TN 25 (04-19)
108.00 Skin Disorders (Effective Date 06/16/08)
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,
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 flareups, 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 disorders(s)? We generally base our assessment of severity on the extent of your skin lesions,
the frequency of flareups 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 flareups. 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 results in marked and severe
functional limitations when we consider your condition over time, especially if your
flareups result in extensive skin lesions, as defined in C1 of this section. Therefore,
if you have frequent flareups, 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 flareups are, how
quickly they resolve, and how you function between flareups to determine whether you
have marked and severe functional limitations that have lasted for a continuous period
of at least 12 months or that can be expected to last for a continuous period of at
least 12 months. We will also consider the frequency of your flareups when we determine
whether you have a severe impairment and when we need to assess functional equivalence.
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 §§ 416.921
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 The 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 108.07 and 108.08, 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 108.00H 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.
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 111.00, and developmental delays or other mental disorders, which we evaluate under the
mental disorders listings in 112.00.
2. Malignant tumors of the skin (for example, malignant melanoma) are cancers, or neoplastic diseases, which we evaluate
under the listings in 113.00.
3. Autoimmune disorders and other immune system disorders (for example, systemic lupus erythematosus (SLE), 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 disorders listings in 114.00.
We evaluate SLE under 114.02, scleroderma under 114.04, Sjögren's syndrome under 114.10,
and HIV infection under 114.11.
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 102.00 and the digestive system listings in 105.00. Facial disfigurement or other physical deformities may also have effects we evaluate
under the mental disorders listings in 112.00, such as when they affect mood or social functioning.
5. We evaluate erythropoietic porphyries under the hemic and lymphatic listings in 107.00.
6. We evaluate hemangiomas associated with thrombocytopenia and hemorrhage
(for example, Kasabach-Merritt syndrome) involving coagulation defects, under the
hemic and lymphatic listings in 107.00. But, when hemangiomas impinge on vital structures or interfere with function, we
evaluate their primary effects under the appropriate body system.
E. How do we evaluate genetic photosensitivity disorders?
1. Xeroderma pigmentosum (XP). When you have XP, your impairment meets the requirements of 108.07A if you have clinical and laboratory findings showing that you have the disorder.
(See 108.00E3.) 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 marked and severe functional limitations 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 108.00E3),
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 108.07B. 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 (102.00), neurological (111.00), mental (112.00), and neoplastic (113.00). We will evaluate the predominant feature of your impairment under the appropriate
body system, as explained in 108.00D.
3. Clinical and laboratory findings.
a. General. We need documentation from an acceptable medical source to establish that you have
a medically determinable impairment.In general, we must have evidence of appropriate
laboratory testing showing that you have XP or another genetic photosensitivity disorder.
We will find that you have XP or another genetic photosensitivity disorder based on
a report from an acceptable medical source indicating that you have the impairment,
supported by definitive genetic laboratory studies documenting appropriate chromosomal
changes, including abnormal DNA repair or another DNA or genetic abnormality specific
to your type of photosensitivity disorder.
b. What we will accept as medical evidence instead of the actual laboratory
report. When we do not have the actual laboratory report, we need evidence from an acceptable
medical source that includes appropriate clinical findings for your impairment and
that is persuasive that a positive diagnosis has been confirmed by appropriate laboratory
testing at some time prior to our evaluation. To be persuasive, the report must state
that the appropriate definitive genetic laboratory study was conducted and that the
results confirmed the diagnosis. The report must be consistent with other evidence
in your case record.
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 101.00M), we will evaluate your impairment under 101.08. However, if your burns do not meet
the requirements of 101.08 and you have extensive skin lesions that result in a very serious limitation (as
defined in 108.00C1) that has lasted or can be expected to last for a continuous period
of at least 12 months, we will evaluate them under 108.08.
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 108.07 and 108.08, 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 108.07A,
we will presume that you meet the duration requirement. For 108.07B and 108.08, 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 result in marked and severe functional limitations. 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 108.07 and 108.08.) However, we may still find that you are disabled because your impairment(s) meets
the requirements of a listing in another body system, medically equals (see §§ 404.1526
and 416.926 of this chapter) the severity of a listing, or functionally equals the
severity of the listings.
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 consider whether
your impairment(s) functionally equals the listings. (See § 416.924 of this chapter.)
When we decide whether you continue to be disabled, we use the rules in § 416.994a
of this chapter.
108.01 Category of Impairments, Skin Disorders
108.02 Ichthyosis, with extensive skin lesions that persist for at least 3 months despite continuing
treatment as prescribed.
108.03 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.
108.04 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.
108.05 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.
108.06 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.
108.07 Genetic photosensitivity disorders, established as described in 108.00E.
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,
2. Inability to function outside of a highly protective environment for a continuous
period of at least 12 months (see 108.00E2).
108.08 Burns, with extensive skin lesions that have lasted or can be expected to last for a continuous
period of at least 12 months. (See 108.00F).