Dermatology for the Small Animal Practitioner Ralf S. Mueller Dr. med.vet., MACVSe, DipACVD, FACVSc Made Easy Series Teton New MediaExecutive Editor: Carn Development Editor: ©. Cann Susan L. Hunsberser Editor: Cynthia J. Roantree Design and Layout: Anita Baran Sykes Printer: Grand Teton Lithography, Jackson, WY Teton NewMedia PO. Box 4833 125 South King Street Jackson, WY 83001 1-888-770-3165 heepsiwwew nets Interior photographs by Ralf S. Mueller (unless otherwise noted) Copyright © 2000 Teton NewMedia All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or for any means, including photocopying, or utilized by any information storage and retrieval systems withour written permission from the copyright owner, ‘The authors and publisher have made every effort to provide an accurate reference text. However, they shall not be held responsible for problems arising from errors or omissions, of from misunderstandings on the part of the reader. PRINTED IN THE UNITED STATES OF AMERICA ISBN = 1-893441-06-7 Print number 5 43 2 1 Library of Congress Cataloging-in-Publication Data Mueller, Ralf S. Dermatology for the small p.cm. -- (Made easy series) ISBN 1-893441-06.7 (alk. paper) ‘Veterinary dermatology. 2. Dags--Diseases--Trea Cots-Diseases--Treatment. |. Title. Il. Made easy series ‘Jaskeon, Wye.) nal practitioner / Ralf S. Mueller ‘SF992.555 M83 2000 636,.089'65--de21 00-059976,Table of Contents Section 1 “How To” Dermatologic History... 1... ee 2 Dermatologic Examination .... 01... - 0.1. ee ll Specific Tests in Small Animal Dermatology. -.-21 Cytology . ..21 Deep Skin Scrapings . . Wood's Lamp EF : Trichogram. Biopsy . Serum Testing for Allerpen-spee Bacterial Quln Patch Testing Section 2 The Approach to Common Dermatologic Presentations The Pruritic Dog... 2... ee eee 53 The Dog with Papules, Pustules and Crusts ..... . 538 The Dog with Alopecia... ................... 69 The Dog with Nodules ..... 1... 16 ‘The Dog with Nasal Dermatitis ..............- 83 The Cat with Miliary Dermatitis... ....... 2... . 87 ‘The Cat with Noninflammatory Alopecia. ...... 92 The Cat with Lesions of the Ec pl Granuloma ComplesThe Car with Nodules.. 0.000000... 00000. 100 The Parient with Oriris Exrerna 10 Shampoo Therapy of Various Skin Conditions . . 115 Trearment of Bacterial Infection 18 Treatment of Pruritus..... Allergen-spec Essential Fatty Acids .......... 1... 128 Glucocorticoids 29 Treatment of Fungal Infections . - Ectoj arasiticidal Agents. nsect Contral aT Patients with Flea. bite Hy Immunosuppressive Therapy .. 6.0.60 00 66406 L41 Treatment of Alopecia due to Hormonal Diseases and Follicular Dysplasia... . 144 Appendices. ................0..0-005..- 145 A. Breed Predilectior - 145 B. Questionnaire... 0... eee 149 Recommended Readings ...........151General Principles The main goal of this book is to provide a readily useable reference for vete rinary dermatology that allows the thorough and logical workup of a patient seen for skin disease, It also provides therapeutic protocols for the most com mon dermatologic problems. There are three 4 ans to this book. The first covers how to take a dermatologic history, interpret the results of this history in light of the clinical findings, and decide on and perform necessary tests. The second explains the approach to certain common dern The ologic problems in small ani cal pp clice, summarizes therapeutic options for specific conditions, Some Helpful Hints Seatrered throughour the text, you will find the following symbols to help you focus on what is really important: ¥ This is a row ne feature of the subject discussed. $4 We will use this selectively, This is a key point to understanding ar topic. Stop. This does not look important, but it can really make a difference. © Something serious will happen if you do not remember this, possils sulting in the loss of borh patient and client sk Drugs and Diseases marked with an asterisk and a colored screen in the ables in Sections 2 and 3, are potentially difficule and/or are dangerous. You may consider referral to a veterinary specialist or seek further advise from a colleague with more knowledge about the drug or diSection 1 rw “How To”In this section, I discuss key questions importante in taking a der- matologic history and their implicati ns, as well as specific der- [ introduce ary dermatology, give t indications, explain necessary techniques in detail, the interpretat Its. matologic lesions and what they tell us. Furthermor various tests important in verer on of the res Dermatologic History Clinical signs for various skin diseases are very similar and the etiology of a the findings of a clinical examination. A thorough history will typically provide clues in regard to the cause of the skin dis- order and allow the veterinarian to prioritize time-consuming and frequently costly laboratory tests needed to confirm the diag- nosis. I prefer my clients to fill out a questionnaire in the wait! room which we then review together during the consultation. This decreases the time needed to extract a good history from the owner, helps ensure a complete history independent of stress tient’s problem may not be apparent based solely levels and time constraints, and allows the client to think about her or his pet’s skin problem for a little while without rily delaying the appointment schedule. A sample of tology questionnaire is enclosed in the Appendix. It is important to phrase questions appropriately, because many owners leave out pertinent facts either because they are not aware of th vance or because they think th by the veter n. Sometime: question seve nneces- derma- rrele- ¢ facts may not be well received is necessary to ask the same eful ing a good h requires tremendous ctice, and effes times in different ways to obtain mi importance of ta ani answers. | cannot overemphasize thi and efficient dermatologic history, wl knowledge, exp skills. To teach this is beyond the scope of this book. However, | do discuss some crucial questions and their implications in more detail Question: What is the breed of the patient? Relevance ive communi ience, pt tion, #7 Some breeds are predisposed ro certain skin diseases and it may be worthwhile to keep a list of such breed predisposition: in easy reach. ¥ A list of reported breed predisposition is given in the Appendix. But beware, breed predispositions y vary with geographic location!Question: How old was the patient when clinical signs were first recognized? Relevance & Very young animals (puppies and kittens) are more commonly presented with congenital and hereditary defects, ectopara~ sites such as Sarcoptes scabici, Orodectes cynotis, ar Demodex canis, infectic h bacteria (impetigo) or fungi (dermatophytosis) or, in dogs, canine juvenile sterile granulo- marous dermatitis and lymphadenitis. 3 # Young adult dogs are more commonly affected by demodico- sis, atopic dermatitis, and flea-bite hypersensitivity, as well idiopathic seborrhea and follicular dysplasia. ¥ In middle age, h on, although allergies s of animals, particularly in cars. as significant consid- gnificant number monal diseases become | occur in as eral & Neoplastic diseases are more commonly seen in older animals Question: How long has the disease been present and how did it progress? Relevance # Acute onset of severe pruritus is frequently associated with scabies. Food adverse reaction may also have an explosive t., ons # If pruritus was the first initial sign and lesions occurred later, then atopy or food-adverse reaction are most likely. Pruritus with lesions that occur at approximately the same time may be due to a wide variety of causes. is typically due to atopic der- n, possibly complicated by sec- > may also cause nonles- @# Chronic nonlesional prurit. matitis or food adverse reac nfections, Scabies incogt ondary nal pruriras. w If curancous signs have been present for years withour the development of concurrent systemic signs, endocrine disor- ders are unlikely. # Nonpruritic alopecia for years without systemic signs points rowards alopecia and follicular dysplasias or hereditary alopeci wv The presence of chronic wounds alone or associated with es the search for an infectious draining tracts necess orgalDiagnostic procedures: Scabies treatment trial, skin scrapings elimination diet, cytology, bacterial culture, fungal culture, biopsy. Question: Where on the body did the problem start? Relevance Tables 1-1 and 1-2 outline typically affected sites of certain diseases.. Table 1-1 Location of Lesions and/or Pruritus of Various Canine Skin Diseases ee So Otitis externa | Atops, food adverse reaction, pa ry infections are common mabe occur with primary endocrine me 1c3, polyps. vod adverse re tis, pemphigus f pies, dis foliaceus Paws is, atopy, food adverse reaction, Malassezia dermatitis, pemphigus foliaceus, abolic epidermal necrosis. Claws | Bacterial or fungal infection, trauma, ted skin diseases. Tail base | Flea-bite hypersensitivity Table 1-2 Location of Lesions or Pruritus of Various Feline Skin Diseases er Otitis extema man Pinnae pemphigus foliaceus Headiface Atopy, fowl adverse reaction, cermarophytenis, insect allergies, feline scabies, pemphigus foliaceus Paws Atopy, food adverse reaction, pemphigus foliaceus, trauma, plasmmacytic podoxdermatitis Claws: Bacterial infection, trauma, immune-mediated pensitivity Question: Is the animal itchy? Relevance Y Pruritus is sometimes difficult to identify. Owners consider licking, rubbing, or biting as ¢ of pruritus (we all have hi fen do not ns indicative rd the story of the dog who is con- stantly licking its feet because “it is a very clean dog ..."), Severalroutine ques: patients: Are they licking or chewing their paws? Are they rubbing their faces? Do they scoot on th they scratching their armpits? be needed ro identify pruritus in some # The presence of pruritus with skin lesions does not help much in discovering the etiology of the pruritus, given that many skin diseases cause pruritus. However, pruritus without lesions typically means either atopic dermatitis or food adverse reac- tion (possibly with secondary infections) or in rare instances scabies incognito. wv The perceived severity of pruritus m: Some owners deny the presence of pruritus despite the patient's frantic scratching in the consultation room, Others insist on severe pruritus in a patient with no evidence of self- trauma on clinical examinat jor skills. and judgement are essential to form a tealistic opinion fe evaluation. If the pet's scratching wakes the owner up at night, the pruritus is severe irrespective of the presence of lesions. ry with the owner. m. Good communic: wv If itch preceeds the occurrence of lesions, atapic dermatitis, food adverse reaction, and scabies incognito must again be considered. Diagnostic procedures: Trichogram in alopecic patients thar are reportedly nonprur Question: Is the disease seasonal? Relevance # Insect bite hypersensitivities (caused most commonly by fleas, but mosquitoes or other insects can also be involved) frequently cause disease that worsens in summer. Whether clinical signs are absent or milder in the colder season depends on specific environmental conditions. @ Avopic dermatitis may also be seasonal in certain climates. In many temperate climates it may occur more noticeably in spring and summer if caused by tree and grass pollens or worsens in sum~ mer and autumn because of weed pollens. Warmer climates such as those found in tropical or subtropical regions usually have an extended pollen season. Hypersensirivities to house dust mites are often nonseasonal, but may be seasonally worse in winter in some and patients. are:# Seasonal noninflammatory alopecia and hyperpigmentation may be due to cyelic follicular dysplasia. Diagnostic procedures: Insect bite trial, intradermal skin test- ing, serum testing for allergen-specific IgE, biopsy, keeping the mal inside to evaluate for mosquito-bite hypers Question: Are there other clinical signs such as sneezing, coughing, or diarrhea? Relevance be seen ™ nd conjunerivi itis and caused by wv Sneezing, coughing, wheezing, concurrently with atopic derm: allergies thorne Diarrhea may be associated with food adverse reaction. Polydipsia and polyuria are com: pathic hyperadrenocorticism. wo Systemi xia, lee toms. wv wv m with iatrogenic and idio- mycoses frequently present with concurrent anore- rey, and with gastrointestinal or respiratory symp- Diagnostic procedures: Cytology of nasal exudate or conjunctiva, elimination dict, urine cortisol/creatinine tatio, low dose dexametha- sone suppression test, and adrenocorticotropic hormone (ACTH)- stimulation test. Question: What is fed to the animal? Was a special diet used in the past? What was it and how long was it fed exclusively? Relevance # Knowing the diet will allow the clinician to determine possi- ble nutri # Ic will also help in formulating an eliminatic (p. 46). # Ifa diet was fed in the past and ir was nor a true eliminar diet (was not fed exclusively or not fed for an appropriate length of time) it may need to be repeated. $1 Contrary two the common bel nal defic ncies: et if indicated on. f, food adverse reactions typically nedi do not occ! ately after a change in feeding habits, Most animals with food adverse reactions have been consur offending diet for y ing the ws before showing clinical signs. @ Remember to ask abour trears and supplements, which are often forgotten, when food is discussed with the client.Question: Are there other animals in the household? Do they show cutaneous sxmptoms? Relevance ¥ Ifother animals in the household are similarly affected, gious disease such as dermarophyrosis or scabies is more ® Other animals may serve as a reservoir for ecropara without showing clinical signs. Diagnostic procedures: If indicated, insect control trial, fungal cultures, or scabies treatment trials should include all animals in the houschold to identify and/or treat possible carrier animals to allow successful long-term remission for the patient. Question: Does any person in the household have skin disease? Relevance ¥ Two zoonoses of major concern in veterinary dermatology are scabies and dermatophytosis (ringworm). However, even if owners are not affected, these diseases cannot be tuled out. # Canine scabies affecting humans occurs as an itchy papular rash in contact areas, such as arms and legs, starting days to weeks after onset of pruritus in the pet often characterized by scaling and ery- and may not be particularly pruritic, but occasionally can present as severely inflammatory and pruritic skin disease. Dermatophytosis may sometimes be misdiagnosed as ecz in humans. ¥ Dermatophytos' them na wv Sporotrichosis and other mycoses have zoonotic potential and may occasionally cause disease in humans. @ Don't forger that the skin disease of the owner may also be completely unrelated co the animal's skin disease. Diagnostic procedures: Wood's light, skin serapings, fungal cul- ture, scabies trial treatment. In severe forms of suspected der- matophytosis, a biopsy and special fungal stains may prove useful for obtaining a quick diagnosis. Question: Was the disease treated before? If so, which drugs were used and how successful was treatment? Relevance Response to previous therapy can be of tremendous help in establishing or ruling out underlying causes for the skin disease.# Initial response to recent glucocorticoid administration may not be helpful because many skin diseases improve for a short period with this symptomatic, nonspecific treatment. # Repeated response to low-dose glucocerticoid therapy sug- gests hypersensitivities (possibly complicated by Malassezia dermatitis caused by Malassezia pachydermatis). # Repeated response to antibiotics and glucocorticoids in combination is of little help, Repeared partial or total response to antibiotics ind pyoderma usually secondary to either atopic dermatitis, food adverse reaction, hormonal disease, or another less comm disorder thae is suppressing the skin's immune system. In addition to antibacterial trearment, the underlying problem needs to be identified and treated to prevent recurrence: kes a @ Ask specifically how much the pet improved while receiving medication because many owners tend vo judge a treatment as not helpful if ic did not cure the disease. Question: What is currently used to concrol fleas? Relevance sensitivity is the most common hypersensi- extremely common skin disease in most small animal practices. If flea-bite hypersensitivity is suspected, a control trial should be commenced. s of the flea control for all animals in the household are important because in a severely allergic animal, clinical signs can be caused by a very small number of flea bites. Inconsi- stent or ineffective flea control can be discovered only through detailed questioning. & Many owners take questions about their flea control as an insult to their own cleanliness and hygiene. Good communica- tion skills are a great help. | own a flea-allergic dog and rou- tinely mention her as an example, which breaks the and increases the client's willingness to listen and follow my instructions. Question: When was the last medication given? Relevance # Recent administration of med presentation. y affect the clinwv It may also affect various indicated diagnostic tests that may need te be postponed. # Long-term glucocorticoid therapy will affect the results of allergy tests — both intradermal skin testing and serum testing for allergen-specifie IgE. It will also affect histopathologic findings and the results of many blood tests. # Antihistamines and short-term systemic and topical glucocor- ticoids (i.e., < 4 weeks) may influence inrradermal skin testing. Some antibiotics, such as timethoprim-sulfonamide combina- tions, will affect blood concentrations of thytoxin. Others such as cephalosporins may affect the glucose readings of some urine test strips. # Reme' ventior ber to ask spe questions regarding heartworm pre- vitamin supplements, or deworming which are a forms of pharmacotherapy. Question: Does the animal get better with a change of environmenc (a weekend away or a day at the in-laws for example}? Relevance nment indicates involvement of an environmental allergen (airborne or con- tact) or irritant. ef Lack of improvement does not rule out these allergies, in that aitborne and contact allergens may be the same in different locations (house dust mites are found almost anywhere in the world). & The animal's improvement in another enviDermatologic Examination A good dermatologic examination requires adequate lighting, a systematic and thorough approach, and should always include a general physical on. Observation from a distance should be followed by close inspection of skin and mucous membranes. | start at the head, look at the lips, mouth, ears, run my hands through the coat of the trunk, lift up the tail te inspect the peri- anal area, and then examine the legs and feet with pads and claws. back — reluctant small pe made to sit up in the lap of the owner; with larger dogs the front paws are lifted up for a short moment, which gives me the oppor- tunity to examine the animal's ventral aspects from the axillae to the groil Next, the patient is rolled on hi: are General Observation Localized or Generalized Problem ¢ Localized problems may be due to infectious organisms that gained entry at a certain site and spread only locally such as atypi mycobacterial or fungal infections. lly. monly due to hypersensitivities wv Neoplastic disease is commonly localized, at least init wf Generalized disorders are more cor or syst ated or metabo © conditions such as endocrine disorders and immune-medi- skin diseases. laterally symmetric lesions are typically caused by internal disease such as hypothyroidism, hyperadrenocorticism, or pemphi- gus foliaceus, Allergies may also present with bilaterally symmetric symptoms. of Asymme ectoparasites (e.g., demodicosis) or fungi (e. Haireoat Quality, Color, and Shine wo Is the haireoat dull or shiny? A dull haircoar m holic or hormonal diseases, nutritional deficiencies, disease. #¥ Are there color ic lesions more commonly have external causes such as dermataphyrosis). he & ¢ chronic skin \e to mera. normalities or changes and if so, did they occur aw2 before or concurrent with the onset of skin dise quence of the disease. Ha hormonal di or follicular dy: ¢ OF as a conse- ated with color changes may be assoc w& Changes in the hair quality (either to a coarse coat or to a fine puppy coat) may again point to hormonal disease or follicu- lar dysplasia. Close inspection of the skin and mucous membranes follows the general observation. Pay spe ny individual lesions. Primary lesions are initial eruptions thar are caused directly by the underlying disease process. Secondary lesions evolve fram primary le are caused by the patient (self- trauma) or environment (med ns). It is important thar the clinician be able both to differentiate between primary and sec- ondary lesions and to understand the underlying pathomech- anism because this helps in the formulation of a relevant list of differential diagnoses. | next discuss the individual lesions and their implications and give the most common differential di noses for lesion. tention ms OF Primary Lesions Macule Figure 1-14 Figure 1-18 Macule . Mecule Definition: A focal, circumseribed, Differential diagnoses-depigmenta- perralpa eho arcane es tion: Vitiligo, discoid lupus erythemartc Gaon eB ees i teed ss, uveodermatologic syndrome, mucoc- patch), Pathogenesis: Pigmentation ancous pyoderma. : change due to decreased or increased Differential diagnoses-hyperpigmen- melanin production, erythema due to tation: Lentigo, hormonal diseases or inflamanstion oF local heiontage post-inflammatory with a multitude of slifis possible underlying causes lentigo. Differential diagnosis-erythema: Inflammation due to a variery of underly ing diseases or hemorthage due to vascu- lopathies or coagulopathies. caused by trauma or vaPapule Figure 1-24 Papule Definition: A solid elevation of up to Tem meter. Larger ne are called plaques. Pathogenesis: Influx of inflammatory cells into the dermis, focal epidermal hyperplasia, early neoplastic lesions. Pustule Figure 1-3A Pustule Definition: A small circumscribed arca within the epidermis filled with pus. Pathogenesis: Most pustules are filled with neutrophils, but eosino- philic pustules may also be seen. Aspiration cytology and biopsy are indicates!, (Courtesy of Dr. Thierry Olivry.) Figure 1-2B Papule Differential diagnoses: Bacterial folliculitis, demodicosis, fungal folli- culitis, fleadbite and mascuite-bite hypersensitivity, scabies, contact aller- £¥, suroimenme skin disease, drug eruption. Figure 1-3B Pustule Differential diagnoses- neutroy Bacterial infection, fun- gal infection, autoimmune skin disease. Differential diagnoses-cosinophils: Insect or contact hypersensitivity, para- sites, immune-mediated skin disease14 Vesicle Figure 1-44 Figure 1-4B Vesicle Vesicle Definition: A small circumscribed Differential diagnoses: Immune- area within ot below the epidermis raodiated and congenital alin filled with clear flui or teritant are called bullae. Vi ery dermatitis. fragile and thus transient. Pathogenesis: Spongiosis and extra cellular fluid collection due to inflam- ation and loss of cohesion. (Courtesy of Dt. Thierry Olivry) Wheal Figure 1-54 Figure 1-5B ‘Wheal Wheal Definition: A sharply circumscribed, Differential diagnoses: Uricaria, faised, edematous leaion that appears invect bites, other hypeniensitivities, and disappears within minutes to drug eruption. hours. Pathogenesis: Subcutaneous edema.Figure 1-64, Figure 1-68 Nedule Nodule Definition: A circumscribed, solid Differential diagnoses: Sterile gran- ulomatous diseases, bacterial or fungal infect neoplastic diseases, calci- nosis cutis: cells into the dermis and subcutis or deposition of fibrin and crystalline material, Tumor Figure 1-74 Figure 1-78 Tumor Tumor Definition: A large mass invelving Dee diagnoses: Sterile gran. skin or subcutaneous tissue. ulomatous diseases, bacterial tiga Pathogenesis: Massive influx of infections, neuplastic diseases. inflammatory or neoplastic cellsPrimary or Secondary Lesions Alopecia Figure 1-8 Alopecia 1 to complete Lene of haus. If-trauma, damage to the hair follicle due ro dysplasia, inflammation ir regrowth aften mary lesion in disorders, relo- Differential diagnoses: Pi fallicular dysplasias, endoc gen effluvium, ana lesion in pruritic sk fungal folliculitis, demodicosis. Scale Figure 1-94 Figure 1-9B Scale Scale Definition: An accumulation of loose Differential diagnoses: Primary fragments of the harny layer of the lesion in follicular dysplasias, idiopathic skin. Parhogenesis: Increased produc- seborthea tion of keratinocytes (often associat: ed with abnormalities of the ke Tinization process) of increased reten- tion of comeucytes. and ichthyosis. Secondary in diseases associated with chronicCrust Figure 1-10A Crust Definition: Adherence of dried exudate, serum, pus, blood, scales, or medications to the skin surface. Follicular Cast Figure 1-114 Follicular cast : An accumulation of ker follicular material to the hair Figure 1-10B Crust Differential diagnoses: Primary dermal necrosis, Secondary lesion variety of skin diseases Figure 1-118 Follicular cast Differential diagnoses: Primary lesion in vitamin A-responsive der- matusis, idiopathic seborrhea, and Secondary lesion demodicosis. MWPigmentary Abnormalities Hyperpigmentation Figure 1-12A Hyperpigmentation Definition: Increased epidermal and/or dermal melanin, Pathogene: Increased production, size, or mela. nization of melanosomes or increased number of melanosomes dus ic or extrinsic fac- variety of int tors, Most common cause: Chronic mmation Comedo Figure 1-134 Comedones Definition: A dilated hair follicle filled with comeocytes and sebaceous material. Pathogenesis: Primary kera- Hinization defects or hypecketatoais due to hormon: normalities or inflammation. | | Figure 1-128 Hyperpigmentation Differential diagnoses: Primary lesion docrine dermatoses, sec- ondary postinflammatory change due toa variety of skin diseases, Figure 1-138 Comedones Differential diagnoses: Primary Iksion in feline acive, some idiopathic seborthess, Schnauzer comedo syn- drome, endocrine diseases, Secondary Tesion in demoxticosis, and less com- monly dermatophytosis.Secondary Lesions Epidermal Collarette Epidermal collarette Definition: Seale of loose keratin flakes or "pecling” keratin arranged in acitcle. Pathogenesis: Remnant of a pustule or vesicle after the top part (the “roof”) has been lost, or caused by a point source of inflammation, dfuch ex'apapule. Erosion Figure 1-154 Erosion Definition: A shallow epidermal defect that docs not penetrate the basal mem- brane. Pathogenesis: Trauma or inflam- mation leads to rapid death andlor loss of keratinocytes Figure 1-148 Epidermal collarette Differential diagnoses: Most likely bacterial infection, less commonly fun- gal infection, immune-mediated skin disease, insect-bite reaction, of contact hypersensitivity. Figure 1-158 Erosion Differential diagnoses: Various skin diseases associated with self trau- ma such as infections or allergies.20 Figure 1-164 Uleer Definition: Focal loss of epidermis with exposure of underlying dermis Pathogenesis: Severe trauma and/or deep and severe inflammation Lichenification Figure 1-174 Lichenification Definition: Thickening and harden- ing of skin characterized by exapger- ated superficial skin markings. Pathogenesis: Chronic trauma such as friction or rubbing. Figure 1-168 Ulcer Differential diagnoses: ases associated with trauma such as ctions and allengs so immune- mediated diseases. ¢ Various skin Figure 1-178 Lichenification Differential diagnoses: All chronic and pruritic skin diseases.Specific Tests in Small Animal Dermatology Cytology Indications Any pruritic, sealy, odo! ous, or alopecic animal should be evaluated for eviclence of bacterial or fungal infection, Thus, cytology is indicated for almost all patients presented with skin disease. Skin scrapings, aspirations, impressions, ear swabs and tape preparations are different techniques to obr. plogic samples. ¥ A superficial skin scraping is used in areas such as the inter digital skin where impression smears may be difficult to obtain. It is also used when the skin is normal, st ¥ An aspirated sample is useful in the evalu content and intracutancous or subcuranean tly moist, or greasy. on of pustul # An impression smear is used when m oozing or discharging lesions is evaluated. vf Ear swabs are used to evaluate ear © vf Dry scaly skin maybe evaluated by tape preparations. This technique is also frequently used in the interdig impression smears may be difficult to obta al area where "1 Technique 1, Skin scraping for cytology ¥ Affected skin is exposed and the very gently and superficially with a s of hair growth, ¥ The debris collected on the bl with the blade in a “buttering the bread” mot urface of the skin scraped de in the direction pelt is applied co a slide and spread n (Figure 1-18) 2. Aspiration of nodules of Aspiration from nodules or abscesses is undertaken with a 12-ml syringe and a 22-2 needle: 2¥ The nodule is firmly grasped and the needle is then inserted (Figure 1-19), aspirated several times (up to the 10-ml mark if possible), the pressure released, and the syringe with needle still hed is withdrawn. at v¥ It is important to release the pressure before withdrawal of the needle or ¢ the aspirate can be sucked back into the barrel of the syringe ~ from which it may not be retrieved wo The needle is de needle re: wo Cells are th 3. Impression Smears ached, the plunger pulled back, and the wtached. n blown onto a slide. The smear is air dried, ¥ Cotton swabs are used to obtain samples from ear canals by inserting them into the canal, rotating, and withdrawing them. They are then rolled gently onto a slide. | hold car slides uni formly on the left side with my left hand, the cotton b from the left car is rolled onto the mid-section of the slide and the cor- ton swab from the right car onto the right third of the same slide. 7 In pe with saline solution and rubbed on the surface of affected skin before it is rolled onto a slide. ¥ In pi ts with moist or greasy skin, the slide can be rubbed or impressed directly onto affected skin (Figure 1-20). be maistened ts with dry skin, a cotton sw: ma 4. Tape Preparation ¥ A direct impression technique uses clear sticky tape to collect debris from the surface of the skin. Although quick, this method does take practice to establish what is “normal.” ¢ The tape is pressed sticky side down onto the skin (Figure 1-21). ¥ Next, it is pressed (also sticky side down) onto a drop of meth- ylene blue or the blue stain of DiffQuick on a slide (Figure 1-22). ¥ The tape serve: even under oil immersion (with directly on top of the tape). v This technique is especially useful for Malassezia evaluation. Other items of interest that can be identified include inflamma. tory cells such as neutrophils (which may have passed through the epidermis in response to a superficial infection), nucl epithelial cells (which are not normal and reflece a kera bnormality), cacci, rods, macrophages, short-hodied demodex mites, Cheyletiella, and occasionally Sarcoptes mites. a cover slip: the sample can be evaluated Il droplet of oil placedFigure 1-18 Debris collected with a superficial skin scraping is spread onto a slide with a “butter the bread” motion. Figure 1-19 Aspiration of a small nodule. Figure 1-20 Impression smears are obtained by gently pressing a slide onto affected skin. Figure 1-21 The tape is pressed sticky-side down caine affected skin. 2324 Stain ¥ A modified Wright's stain (e.g., DiffQuick) can be used to sti the air-dried slides. It is much faster and easier than G and sufficient to evaluate nearly all skin cytology samples. Bur Grams stain is also suitable. m's st Interpretation # Yeast organisms are most often M. pachydermatis (Figure 1-23), though Candida spp. may occasionally be involved. ¢ Cocci are most often Staphylococcus intermedius (Figure 1-24). 8. aureus or Streptococci may be found in some patients. ped organisms are found mostly in the ear canal and are n Psetdsmonas aeruginosa or Proteus mirabilis (Figure 1-25). Of The number of organisms is important. Occasional coc e F yeast are probably not relevant. On the skin, I consider one or more yeast organisms per high-power field (HPF) relevant; cocci cocci typically occur in high numbers; any rods prese abnormal. Don't mistake exogenous bacterial contaminants for infection. re ¥ Inflammatory cells with intracellular organisms are parhogn monic for a clinically relevant infection (Figure 1-26). ¥ Eosinophils typically indicate aller € Neopk: so that the help of a clinical pathologist is typically needed. Even with high skill levels, neoplastic skin disease should not be diagnosed exclusively by cytology (with the exception of mast cell tumors); a biopsy should always confirm any suspicions ralsed clinically and cyto- logically. 7 If mast cells are found cytologically (Figure 1-27), the of mast cell rumor is confirmed, bur complete sur should still be confirmed by histopathology. In so: mast cell tumors, mast cell granules do not stain with routine DiffQuick and thus a negative cytologic result can not rule our 1 tocytosis, ic skin disease or pars tic cells may be difficult to recog tercellu- # Acantholytic cells are keratinocytes that have lost thei lar connections (desmosomes) and present as round cells with a pur- ple cytoplasm and a central dark purple nucleus (Figure 1-28). These cells suggest pemphigus foliaceus or erythematosus but can also be seen.on cytologic samples of severe pyodermas. A biopsy is to confirm the diagnosis.Figure 1-22 ‘Tape is then pressed sticky-side down ote a drop of methylene blue on a slide. Figure 1-23 Malassezia pachydermatis on a tape preparation stained with blue stain of DiffQuick (original magnification x400). Figure 1-24 (Cecei on an impression smear stained: with DiffQuick (original magnification x 1000). Figure 1-25 Rods.on an impression smear obtained from otitis externa and stained with DiffQuick (original magnification x00).26 f+ Remember, that bacterial and yeast infections are usually secondary to other diseases, which need to be identifi treated to prevent recurrence of the infection. fer Cytologic re is crucial because or; ‘d and the of antimicrobial therapy y change during trearment. For nted with bacterial infection may ment, preventing clinical improvement and vice versa. Treatment of bacte discussed in Section 3 infections and antifungal therapy are Superficial Skin Scrapings Indications Any pruritic or scaly dog and cat may be inf Cheyletiella spp., Otodectes cynotis, Scabies cati and should be scraped. ed with ou Notoedres- Technique # If scabies is suspected, preferred ar elbows, hocks, and ventrum re the ped this arew. ngs ar margins should be seri any pruritus or scaling is observed i thoroughly i Sometimes scaling is subtle and only becomes evident on close examination. Sites are gently clipped with #40 clipper blades. Mites may be difficult ro find (especially canine scabies mites), so thar the big- ger the surface area scraped, the greater will be the chance of a positive skin scraping. ¥ Several drops of mineral oil are applied directly to the clipped skin and distribuced evenly in the area. o The oil is scraped off with a <11 sei le (Figure 1-29) and transferred to one or more gl times especially when canine scabies is suspected. / A cover slip is used to allow rapid yet thorough evaluation of collected debris (Figure 1-30) and the slide(s) is (are) evaluated under low power (x40 or x 100) systematically from the left upper corner to the right lower corner.Figure 1-26 Neutrophils with intracellular cocel (arrow) pathognomonic for bacterial infection stained with DiffQuick (origi- nal magnification x1000). Figure 1-27 Mast cells on an aspirate from a feline fast cell tumor stained with DiffQuick (original magnification x1000). Figure 1-28 Acancholytic cells on an aspirate of an intact pustule from a dog with pemphigus foliaceus stained with DiffQuick (original magnification x1000). Figure 1-29 A scalpel blade is used to scrape applied coil off the affected and clipped skin.28 Interpretation A finding of one mite or egg of Sarcoptes spp., Noroedres cati, Cheyletiella spp. or Otodectes cynotis (Figures 1-31, 1-32, and 1-33) is diagnostic for the cause of the skin disease. Negative scrap- ings do not rule out the presence of mites and clinical disease par- ticularly in canine scabies. Cheyletiella spp. and Orodectes cynotis may also be missed by superficial skin scrapings. The next step would be a therapeutic trial (p. 49), possibly in conjunction with other diag- nostic tests such as an elimination diet (p. 46) to evaluate other causes of pruritus. Deep Skin Scrapings Indication Any dog or cat with possible demodicosis must be scraped. Thus, every alapecic patient and every patient with papules, pustul crusting, and particularly interdigital pododermatitis must scraped for the presence of demodicosis. Effective deep skin scrap- ings of paws may require sedation or general anesthesi Technique @ Because Demadex canis and felis mites live deep in the hair folli- cle, it is useful to squeeze the skin as hard as the patient can tolerate before scraping in an attempt to push mites our from the depths of the follicles. $+ A blade covered with mineral oil should be used in the diree- tion of hair growth until capillary bleeding is observed (Figure 1-34). > Feet and faces are hard to scrape, so that it may be worthwhile to scrape erythematous areas adjacent to papules and crusts interdig ly to maximize the yield and ro minimize bleeding associated with scraping. Hair plucks may be useful for those areas, the plucked hair is placed in a drop of mineral oil on a slide, with a cover slip and ly for the presence af mites (p. 38) evaluated m Negative scrapings or hair plucks of interdigital areas do not rule out pododemodicosis; a biopsy may he needed to confirm or rule out the diagnosis. of Old English Sheepdogs, Scortish Terriers and especially Shar-peis may produce negative results on scrapings and may have to be biop- sied for diagnosis. Although not documented, it is thoughe thar these breeds have more tortuous and deeper hair follicles.Figure 1-30 sand the oil and gathered debris are transferred to a slide. Figure 1-31 Sarcopres scabiei mites and eggs obtained with a superficial skin scrap. ing from a dog with scabies (original magnification x40). Figure 1-32 ‘Cheyletiella parasitivorax (original magnification x40). Figure 1-33 Otodectes cynotis mites and eggs (original magnification x40). (Courtesy of Dr. Peter Ihrke.) 29,30 # The finding of more than one mite should be considered diagnostic. Interpretation ¥ Ivis important to assess the relative numbers of adults (both live and dead), larvae/nymphs and eggs (Figure 1-35) per low power field (LPF) and to record the site of scraping. During sub- sequent visits, assessment of response to therapy relies on the comparison of such numbers, so we routinely repeat scrapes ar the same sites monthly when monitoring cases with demodicosis. Treatment for demodicosis is outlined in Section 3. Wood’s Lamp Examination Indication Any dog or cat with possible Microsporum canis infection should be examined with a Wood's lamp. Any patient with : papules, pustules, and/or crusts may benefit from the procedure. Technique of The Wood's lamp should be warmed up for 5 minutes before use be length and intensity depends on temperature. ause the stability of the light’s w # The animal is examined under the lamp in a dark room. fr Hairs invaded by M. cai cence. This fluorescence runs along the f rather than fluarescing on d may be seen in normal animals and humans, may show a yellow-green fluores- shafts (Figure 1-36) individual, occasional scales, as a Some drugs, soaps, and bacteria such as Pseudemonas aeruginosa y also cause fluorescence but are usually nor associated with hair shatis. Interpretation of In approximately 50% of all infec fluorescence of tryptophan metabo! light at 253.7 nm, # Positive fluorescence is diagnostic for dermatophyto far the most common fluorescing dermatophyte in veterinary medi- cine is M. canis. Some other dermatophytes may show fluoresce: but these are not relevant in veterinary dermatology. s, gree seen under ultFigure 1-34 To evaluate a patient for demodicosis, scrapings must be deep, until capillary bleeding is observed. The skin should be squeezed to maximize the yield. Figure 1-35 Demodex canis (A) mite and (B) cez (original magnification x100). Figure 1-36 Green fluorescent hair shafts under Wood's lamp examination in a cat infected with M. canis. ia32 Bet A lack of fluorescence does not rule out dermatophytesis. Fungal culture and/or biopsy are the next steps. Ti ment of dermatophytosis is outlined in Section 3. Fungal Culture Indication A fungal culcure may be indicated in any dog or cat with possible fun- gal infection and thus in any patient with alopecia, papules, pustules, and/or crusts. Technique # Hairs and scale from the edge of a lesion (preferably the ones fluor escing under the Wood's lamp) should be taken (Figure 1-37). #7 If lesions are not well circumscribed or if asymptomatic carriers are suspected, | recommend the McKenzie tooth brush method. In this technique, the hair is brushed with a sterile toorhbrush (any new tooth brush in a sealed package is sufficiently sterile mycologically). Scales and loose hairs caught in the tooth brush are gently imprinted onto the agar (Figure 1-38). o Sabouraud's agar is the most common medium for fungal cultures. In practice dermatophyte test medium (DTM) is frequently used. DTM is essentially a Sabours slor indicator and added ingredients to inhibit overgrowth with saprophytes and bacteria. ar with: © After being innoculated, the culture jars should be incubated at between 25° and 30° C art 30% humidiry, or in a warm dark corner with the lids nor screwed down tightly. # Cultures should be incubated for 2 to 3 weeks and must be ewaluat- ed daily. Interpretation ft A pH change (and subsequent color change) that occurs as the colony grows indicates dermatophytes (Figure 1-39). These fungi use protein and produce alkaline metabolites which cause the pH and color change. It is imperative that the color change is observed coinci- dentally with the development of the colony. Color changes also occur in association with mature (i.e., large) saprophyte colonies. Saprophytes initially utilize carbohydrates. Once all carbohydrates have been used and the colony is already grown (Figure 1-40), they turn to the proteins and rapidly change the color and pH with the subsequentFigure 1-37 Hairs and scales from the edge of skin lesions are chosen for fungal culture. Figure 1-38 Contents of a tooth brash are transferred toa fungal culture median after using the McKenzie toothbrish technique. Figure 1-39 A dermatophyte culture changes the color of the dermatophyte test medium in early stages of growth. Figure 1-40 A large saprophyte colony prior to calor change.alkaline metabolites (Figure 1-41). It may be impossible to distinguish ‘on gross appearance whether a mature colony with significant red pig- mentation to the underlying and surrounding agar is a pathogenic or saprophytic fungus. w Always check the colony microscopically for characteristic macro- conidia. Clear sticky tape is impressed geutly onto the culture (sticky side down), then laid onto a drop of methylene blue or the blue stai of DiffQuick (also sticky side down) on a microscope slide and evalu- ated under the microscope. The surface of the sticky tape acts own cover slip. If required, microscope oil can be placed directly onto the surface of the tape. of Microsporum canis grows in a white, wooly colony with a yellowish reverse pigment (which maybe difficult to assess if grown on DTM). Abundant spindle-shaped macroconidia with knobs at the terminal ends and typically more than six internal compartments are seen microscopically (Figure 1-42). & M. canis is a zoophilic fungus and patients typically were infected by another animal or human. Humans and other ani- mals in contact with the patient are at risk to develop the infec- tion or may be asymptomatic carriers and need to be carefully evaluated and possibly treated as well. # M. aypseum grows in a granular beige culture with yellowish reverse pigment and has thin-walled echinulare macroconidia with fewer than six internal compartments (Figure 1-43). M. gypseum a geophilic fungus that is acquired by exposure to contaminated soil and thus has a limited zoonotic potential. # Trichophyton mentagrophytes grow in colonies of variable texture and color that characteristically have a few cigar-shaped macroconidia and globous microconidia (Figure 1-44). Typical hosts for T. mentagrophytes are rodents and humans; infections are usually associated with exposure to these hosts or their immediate environment. See Section 3 for treatment of dermatophytosisFigure 1-41 Saprophyte colony of Figure 1-40 24 hours later. Figure 1-42 Hyphae and macroconidia of Microsponim canis. Figure 1-43 Hyphae and macroconidia of Microsporum gypseuer. Figure 1-44 Hyphae and microconidia of Trichophyton ‘mentagrophytes. 3536 Trichogram Indication Trichograms may be useful in any alopecic animal as well as in animals with suspected dermatophytosis and associated papules, pustules, or crusting Technique 7 A forceps is used to forcefully pluck hairs from affected skin (Figure 1-45). & The h: are then placed onto a slide and evaluated under low power. I generally use mineral oil and a cover slip to prevent the hair sample from blowing all over the table rather than remaining under the microscope (Figure 1-46). Interpretation A trichogram is taken for several reasons # To determine how many hairs are in telogen (or resting) versus anagen (or growing) phase (in shedding or suspected endocrine problems). This requires practice! Anagen-phase bulbs are rounded, smooth, shiny, glistening and soft so the root may bend (Figure 1-47). Telogen bulbs are club- of spear-shaped with a rough surface gure 1-48). A sample with exclusively or mostly telogen hairs Points to an endocrine disorder ar follicular arrest o To determine if a cat or dog creates hair loss by licking or rub- bing, or if the hair falls out for another reason. If the animal is pru- and licks the hair off, the tips of the hairs are broken off (Figure 1-49). Any trauma to the hair shaft, such as occurs in der- marophytosis or anagen defluxion, may also cause hair with broken ends. If the hair falls our for other reasons, the tips are (Figure 1-50). ov Trichoy nely in human dermatology to evalu- ate alopecias, bur their usefulness in veterinary dermatology has not been explored in any grear detail and is hampered by the marked variations in breed characteristics. fe? A trichogram is most useful to determine if bald cats thar present with a history of "nonprui " alopecia are really so-called “closet lickers" or “hidden groomers” (in which case the hair-shaft ends will be fractured) or if the hair falls to telogen effluvi- um or, very rarely, for hormonal reasons. pered ms are used re duFigure 1-45 (A forceps is used to pull hairs from affected skin for a trichogram. Figure 1-46 ‘The hairs are placed in oil onto a slide under a cover slip. Figure 1-47 Anagen bulbs in.a trichogram of ae dog (original magnification x100), Figure 1-48 Telogen bulb in a trichogram of a dog with hyperadrenocorcicism (original magnification x10),3B nine demodicosis. $F Trichograms may also be used to diagnose If mites are found microscopically, the diagnosis is confirmed. However, if no mires are present, demodicosis cannot be ruled ow $f Trichograms can also help to diagnose color-diluent alopecia. In this disease the melanin in the hair shaft is present in big nps rather chan finely dispersed as in normal pigmented hair. Biopsy Indication ¥ Any skin that appears unusual to the clinician should be biopsied. ¥ A biopsy should also be considered if lesions fail to respond to appropriate empiric therapy. # Nodules are possibly neoplastic and should be biopsied. @ The presence of any suspected disease for which trearment is expensive and/or life-threatening should be confirmed histopatho- logically. ¥ One of the major reasons to perform a skin biopsy is to rule our other diagnoses ("I think this is an allergy bu . In such a situs tion, the biopsy report of “chronic hyperplastic dermatitis with mononuclear perivascular infilerate” has at least ruled our common. infectious agents and unusual dermatoses. A supportive pathologic diagnosis interpreted in conjunction with the clinical impressions may be just as useful as a confirmatory diagnosis. Technique Selection of the Site ¥ Selection of the site requires careful examination of the entire ani- mal for the most representative samples, identification of the primary and secondary lesions present, and the formation of a list of differen- $f With the exception of a solitary nodule, we recommend taking multiple tissue samples. "These should include primary lesions if pres- ent, Conhin a representative range of lesions, and above all, should be taken and handled carefully. A normal sample of haired skin should also be included. # Depigmenting lesions should be biop: in am area of active depigmentation (geay color) rather than the final stage (white or pink color). # Alopecia should be biopsied in the center of the worst as in junctional and normal areas, aas wellFigure 1-49 Hair tips are br cat with atople demaa magnification x10). Figure 1-50 ps from an alopecic « yreradrenocorticism (original magnification x100). # Ulcers and erosions should not be biopsied. Da nar expect a pathologist to be able to describe more specifically than “an ulcer” if an ulcer is biopsied or “a crusted erosion” if an excoriated area is selected. Preparation of the Site of With the exception of excision biopsies of nodules, no surgical preparation of the site should be employed. Even topical application of alcohol and air drying may alter the epidermis. If crusts are present, these should be left on the skin. If they identally dislodged they should still be placed in the for- malin and a note “please cut in crusts” should be added to the request form. Crusts may contain microorganisms or acanthalytic cells that will help to obtain a diagnosis, Infection as a result of lack of surgical preparation does not seem to be a problem. Wedge versus Punch Biopsy &¥ There inary med. ter is com re two commonly employed biopsy techniques in veter- e-the punch biopsy and the wedge biopsy. The lat- only employed as an excisional technique when removing solitary nodules. It is also indicated with vesicles (which are typically too fragile to survive a punch biopsy with-40 out rupturing), suspected cases of panniculitis (in which suffi- ent depth of biopsy may nat be achi ved with a punch) and when biopsying the edge of a lesion in a spindle shape (which allows correct orientation of the lesion in the laboratory where spindle-shaped lesions are always cut in longitudinally), ¥ The punch biopsy is quick, rel employed with suspected infect pmatory, and ende matoses, Disposable biopsy punches are readily available in various sizes. They can be cold-sterilized and reused. > With the exception of face and foot biopsies, 8 mm punches should be used! Smaller punches with a diameter of 4 or 6 mm are employed to biopsy face and feet. Very small punches (i.¢., 2 to 3 mm) are not useful in sm ith the exception of eyelid biopsie: w The overlying hair is clipped and gently removed and the biopsy te is marked with a water-proof marker pen (Figure 1-51). If crusts © present, using scissors may be less traumatic. @} General anesthesia is indicated for nasal ar footpad biopsies. Tuse a combination of ketamine at 5 mg/kg bodyweight and diazepam at 0.25 mg/kg body weight given intravenously in one syringe. No fur- ther preparation is necessary. If the biopsy is to be performed under manual restraint or with sedation (1 use xylazine at 0.4 mp/kg or medetomidin 10 meg/kg intravenously), then a subcutaneous injection of Iml xylocaine (or the less stinging prilocaine) without adrenaline will usually provide adequate local anesthesia (Figure 1-52). If the agent is administered subcutaneously with the needle entry point outside the proposed biopsy area, there should be no disruption to the biopsy. @ Don't overdose small animals with lignaca this can cause cardiac arrhythmias. ine (> Iml /5 kg), since > Allow 3 to 5 minutes for the local anesthetic to have effect. ¥ Ifa punch is used, it is held at right angles to the surface of the skin and gently placed over the selected lesion (Figure 1-53). Firm continu- ous pressure is applied and the punch is rotated in one direction (note carefully!) until a sufficient depth has been reached to free the dermis from its underlying attachment. The punch is remaved a should be carefully blorred. of The section of tissue is grasped at the base-which should be the panniculus—and subcutaneous attachments severed (Figure 1-54). Under no circumstances should the dermis or epidermis be grasped with forceps because this leads toa “crush artifact.” Crushed tissue may be misinterpreted as scarring at best, and at worst renders the sample worthless. The tissue is rolled an gauze to gently blot the blood dd any bloodFigure 1-51 The biopsy sit marked with a Figure 1-52 ynacsthetic is injected subcura- Figure 1-53 The punch is placed vertically onto the su rotated in only one ction. Figure 1-54 The sample is removed by grasping its hase with a forceps and cutting it. ay42 from its surface. A thin yple should then be placed with the pan- niculus face down—onto a rigid piece of cardboard or broken tongue depressor (Figure 1-55). This prevents the tissue from curling when placed in the formalin optim rerpretation by the patholo- gist. Thick lin withour such support. ¢ The un is placed in 10% formalin (tissue side down) and allowed to fix for L hours before see- tioning. The volume of formalin required is at least LO times the volume of the sample. Nodules should be sectioned into 1 em thick pieces to allow adequate penetration of the formalin into the center of the lesion. tof tissue and cardhe ve Submission of Biopsy Samples © Careful completion of the appropriate skin biopsy request form, including history and physi will greacly improve the chances of a diagnostic report. # A list of differential diagnoses is impan case but ntial with dermatologic patients. Seborthea or draining tracts can be the result of a wide range of disease processes. This list is important for the clinician to ensure that he or she has considered all options and obtained as much info ion as possible from both pet and owner as necessary before taking the biopsy. It is also important for the parhologise and may aid in choosing special stains to rule out or confirm unusual diseases. | examination int with any clinical Serum Testing for Allergen-specific IgE Indication Useful if the owner of an atopic dog or cat diagnosed by history, ical examination, and ruling out of differential diagnoses, is either curious about what c ses the problem or is interested in allergen-specific immunotherapy. Interpretation wv Differe! have improved over the y d serum resting has beco alternative to intradermal skin testing for many small animal sners. However, tests vary in their sensitivity and speci- ty so that careful selection of an appropriate test is important. t serum tests are available. Laboratory techniques rsaFigure 1-55 Ifthe biopsy specimen is thin, it is pliced onto a cardboard or tongue depressor before placing it into formalin. Testing for individual allergens rather than allergen groups is prudent to avoid immunotherapy with inappropriate allergens. Ir is impossible to tell which of the allergens in a particular react- ing group are involved in the disease process. # Results need to be interpreted in light of the cli patient. A dog with positive reactions to grass pollens only and a clin- ical history of nonseasonal pruritus for years in a temperate enviran- ment such as in England or Canada will most likely not benefit from allergen-specific immunotherapy. # [still consider intradermal skin resting my first choice for the identification of offending allergens in atopic dermatitis for several reasons: 1) more individual allergens are used in skin resting than in serum testing; 2) the skin is the affected organ and thus it seems logical to rest the © affected: and 3) the input of a veterinary dermatologist in regards to the interpretation of test results and man- agement of patients on allergen-specific immunotherapy is inv Me for practitioners with limited experience in this parti eld. Bacterial Culture Bacterial cultures are used infrequently in veterinary dermatology. Most bacterial skin infections are caused by Staphylococcus intermedius. If cocei are identified on cytology, empiric antibiotic therapy is sufficient in almost all patients. Indication # Empiric therapy at appropriate doses for an appropriate time has failed to resalve the pyoderma (lesions are still present and cytology still reveals cocci).¥ Numerous rod-shaped bacte: ¢ identified on cytology samples from ear canals. These organisms may also rarely play a role in cuta- neous infections of patients clinically not responding to empiric therapy. Procedure wv Swabs @ Aspirates from intact pustules are useful in p: superficial pyoderma. $+ Swabs from the skin surface to culture organisms from patients with deep pyoderma are not suitable. Samples are taken in a similar manner to that used in biopsies under aseptic tions (scrub the skin surfa instr id gloves). The upper half of the tissue sample with the epidermis and hair is cut off and the lower half is submitted in a sterile container placed on a sterile gauze pad soaked in a sterile saline solution for maceration culture. This prevents overgrowth of the culture by surface bacteria not relevant to the deep infection. Each s nied by cytologic examination, and culture results must be inter- preted in relationship to cytologic findings. taken from. als as described for cytology samples. ar Ci nts with ond i- cd use ste © 1 mple for culture and sensitivity should be accompa- Patch Testing This is the test of choice to confirm contact allergy. In classic parch testing, the test substance is applied onto intact skin (clipping is rec- ommended 24 hours earlier, to minimize any confusion due to clipper rash in a sensitive individual), covered with an impermeable sub- stance, and fixed, Human test kits are available (Figure 1-56). Alternatively, an arca may be clipped and tape applied in a checker- board pattern to leave two, four, or six spaces of bare skin surrounded by areas covered by tape (Figure 1-57). Then individual antigens are placed on to the bare patches and fixed with a tape. Fresh material may need to be cut up in small pieces and applied to the skin with the help of an ophthalmic lubricant gel. On top of this taped area, a whole trunk bandage is applied (and fixed around the neck as well) ro avoid movement of the bandage and the allergens (Figure 1-58). After 2 days, the patch is removed and reactions are observed. After removing the bandage and allergens, the individual areas are marked with a permanent marker pen (to make possible a second evaluation 24 hours later). No reaction is graded as 0; erythema as 14; erythema and edema or induration as 2+; and erythema and vesiculation as 3+.The latter two reactions are considered significant. The bandage should then be reapplied (without taping and allergens) to avoid self- trauma and removed 24 hours later for a second evaluation. True con- ract allergy is characterized by a delayed-type reaction persisting or 24 hours withour the allergen on the skin. increasing during thes Figure 1-56. Human rest kit on a dog. (Courtesy of Dr. Thierry Olivry.) Figure 1-57 Patch test using tape Figure 1-58 Teunkal bandage cov test site ws the patch 45,46 her erythema nor vesiculation is present, the reaction on s probably caused by an irritant rather than ic steroids must be with- the previous day w allergic dermatitis. Topical or syste drawn for 3 to 6 weeks before testing. marked test 5-day pe and ede In open-patch testing, the allergen is rubbed inte site of normal skin and then examined daily over vd. The reactions similarly consist of mild crythen The technique is suitable only for liquid or plant allergens (in which crushed leaves are used). An already sparsely haired clinically unaffected area, such as the medial thigh or the inner pinna commonly used. Diagnostic Trials Diagnostic trials are well accepted rests in vererinary dermatology. They are performed when a certain problem is suspected and the trial is either the only or the best way to diagnose the possible underlying disease. A response to the trial confirms rhe diagno: in some instances (such as the scabies treatment trial), but in other i $a relapse after discontinuing the trial with subse- quent resolution on restarting the trial is diagnostic (such as in elimination diets). If there is no response to a well-conducted diagnostic trial, the suspected disease is extr ly unlikely (which helps veterinarian, owner, and patient, and needs ro be emphasized to clients frustrated by the lack of response 5 Elimination Diet Indication An elimination diet is used to & which can occur with any food fed over a period of time. As a general rule food adverse reactions present infrequently. Any dog luate food adverse reaction with nonseasonal pruritus (pz ularly if the face, feet, or ears are affected) or recurrent pyoderma, or any car with miliary der- matitis, nonindl; ory alopecia, eosinophilic granuloma co n underly- plex, or head and neck pruritus could possibly have ing food adverse reaction.Procedure $+ An elimination diet for dogs consists of one protein source and one carbohydrate source previously not fed! This means that the elimination diet for a particular patient is determined by the dict fed so far to this animal, Cats are fed only one pro- tein without the carbohydrate source to enhance compliance. ¥ Possible options for proteins are chicken, turkey, duck, veni- son, mutton, beef, horse, buffalo, rabbit, hare, kangaroo, emu, Carbohydrates may consist of rice, potatoes, sweer potatoes, beans, or others. v The di heart-worm prophylaxi flavor extracts. various sorts of fish, among other: t chosen needs to be fed exclusively! Concurrent or supplements must not contain food # It may take 6 to 8 weeks before a response becomes evident. &— After initial improvement, a rechallenge with the normal dict previously fed is essential because improvement may result from other tors such as seasonal or environmental chan, n. Ifa relapse oceurs within 2 weeks and 3 resolve again after reinstitution of the climination. agnosis is confirmed, concurrent medicat Tips to increase compliance ¥ Warming the food may improve parient compliance. Y Spices such as garlic of salt (in small amounts) may also be beneficial to improve palaribiliry. @. If the animal (and owner) is used to treats, the habit should be continued in a modified fashion to prevent feeding of inappropri- ate proteins. Little pieces « protein can be fried and kept in the fridge for use as treats, The selected meat can be dried (in the oven or microwave) and given as treats. [fan animal is receiving potatoes in the diet, then fried pieces of potato may be used (so long as they are not fried in butter, but in a plant-derived oil). If rice is chosen, rice cakes may be an additional option. the selected m vf If bones are part of the normal diet, bones of the meat selected for the elimination dict may be fed if available. o& Good client communication is essential. Ir must be made clear that an occasional slip in feeding habits (as little as once or twice weekly of a very small amount of a different protein) may destroy all the effort. # Ir may be worthwhile to advise neighbors about the diet as well. a7¥ Ifa home-cooked diet is not an option, a commercial diet consisting exclusively of a protein source and a carbohydrate source not previously fed may be considered. The same prin apply to commercial as to home-cooked elimination diets. However, some animals with food adverse reactions may be missed when using commercial diets les. of food adverse reaction is confi After a diagne ed, the client has two options: 1, To continue a commercial elimination diet forev nient option; 2. A home-cooked dict. It should be properly balanced (the help of a veterinary nutritionise may be indicated) the more conv # Identifying of the offending allergen allows a more varied diet nd is achieved through a sequential rechallenge with proteins formerly fed. Beef, lamb, chicken, or cheese and milk products are added to the elimination diet one at a time for 2 weeks each. Ifa relapse occurs within the first 2 weeks (many patients show symptoms within the first 2 days), the protein is discontinued until the patient's condition settles. That particular protein is avoided in the future. After 2 weeks of a given protein without clinical symptoms, a reaction to this protein is ruled out and ry be fed in the future. Some dogs will tolerate any home: ked diet, but relapse on commercial diets may be caused by a reaction to addit col oF preservatives. Insect Control Trial Indication An insect contro! trial may be used in any parient with suspect> ed insect-bite hypersensitiviries. Most animals with insect-bire hypersensitivities will be allergic ro fleas. Clients generally accept these trials more readily when they are labeled “insect control trials" because many do not believe fleas cause the prob- lem, whereas most will accept ants or mosquitoes as a possible cause. Any dog with pruritus, alopecia, and/or a papular or ‘crusty rash in the tailbase or inguinal area, and any cat with mil- iary dermatitis, noninflammatory alopecia, or eosinophilic granu- loma complex may benefit from an insect control trial Mosquito bite hypersensitivity in the cat is characterized by papules and crusts on the nose, pinnae, and foot pads. A tri using insect repellents may be beneficial to these animals.Procedure # The patient should be treated regularly with an insecticide. In a diagnostic trial, | often increase the frequency of administration above the m: mendations. Fipronil spray, imida- cloprid, permethrin, and selamect every 2 weeks. Pyrethroid sprays are administered daily depending on the product. Nitenpyram tablets are given either daily or every other day. Which products to use depends on the individual cir- ances, More details are provided on page 138. turer's re nu ons are administered spot cums 1, treat the animal's environment with ‘b, lopment inhibitor such as methaprene, fenoxy Is are provided on page 138. insect-de n or pyriproxifen, More de ¥ Contact animals (either living in the same household or those t visit on a regular basis) must be treated as well, although the frequency between adulticide applications may be increased co the manufacturers’ recommendations. ¥ Acthe start of che trial, | often prescribe 5 to 7 days of pred- nisolone at 1 mg/kg bodyweight daily to hasten clinical response. If there is good response to the trial, inseet-bite hypersensitivity | may be pered to the minimum is present and insect contr required. te Re varies seasonally, as does the insect load, member that the required minimum treatment typically Scabies Treatment Trial Indication ic dog or cat could possibly be infested with Sarcoptes rly if the pruritus ventrum, and clbows are prur Any pruri scabiei or Notoedres cati, respectively, pa was of sudden onset or if pinns tic. With spot-ons used for flea control, I have seen patients wit prurirus and lesions limited to ventrum and lower legs. Negative superficial skin scrapings do not rule out scabies (p. 26) so trial treatment is indicated in any patient with suspected seabies irre- spective of negative skin scraping results. In as much as Cheyletiella spp. and Otodectes cynatis are sensitive to the same antiparasitic agents, a scabies tr Ibe useful for these pa ticul sites as well. 4950 Procedure w Several treatments for scabies are not labeled for this use. lable but many of them re ay # Topical weatments include ivermectin, lime sulfur di traz, and other antips re used weekly for 4 weeks. More details are given on page 133. sitic rinses. The v Systemic therapy may be undertaken with selamectin, iver- mectin or milbemycin. Treatment details are outlined on page 133, # Allanimals in contact with the patient need to be treated as well! # Initial deterioration during the occur. Treat with glucocorticoids daily for 3 to 4 days body weight. t days of treatment may tl maefke v Remission should be achieved within 4 weeks although some need extended treatment for up to 8 weeks.Section 2 “The Approach | id to Common y Dermatologic Presentations52 In this section, | offer an approach to various common presenta- ions in vet y dermatology. I begin each topic in this sec- ith general comments followed by tables containing the , their clinical features, diag- ma now: most common differential diagnos nostic procedures of choice, trearment, and prognosis. I have attempted ta list diseases in order of prevalence. Diseases parked with an (7) and a colored screen are potentially difficulr to diagnose or their management often requires considerable experience to achieve the best possible outcome. You may con- sider offering your client a referral to a vererinary dermatologist if you do not feel comfortable diagnosing or creating this disease. This is not a textbook of veterinary dermatology so these tables do not contain all possible details but rather a cancise overview concentrating on the most important features. Similarly, the flow charts at the end of cach topic ate concise and simplified to maximize the benefit for the busy small animal practitioner. They will be useful in most instances, but remember that some of your clients may not have read the textbooks. Even though this information is aimed at helping you as competent veterina to reach a diagnosis and formulate a treatment plan, your eri acumen, examination, and communication skills r most crucial instruments for success in your daily practic main theThe Pruritic Dog Key Questions All questions discussed in Secrion 1 (pages 2-10) may be rele- vant for a pruritic patient. Differential Diagnoses If lesions are present, see page 58, The Dog with Papules, Pusrules and Crusts. If no lesions are present, differenrial diag- noses are listed in Table 2-1 53po uone|ARO] mC pue suatiia|ye Surpuayo od) gt] 2y;oads (eds pyou jo 4 "anp amoy ‘eus|jod myuan fyppns Suasuay]e auoyI OD aay ‘2004 | Aapspisussioddyy) ,Adoayy aswasiq suoIsa] yNOYyUA Gog sHUNIY e UI SIsOUGo1g pur ‘sudndD JUaWyeaIL ‘sysa_ 2nsoubeig papuswworay ‘says papayy AjuoWWO; ‘sasouGerg jenualayia L-z agerAdbarpes pure emayaiao: Smpadope: pou 7-z ainBiy b-@ aunBiy 5556 Figure 2-5 ‘Ventral erythema, alopecia, and papules in the dog scen in Figure 2-4, Figure 2-6 Hyperpigmertation and alopecia ina 2-year-old, spayed German 5 with Malassegia canis. (Courtesy of Dr. Thiery Olivry.) Figure 2-7 Malassecia-related dermatitis in a 9-year- old, male British Bulldog (Courtesy af Dr. Michael Shipstone.) Figure 2-8 Pedal salivary staining inv an 8-year-old, spayed Schnauzer with Sood-adverse reaction. (Courtesy of Dr. Peter Icke.)Figure 2-9 The Nonlesional Pruritic Dog Cytology (p.21) Scabies, Atopy, Adverse food reaction Malassezia dermatitis Scabies treatment trial (p. 49) Elimination diet (p. 46) No response Good response Food rachallenge, it Relapse No relapse l Scabies, Atopy out of season Monitoring Sequential rechallenge Relapse Remission for >12 months Sah Ss?The Dog with Papules, Pustules, and Crusts Key Questions. # Whar is the breed of this patient? (p. 2) ¥ How old i recognized? (p. 3) this patient when clinical signs were first ¥ How long has the disease been present and how did it progress? (p. 3) # On which part of the body did the problem start? (p. 4) ¥ Is the animal itchy? (p. 5) # Is the di ¥ Are there other clinical signs, such as sneezing, coughing, or diarrhea? (p. 7) # Whar do you feed the the past? (p. 7) ¥ Are there any other animals in the se seasonal? (p, 6) mal? Was a special diet used in nuschold? (p. 8) # Does anybody in the household have skin disease? (p. 8) ¥ Was the disease treated before? If so, which drugs were used and how successful was treatment? (p. 5) & What is used for flea control currently? (p. 9) # When was the last medication given! (p. 9) Differential Diagnoses pules may develop into pustules and crusts, and any dog with acute papular rash may eventually show pustules or crusts. Some dis- eases are characterized by papules that do not typically develop fur- ther into pustules (such as flea-bite hypersensitivity); other diseases typically show crusting as their predominane symptom (such as zine- responsive de i -3, and 2-4 list the major differ. ential diagnoses for dogs with papules, pustules, z Lesions may be follicular or nonfollicular (Figure 2-10). Follicular papules and pustules indicate a pathologic process concentrating on the hair follicle, most commonly bacterial folliculitis, demodicosis, or dermato- a ad crusphytosis. Nonfollicular lesions may indicate pathologic processes concentrating on the epidermis, dermis, or dermo-epidermal juncti such as superficial spreading pyoderma, flea-bite, contact hypersensi- tivity, or immune-mediated skin diseases, Be aware that some nonfol- licular processes may occasionally involve hair follicles as well. Nonfollicular papule and pustule Figure 2-10 59yo voueaay “eauguiogas * open ante pcclAay prone pitas sStenp 1 F i ane pes ray daratassusszad At, sajndeg yy Bog e u! sisouBoig pue 'suondo juaiujeod, 51531 INsouBbelg papusuworay “sayis papayy AjuoWWOD ‘sasouBelg jenuaiay4iq e-Z ageL 4}Peprng: Ww LL-@ aunBiy neeipe “hd “hoon at Gofal a[uors “uopsioxa peoiitang at) Astony (iz) hig (az-z ainda) Apog oxy Jo yey [epte> ay Uo ApuouruIOD BOYSssoupoutap pact 91-z aanby seunapaid jruaipeq, Yen saxaunay sopeqey powesase> ape “pjouk ig vu soyncied paasnucy blz aunbyy “siso2qpouap pazesauat Ypen soxog ayeurgy €L-Z unB4 62Oz-z an6l4 ssuonpapay uentydoysay {pin woos Apusnbay ups Pomayeuow pur porsoys up a10Ny ” sealepfotonusus swnatydoyoeay, Agy posnes sisopdydomunap Yin opfesy paren somu0a wiod} Be sanbe pt , 6L-z eanbiy “nsompouimpsainysng yy Gog e ul sisouBosg pue ‘suondg uaUjeady ‘s}sa1 21}s0UBe\q papusUOrdy ‘so115 pay ayy AjUOWWOD ‘sasouBbelg jenuaayIG €-2 F19eL " d 1z-z aunby65 b?-7 aunBiy sro poss ers cea nares eae ‘sped 209) ‘seuuid jo saepns 204 200d “iuauLTan (it) (gerd) | sauuy ‘opzma pesrop ‘ody ‘wore: aueuddondde yria a0 ‘uowsauddnsount Sado (12 A) 0p aeyresouad! ‘apse wimponpur-arup: 2g] Arp “sory soun PTretitel yy Rite tes MS cer rr wr s3smu> yan Gog e ul sisouBosg pue ‘suondg juawyeas ‘sysa 2)s0uUBelg papuauwodsay ‘says paypayy AjuouWO ‘sasoubelg jeuaayig ve FI9eLThe Dog with Alopecia Many diseases are associated with alope prurirus and other lesions. Here we discuss dogs with clinically noninflammatory alopecias. in conjunction with Key Questions 2) s this patient when clinical signs we ¥ What breed is the patient? (; ¥ How old (pe. 3) # How long has the disease been present and how did it progress? (p. 3) # On which part of the body did the problem srart? (p. 4) # Is the animal itchy? (p. 5) © first recognized? wv Is the disease seasonal! (p. 6) v Are there other animals in the household? (p. 5} ¥ Does anybody in the household have skin disease? (p. 8) wo Was the disease treated before? If so, which drugs were used and how successful was treatment? (p. 8). If the alopecic dog is pruritic but lacks other lesions, the approach is difference from that used in a bald dog without pruritus. Many alope- cias are characterized by dry skin and mild scaling, which may or may not be pruritic. The use of moisturizers will help the dryness and may address concurrent pruritus. If pruritus persists, then the approach is same as for the dog with pruritus without lesions (jp. 54). Differential diagnoses for noninflammatory and nonpruritic alopecias are outlined later in this section.=k B HLOW “(4 2 7 Jeuaupe) Aydestiouosesiyn “| av} Sot acliy auapucdlop and 40} 9Joreue> dun tp . spaunuds ayajcy03-04- [eH -anpoxd! aaqss90X9 Ue st nuoj snosumueds ayy (1 -1pedoypy 40 snosursuedds) stislonanouarperadyy SS ,Euaupe aALns OF 2JSURIOURUE SUT Hoda sua sic | jolarsajoyp * ao sho mingog) Aristtiogoong tu ET Nera] epadoyy Jjuniduoy ‘uojyewweyujuoN yp s6oq ul sisouboig pue ‘suojdg juauyeas, ‘s}sa] 2/}s0ubeIg pepuawmWwodsay ‘says paayy Ajuowwo> ‘sesoubelg jequalayig Se 51921 70vuonsstua ndusoa on spe] iste HOM 10 posses A JO IUED|FION aaron! Jee) gd Oy yamouil ‘sayeuny padeds Uy UsKonis9 -su> UL auucUaRSOSOY *SHop -Sun/uOD UE 1D9TOU UBHUaR (usis1e9 » *(a1uaioiaqeip) aucutt pom a) Asdong (az “dy sae widen ZT) uoneomspidns | unys (gg “d) meas “(1g a) Ato auuzepua “(gg oe) Asclongy (ro-7 poe g-7 saint) spou nay que ‘una “suontiar peut dup yo etaade nprundiy ‘sates 40p09 ako “Weoo ayeY oye] gy (2g-7 sung) My WunwNIOM pue ssa “Sea paso Pye wpadopy (.X epadoge,, 6 stpstion pidnoait og Set eys sawWoxpUAS 3834p aap nasasoz "USSLUS9 SISO REMI) 2A -tvosou-amoUa0y) POI paso -aipoud ave spuno4piain auptuaeais yt sop ane yor uormuaaand 05 sity “up peau soy Chon “d) uruonepayy (pe “e} Asdongy (ber “dy squuy pur wlsadope dao AROS UsMy LT Cpe men aaaye sypuour ¢ oF | Ano SUP] PSUs |e pin A uadojay usy) pur uasiewes quaaa a) spoys Hs nism ssans jt ‘papoau aon, | -(g¢ ~d) uumsiogaun ‘hioueypy my UNAS uarOpaL (Auappns yo syeaq ney ‘snes aK PST “ye rey Gps asnu> Hurssaapp' SunyPMIOURE 4 smunsa “sauO pane? pue uA ‘SyueY pul axl joe wig areas HAS AY EIU GE usneationsadiyy ‘uoissanddns sou (ual posearsus ‘say a pI sana] aL J UOEN|EA 2080] | fd) lou, | -joo se cadoye aunacimads Ayer aep paprend ‘ssn OU LRA auiaypaoRy Lopes panunuos ¢-z ajqeL 72saad aq jo hoi Cor we) “woody Wty Le-z aun6iy O€-Z ainbiy wisjomuoooussperoddy qwuapuadap-Arernnd 01 anp sana sisourspe> Spin soa] pyng paar “sua apna tpjo-anad-g ue ur east pur saindeg 82-2 aunby on anpersadoyy 62-7 aunBi4 (umouyun tsvam paddiys wi uta aes spay 0: 40 21240) seare paddy) dondony 3 Sadao} *éyuo seaae poddr]> ut ers 4 sypuous p7-9 UE auaypoxg | PEG MOFT [IM HE} SUK, 73‘suojsaj OU WUr ‘Gop snunud se dN-OAA smaueud yo uanenjena JopHsuor9: “Ayaqt) YOu J Guryviang | nse ey sqing uabojay =——sqnq uaGeuy ‘anisnj2U02u] yewuougy spua pauade] spua uayaig aiquised 41 TanAniya uabope ‘aseamp jeuouuoH [epadoye uoungp 10j0 ‘elseidsAp senyja4 a) (ed) (97"0) werboyrup Guides unas, (zed) aumyno jeBuny paveaipul se sys93 poojg pur BuUN, tusipaDouUaIpesadAy 40 SuBis omuoasts Jo s2uaping wsipioskuyaddy yo s2uapine ON, epadojy s1niduoy AojewweyujuoN YM bog ayy S€-2 aunBiy 7576 The Dog with Nodules Key Questions # How old was this patient when clinical signs were first recognized? (p. 3) # How long has the disease been present and how did it progress? (p33) & Ate there any other animals in the household? (p. 8) # Does anybody in the household have skin disease? (p. 8) & Was the disease treated before? If so, which drugs were used and how successful was treatment? (p. 8) Differential Diagnoses The differen arate fearure: al diagnoses are predicted primarily based on two sep- (1) Is there only one lesion (which increases the like- lyhood of neoplasia or a kerion) or are there multiple lesions (which may be due to sterile ry diseases, more aggressive neo- plastic disease or severe infection); and (2) Are draining tracts absent or present (increasing the likelihood of foreign bodies, severe bacterial or fungal infection, or sterile inflammatory d s straightforward. History scopical evalua- The approach to the dog with nodule: and clinical examination are followed by mier n of impression smears (if draini cytology will reveal an infectious organism or classic neoplastic cells and thus a diagnosis. In most patient: tion will further narrow the list of differential diagnoses, but a biopsy (p. 38) will be necessary to reach a diagnosis. With nodu- ion of one or more nodules should be cytologic examina- lar lesions, complete exci performed. If draining tracts are present and/or cytology indi cates possible infection, a culture may be useful as well. Dee tissue should be submitted rather than a culture sqs: aunyyns *(9¢ “dy (bt asrasap sanaishs satuerp “erxanc _20) sploorio anon oittinsks ‘ 40 3] uruiata ‘suo Aaewjos 40g ots pouting (9¢ 4) dsdowg coyed wanounpun Ajascnitt) sural 33S Seer mae oe) rece te] Peter lay Breet tr cre] sa|NPON yum Bog e ul sisouBolg pue ‘suondg yuaujeay, ‘s1say 2s0UBelg papuawworay ‘says payayy AjuowWOD ‘sasoufelg jenuasayig 9-7 9IGeL 77a 1p sjsoueaboaodds au mryuemprs xe niyd des yestuny aayjcluouslp pe Sururesp pue ny “Stes Je|NDG UE sNOAI acnesidss ny sot pacrtdioudiooounitruat ayo tr, uonoqut ae eo pos0KLL EST errr gas panunuos 9-2 ajqeL 78uot popiensy temp 510: ee (gt) 4) Ader Jeuarequue wi21 Buoy Paof}oy wowsraxe eating Surasay Aupiqudases ous i uo pose (Ug ody At MUNIUH: Aq PAO} Jo} Motoa peotians apyyy “(ze “d) sam po easy (att) ase, (ze 8) suman “(ge “d) thn “Uz “h Bop), Spot anges 4 ees ompe Kees | Pee sicen autre aie NUIT“) ABlopoad | Sed ‘Suams snoaueegns (ze ~) ammo (gg dl) ssding lz “th ABOPOUD Bintad) au “er sarees 200] leas pay aunscxdsar pur u (zea) | Aittog oan dojaaop soy pue sood on popuengy worse [FoEuns apg, aunyjno ‘(pe “dy Asdowg | a3e) aup yo saynpou parersoi7y (eaonDyaT pa sp 0 “spoontean> ‘A 159) pu 4s osnie> pure soadyoales | (ze-d) aumyno (ge “dy | Bun cs mapa) Aseling ai ABopue) SF HOIPUEION, | nO puw rnrSorincay | (winamp muBMAdOT ccs (S009 ‘sarap gis a i cous Sy snot Panujuos 9-z ajqeL 800D 8 UT sasA9 sna) 2€-7 aunBiy oxy poe opment Ss] S| NIPORY BE-Z aunBig 9€-Z eunBiy a1The Patient with Otitis Externa Otiris externa may be seen with many diseases in conjunction ical signs, which are helpful in the form a list of differential diagnoses. This discussion is the appr the dog with otitis externa and no other symptoms. with other c' Ic is important to differentiate between predisposing, primary, and perpetuating factors in the pathogenesis of otitis externa. Predisposi ctors are independent from the underlying di and alone will not se se disease, b t will facilitate the patholog- ic process. Conformation, including dense hair in the ear canal, long and narrow ear canal, pendulous cars, and climate-relared mal factors such as incecased temperature and humidicy arc examples of predisposing factors. Complicating factors occur only after the primary pathologic process has begun, but contin- ry disease has been successfully re otitis media, ba se ue tot a problem after the prim identified and treated. Examples fungal infections, and chronic proliferative changes due to inflammation. These complicating f need to be treated independently. The most common prir Table 2-12 cterial or tors y factors are listed in Key Questions of How old was this patient when clinical signs were first recognized? (p.3) o Is the disease seasonal? (p. 3) # What do you feed the a (p. 7) o Are there wo Was the disease treated before? If so, which drugs were used and ment? (p. 8) @ When was the last medication given? (p. 9) imal? Was a special dict used in the past? ny other animals in the household? (p. 8) how successful was tr 107eus3 sg SHO YA JualTeY & ul sisouBolg pure ‘suondo quawjead ‘s}sal 2ysOU! een e PCE NMS Cre Te] Iq PapuawiWOoray ‘sanj> |e! ZL-z ayqeL 1D weyoduyy aswasiq sasoubelg jenuaayig 1081090 sasvpsmous -oupseouspe purse | a pur porn a -OUZpH puE]y snouTUTU>) Aysiapduuos pr "poor i: aun SfHAUU 4opjo *yuaepUp _geesuydoony (id) ‘d) je a “uDfs paneypows-aantuats) orssoaddnsournanay sky (12) HN) a id Jo Somme x esteperpop sneqdaayy Advasy2 oy aenodsar a2yduiocy | unoy snooueruods aq | “¢¢-7 qe a) peyooyene | -apedoypy 0 mooraus) Ses PS. eee*(drumnag wAuog ag] JO Assume) snitiyditiad qa dy, peau £9-2 aanBiy “{Avuanig eduog acy yo Asaumogy) Adore ipa. sana, SULA, PURI Asay, w UE stUONS coro pale “uypeos eanpiAus pug, 69-7 aunbi4 vtFigure 2-68 Identification of the Primary Disease in the Patient with Otitis Externa Otoscopic examination Inflammation. Mass or foregn body and ae Young eo Older animal Surgical or manual removal cafyroid testing, urine ‘ol creatinine ratio past antimicrobial treatment (p. 118) Depending on patient and owner Nondiagnostic Diagnostic Further testing of treatment as indicated Remission Relapse No change intradermal skin testing, serum IgE testing (p. 42) | Monitoring — felapse 112ytology is essen ny dog or cat with otitis externa; ex: nation must be separate in the left and right ear canals as infec tive microorganisms may be different from one ear to the other. In some animals, particularly in patients with chronic long- standing otitis externa and concurrent otitis media, organisms in the middle car may differ from the those isolated in the external ear. Antimicrobial treatment in the ear canal is most effective topically and determined by cytology (p. 21) and in vitro suscep- til y (p. 42 and 46). Repeat cytology examinations during treatment is essential and changes in the otic flora may necessi- tate changing medications. Otitis media is best creaced with systemic medication. Many dogs with chronic otitis externa and otitis media may not respond to treatment because of severe accumulation of purulent ot waxy ate! in the ear canals. An ear flush may be needed followed by a new attempt of topical and concurrent sys- temic therapy. The tympanum may rupture prior to flushing or during flushing because in an inflamed ear the tympanum is much more fragile than normal. Frequently there are few alter- natives for antimicrobial treatment in these patients. Sometimes: they may have to receive potentially ototoxic topical medica tion. Be sure to discuss this possibility with owners before begin- ning therapy. Regular cytologic examinations are a precondition for successful man nes with otitis externa. They 2 not specifically mentioned in Figure 2-68. Therapeutic trials and tests for primary diseases may be influenced by concurrent tion and thus must be planned, executed, and anding ot extremely frustrating for pat patients may benefit from referral to a veterinary dermatologist. 13.In this section, I will summacize the most common treatment modalities, their formulations (which may vary in different parts of the world), indications, and doses. Given that detailed d sion of individual drugs, their mechanisms of action, phar nd protocols is keyond the scope of this text, further ay be required. See Recommended Readings kinetics, reading Drugs marked with an (3) and a colored screen are potentially dangerous and the clinician inexperi i may consider offering referral to a veterin further advice from particular agent Shampoo Therapy of Various Skin Conditions Shampoo therapy can provide effective wement of dermatoses with both medical and cosmetic presenting complaints (Table 3-1). There are few adverse effects associated with shampoo therapy, although they are recognized. However, shampoo therapy is sympco- matic treatment; it rarely “cures dermatosis @ a shampoo involves selecting the proper shampoo for both hampoo manufacturers have under- Presea the dermatosis and the client. en considerable research and development in order to produce for- ppealing smell, offer little irti- their intended purposes. In addition to selecting the appropriute shampoo, the veterinarian’ instructions will have a significant impact on the efficacy. The fre- quency of bathing and duration of skin contact time will influence the obtained result. A 10-minute contact time is generally recom- mended. This is a long time for the owner of a fidgety, shivering dog to wait and it will frequently be cur short! Techniques to improve contact time include ¥ Take a clock into the bathing area and time LO minutes accurately. # Use the time for patting and bonding. nzies 14518 Treatment of Bacterial Infection ¥ Antibioti because n sare frequently used in veterinary dermatology, ny conditions wed with secondary bacterial Fe ASSOC Wlergies, immune-mediated der- matoses, or endocrinopathies frequently de infection. Dogs with chronic lap secondary pyo- dermas that exacerbate these conditions and necessitate antibac- treatment (Table 3-2). ¥ Nor all available antibiotics are useful for ski thar spectrum of activity as well as pharmac ntibacterial drugs has to be considered. ft The overwhelming majority of skin infections in the dog and car is caused by Staphylococcus intermedius. Mixed infections can in > Escherichia coli or Pseudomonas aerugino: wally develop concurrently with most patients’ primary agent, S, intermedius $F Proper dosage and proper duration are important for the suc- cess of antibacterial therapy, Antibiotics should be given for at least 3 weeks or longer or uncil at least | week after resolution of clinical signs. Relapses are common in patients on short courses of pharmacotherapy or those receiving medications ar low dosages! Deep infections may take 6 to 12 weeks to resolve. of Pyodermas can, at least initially, be treated empi priate therapy does not resolve the condition, indicated (p, 32). # Each sample for ex by cytologic examination and culcure results interpreced in lighe of the cytology, as growth of different OOrg indicate necessarily that they are present in signific teri infecti ns so gy of the different organisms such lly. If appro: ing a culture is ture and sensitivity should be accompanied anisms does not nt numbers: in vivo.ora poop way Y 71 Baye oF-og “agai eokuemMay pare op ‘poong] igdag SUNN 1909 aalysud sow aos (urssunorypda ‘sayeiira Bus OE OOs PUR O07 (ora poop moyen 4g b aya CT (a) TL b soya ee ans yen yous Syn anno as neato sannTatieundt Aue yy “rusizey aantod | wea ape suonsayuy vost Seoyaep ‘BUNT, Suxo1oa ectay {(uemssaudins moa yay ayy pur pur ‘SOEs USE *Suc04SUtg] WEMLIDGOK] 10} ION ZT [yin gg ‘yusptian ‘Ob ‘]uysur Oz Sa}qe ous ur DOE PL As peut | pfu 6 Sur ogg /Su OST suo Ey (sma | emucauopray 08 yaludboens ote ase ama MONE ‘ td auzt Sytner OF “1 aucyy, pion ated Bx) YL pueda ‘suondnus sour suranountuosoeZy SOSTEE EEC] apy 4 ayy wi sa2y UI MEW AGOC] 404 JOR] “Ry CHA Og BLL QT (PAu ob “I3}9RI poss ABojoyewuag jewluy jews ur ssnoignuy payalas Z-€ 21geL 19drunks junjsius Qe re 7d) A umypusy panunuod Z-¢ ajqeL 120(Od) TP bay c |< (Oy +2 Dagan ¢ ‘eusisegeaku “1330351 Anglers yim suonsagu qeunue rata ‘ur anos dew sunsnurivn asnaeSioueineT BOIL roe tess ANNOY spa. 9 Apeynanind tanga Avu SORTS SOY “SUSIE 2g) porwo OG * Fut gez ‘ut OO] mpexoponicy quae tn) Pesaran esi OOS-OSZ Jgoixororday ‘suonsear arxmovrgl Swampy pue | deus up usd sound a pian jo uontao |-apiuo ao gy ursuanoyghun: “EAP TUNWOA ‘wos | Yala Laat aq 20U pjNOYS UNS MMTAeUEGLIOD we @ SODA "129030 pure Hlunnuio souseue IUPUI aap Fini gg] iu gg y pz b iyi g7-¢ ar Ap suOTESUT sna! ur swoon sy ‘thu pg Hua Zz “Hau yc UIseNeyouN pnsdies Fu Qog Fue OST Fa cy wpkuEpUT cl 1 c sus Joop ‘Suna ‘eosnepy Bus 07 wt OO] sumiskxog ssypedies atu pg “Aw cz ouyppdonnsy qtwv If there is no response to allergen-specific immunotherapy after 4 ro 6 months, | recommend thar you contact your nearest veterinary dermate « for advice while there is still sufficient vaccine left to change the dose and frequency of the injections by adjusting them to the needs of that particular patient. Many patients need an approach suiting their particular requirements and the help of a veterinarian experienced in immunotherapy may be of great benefit. I sincerely believe that allergen-spe immunotherapy is cure rently the best available treatment for canine atopic dermatitis, but it will only be successful in most atopic animals if owners and veterinarians have realistic expectations and are prepared to put in int effort over the period that sometimes extends over many months. Only then will maximal benefit be achieved! In as much as the first months on immunotherapy may be deain- ing for owner and veterinarian, consider offering referral to a veterinary dermatologist, particularly if you are not experienced in this therapy. Antihistamines # Antihistamines are useful adjunctive agents in the manage- ment of pruritic patients. The classical antihistamines act by blocking H1-receptors. First-generation antihistamines also have an anticholinergic, sedative, and local anaesthetic effect. Second-generation antihistamines penetrate less through the blood brain barrier or have a low affinity for the brain compared with the action on peripheral H1-receptors, Thus they are effec- tive yet produce less sedation (Table 3-3). # The advantage of antihistamines is the rare occurrence of adverse effects. Drowsiness is the most common finding and may decrease after 2 to 3 days of therapy. Thus, it may be worthwhile continuing treatment for several days before final evaluation. Less common are gastrointestinal signs, Acute poisoning follow- ing an overdose is characterized by CNS hyperexcitability. Due to the anticholinergic properties of terfenadine and cyprohepta- i hi drugs should not be used in patients with severe car- diovascular disease, since they may cause hypertension. ¥ The necessity of frequent administration (two to three times daily) and the high cost of some antihistamines limit their long- term use in many jienrs, especially larger dogs. 125126 # A further shortcoming in dogs is the relatively low suecess rate, which varies between 5% and 30%, depending on dosage and drug used. fer Cats are much more likely to respond to antihistamines than dogs. However, administering oral medication on a long- term basis may be challenging in this spec # If a patient responds to antihistamine therapy and the owner is willing to maintain the animal on it, antihistamines represent safe long-term treatment that is preferable to glucocorticoids! # Antihistamines in humans are not used to treat present symp- toms but to prevent onset of symptoms. Thus, administration should not be intermittent assuming the same holds true in ani- mals. © The potential success rate can be different antihistamines sequentially because patients may be responsive to one antihistamine bur not to another. Antihistamines have been reported to be effective in lower- ing the corticosteroid dose, even if they not help the animal as a single therapeutic agent. & Because the withdrawal time of antihistamines before an intradermal skin test is much shorter than that of glucocort coids, they can be used to relieve pruritus during the preparation time where the latter are contraindicated.127 ‘SuIpeuapol Jo SunOS No UPAUIOUTS SPL ge | voto 2 tus ogy "Aw gz * Bul O9 neti (9) (aya (4 Zl pursed sum) Auoxbsns pus 7 S9)g) SPO) H+2 bys c7"9 (Say yozeuo zea ooeuoa0iay Ipbw ApuouAsueD MLDS on saajqen Hu cz “ut OY Sip uss SAD] wiry ASAIO fdas aaMLAZUG OLS assy se UEAunOUYpALD Jo ‘orl waise ayy palm ApuaAshouK 20U og) (ay yz 09-0€ (a) 471 bSu [S79 (O)-4 $2-71b ag ADDY FETT Ba Og-g (Order bias CH EEZLD MOG wuts | “s12]gea porooe shu gy dna juyjtian | “aayqee stu gy (ora 3°) 477 b yt z-] (9) ¢z1 b an gz (a) 4 Z1-§ b tu g-7 (oe (uz (4 beg bay 7 syasoun s} pur 1ST TW OF autpensoyouttcy pas 4]jenusied ‘sarsuadesuy Sunepos Ayjeruaied ‘satsuadxouy summestuse ogy | Sunyepas Ayertuayod ‘sarcusdxouy sasjqes flu: g superusydsoyy sag] SAW sUasIAdAH jeu [JEWS JO JUaWUZeAAL B43 UL pasn seUjWweIs;ynUY Pa}2a/95 E-€ ageEssential Fatty Acids # Essent | function, as components of cell membranes, and as the precursors of inflammatory mediators. wv Supplementation with specific EFAs, especi: (in sunflower and safflower oil), gi rrier fatty acids (EFAs) are important for epiderr id ly linol mma-linolenic acid (in rose oil) and eicosapentana! id (in cold water il), © acid is needed for maintenance of stratum corneum barrier func- its transepidermal water loss and is thus better suited for atment of scaling (Table 3-4). # Success mite of EFA therapy is rela of It may take seve effects become evident. marine fish in have anti-inf fects. Linole: mmatory ely low in dogs, higher in cars. al weeks of supplementation until clinical of In essence, EFA supplementation decreases production of inflammatory prostaglandins and leukotrienes in favor of an increased production of noninflammatory or antiinflammatory prostaglandins and leukotrienes. # Adjunctive therapy with essential fatty acids can be beneficial py allergies: im a patient w * tty acids have been reported to he effective in lowering the corticosteroid dose, even if they did not help the animal as a sin- gle therapeutic agent. ® Start with a small dose to avoid possible diarrhea and gradu: ally increase the dose. of Ideal doses and w-6/w-3 ratios are a subject of continuing active research. . Table 3-4 . Essential Fatty Acids and Their Doses eta a Linoleic acid 20. 0 mghke q 24h 128Glucocorticoids @ Glucocorticoids are very commonly used in the treatment of skin conditions (Table 3-5). Y At anti-inflammatory dosage, they decrease inflammatory cell activity and migration, ¥ Corticosteroids are effective in most patients with atopic disease and resolve the symptoms at least initially on reasonably low dosages. Flea-allergic animals will also often respond to these drugs, although typically at slightly higher dosages. Glucocorticosteroids can be considered the treatment of choice in animals with a mild seasonal pruritus of 1 to 2 months duration. that is controlled with anci-inflammatory dosages (<1 mg/kg) of prednisolone every other day. ¥ Every other day therapy is definitively preferred over daily drug administration because as it is thought to lower the chances of iatrogenic hyperadrenocorticism. ¥ Luse prednisolone at anti-inflammatory doses for severely affect- ed dogs after skin testing and short term to break the itch-seratch cycle, However, the need to increase the dosage over time to con- trol the clinical signs in most of these patients, combined with the potentially severe long-term side effects make glucocorticoids a poor long-term choice for atopic patients. ¥ Adverse effects include polyuria, polydipsia, polyphagia, increased susceptibility to infection, and other well-known symp- toms of iatrogenic hyperadrenocorticism. The most commonly encountered infections affect the urinary tract, skin, and lungs. ¥ Drugs should always be tapered to the lowest effective dose. Sy Frequ decreased when adjunctiv ntly, the dose necessary co control clinical signs can be therapy is used. Fatty acids and antihis- nines have been reported to ke effective in lowering the corti- costeroid dose, even if they did nor help the animal as a single therapeutic agent. Regular topical therapy (e.2., shampoos) may be another means of decreasing the need for systemic glucocorticoids. $4 [ recommend to the owners of my atopic pa ated with glucocorticoids the lowest possible dose, on which the animal is mildly itchy but not uncomfortable. If no pruritus is present, the dose used is too high. ients tre + The glucocorticoid dose needed with individual patients ofte! varies seasonally. 129“uorinposaa tuaisds pure 149 purcrdag, aHopordo ased syaam f pur aanayns aanesau v ised syaam 7 Ajoaeuyxosdde sy yong (un, yuo aan qun a0 (dds 1 ‘Aypeapy “(ge “d) Asdorg ro/pue (z¢ -d) any aisod. Aq pasoump st UORSagut jemuNy soaye posn sae juny Aq *(g¢ *d) du Q-€ aqUL) siudt suolpeayuy jebung Jo JUaWyeaIL 10) 3s Awooum Nags ao pL Sey ZO 1-4] OY Tea bye oso ty 7g “Tu gy tu f “Suu 7 ) 4 Sk-bz b ays 7-1 ‘saapqea Sia gS (CO) 4 Sb-ez batyatu | -C-0 “hu ¢7 ‘Bun yz “tu ¢ wu | auopSTUpany (CO) 4 gbrbz b typi 7-1 HOG (a) 4 si-t7 baygtw p-c9 Fun gz ‘Hur ¢ ‘ur | al Sr ied 5 Ne aBesog say, pue sp1o3110303n|/5 paysajas S-E 91921 130bytm 67-91 XD 4G un AL yt 0 wnt sfup expo [eye oo-B ve) (ei eres ies) PrerPrr ed Ere el] Eel oe} aaodury up Sm-pe| gm Peet ane ee] panujquod 9-¢ a1qeL 132xp ony syain 7 Jestop aya Swope pode To) Py EOS ng20 say aye Spam eorqnes sinus Sootpoulsp iv OOS Avp uo [enpe Or iste on Ape ent (yee meer] cre Brera iv) errs WwwIOy ABojopewsag jewluy [/ewWs U| spUaby jep!rigisesedoy2g payrajas 2 et age, (L-€ A1qQeL) esta ag}4 pur paar aq or aavy ou A stop jt 1 Syua ‘saNquas Upway payray, -Sny> pur xopouiagy ade CONDPPA\ “Ppnquioao. []>as se pouspisu s}uaby |epiijiseiedo}39 133eas] sapnugy 's9 ayes aa, eas *sts01] 9099] 494 | uusopadd 200 p apdoad ne sia uDy po sunny ‘wHtL994 snouks samp pue] you | | sadiy ‘emapodiy | sogqeas ‘seoypnapioy> | -sasuns ] semunud ‘uotepag | ‘sisooqpouap au ru + | (siv9) uoisusdsns mu gf? | Sel (stop) siajqea | BW GOR SW 6 FOT fioup ayes a9, | Sina gg ‘sar cf | wosnu9y"7] -pourop 209 Burdezs spas g youn step yim 7 SSESIPOURAY] HIM wpounp “smqes suonussaid moat} tins ayes Aaa, Panuguod /-€ 3/qeL 134rauddsdp 770 w soot stio-tods sku (yp ore a eunpiousa,] %ZO-SOO (OO) 4 té-47 bas, ‘ vd “ de sopmisd pur stad unpaaky qt sla) mr ~ ony pm bas oO) ero TaSnRSRH -Yooy pure ‘tuzampunor ‘gonusvand usastrest, “saigeas "uonesayu! ‘sqm Bun oby pu “iu O77 “tut 9 (2 'C)wo-reds « (}qistanany “Hw gh ‘ur Og “Au ST 8 AyyRoUt you 7T-9 enodoye pesca JOU Shop Fai oF ams soda Yaueos Sue our ang “uoceonpah: ance sinod] gp pacodureys 2x dees setaare ‘koe [uepgz ap atiESn 8: 7 Sphog pu oy sok gL SL Theg b Ayyut g-p shade sisoyjonopiayp pue | ypu ua ssiqess gesed ‘opnt | nua) go-aods wey. “eau Ly KP LLY | anniajgs aun Ades qwerty 135136 Insect Control Trials and Individual Management of Patients with Flea-bite Hypersensitivity Flea control trials w Treatment recommendations will vary significantly with indi- vidual situations. Confirmed flea-bite hypersensitivity, suspected flea-bire hypersensitivity, or pets that show no sign of discomfort, but have some fleas, are treated very differently. # Reasonably safe and effective products are available (Table 3-7}. As veterinarians, we are in the best position ro advise clients on a flea-control program tailored to their spe needs that considers their personality and life style as well as their pet's little pee fr Am arities. jor reason for failure of flea control programs is owner compliance. They are either unwilling, not educated properly, too careless, or simply nor physically able to da what we ask them to do for whatever reason, Choosing the right protocol and educating owners properly, taking the time and possibly using nursing staff, brochures, and message boards will greatly increase your chance of success tion should be nor the veterinary technician/nurse to demonstrate the correct procedure to the owner. @% With all topical produ dministered in the cli ts, the first appl > by the veterinar # Another reason for failure may be resistance of the organism to the products used. Resistance will always develop to any prod- uert, the question is thus not if, but rath when. In essence, we speed up evolution and create resistant fleas by putting pressure on the population when using products for flea control. However, there are ways to delay this development of resistance. The first possibility is to combine different flea products, as it is much less likely that an individual flea gets resistant to two dru at the same time. This approach is called integrated flea control and is becoming more popul possibility is to switch products quickly when signs of resistance oceur and the resistant flea with another effective product before it has time to multiply in big numbers all over the world. The second# Suspected flea-bite hypersensitivity: Agressive flea control is needed for 4 wo 6 weeks. If there is no improvement, we most likely do not deal with flea-bite hypersensitivity. With signiti- cant improvement or remission, we established a diagnosis and need ro discuss long-term strategies with that particular owner. In such a trial, we usually recommend the frequent use of an adult cide in combination with an insect growth regulator in the en’ ronment to quickly lower the flea pressure (Tables 3-8 and 3-9). end # Confirmed flea-bite hypersensitivity: Ideally, we recom an inseet growth regulator/insect development inhibitor on permanent basis (systemically, topically or in the environment) and an adulticide as needed ( les 3-8 and 3-9). The second option is an adulricide only, in which case we need to switch products very quickly at the first sign of resistance. However, as adulticides are tapered slawly co identify the longest possible interval in berween applications, recurrences may indicate insuf- ficient frequency of application rather than resistance. 3 No flea-bite hypersensitivity present: In these cases, we do not recommend flea control because permanent flea expose may be less likely to induce flea-bire hypersensitivity than off- and-on flea control by an owner who is not pressed into compli- ance by an itchy per. Lf the client does wane to start some sort of flea control, insect growth regulators or development inhibitors are recommended. Mosquito-bite trial The safest and most thorough mosquito-bite t Lin cats with papules and crusted papules on nose, pinnac or foot pads is to keep the patient indoors for 2 weeks. When there is no expo- sure to mosquitoes, the disease regresses rapidly. However, in cats used to outdoors this option may not be vinble. Alternatively, exposure is decreased when outdoor activities are limited and cats are trained to come in before dawn by feeding them in the late afternoon. In addition, a mosquito repellent safe for use in cats such as pyrethrin spray may ke applied by wetting a cloth and wiping the feet and head daily before the cat goes out. 137uonesydde Ayyruous i WE a Aww Fern oa rym ano-43004 gainb ‘s1zasu sada 2 esto pues Aude 02 f-7 duaa Ajuo posn asneoq “HUSTUDALOT papssu seep pb siqqey | ureadduanyy mean ogT | pedopsepry sayqescd won onpoud #89 2]quya ‘spew jue aia] ay aapetradxa, tiouy3e Huyjadan oy seyaam feez dana dye “WUAUOD youd oodueys este any) Jordon 139aap MUO? B2]p AWE U} muMmAU pasn FP 9-f 40 P py b bor dn asapos peaIpur 1c PON FF IP ET bor dn snposd yenprrpur uo duspusdap sunuies, | Avads uimpauuag wo-andls MAU SPIN Oop A SPAM Qe tous pladopepnity PON OFS spon ce +0 fads ood Das KC und seu youn span pz b Apanisuasiad A} ayiq-eaj4 payzadsns SINPodd Pal payre|as Jo uoHeriddy 6-E 81921 m in aka OY uoneoidde Apyruou vu. id prue aon Surpuadap ‘san ren aqisod ang o7es oy 182 uy 268 30 Of] Sl< stop 104 HI SSRI AL C1> Sop 10} uo -tosls 8 uo] 10 soma duand sunssaxd) © noe YOUN Huigidoy suNaWO> hen) ae) panuyuoe g-€ 21921 140az ¥ Taper the drug once the patient is in clinical remission or if adverse effects are intolerable. In a patient with severe adverse effects and concurrent clinical signs of active disease, new drugs need to be added at the same ti ne. @° Monitoring, as described in Table 3-10, is essential. | only nonitering standards because of financial con- patients facing euthanasia otherwise comprom erations i eon #¥ Some dogs will have seasonal rel currently not understood. If a well-controlled pa seems to relapse, always check for demod terial infections first. Rather than a flare-up of the immune-medi- ated disease you may be encountering a problem secondary to your treatment. These patients are immunosuppressed and thus easily may be affected by infectious diseases! Increasing the dose of the immunosuppressive drug may not always be a good idea. lapses. This mechanism is tient suddenly ind fury or bac-Pree rre rere tg cel swoydwics snoaueyn> YIM Siepsosig auU2OpUq yo yUsyead] 9y3 UI pasp sHnug pa|z2aja5 bL-E 1981 (LL-€ a1qeL) eElsejdsAq se;nNd1|;04 pue sesessiq JPUOLLIOH] O} aNp epadoyy jo JUSsW}eAIL 144Gordon Serter Great Dane Great Pyrenees Irish Setter Irish Water Spaniel Jack Russel Terrier Keeshond Labrador Retriever Lhasa Apso Malamute Newfoundland Old English Sheepdog, Pekingese Persian Cat Pointer Pomeranian Poodle Portuguese Warer Dog Atopy Hypothyroidism, ‘Acral lick dermatitis Bacterial Callus formation Demuxlicosis Hypothyroidism, Demudicosis Pyotraumatic dermatitis Atopy Color dilution alopecia Hypothyroidism Follicular dysplasia Atopy Demodicosis Alopecia X due to sex hormone imbalances Hyposomarorrapism Hypothyroidism Acral lick dermatitis Awopy Bacterial pyoderma Food adverse reaction Pyotraumatic dermatitis Seborrhea Atopy Malassezia dermatitis Zine-responsive dermatitis Becterial pyoderma Pyotraumatic dermatitis Atopy Demadicosis Incertrigo Cheyletiellosis Dermatophyrosis Intertrigo Sebarrhea Acral mutilation Demadicosis Hereditary lupoid dermatosis Adrenal sex hormone abnormalities Hyposomatotropism Hyperadrenocorticism Hypothyroidism Injection reactions Sebaccous adenitis (Standard) Follicular dysplasia 147West Highland White Atopy Terrier Food adverse reaction Malassezia dermatitis eborrhea Yorkshire Terrier Color dilution alopecia Injection reactions Traction alopecta B. Questionnaire What is the main problem? Atwhat age was this condition first noticed: Has there ever been’ ¥y previous dermatitis? G Yes Na Do the symptoms vary? If the dermatitis has been present for some time are the symproms worse in: mer? Cautumn? winter? Are the symptams present all year round? Yes Na If yes, would there be a time of ne symptoms at some stage?) Yes. No Whar (if anything) causes a worsening of symptoms? What helps? Home details: Do you have any other pets — and if so how many! cats __dogs __birds __other Do you know of any relative of this pet chat has skin problems? Yes No Does any human inv che house have skin problems? 0 Yes © No Cspring? Where does this pet sleep? Have there been any other illnesses? Bathing and fleas: Does bathi How offen do you prefer to bath your pet! weekly Qmonthly rarely ‘When was the last time a flea was seen on this pet?___ other pets?____ Whar is the current Mea treat Is flea treatment used an other pets: Medication: If previous medications have been used, de you know what they were? oYes ONe If yes, were thi Last tablet giv Last injection given (date) Is your dog on heartworm 1 -Ohelp worsen make no difference on this pec? rinses Olinjections ©) rablets © ointments Dsome O goad ¢:Onene Csome 2 good Yes: Q daily 9 monthly 149150 What do y Diet: Whar do you normally feed your per! cans Cidry table scraps Gi meat fm which types? Any other foods? (e Hi veverf biscuits) ve y » 2 Yes: What? 1a special diet? Symptoms? Have any of the following heen observed sores scabs ol dandru hairloss Sodor Chives Olredness sweating Clear problems © watery nt gain © vomitiny increased appet Doe: hear weight loss diarrhea increased thirst depression your pe rub at the face lick or chew the paws scratch at the sides roll on the back —O bite at the wil are lick the stomach area se snort wheeze other. nk could be the cause of theDermatology for the Small Animal Practitioner The quick reference manual you need for Dermatology * Practical guidelines for di: treatment of the skin dise: every day in practice. mosis and 5 that you see ®@ Over 115 Color illustrations integrated with Ralf S. Mueller the text for easy identification of lesions. Dae ates * Carefully designed tables for quick access FACVSe to important diagnostic and treatment information. ® Formulary of dermatologic drugs and preparations. * Provides quick identification of rare and complicated dermatologic tests. ® Clear, step by step descriptions of commonly performed diagnostic tests. * User friendly, consistent design which helps the reader focus on the really important information. * Companion CD-ROM provided which contains the book plus an expanded library of color illustrations for instant search and retrieval of information. Forthcoming titles in the Made Easy Series for the Small Animal Practitioner: Thoracic Radiology + Transfusion Medicine « Endocrinolog: + Echocardiography detain 9 ll | | T™NM ISBN #1-893441-06-7