Skin Disorders

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, and burns.

To satisfy the requirements of these listings, you must meet the required level of medical severity, and be under continuous treatment as prescribed by the listing; and your treatment must have lasted at least three months. However, these general requirements do not necessarily prevent allowance under a listing on the basis of equivalent severity, or by means of medical-vocational considerations related to the severity of a skin disorder in combination with your age, education, and work experience.

The SSA will want to know all of the important information about the nature and severity of your skin disorder, including: • the date of onset • the duration of the disorder • the frequency of flare-ups • the location and size of lesions (“extensive” lesions are required—see below) • any factors that worsen your disorder (such as exposure to irritants, toxins, or allergens) • your expected response to treatment (prognosis) • your response to treatment, and • any side effects of treatment. And your ability to function outside of a highly protective environment. To confirm the diagnosis, the SSA 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.

The skin impairment listings all mention a requirement of “extensive” lesions—meaning lesions that involve multiple body sites or critical body areas, and that cause very serious functional limitations. Examples of what the SSA considers extensive skin lesions include, but are not limited to: • Lesions that interfere with joint motion and that seriously limit use of more than one extremity— such as marked limitation in your use of both hands, both legs, or one arm and one leg. • Lesions on the palms of both hands that seriously interfere with your ability to perform gross and fine manipulations. • Lesions on the soles of both feet (plantar surfaces of the feet), the perineum, or inguinal areas that seriously interfere with your ability to walk.

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 flare-ups. 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 prevents you from doing any gainful activity when we consider your condition over time, especially if your flare-ups result in extensive skin lesions, as defined in C1 of this section. Therefore, if you have frequent flare-ups, 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 flare-ups are, how quickly they resolve, and how you function between flare-ups to determine whether you have been unable to do any gainful activity for a continuous period of at least 12 months or can be expected to be unable to do any gainful activity for a continuous period of at least 12 months. We will also consider the frequency of your flare-ups when we determine whether you have a severe impairment and when we need to assess your residual functional capacity.

1. L isting 8.02: Ichthyosis, With Extensive Lesions That Persist for at Least Three Months Despite Continuing Treatment as Prescribed. (Adults)

Ichthyosis refers to several skin disorders, usually hereditary, whose principle feature is a scaly appearance to the skin. Not all cases of ichthyosis are considered severe disorders. For example, ichthyosis vulgaris is a common skin condition of modest scaliness that spares the face and functional areas on the feet and hands. X-linked ichthyosis is found only in men and results in a dirty brownish appearance to the skin. It also spares the functional areas of the hands and feet and its most limiting feature is cosmetic.

Ichthyosiform erythroderma is the most serious of the ichthyosis disorders and affects both sexes. Fortunately, it is a rare disease. At birth, the infant is covered with a membrane that resembles collodion; hence the name “collodion baby.” With survival, the person faces a lifetime of disease—large scales widely affecting skin surfaces, including the palms and soles of the feet, which may include painful fissures in the skin. Inability to sweat puts the person at risk of overheating during strenuous exercise, especially in hot weather.

Another variant is bullous congenital ichthyosiform erythroderma. This blistering disorder is characterized by erythroderma with thick scales over most of the skin surface.

a. L isting Level Severity Medical judgment is applied; greater weight is given when the hands and feet are involved. The palms of the hands and soles of the feet are particularly important because of the pressure against the skin during physical work. The listing does not require involvement of the hands or feet, however.

As stated in the listing, you must have ichthyosis with extensive lesions not responding to prescribed treatment.

2. L isting 108.02: Ichthyosis, With Extensive Lesions That Persist for at Least Three Months Despite Continuing Treatment as Prescribed. (Children)

a. L isting Level Severity

3. L isting 8.03: Bullous Disease (for Example, Pemphigus, Erythema, Multiforme Bullosum, Epidermolysis Bullosa, Bullous Pemphigoid, Dermatitis Herpetiformis) (Adults)

Pemphigus is a general term that includes a number of related skin disorders associated with the formation of large skin blisters. The various forms of pemphigus are autoimmune disorders in which the patient’s own immune system attacks the skin with blister formation.

a. L isting Level Severity

For your condition to be severe enough to meet this listing, you must have pemphigus, erythema multiforme bullosum, bullous pemphigoid, or dermatitis herpetiformis with extensive lesions not responding to prescribed treatment. Medical judgment is applied; greater weight is given when the hands and feet are involved. The palms of the hands and soles of the feet are particularly important because of the pressure against the skin during physical work. The listing does not require involvement of the hands or feet, however. As stated in the listing, you must have bullous disease with extensive lesions not responding to prescribed treatment.

4. L isting 108.03: Bullous Disease (for Example, Pemphigus, Erythema, Multiforme Bullosum, Epidermolysis Bullosa, Bullous Pemphigoid, Dermatitis Herpetiformis) (Children)

5. L isting 8.04: Chronic Infections (Adults)

For your condition to be severe enough to meet this listing, you must have chronic infections of the skin or mucous membranes, with extensive fungating or extensive ulcerating skin lesions that persist for at least three months despite continuing treatment as prescribed, or deep fungal infections with extensive fungating, ulcerating lesions not responding to prescribed treatment.

6. L isting 108.04: Chronic Infections (Children)

7. L isting 8.05: Dermatitis (for Example, Psoriasis, Dyshidrosis, Atopic Dermatitis, Exfoliative Dermatitis, Allergic Contact Dermatitis) (Adults)

8. L isting 108.05: Dermatitis (for Example, Psoriasis, Dyshidrosis, Atopic Dermatitis, Exfoliative Dermatitis, Allergic Contact Dermatitis) (Children)

9. L isting 8.06: Hydradenitis Suppurativa (Adults)

Hydradenitis suppurativa is characterized by inflammation and destruction of sweat gland ducts, followed by secondary bacterial infection. The areas of skin most often involved are the axillae and the groin area. The bacterial infection can lead to pain, abscesses, and scarring. Surgery and skin grafting may be necessary, along with treatment with antibiotics. Severity of the disorder varies.

10. L isting 108.06: Hydradenitis Suppurativa (Children)

11. L isting 8.07: Genetic Photosensitivity Disorders (Adults)

Although there are many types of photosensitivity disorders, characterized by skin reactions to sunlight—for example, associated with various drugs or metabolic diseases—this listing only concerns inherited disorders. There are four major genetic photosensitivity disorders: • Xeroderma pigmentosum • Bloom syndrome • Cockayne syndrome • Rothmund-Thomson syndrome. All of these disorders are rare and characterized by the inability of DNA in the skin to repair itself after light exposure.

Xeroderma pigmentosum starts in infancy and is associated with a tendency to develop various forms of skin cancer, including dangerous malignant melanomas. Even when cancer is not present, the skin has painful, red, scaling, or blistering lesions. There is eye damage with the possible development of blindness. Deafness and neurological abnormalities occur in some instances, and mental retardation may be present. Death often occurs early in life, but some individuals survive into adulthood. Bloom syndrome starts in infancy with redness and blistering of the lips and arms after exposure to sunlight. There may be associated antibody deficits with increased infections, abnormalities in the number of fingers, and a greater tendency to develop certain forms of cancer. Cockayne syndrome is associated with dwarfism and mental retardation. Progressive deafness, retinal degeneration, nervous system degeneration, and premature atherosclerotic vascular disease are only some of the abnormalities that may be present. Survival may occur into several decades of life. Rothmund-Thompson syndrome may be noticed at several months of age with redness, scaling, and blistering on sun-exposed surfaces such as the arms and face. Although there is a tendency to develop cataracts and a greater than normal risk of skin and other cancers, these individuals may have a normal lifespan and mental development.

a. L isting Level Severity

Genetic photosensitivity disorders, established by clinical and laboratory findings. You can satisfy the listing by qualifying under either A or B. A Xeroderma pigmentosum. If you have this disorder, you will be considered disabled from birth without having to provide any evidence of functional loss. Severe functional loss is presumed from the nature of the xeroderma pigmentosum disorder. 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; or 2. Inability to function outside of a highly protective environment for a continuous period of at least 12 months. Regardless of the specific type of genetic photosensitivity diagnosis, you will need medical documentation that you have the disorder. Laboratory testing as chromosomal analysis showing DNA damage from light will satisfy the laboratory requirement of the listing. This should not be a problem, because it is unthinkable that your doctor would diagnose a serious photosensitivity disorder without appropriate testing. However, the SSA does not need the actual laboratory report, if the medical evidence is persuasive that the testing was done.

12. L isting 108.07: Genetic Photosensitivity Disorders (Children)

13. L isting 8.08: Burns (Adults)

Burns can be caused by skin’s exposure to extreme temperatures (heat or cold), electricity, or chemicals. Depending on the nature and extent of exposure, other organs besides the skin could be involved— such as the eyes or lungs. Extensive burns are extremely painful and lifethreatening. Skin grafting is often necessary if large areas of skin are involved. Even after optimum healing, the formation of scar tissue across joints can cause lasting functional limitations in the use of hands, arms, or legs.

If staged surgical procedures are necessary, evaluation should first be done under the appropriate listing (Listing 1.08 for adults or 101.08 for children; see Chapter 16). Similarly, damage to other body systems, such as the lungs, would be evaluated under the appropriate listing. If no other listing applied, then this listing would be used

a. L isting Level Severity

To qualify under this listing, you must have extensive skin lesions that have lasted, or can be expected to last, for a continuous period of at least 12 months. The SSA intends that this listing be considered only if the claimant does not meet the requirements for staged surgical procedures in Listing 1.08 or 101.08 (Chapter 16), yet still suffers severe functional limitations.