Friday, July 24, 2015

Managing skin conditions in practice: tips from veterinary dermatologists

Skin lesions on the abdomen of an itchy and unhappy cat.

Skin conditions in companion animals can be a source of frustration, for the animal, the owner and even the veterinarian. If you’ve ever lived with a dog or cat that is scratching or licking 24/7, comes out in welts every time he or she goes for a walk, or has seemingly never-ending ear infections you know the pain. Owners are often at their wit’s end, and just want and end to it – but treatment can take time.

On the flip side, if you can help manage skin disease, you can improve an animal’s quality of life massively.

In today’s post, top veterinary dermatologists share their tips for veterinarians managing skin conditions in general practice. They happen to be gathering in Australia in September at the CVE’s clinical dermatology conference in Port Douglas. If you want to find out more about evidence based dermatology and current controversies in the field, while scratching your itch to travel, find out more here.

Dr Mandy Burrows BSc BVMS MACVSc (Canine Medicine) FACVSc (Dermatology)

  1. Empathise: take time to work out your client and what they can and cannot understand and can and cannot do. Ask them to tell their story.
  2. Communication: the challenge and success as well as the rewards of chronic care management for most dermatologic conditions in dogs and cats is based in the successful communication of clear expectations to clients; this does not mean that expectations should be low, but there has to be an understanding that chronic skin diseases require both short and long-term planning for successful outcomes.  Share the plan in different ways; talk about it, draw it on the white board, write it down to take home and then have your staff call and talk it over a few days later. Make sure that you have an adequate follow-up system in place so that skin cases attend their scheduled revisit appointments.
  3. Topical therapy: in many instances, topical therapy for allergic and infected skin disease is of significant value but overlooked; in areas of regional pruritus such as ears and feet, the application of modern “soft” steroids and topical antibacterial products are a valuable tool for long term management of atopic dogs with minimal adverse effects; these products are very helpful in reducing reliance on systemic antimicrobial agents, glucocorticoids and other immunomodulatory drugs. Before you prescribe, stop and think! Could I reduce my reliance on systemic drugs for this patient by combining some topical therapy?

Dr Greg Burton BVSc (Hons) MACVSc (Small Animal Surgery) FACVSc (Dermatology)

  1. Elimination diets: Don’t forget gelatin capsules may contain beef and pork and many routine oral medications (even non-flavoured ones) can contain soy, wheat, rice, milk, pork proteins. Resolve infections prior to starting the food trial and maintain with topical treatments throughout the elimination diet. This includes flea control and heartworm prophylaxis medications.
  2. Allergic conjunctivitis is often overlooked in atopic dogs as pruritus is not always present. Allergic conjunctivitis can cause tear film abnormalities and progress to corneal (vision threatening) disease. Continuous maintenance therapies with antihistamine drops can be safe and effective. Systemic absorption from ocular steroid containing drops can be clinically significant in small breed dogs. 
  3. Denial is MRSP’s (Multiresistant Staphylococcus pseudintermedius – formerly known as MRSI) best friend. Consider MRSP in every dog with persistence of bacterial pyoderma in the face of compliant beta lactam antimicrobial therapy. Culture early, specifically ask the laboratory to look for MRSP and ensure post-consultation hygiene measures are adequate in-clinic (room and staff). F10 disinfection of the room and 70% alcohol on all washable surfaces (including computer keyboards) and effective hand washing before re-using the consulation room can limit spread of MRSP within the clinic.

Dr Rusty Muse DVM Diplomate ACVD MANZCVS

  1. Spend the time to take a complete history regarding the skin disease present.  The skin has limited reaction patterns so the history of a patient and its skin disease including how it started, how it has progressed, the areas affected and response to therapy will give you most of the information that you will need to know to proceed with accurate diagnostics and therapeutics.
  2. Pursue underlying primary diseases when secondary problems present.  Bacterial or Malassezia infections whether of the skin or the ear have a primary cause in most every case.  Develop a plan to pursue or manage the primary disease because if you don’t relapsing infections whether skin or ears will cause you to lose clients.
  3. There is no substitute for clear, concise and very detailed discharge instructions in managing skin disease.  Most clients will follow your instructions if they know what is expected of them. It is imperative in most cases of skin disease, that clients continue therapy until remission or control of the condition has been achieved and then a long term management plan can be instituted on follow up visits. 

Dr Wayne Rosenkrantz DVM Diplomate ACVD

  1. When dealing with the pruritic dog, keep in mind the four most common causes of pruritus (Atopic dermatitis, Flea allergy, Adverse food reactions and Scabies). Correlate the diseases by emphasis on history and physical lesion distribution.
  2. Eliminate simple things first when approaching chronic inflammatory skin disease. The most common component of pruritus in dogs with chronic inflammatory skin disease is microbial disease; therefore, this should be tested for first with cytology. In atopic dermatitis cases, secondary pyoderma is present in approximately 80% of the cases and Malassezia in 35%. It may be even more prevalent based on how aggressively one looks for secondary infections.
  3. Combined treatments (Multimodal) are more effective than monotherapy when handling chronic atopic dermatitis cases. By combining therapies you can often reduce the dosage and frequency of more potent drug therapies (glucocorticoids, ciclosporin, oclacitinib) and achieve similar results. Always attempt to utilize safer long-term options ie, allergen specific immunotherapy (ASIT), essential fatty acids and topical therapy when managing chronic atopic dermatitis.

Thank you Drs Burrows, Burton, Muse and Rosenkrantz for sharing those pearls of dermatology wisdom. If you want to meet them and review your approach to dermatology, view the program here