You are on page 1of 5

DERMATOLOGY

Clawdiseaseindogs:part2
diagnosisandmanagement
ofspecificclawdiseases
Because of the numerous causes of claw and claw fold diseases in the dog, it is obvious that
a wide variety of diagnostic tests or procedures may be indicated in order to narrow down
a large list of possible differential diagnoses. Furthermore, effective management is most
accurately instituted when a specific diagnosis is determined, which may be challenging in
some cases, and especially in those of symmetrical disease.
10.12968/coan.2013.18.5.226
Sarah Warren BVetMed MSc (Clin. Onc) CertVD MRCVS
Regional Veterinary Dermatologist, CVS Southern Region, Mildmay Veterinary Centre, Winchester, Hampshire
Key words: Claw|Clawfold|Paronychia|Onychodystrophy

n part one of this review, the anatomy of the claw and


appropriate diagnostic approaches were discussed along
with a summary of the large differential diagnoses for
claw and claw fold diseases in the dog. In part two, diagnosis and management of specific claw and claw fold diseases
are considered.

Environmental:trauma
Trauma is the most common cause of damage to the claws of
dogs. Usually the trauma is physical, resulting in avulsion of the
claw bed (Figure 1). This commonly occurs in working dogs and
226

Figure 2: Multiple onychogryphosis in a case of Leishmaniasis

racing Greyhound breeds. Secondary bacterial infection with


associated exudation is a common sequel. Chemical trauma
due to substances such as fertilisers may also occur. Therapy
involves removing the fractured portion of affected claw and
applying topical antiseptic soaks twice daily (e.g. 2% chlorhexidine diluted 1:40 with warm water). Pain relief and supportive
dressings may be indicated.

Infectious:bacterialparonychia
Bacterial infections of claw folds are common and almost exclusively secondary. Trauma is the most common primary cause.
Companion animal|July 2013, Volume 18 No 5

2013 MA Healthcare Ltd

Figure 1: Old claw avulsion injury in a working dog; photo courtesy of


Candace Souza

DERMATOLOGY

KEY POINTS 1
zzWhen claws are removed, it is very important to preserve

the underlying dermis or quick if possible


zzIf the quick is damaged, claw regrowth may be abnormal/

absent and concern exists for osteomyelitis or avascular


necrosis of P3 (see Figure 3)
zzIn some cases, trimming and filing, so that diseased claws
are not pressed against the ground when walking, will
alleviate pain and lameness without the trauma associated
with avulsion.

Other underlying causes include allergic dermatitis, autoimmune disease, symmetrical lupoid onychodystrophy, endocrinopathies (hypothyroidism, hyperadrenocorticism and diabetes
mellitus), other infectious causes (fungal or parasitic) and
neoplasia. Purulent exudate within the claw fold or under the
claw (rather than material from the surface of the claw which
is invariably contaminated) is the preferred source of sampling
for cytological examination and for culture and sensitivity testing. Systemic antibiotic therapy based on results should be prescribed for several weeks to months. In severe cases, avulsion of
the affected claw(s) may need to be undertaken under general
anaesthesia (see key points 1 above). Supportive dressings and
analgesia may be indicated.

Figure 4: Onychomycosis due to M. canis; photo courtesy of Candace Souza

Infectious:onychomycosis
Onychomycosis refers to fungal infection of the claws. Dermatophytosis is usually due to infection with Trichophyton mentagrophytes or occasionally Microsporum canis (Figure 4). Dermato-

2013 MA Healthcare Ltd

Figure 5: Malassezia pododermatitis and paronychia secondary to atopic


dermatitis; photo courtesy of Candace Souza

Figure 3 Structure of the canine claw; figure courtesy of Patel


Forsythe. Copyright Elsevier; permission granted
Companion animal|July 2013, Volume 18 No 5

Figure 6: Onycholysis, onychomadesis and haemorrhagic purulent exudation


associated with symmetrical lupoid onychodystrophy; photo courtesy of
Pascal Prelaud
227

DERMATOLOGY

228

Figure 7: Onycholysis and onychomadesis in a case of symmetrical


lupoid onychodystrophy; photo courtesy of Christian Collinot

Figure 8: Onycholysis and onychomadesis in a case of symmetrical


lupoid onychodystrophyclose up of a single claw; photo courtesy
of Christian Collinot

Figure 9: Subungual squamous cell carcinoma; photo courtesy of


Peter Forsythe

Figure 10: Onychodystrophy and micronychia associated with


vasculitis; photo courtesy of Pascal Prelaud

phytes invade the claw keratin and cause onychodystrophy and


onychomalacia, with the claws appearing friable and misshapen.
Claws may be brittle and easily broken or powdered. Blastomycosis, cryptococcosis and sporotrichosis have also been reported.
Commonly, only one or two claws are affected but many claws
can be involved and lesions are not always confined to the claws.
Therapy for onychomycosis should be aggressive and protracted
and may involve systemic antifungal agents which accumulate
in the keratin and have long residual activity, such as itraconazole (510 mg/kg/day), and adjunctive topical antifungal therapy
such as 2% enilconazole, 2% miconazole and 24% chlorhexidine
may also be helpful. Treatment should continue until all damaged claw material has grown out and been trimmed off, which
may take several months In more severe cases, claw avulsion may
speed recovery.
Malassezia infection may affect only the claw and can also
result in paronychia (Figure 5), especially in animals with a
primary disease such as atopic dermatitis. Classically, this is
characterised by tightly adhered dark brown-red, dry to slightly
moist claw fold exudate extending onto the claw itself mainly
at the base. Pruritus may be present. Therapy including topical
2% chlorhexidine/2% miconazole shampoo therapy (Malaseb;
Dechra Veterinary Products), 3% chlorhexidine shampoo (Mi-

crobex; Virbac Ltd), 2% acetic/2% boric acid shampoo or sprays


(Malacetic shampoo, Malacetic conditioning spray; Dechra
Veterinary Products) and systemic antifungal therapy may be
useful.

Infectious:parasiticdisease
Demodicosis may be accompanied by a paronychia that stimulates abnormal claw growth. Leishmaniasis (which is a multisystemic protozoal disease and affects the claws in up to 25%
of cases) (Figure 2) is most commonly associated with onychogryphosis. Hookworm dermatitis may produce rapid claw
growth, onychogryphosis and onychodystrophy. Therapy should
be targeted specifically to the primary disease and is beyond the
scope of this article.

Neoplasia may also involve the claw or the distal digit. Subungual
squamous cell carcinoma originating from germinal claw epithelium is the most common digital tumour of the dog (Figure 9).
This usually affects black large breed dogs (Standard Poodles,
Scottish Terriers, Labrador Retrievers). Melanoma, mast cell tumour, soft tissue sarcoma, subungual keratinising acanthoma and
inverted squamous papilloma have also all been reported. IndiCompanion animal|July 2013, Volume 18 No 5

2013 MA Healthcare Ltd

Neoplasticdisease

DERMATOLOGY

daily for dogs <15 kg) 500 mg three times daily for dogs >15 kg
and nicotinamide (250 mg three times daily for dogs <15 kg;
500 mg three times daily for dogs >15 kg). This is a difficult
disease to manage.

Figure 11: Onychogryphosis, erythema, alopecia and scaling associated with


dermatomyositis in a young crossbreed dog

viduals usually present for swelling of a single digit or claw/claw


fold and variable degrees of paronychia, ulceration, secondary
infection and pain. Rarely, multiple claws and/or digits may be
involved. Biopsy for histopathology is indicated for any suspected
digital or claw/claw-fold mass and specific treatment (surgical
and medical) initiated depending on the definitive diagnosis.

Immune-mediateddisease
Immune-mediated diseases often involve the claw fold resulting in paronychia. In some cases, other claw changes such as
onychomadesis may occur. When claw disease alone is seen, lupus erythematosus, subepidermal bullous dermatoses and pemphigus vulgaris are the most likely immune-mediated causes.
With paronychia or footpad involvement, pemphigus foliaceus
is most likely. Drug reactions and vasculitis (including post-vaccination reactions) have also reportedly affected the claws (Figure 10). Vascular occlusion or ischaemia may also result in claw
abnormalities. Usually disease is symmetrical. Therapy should
be tailored specifically to the individual and the primary underlying cause and usually involves immunosuppressive therapies.

Congenital:dermatomyositis
Canine familial dermatomyositis is a congenital inflammatory
disease of skin and muscle characterised by a symmetrical scarring alopecia of the face and distal limbs, and muscle weakness
due to myositis. It is thought to be due to an ischaemic dermatopathy and, as with many vascular diseases, the extremities
and prominences such as the face, tail, pinnae and limbs are
mainly affected, and footpad and claw lesions such as onychorrhexis, onychoschizia or onychomadesis are not uncommon
(Figure 11). The disease occurs more commonly in Collies and
Shetland Sheepdogs but has also been reported in the Chow
Chow, Welsh Corgi and German Shepherd Dog. Treatment options include pentoxifylline (25 mg/kg twice daily) alone or in
combination with prednisolone (1 mg/kg daily). It is important
to note that the maximum benefit of pentoxyifylline administration is often not seen for 4-10 weeks Other options include
combination therapy with oxytetracycline (250 mg three times
230

This condition has recently been regarded as a reaction pattern


by many dermatologists rather than a specific immunemediated disease entity. It is characterised by progressive shedding of multiple nails on all four feet over a period of weeks to
months with associated pain, lameness and paronychia. Commonly, dogs will present with onychodystrophy (Figures 68),
onychomalacia, onychomadesis, onychalgia, onycholysis and
onychorrhexis. The claws will separate from the claw bed typically with evidence of exudation. The underlying mechanisms
that lead to the immune reaction and claw damage are not clear
in the majority of cases and are considered idiopathic. The disease may, in some cases, be a manifestation of an adverse reaction to drug or food administration, but in most cases a specific
primary disease may not be identified even after extensive investigations.
Diagnosis is therefore often based on typical presenting
signs, breed predisposition (e.g. German Shepherd Dogs and
Gordon Setters) and conscientiously ruling out other possible
causes of symmetrical claw disease. Histopathological examination of biopsy material (amputation of P3 including claw bed)
is not always diagnostic in reliably identifying the characteristic
interface dermatitis pattern that is present in the active phase
of this disease, but may be useful in some cases.
Symmetrical lupoid onychodystrophy can be a challenging
condition to treat and most dogs are likely to require long-term
therapy to prevent relapse. Medical management should be
based on individual case assessment and discussion with the
owner regarding the potential side effects of each long-term
therapy. Options include high-dose essential fatty acids supplementation with or without biotin, combination therapy with oxytetracycline (250 mg three times daily for dogs <15 kg; 500 mg
three times daily for dogs >15 kg), nicotinamide (250 mg three
times daily for dogs <15 kg; 500 mg three times daily for dogs
>15 kg), and pentoxyfylline (1015 mg/kg three times daily).
For refractory cases, prednisolone (1 mg/kg once to twice
daily) ciclosporin (5 mg/kg/day) or azathioprine may be effective. With successful therapy, clinical improvement is usually
evident within 3 to 4 months. Once a favourable response has
been maintained, certain drugs may be tapered, but if treatment is stopped, the condition often relapses.
In the acute stages of the disease, careful removal of loose
and painful nails should be performed under general anaesthesia (See key points 1). Antibacterial therapy based on culture
and sensitivity testing is indicated if secondary paronychia is
present, and antibacterial soaks, supportive dressings and analgesia may also be helpful. Regular clipping and/or filing of
claws to reduce the pressure on the claw bed can be of value
in the long-term management of the disease. Radical total P3
amputation may be considered in dogs that do not respond to
Companion animal|July 2013, Volume 18 No 5

2013 MA Healthcare Ltd

Idiopathicdisease:symmetricallupoid
onychodystrophy

DERMATOLOGY

Continuing Professional Development

In order to test your understanding of this article, answer these


multiple choice questions, or if you are a subscriber, go online at
www.ukvet.co.uk, and find many more multiple choice questions
to test your understanding.

Adjunctive tests
1. The most common cause of damage to the claws of
dog is:
a. Fungal infection
b. Bacterial infection
c. Trauma
d. Immune-mediated disease
e. Neoplasia

2. Bacterial paronychia is commonly associated with:


a. Trauma
b. Allergy
c. Neoplasia
d. Immune-mediated disease
e. All of the above

3. Malassezia onchomycosis and paronychia commonly


causes:
a. Leuconychia
b. Red-brown staining at the base of the claws
c. Onychomalacia
d. Onychomadesis
Figure 12: Onychophagia presumed secondary to an underlying
neuropathy; photo courtesy of Pascal Prelaud

For answers please see page 242

KEY POINTS 2

medical therapy or for whom life-long medical therapy is not a


feasible option.

zzThe causes of claw and claw fold disease in the dog are

Neuropathy:Acralmultilationsyndrome

zzA wide variety of diagnostic tests may be indicated in

Acral mutilation syndrome is a rare canine hereditary sensory


neuropathy that results in progressive mutilation of the distal
extremities. It has been reported only in German short haired
pointers, English pointers, English springer spaniels and French
spaniels. Clinical signs are usually first noted between 3 and 12
months of age. Affected dogs lick, bite and severely self-mutilate their distal extremities resulting in ulcers with secondary
bacterial infection. Auto-amputation of claws, digits and footpads occurs in severe cases and may affect one or more feet.
Treatment options are limited and the majority of dogs are euthanased. CA

numerous
order to narrow down a large differential diagnoses list
zzAchieving a definitive diagnosis in the case of diseases

such as symmetrical lupoid onychodystrophy may


be challenging
zzEffective management, however, is most accurately
instituted when a specific diagnosis is made
zzIn most cases, therapy for claw and claw fold diseases is
protracted because of the slow re-growth of
claw material.

2013 MA Healthcare Ltd

Furtherreading
Mueller RS (1999) Diagnosis and management of canine claw diseases. Vet Clin
North Am Small Anim Pract 29(6): 135771
Mueller RS, Friend S, Shipstone et al (2000) Diagnosis of canine claw disease
a prospective study of 24 dogs. Veterinary Dermatology 11(2): 13341
Mueller RS, Olivry T (1999) Onychobiopsy without onychectomy: description of
a new biopsy technique for canine claws. Veterinary Dermatology 10(1): 559
Ziener ML, Bettenay SV, Mueller RS (2008) Symmetrical onychomadesis in
Norweigian Gordon and English Setters. Veterinary Dermatology 19(2): 8894
Boord MJ, Griffin CE, Rosenkrantz WS (1997) Onychectomy as a therapy for
symmetric claw and claw fold disease in the dog. J Am Anim Hosp Assoc
33(2): 1318
Scott DW, Rousselle S, Miller WH Jr. (1995) Symmetrical lupoid onychodystrophy in dogs: a retrospective analysis of 18 cases (1989-1993) J Am Anim Hosp
Assoc 31(3): 194201
Patel A, Forsythe P (2008) Saunders Solutions in Veterinary Practice: Small Animal Dermatology. 1st edn. Saunders Elsevier, Philadelphia: 31632

Companion animal|July 2013, Volume 18 No 5

231