This study evaluated the dosimetric impact of surface dose reduction due to the loss of backscatter from the bone interface in kilovoltage (kV) X-ray radiation therapy. Monte Carlo simulation was carried out using the EGSnrc code. An inhomogeneous phantom containing a thin water layer (0.5–5 mm) on top of a bone (thickness = 1 cm) was irradiated by a clinical 105 kVp photon beam produced by a Gulmay D3225 X-ray machine. Field sizes of 2, 5, and 10 cm diameter and source-to-surface distance of 20 cm were used. Surface doses for different phantom configurations were calculated using the DOSXYZnrc code. Photon energy spectra at the phantom surface and bone were determined according to the phase-space files at the particle scoring planes which included the multiple crossers. For comparison, all Monte Carlo simulations were repeated in a phantom with the bone replaced by water. Surface dose reduction was found when a bone was underneath the water layer. When the water thickness was equal to 1 mm for the circular field of 5 cm diameter, a surface dose reduction of 6.3% was found. The dose reduction decreased to 4.7% and 3.4% when the water thickness increased to 3 and 5 mm, respectively. This shows that the impact of the surface dose uncertainty decreased while the water thickness over the bone increased. This result was supported by the decrease in relative intensity of the lower energy photons in the energy spectrum when the water layer was with and over the bone, compared to without the bone. We concluded that surface dose reduction of 7.8%–1.1% was found when the water thickness increased from 0.5–5 mm for circular fields with diameters ranging from 2–10 cm. This decrease of surface dose results in an overestimation of prescribed dose at the patient’s surface, and might be a concern when using kV photon beam to treat skin tumors in sites such as forehead, chest wall, and kneecap.