evidence from an acceptable medical source (AMS) who has
examined you for the disorder.
2. We will make every reasonable effort to obtain your medical history, treatment
records, and relevant laboratory findings, but we will not purchase genetic testing.
3. When we evaluate the presence and severity of your skin disorder(s), we generally
need information regarding:
a. The onset, duration, and frequency of exacerbations (see 8.00B7);
b. The prognosis of your skin disorder;
c. The location, size, and appearance of lesions and contractures;
d. Any available history of familial incidence;
e. Your exposure to toxins, allergens or irritants; seasonal variations; and stress
factors;
f. Your ability to function outside of a highly protective environment (see 8.00E4);
g. Laboratory findings (for example, a biopsy obtained independently of Social Security
disability evaluation or results of blood tests);
h. Evidence from other medically acceptable methods consistent with the prevailing
state of medical knowledge and clinical practice; and
i. Statements you or others make about your disorder(s), your restrictions, and your
daily activities.
D. How do we evaluate the severity of skin disorders?
1. General. We evaluate the severity of skin disorders based on the site(s) of your chronic skin
lesions (see 8.00B2) or contractures (see 8.00B3), functional limitations caused by
your signs and symptoms (including pain) (see 8.00D2), and how your prescribed treatment
affects you. We consider the frequency and severity of your exacerbations (see 8.00B7),
how quickly they resolve, and how you function between exacerbations (see 8.00B7),
to determine whether your skin disorder meets or medically equals a listing (see 8.00D3).
If there is no record of ongoing medical treatment for your disorder, we will follow
the guidelines in 8.00D6. We will determine the extent and kinds of evidence we need
from medical and non-medical sources based on the individual facts about your disorder.
For our basic rules on evidence, see §§ 404.1512, 404.1513, 404.1520b, 416.912, 416.913, and 416.920b of this chapter. For our rules on evaluating your symptoms, see §§ 404.1529 and 416.929 of this chapter.
2. Limitation(s) of physical functioning due to skin
disorders.
a. Skin disorders may be due to chronic skin lesions (see 8.00B2) or contractures
(see 8.00B3), and may cause pain or restrict movement, which can limit your ability
to initiate, sustain, and complete work-related activities. For example, skin lesions
in the axilla may limit your ability to raise or reach with the affected arm, or lesions
in the inguinal region may limit your ability to ambulate, sit, or lift and carry.
To evaluate your skin disorder(s) under 8.07B, 8.08, and 8.09, we require medically
documented evidence of physical limitation(s) of functioning related to your disorder.
The decrease in physical function must have lasted, or can be expected to last, for
a continuous period of at least 12 months (see §§ 404.1509 and 416.909 of this chapter). Xeroderma pigmentosum is the only skin disorder that does not include
functional criteria because the characteristics and severity of the disorder itself
are sufficient to meet the criteria in 8.07A.
b. The functional criteria require impairment-related physical limitations in using
upper or lower extremities that have lasted, or can be expected to last, for a continuous
period of at least 12 months, medically documented by one of the following:
(i) Inability to use both upper extremities to the extent that neither can be used
to independently initiate, sustain, and complete work-related activities involving
fine and gross movements (see 8.00B5) due to chronic skin lesions (see 8.00B2) or
contractures (see 8.00B3); or
(ii) Inability to use one upper extremity to independently initiate, sustain, and
complete work-related activities involving fine and gross movements (see 8.00B5) due
to chronic skin lesions (see 8.00B2) or contractures (see 8.00B3), and a documented
medical need (see 8.00B4) for an assistive device (see 8.00B1) that requires the use
of the other upper extremity; or
(iii) Inability to stand up from a seated position and maintain an upright position
to the extent needed to independently initiate, sustain, and complete work-related
activities due to chronic skin lesions (see 8.00B2) or contractures (see 8.00B3) affecting
at least two extremities (including when the limitations are due to involvement of
the perineum or the inguinal region); or
(iv) Inability to maintain an upright position while standing or walking to the extent
needed to independently initiate, sustain, and complete work-related activities due
to chronic skin lesions (see 8.00B2) or contractures (see 8.00B3) affecting both lower
extremities (including when the limitations are due to involvement of the perineum
or the inguinal region).
3. Frequency of exacerbations due to chronic skin lesions. A skin disorder resulting in chronic skin lesions (see 8.00B2) may have frequent
exacerbations (see 8.00B7) severe enough to meet a listing even if each individual
skin lesion exacerbation (see 8.00B7) did not last for an extended amount of time.
We will consider the frequency, severity, and duration of skin lesion exacerbations
(see 8.00B7), how quickly they resolve, and how you function in the time between skin
lesion exacerbations (see 8.00B7), to determine whether your skin disorder meets or
medically equals a listing.
4. Symptoms (including pain). Your symptoms may be an important factor in our determination of whether your skin
disorder(s) meets or medically equals a listing, or whether you are otherwise able
to work. We consider your symptoms only when you have a medically determinable impairment
that could reasonably be expected to produce the symptoms. See §§ 404.1529 and 416.929 of this chapter.
5. Treatment.
a. General. Treatments for skin disorders may have beneficial or adverse effects, and responses
to treatment vary from person to person. Your skin disorder's response to treatment
may vary due to treatment resistance or side effects that can result in functional
limitations. We will evaluate all of the effects of treatment (including surgical
treatment, medications, and therapy) on the symptoms, signs, and laboratory findings
of your skin disorder, and on your ability to function.
b. Despite adherence to prescribed medical treatment for 3
months. Under 8.09, we require that your symptoms persist “despite adherence to prescribed
medical treatment for 3 months.” This requirement means that you must have taken prescribed
medication(s) or followed other medical treatment prescribed by a medical source for
3 consecutive months. Treatment or effects of treatment may be temporary. In most
cases, sufficient time must elapse to allow us to evaluate your response to treatment,
including any side effects. For our purposes, “sufficient time” means a period of
at least 3 months. If your treatment has not lasted for at least 3 months, we will
follow the rules in 8.00D6a. The 3 months adherence to prescribed medical treatment
must be within the period of at least 12 months that we use to evaluate severity.
c. Treatment with PUVA (psoralen and ultraviolet A (UVA) light) or
biologics. If you receive additional treatment with PUVA or biologics to treat your skin disorder(s),
we will defer adjudication of your claim for 6 months from the start of treatment
with PUVA or biologics to evaluate the effectiveness of these treatments unless we
can make a fully favorable determination or decision on another basis.
6. No record of ongoing treatment.
a. Despite having a skin disorder, you may not have received ongoing treatment, may
have just begun treatment, may not have access to prescribed medical treatment, or
may not have an ongoing relationship with the medical community. In any of these situations,
you will not have a longitudinal medical record for us to review when we evaluate
your disorder. In some instances, we may be able to assess the severity and duration
of your skin disorder based on your medical record and current evidence alone. We
may ask you to attend a consultative examination to determine the severity and potential
duration of your skin disorder (see §§ 404.1519a and 416.919a of this chapter).
b. If, for any reason, you have not received treatment, your skin disorder cannot
meet the criteria for 8.09. If the information in your case record is not sufficient
to show that you have a skin disorder that meets the criteria of one of the skin disorders
listings, we will follow the rules in 8.00I.
E. How do we evaluate genetic photosensitivity disorders under
8.07? Genetic photosensitivity disorders are disorders of the skin caused by an increase
in the sensitivity of the skin to sources of ultraviolet light, including sunlight.
1. Xeroderma pigmentosum (XP) (8.07A). XP is a genetic photosensitivity disorder with lifelong hypersensitivity to all forms
of ultraviolet light. Laboratory testing confirms the diagnosis by documenting abnormalities
in the body's ability to repair DNA (deoxyribonucleic acid) mutations after ultraviolet
light exposure. Your skin disorder meets the requirements of 8.07A if you have clinical
and laboratory findings supporting a diagnosis of XP (see 8.00E3).
2. Other genetic photosensitivity disorders (8.07B). The effects of other genetic photosensitivity disorders may vary and may not persist
over time. To meet the requirements of 8.07B, a genetic photosensitivity disorder
other than XP must be established by clinical and laboratory findings (see 8.00C)
and must result either in chronic skin lesions (see 8.00B2) or contractures (see 8.00B3)
that result in functional limitations (see 8.00D2), or must result in the inability
to function outside of a highly protective environment (see 8.00E4). Some genetic
photosensitivity disorders can have very serious effects on other body systems, especially
special senses and speech, neurological, mental, and cancer. We will evaluate your
disorder(s) under the listings in 2.00, 11.00, 12.00, or 13.00, as appropriate.
3. What evidence do we need to document that you have XP or another
genetic photosensitivity disorder? We will make a reasonable effort to obtain evidence of your disorder(s), but we will
not purchase genetic testing. When the results of genetic tests are part of the existing
evidence in your case record, we will evaluate the test results with all other relevant
evidence. We need the following clinical and laboratory findings to document that
you have XP or another genetic photosensitivity disorder:
a. A laboratory report of a definitive genetic test documenting appropriate chromosomal
changes, including abnormal DNA repair or another DNA abnormality specific to your
type of photosensitivity disorder, signed by an AMS; or
b. A laboratory report of a definitive test that is not signed by an AMS, and a report
from an AMS stating that you have undergone definitive genetic laboratory studies
documenting appropriate chromosomal changes, including abnormal DNA repair or another
DNA abnormality specific to your type of photosensitivity disorder; or
c. If we do not have a laboratory report of a definitive test, we need documentation
from an AMS that an appropriate laboratory analysis or other diagnostic method(s)
confirms a positive diagnosis of your skin disorder. This documentation must state
that you had the appropriate definitive laboratory test(s) for diagnosing your disorder
and provide the results, or explain how another diagnostic method(s), consistent with
the prevailing state of medical knowledge and clinical practice, established your
diagnosis.
4. Inability to function outside of a highly protective
environment means that you must avoid exposure to ultraviolet light (including sunlight passing
through windows and light from similar unshielded light sources), wear protective
clothing and eyeglasses, and use opaque broad-spectrum sunscreens in order to avoid
skin cancer or other serious effects.
F. How do we evaluate burns under 8.08?
1. Electrical, chemical, or thermal burns frequently affect other body systems, for
example, musculoskeletal, special senses and speech, respiratory, cardiovascular,
genitourinary, neurological, or mental. We evaluate burns in the same way we evaluate
other disorders that can affect the skin and other body systems, using the listing
for the predominant feature of your disorder. For example, if your soft tissue injuries
resulting from burns are under surgical management (as defined in 8.00B6), we will
evaluate your disorder under the listings in 1.00.
2. We evaluate burns resulting in chronic skin lesions (see 8.00B2) or contractures
(see 8.00B3) that have been documented by an AMS to have reached maximum therapeutic
benefit and therefore are no longer receiving surgical management, under 8.08. To
be disabling, these burns must result in functional limitation(s) (see 8.00D2) that
has lasted or can be expected to last for a continuous period of at least 12 months.
G. How do we evaluate chronic conditions of the skin or mucous
membranes under 8.09? We evaluate skin disorders that result in chronic skin lesions (see 8.00B2) or contractures
(see 8.00B3) under 8.09. These disorders must result in chronic skin lesions (see
8.00B2) or contractures (see 8.00B3) that continue to persist despite adherence to
prescribed medical treatment for 3 months (see 8.00D5b) and cause functional limitations
(see 8.00D2). Examples of skin disorders evaluated under this listing are ichthyosis,
bullous diseases (such as pemphigus, epidermolysis bullosa, and dermatitis herpetiformis),
chronic skin infections, dermatitis, psoriasis, and hidradenitis suppurativa.
H. How do we evaluate disorders in other body systems that affect the
skin? When your disorder(s) in another body system affects your skin, we first evaluate
the predominant feature of your disorder(s) under the appropriate body system. Examples
of disorders in other body systems that may affect the skin include the following:
1. Diabetes mellitus. Diabetes mellitus that is not well controlled, despite treatment, can cause chronic
hyperglycemia resulting in serious, long-lasting or recurrent exacerbations (see 8.00B7)
or complications. We evaluate those exacerbations (see 8.00B7) or complications under
the affected body system(s). If the complication involves soft tissue or amputation(s),
we evaluate these features under the listings in 1.00. If the exacerbations (see 8.00B7) or complications involve chronic bacterial or
fungal skin lesions resulting from diabetes mellitus, we evaluate your limitations
from the skin disorder under listing 8.09.
2. Tuberous sclerosis. The predominant functionally limiting features of tuberous sclerosis are seizures
and intellectual disorder or other mental disorders. We evaluate these features under
the listings in 11.00 or 12.00, as appropriate.
3. Malignant tumors of the skin. Malignant tumors of the skin (for example, malignant melanomas) are cancers, or malignant
neoplastic diseases, that we evaluate under the listings in 13.00.
4. Immune system disorders. We evaluate skin manifestations of immune system disorders such as systemic lupus
erythematosus, scleroderma, psoriasis, and human immunodeficiency virus (HIV) infection
under the listings in 14.00.
5. Head or facial disfigurement or deformity, and other physical
deformities caused by skin disorders. A head or facial disfigurement or deformity may result in loss of your sight, hearing,
speech, or ability to chew. In addition to head and facial disfigurement and deformity,
other physical deformities may result in associated psychological problems (for example,
depression). We evaluate the effects of head or facial disfigurement or deformity,
or other physical deformities caused by skin disorders under the listings in 1.00, 2.00, 5.00, or 12.00, as appropriate.
I. How do we evaluate skin disorders that do not meet one of these
listings?
1. These listings are only examples of common skin disorders that we consider severe
enough to prevent you from doing any gainful activity. If your impairment(s) does
not meet the criteria of any of these listings, we must also consider whether you
have an impairment(s) that satisfies the criteria of a listing in another body system.
2. If you have a severe medically determinable impairment(s) that does not meet a
listing, we will determine whether your impairment(s) medically equals a listing.
See §§ 404.1526 and 416.926 of this chapter. If your impairment(s) does not meet or medically equal a listing,
you may or may not have the residual functional capacity to engage in substantial
gainful activity. We proceed to the fourth step and, if necessary, the fifth step
of the sequential evaluation process in §§ 404.1520 and 416.920 of this chapter. We use the rules in §§ 404.1594 and 416.994 of this chapter, as appropriate, when we decide whether you continue to be disabled.
8.01 Category of Impairments, Skin Disorders
8.02–8.06 [Reserved]
8.07 Genetic photosensitivity disorders, established as described in 8.00E. The requirements of this listing are met if either
paragraph A or paragraph B is satisfied.
A. Xeroderma pigmentosum (see 8.00E1).
OR
B. Other genetic photosensitivity disorders (see 8.00E2) with either 1 or 2:
1. Chronic skin lesions (see 8.00B2) or contractures (see 8.00B3) that cause an inability
to function outside of a highly protective environment (see 8.00E4); or
2. Chronic skin lesions (see 8.00B2) or contractures (see 8.00B3) causing chronic
pain or other physical limitation(s) that result in impairment-related functional
limitations (see 8.00D2), as evidenced by:
a. Inability to use both upper extremities to the extent that neither can be used
to independently initiate, sustain, and complete work-related activities involving
fine and gross movements (see 8.00B5) due to chronic skin lesions (see 8.00B2) or
contractures (see 8.00B3); or
b. Inability to use one upper extremity to independently initiate, sustain, and complete
work-related activities involving fine and gross movements (see 8.00B5) due to chronic
skin lesions (see 8.00B2) or contractures (see 8.00B3), and a documented medical need
(see 8.00B4) for an assistive device (see 8.00B1) that requires the use of the other
upper extremity; or
c. Inability to stand up from a seated position and maintain an upright position to
the extent needed to independently initiate, sustain, and complete work-related activities
due to chronic skin lesions (see 8.00B2) or contractures (see 8.00B3) affecting at
least two extremities (including when the limitations are due to involvement of the
perineum or the inguinal region); or
d. Inability to maintain an upright position while standing or walking to the extent
needed to independently initiate, sustain, and complete work-related activities, due
to chronic skin lesions (see 8.00B2) or contractures (see 8.00B3) affecting both lower
extremities (including when the limitations are due to involvement of the perineum
or the inguinal region).
8.08 Burns (see 8.00F). Burns that do not require continuing surgical management (see 8.00B6),
or that have been documented by an acceptable medical source to have reached maximum
therapeutic benefit and therefore are no longer receiving surgical management, resulting
in chronic skin lesions (see 8.00B2) or contractures (see 8.00B3) causing chronic
pain or other physical limitation(s) that result in impairment-related functional
limitations (see 8.00D2), as evidenced by:
A. Inability to use both upper extremities to the extent that neither can be used to
independently initiate, sustain, and complete work-related activities involving fine
and gross movements (see 8.00B5) due to chronic skin lesions (see 8.00B2) or contractures
(see 8.00B3).
OR
B. Inability to use one upper extremity to independently initiate, sustain, and complete
work-related activities involving fine and gross movements (see 8.00B5) due to chronic
skin lesions (see 8.00B2) or contractures (see 8.00B3), and a documented medical need
(see 8.00B4) for an assistive device (see 8.00B1) that requires the use of the other
upper extremity.
OR
C. Inability to stand up from a seated position and maintain an upright position to
the extent needed to independently initiate, sustain, and complete work-related activities
due to chronic skin lesions (see 8.00B2) or contractures (see 8.00B3) affecting at
least two extremities (including when the limitations are due to involvement of the
perineum or the inguinal region).
OR
D. Inability to maintain an upright position while standing or walking to the extent
needed to independently initiate, sustain, and complete work-related activities due
to chronic skin lesions (see 8.00B2) or contractures (see 8.00B3) affecting both lower
extremities (including when the limitations are due to involvement of the perineum
or the inguinal region).
8.09 Chronic conditions of the skin or mucous membranes (see 8.00G) resulting in:
A. Chronic skin lesions (see 8.00B2) or contractures (see 8.00B3) causing chronic pain
or other physical limitation(s) that persist despite adherence to prescribed medical
treatment for 3 months (see 8.00D5b).
AND
B. Impairment-related functional limitations (see 8.00D2) demonstrated by 1, 2, 3, or
4:
1. Inability to use both upper extremities to the extent that neither can be used
to independently initiate, sustain, and complete work-related activities involving
fine and gross movements (see 8.00B5) due to chronic skin lesions (see 8.00B2) or
contractures (see 8.00B3); or
2. Inability to use one upper extremity to independently initiate, sustain, and complete
work-related activities involving fine and gross movements (see 8.00B5) due to chronic
skin lesions (see 8.00B2) or contractures (see 8.00B3), and a documented medical need
(see 8.00B4) for an assistive device (see 8.00B1) that requires the use of the other
upper extremity; or
3. Inability to stand up from a seated position and maintain an upright position to
the extent needed to independently initiate, sustain, and complete work-related activities
due to chronic skin lesions (see 8.00B2) or contractures (see 8.00B3) affecting at
least two extremities (including when the limitations are due to involvement of the
perineum or the inguinal region); or
4. Inability to maintain an upright position while standing or walking to the extent
needed to independently initiate, sustain, and complete work-related activities due
to chronic skin lesions (see 8.00B2) or contractures (see 8.00B3) affecting both lower
extremities (including when the limitations are due to involvement of the perineum
or the inguinal region).