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DOI: 10.1111/j.1365-3164.2008.00662.

Pathogenesis of canine interdigital palmar and plantar


Blackwell Publishing Ltd

comedones and follicular cysts, and their response to


laser surgery

David D. Duclos*, Ann M. Hargis†,‡,§ and sinuses. One dog was euthanized for orthopaedic
Patrick W. Hanley§ lameness 1 month after laser surgery, but post-surgical
follow-up (1.0–8.0 years – mean 3 years) from the
*Animal Skin and Allergy Clinic, Lynnwood, Washington, USA remaining 27 dogs revealed that laser therapy of
†DermatoDiagnostics, Edmonds, Washington, USA affected skin and adjacent hair follicles resulted in
‡Phoenix Central Laboratory, Everett, Washington, USA resolution of interdigital lesions in 25. Two dogs con-
§Department of Comparative Medicine, School of Medicine,
tinued to develop interdigital cysts.
University of Washington, Seattle, Washington, USA
Correspondence: Ann M. Hargis, E-mail: hargisann@comcast.net Accepted 14 February 2008

What is known about the topic of this paper


• Dermatitis with development of nodular lesions and
draining sinuses in interdigital skin in dogs is painful,
often recurrent, and can be difficult to properly diagnose Introduction
and manage clinically and surgically. Interdigital dermatitis (pododermatitis, pedal folliculitis
• There are different causes of interdigital dermatitis and
and furunculosis, interdigital furunculosis) in dogs is a
the role of follicular cysts is controversial.
multifaceted disease that is often recurrent and difficult to
What this paper adds to the field of veterinary diagnose and treat. Causes are varied and include exogenous
dermatology
foreign bodies, contact irritants, hypersensitivity reactions,
• This paper describes in dogs a previously unrecognized
syndrome consisting of multiple comedones and follicular parasitism (demodicosis, hookworm dermatitis, Pelodera
cysts in palmar or plantar (ventral) interdigital skin that: sp. dermatitis), infections with yeast, fungi, and bacteria,
(i) result in sinus tracts that open and drain on the dorsal and disorders associated with immunosuppression.1,2
interdigital skin surface giving the false impression that A variety of types of trauma are thought to contribute
lesions develop dorsally, and (ii) describes a laser surgical including external contact with irregular or rough surfaces
procedure that can cure the syndrome. such as vegetation or gravel, and self-trauma from licking
associated with allergic skin disease.2 It has also been
speculated that trauma to interdigital skin caused by short,
bristly hairs rubbing against the skin of apposed interdigital
webs can play a role.2 In addition, chronic friction, as seen
Abstract in callus pyoderma may contribute to obstruction and
This study documents the presence of comedones and subsequent rupture of follicles, especially in dogs with
follicular cysts of palmar and plantar interdigital skin abnormal foot conformation.2 Recently, a form of lympho-
as an underlying cause of recurrent dermatitis, and plasmacytic pododermatitis that responded to immuno-
describes the use of a carbon dioxide laser to surgically suppressive therapy has been reported.3 It has been stated
remove lesions. The 28 dogs included in the study had: that the cause of interdigital dermatitis (pododermatitis) is
(i) recurrent lameness, pain, and nodules, or draining often undetermined, but in no cases are the resulting
sinuses in the dorsal interdigital skin, (ii) failed to lesions cysts.1 In contrast, the presence of follicular cysts
respond to antibiotic therapy, and (iii) were negative associated with interdigital dermatitis has been documented
for Demodex mites and dermatophytes. All 28 had in some dogs.2 Clinical lesions include erythema, oedema,
laser surgery; nine dogs had two surgical procedures nodules, pustules, ulcers, haemorrhagic bullae, haemorrhagic
and two dogs had three surgical procedures for lesion draining tracts, and scarring from recurrent episodes.1,2
recurrence. Fifteen dogs had skin samples collected Histological lesions vary with the cause. Perifolliculitis,
for histopathology. Clinical features in ventral inter- folliculitis, and furunculosis, draining tracts, and scarring
digital skin included alopecia, callus-like thickening, are reported. Treatment includes eliminating specific
and comedones. Histological features included hyper- aetiological agents when present, soaking paws in
keratosis, acanthosis, comedones and follicular cysts, antiseptic solutions, long-term antibiotic therapy, and
furunculosis, draining sinuses, and scarring. Surface surgical debridement.1 In severe cases, podoplasty has
trauma to the ventral interdigital skin appeared to been advocated.4
contribute to lesion development. Laser surgery Herein, the clinical and histological lesions and a proposed
allowed removal of multiple layers of cysts and adja- pathogenesis for a subtype of canine recurrent interdigital
cent hair follicles and the tracking and removal of dermatitis believed to be secondary to the formation of

134 © 2008 The Authors. Journal compilation © 2008 ESVD and ACVD. 19; 134–141
Palmar and plantar interdigital follicular cysts

multiple comedones and follicular cysts in the palmar or Carbon dioxide (CO2) laser surgery methods
plantar (ventral) interdigital skin are described. These A Luxar LX 20 SP Novapulse® 20-watt laser system (Aesculight Inc,
comedones and follicular cysts are present in multiple layers Woodinville, WA, USA) with a pre-sterilized NovaScan scanning hand-
piece was used. An Acu-Evac® filtration particulate and smoke evacuator
of the ventral interdigital skin. Each is prone to rupture
(Acuderm Inc, Ft. Lauderdale, FL, USA) was used to remove aerosolized
and, because multiple comedones and cysts are present, tissue and debris. The CO2 laser is named from the medium used to
their periodic rupture leads to repeated episodes of generate the laser beam. When CO2 gas contained in a vacuum
pyogranulomatous dermatitis and fistulous tracts. These tube is energized, it emits a beam of light in the near infrared spectrum
tracts migrate to and drain onto the dorsal interdigital (10 600 nm). This beam, is concentrated by lenses and mirrors
space, leading to the misinterpretation that the lesions through the end of the handpiece, is highly absorbed by water, and
develop in the dorsal interdigital skin. Failure to recognize quickly vaporizes tissues with high water content (e.g. cells comprising
cutaneous soft tissue) into carbonized debris.6 Tissues or substances
the ventral origin of the cysts and remove them leads to
with low water content such as keratin need more laser energy to
frequent failure of therapy and repeated episodes of lesion achieve ablation and hence are more slowly removed by the CO2 laser.
recurrence. A laser surgical procedure that can cure or The initial laser setting for removal of surface tissue, comedones, and
improve lesions is also described. follicular cysts was continuous wave (CW) at 8–10 watts of power.
Depending on the number of cysts, the duration of the CW mode was
approximately 5–20 min. The remainder of the surgical procedure was
Materials and methods performed with reduced laser settings (super pulse mode at 4–5
watts) necessary to prevent unwanted destruction of normal tissue.
Selection of affected dogs Depending on the severity of lesions, the duration of SP mode was
The dogs were evaluated at the Animal Skin and Allergy Clinic approximately 5–10 min. The total procedure lasts about 30 –45 min
between 1997 and 2006, and were included in the study on the basis per foot. The scanner head was slowly passed over the surface of the
of: (i) recurrent lameness, pain, and nodules, or draining sinuses in surgical site ablating to a depth of approximately 0.3 mm of tissue
interdigital skin associated with multiple ventral comedones and follicular with each pass. Ablated tissue and debris were removed with sterile
cysts; (ii) failure to respond to a 30-day course of oral cefalexin saline by irrigation or on gauze pads. After final thorough irrigation, the
(Ranbaxy Pharmaceuticals, Inc., Jacksonville, FL, USA) 30 mg/kg/bid wound was packed with mupirocin 2% ointment (Taro Pharmaceuticals
and oral rifampicin (Rifadin®, Hoechst Marion Roussel, Inc., Kansas City, Inc., Brampton, Ontario, Canada), and a compression bandage was
MO, USA) 5–10 mg/kg/sid; and (iii) undergoing laser surgery for the applied. The treated site was allowed to heal via granulation tissue.
lesions. Dogs with interdigital dermatitis from other causes such as
antibiotic-responsive bacterial infection, demodectic mite infestation Post-operative care
or fungal infection were not included. All dogs were given a dermato- The dogs were treated with oral cefalexin (30 mg/kg/bid), and topical
logical evaluation including a complete physical examination, skin mupirocin 2% ointment, at the time of bandage changes; both pro-
scrapings for parasites, hair examination for fungal spores and cedures were continued until the surgical wounds healed. Some
hyphae, and cytological examination for microorganisms, and were dogs required pain management and were given oral deracoxib
reported to have normal thyroid function by referring veterinarians. (Deramaxx® Novartis Animal Health, Greensboro, NC, USA) at 1–
Statistical analyses were performed because it appeared that there 2 mg/kg/day as needed during the first 7–14 days. Most required
might be a breed, age, sex, body weight, paw, and interdigital web bandaging for 4–5 weeks, and a few for 6 weeks. During the first
predisposition. Demographic and clinical characteristics were evaluated 2 weeks after surgery, the bandages were changed at least every 3–
between Labrador retrievers and other breeds affected, and for dogs 4 days while over the next 2–4 weeks a weekly change was usually
with and without post-surgical recurrence of disease. Demographic adequate. Waterproof coverings, including empty intravenous fluid
characteristics included the age at onset of disease, body weight (kg), bags or commercial dog boots, were used to keep the bandaged
and sex. Clinical characteristics included the number of affected paws paws dry. The clients were instructed to keep their dog in a restricted
and the location of affected interdigital webs (4/5, 3/4, and 2/3). area to prevent activity and trauma to the interdigital skin. Information
Statistical association was assessed by chi-squared analysis for on post-operative outcome was obtained during office visits for band-
categorical variables and t-test analysis for continuous variables age changes and assessment for healing and clinical improvement,
using Stata 9.0 (Statcorp. College Station, TX, USA).5 Significance was and via telephone calls to owners.
determined if the P-value was < 0.05.

Biopsy and surgical procedures Results


Dogs were initially anaesthetized with propofol (PropoFlo®, Abbott
The breeds and sexes of the 28 affected dogs are listed in
Laboratories, North Chicago, IL, USA) 5.5 mg/kg given intravenously
and titrated against the patient response, and anaesthesia was thereafter
Table 1. They had a mean weight of 45 kg (range 15.3–74.6),
maintained by isoflurane (Aerrane®, Baxter, Thousand Oaks, CA, and a mean age at lesion onset of 2.9 years (range 1–
USA) inhalation. Interdigital skin was clipped and prepared for a sterile 9 years). The mean duration of clinical signs before laser
surgical procedure, and the affected areas were covered with a surgery was 2.4 years (range 0.5–7 years).
sterile drape. Clinical lesions included nodules (Fig. 1) or draining
Skin samples were collected from the ventral interdigital skin of 15 sinuses in dorsal interdigital skin. Dorsal lesions were not
of the 28 dogs via punch or incisional sampling either before or during
always visible unless the hair was clipped. The ventral
the laser surgical procedure. Between one and four samples were
collected from lesional skin in each of the 15 dogs. Skin from one dog interdigital skin opposite the dorsal lesions contained an
was sampled during three separate laser surgical procedures; nine area of alopecic, thickened, firm, callus-like skin with multiple
had biopsy samples collected from one paw, and six had biopsy comedones (Fig. 2). Four affected dogs (three Labrador
samples collected from two paws. The skin samples were taken from retrievers and one Labrador retriever husky crossbred) had
areas with a variety of clinical lesion appearances to investigate thick, hard, rough tissue overlying the area of alopecia and
underlying causes and perpetuating factors. In addition to affected
comedones, and had broadening of the digital pads. This
tissue, samples were taken from clinically normal ventral interdigital skin
and the callus-like thickenings suggested that either
(one from a Saint Bernard and two from a Labrador retriever). Blood was
blotted from the skin samples, which were then placed in 10% neutral- weight bearing was occurring in the haired skin adjacent
buffered formalin, and processed by standard techniques to paraffin to the digital pads or that there was frictional trauma
wax. Sections (4–6 mm) were stained with haematoxylin and eosin. between haired skin and another pad (Fig. 3). Punch biopsy

© 2008 The Authors. Journal compilation © 2008 ESVD and ACVD. 135
Duclos et al.

Table 1. Demographic characteristics of dogs with interdigital cysts

n (28) %
Age at onset (years)
≤3 21 75.0
>3 7 25.0
Body weight (kg)
< 30 2 7.1
30–50 16 57.1
> 50 10 35.7
Sex
Male 19 67.9
Female 9 32.1
Neutered
Yes 20 71.4 Figure 3. Thick, hard, rough tissue (arrows) overlying the area of
No 8 28.6 alopecia and comedones in ventral interdigital skin adjacent to digital
Breed pad. In this dog the thickened area rubbed against the metacarpal pad.
Labrador retriever 13 46.4 Note the adjacent digital pad (arrowheads).
Other breeds* 15 53.6
*Labrador mix (2) Irish setter (2), Saint Bernard (2), Malamute and
Malamute crossbred (2), and one each Shepherd mix, Bull mastiff,
Great Pyrenees (Pyrenean mountain dog), Rottweiler, Doberman
pinscher, Brittany spaniel, and English bulldog.

Figure 4. An example of a large follicular cyst below the thickened


skin. Note the cyst contents (arrow) and the follicular wall (arrowheads).

bandaging paws) without resolution of lesions. The lesions


Figure 1. Nodular area on dorsal interdigital skin between digits 4 were considered to be ‘refractory’ to therapy. The dose,
and 5. Note the swelling and erythema, and inflammation about to duration, and frequency of specific medications given
rupture through the skin surface (arrow). varied with the referring veterinarian and were not
always available. In addition, prior to inclusion, a 30-day
course of an oral cephalexin 30 mg/kg/bid and rifampicin
5–10 mg/kg/sid was given to all 28 dogs, and none
responded to the antibiotic therapy.
The majority of the 28 dogs (26) had cysts involving at
least one front paw, and 14 had cysts affecting both front
paws (Table 2). In contrast only seven had cysts affecting
at least one rear paw, and six had cysts affecting both rear
paws. Twenty-six had lesions in the haired interdigital skin
of the palmar or plantar (ventral) surface (Table 2). One had
cysts at the haired skin paw pad junction only, and another
had lesions in the haired ventral interdigital skin and at the
haired skin paw pad junction. Twenty-six dogs had lesions
between digits 4 and 5 (Table 2), indicating that the ventral
Figure 2. Alopecia and comedones (arrows) in ventral interdigital skin
interdigital webs of the lateral digits of the front paws
revealing expression of follicular contents (arrowheads) caused by
pressure from the dorsal surface.
were the areas most often affected.
For interdigital lesions, no significant differences were
identified with regard to age at onset of lesions, body
sampling (Fig. 4) or laser surgery revealed the presence of weight (kg), sex, number of affected paws, or location of
comedones and follicular cysts beneath the thick, alopecic, affected interdigital webs between Labrador retrievers
callus-like skin. Prior to referral, different veterinarians and other breeds. No significant differences were identified
treated the dogs with a variety of systemic and/or topical with regard to age at onset, body weight (kg) or affected
therapeutic regimes (e.g. antibiotics, steroids, sometimes paws or toe webs between dogs that had a recurrence of
surgical lancing, soaking paws in antiseptic solutions, and disease and those that did not.

136 © 2008 The Authors. Journal compilation © 2008 ESVD and ACVD.
Palmar and plantar interdigital follicular cysts

Table 2. Locations of interdigital cysts in dogs

n (28) %
Feet affected
One front foot (left or right) 7 25.0
Both front 14 50.0
Both rear 2 7.1
All feet 2 7.1
Other* 3 10.7
At least one front foot† 26 93.0
At least one rear foot† 7 25.0
Sites affected
Ventral haired skin 26 92.9
Haired skin and footpad junction 1 3.6
Both ventral haired interdigital skin, 1 3.6 Figure 6. Ventral interdigital skin with superficial tissue ablated by
and haired skin and footpad junction the laser. Abscesses (large arrows) were identified after layers of
Interdigital webs affected‡ comedones and cysts were removed by laser surgery. Note the
Lateral (4th/5th digital space) 26 92.9 contents (small arrow) expressed from a follicular cyst at the edge of
Central (3rd/4th digital space) 7 25.0 the surgical field.
Medial (2nd/3rd digital space) 3 10.7
*Represents either a dog that had both rear feet and one front foot
affected or a dog that had both front feet and one rear foot affected.
comedones and cysts. As the follicular contents were
†Five dogs are listed twice because they had both a front and a hind
released, frequent cleaning of the surface with sterile
foot affected. Each category (front vs. hind) is a percentage of the
28 dogs. saline (on gauze sponges and by irrigation) was required to
‡Dogs could have multiple webs affected. Each interdigital web space remove debris and keratin, and maintain good visualization
is a percentage of the 28 dogs. of the surgical field.
Multiple layers of comedones and cysts became visible
as the layers of tissue were gradually ablated. Typically,
once one level of comedones and cysts was removed
the tissue became more normal in appearance; however,
continued laser ablation revealed additional levels of come-
dones, cysts, and sometimes small abscesses (Fig. 6). In
most dogs there was at least one and sometimes multiple
haemorrhagic, draining sinuses between the last layer of
cysts and the dorsal interdigital skin.
Placement of a sterile cotton-tipped applicator in the
opening of the haemorrhagic sinus on the dorsal surface
and applying pressure with this applicator helped identify
the location of the draining sinus in the surgical field on the
ventral surface, enabling the laser to be directed dorsally
Figure 5. Ventral interdigital skin with the surface ablated by the
towards the sinus (applicator). This pressure occasionally
laser. Note the lack of haemorrhage. The follicular walls (arrowheads) caused the expression of keratin from the cysts in the
border expressed follicular content (arrows). palmar or plantar skin, thereby providing an additional visual
aid for cyst location. Great care was used when surgery
approached large digital vessels and nerves to avoid
Other health or skin problems in dogs with interdigital damaging them. In some dogs, the laser surgery extended
dermatitis included atopic dermatitis (seven dogs) and completely through the interdigital skin to open on the
orthopaedic lameness (two dogs). Nineteen had no other dorsal interdigital surface.
problems. In an attempt to prevent future development of come-
dones and cysts in follicles adjacent to the surgical site,
Laser surgical procedure hair follicles in normal skin approximately 5 mm around all
Surgery on the paws always began on the ventral surface. sides of the affected area (lateral, proximal, distal, and dorsal)
The CO2 laser ablated the tissue, sterilized the surface, were also ablated.
and sealed the small capillaries, which helped to prevent
haemorrhage and improved visualization of the surgical Skin sample evaluations
site (Fig. 5). The CO2 laser energy quickly ablated tissue The skin samples varied in size from 4 mm to 2.5 cm, but
with high water content (e.g. soft parenchymal tissues most were small and not representative of the entire surgical
bordering cysts), leaving tissue with low water content field. The samples were selected to evaluate specific
(e.g. keratin) unaltered. This differential in speed of ablation features in the surgical site. Histological lesions of the
helped identify the comedones and cysts in the tissue palmar or plantar (ventral) interdigital skin included moderate
during surgery (see Fig. 5). Digital pressure on the dorsal to extensive compact hyperkeratosis and acanthosis of
interdigital space helped to expose and stabilize the epidermal and follicular infundibular epithelium (Fig. 7).
affected tissue, improved visualization of the ventral surgical Multiple follicles were cystically dilated, often extensively.
site, and helped to express the contents of the follicular Thirteen of the dogs sampled had follicular cysts and two

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Duclos et al.

haired skin of the palmar and plantar webs causing epidermal


and follicular infundibular hyperkeratosis and acanthosis,
plugging or narrowing of the follicular ostia, and retention
of follicular contents (Fig. 8). Since the compound hair
follicles of dogs can have 15 or more secondary follicles
entering and exiting one compound follicle unit,7 the
narrowing or plugging of one follicular ostium could lead
to the formation of multiple cysts. Dilated cysts are prone
to rupture, which creates a foreign body inflammatory
response and often a secondary bacterial infection. The
presence of the released follicular contents causes an
endogenous foreign body reaction and is the probable
reason why lesions fail to completely respond to antibiotic
therapy. Exudate from ruptured follicles can coalesce
and lead to the formation of draining sinuses. However,
because both the palmar and plantar interdigital skin is
Figure 7. Photomicrograph of ventral interdigital skin. Note compact thickened by hyperkeratosis, acanthosis and scarring, it is
hyperkeratosis (arrowheads) covering acanthotic epidermis. Follicular unlikely that a draining sinus could easily penetrate this
cysts are present (arrows). Haematoxylin and eosin. Low magnification.
dense tissue and open on these thickened surfaces.
Instead, as discovered during the laser surgical procedure,
the draining sinuses extend towards the more normal less
others had draining tracts containing hair or keratin. The inflamed and scarred tissue of the dorsal interdigital
number of cysts in one histological section varied from 1 space. Support for this hypothesis comes not only from
to 14, but it was not always possible to determine with the clinical and histological lesions and surgical dissection
certainty if cysts were interconnected outside the plane of in the present study, but also from comparison of the
the section. Two dogs had coccoid bacteria and five dogs interdigital lesions to calluses that develop in interdigital
had Malassezia sp. in the cysts. Fourteen of the dogs with skin and at other sites, and from other studies that
interdigital lesions had furunculosis. The released follicular describe development of interdigital lesions in dogs and
contents were associated with a granulomatous inflam- measure forces affecting digital pads and limbs.8,9
matory response. In some dogs with chronic lesions, hair For example, trauma was proposed as a cause of
shafts were embedded in areas of scarring. Five dogs with interdigital dermatitis and cysts in an epidemiological
interdigital lesions had histologically visible tracts from study of 732 laboratory beagles in which the interdigital
areas of furunculosis to other areas of the skin sample. lesions were described as raised, firm areas located in the
Two skin samples from clinically normal ventral interdigital dorsal aspect of the interdigital space. The prevalence of
skin had no significant lesions. In the remaining sample, interdigital lesions in beagles was greater in the front than
the epidermis was moderately acanthotic and covered by the hind paws,8 and in those beagles with a large body
compact stratum corneum. In this sample, there was mild condition score. The lesions developed more commonly in
follicular hyperkeratosis and dilation, with small numbers beagles exposed to one type of suspended cage flooring
of periadnexal lymphocytes, plasma cells, a few neutrophils (flat bar coated flooring), which may have increased contact
and histiocytes. One small focus of granulomatous of the ventral interdigital skin with the coated bars, as the
furunculosis was identified, compatible with a subclinical number of affected beagles increased as the time of
lesion. exposure to this flooring increased.8 These findings provided
support for the role of surface trauma to the bottom of the
Post-surgical outcome paws in larger/heavier beagles as a contributory factor in
Twenty-five of 27 dogs with the palmar/plantar interdigital the development of raised, firm dorsal interdigital lesions.
comedo and follicular cyst syndrome were cured by However, as this was an epidemiological study, there was
laser surgery (follow up time 1–8 years; mean 3 years). no accompanying histopathological description, which
The 28th dog was euthanized for orthopaedic lameness 1 prevents the identification of the nature of the lesions and
month after laser surgery preventing acquisition of long- knowledge of the presence or absence of follicular cysts.
term follow-up information. Seventeen dogs required one In addition, vertical forces affecting paw pads have been
laser surgical procedure, nine required two procedures studied during walking in greyhounds and Labrador
and two required three procedures. Two of the dogs con- retrievers,9 in both of which the vertical forces in the fore
tinued to develop interdigital cysts after lesion ablation; limb were greater than those in the hind limb.9 Digital pads
repeat surgery has been recommended for one, but as the 3 and 4 were identified as the major weight-bearing pads,
cysts in the other dog were mild additional surgery was but digital pad 5 and the metacarpal and metatarsal pads
not considered necessary. In addition, three dogs developed also carried a substantial amount of the load. These findings
ventral interdigital cysts on a previously unaffected paw. indicate that more weight bearing occurs on the front than
on the hind paws of dogs, and that the digital pads 3, 4,
and 5 bear more weight than digital pad 2. This may help
Discussion explain the results in the current study where front paws
The pathogenesis of interdigital follicular cysts in the dogs were more commonly affected than hind paws; where the
appeared to result from external surface trauma to the interdigital webs between pads 3/4 and 4/5 were more

138 © 2008 The Authors. Journal compilation © 2008 ESVD and ACVD.
Palmar and plantar interdigital follicular cysts

Figure 8. Schematic illustration of the proposed process of lesion development. The ventral interdigital skin becomes hyperkeratotic and acan-
thotic, and primary and secondary follicles become dilated with keratin. Hairs on this surface are lost as the lesions become more severe, and the
interdigital skin thickens. Follicles can rupture causing an inflammatory response and the development of draining tracts that migrate dorsally and
open within the dorsal interdigital space.

commonly affected than that between pads 2/3; and skin may promote formation of keratin-filled follicles that
where affected dogs were also heavy large breeds. can rupture as seen in callus pyoderma.2 Thus the studies
The study of vertical forces affecting paw pads in of interdigital lesions in laboratory beagles, studies of
greyhounds and Labrador retrievers also revealed a breed vertical forces on paw pads of dogs, and similarities to
difference in paw conformation.9 Greyhounds had long, callus formation in interdigital skin and at other sites help
narrow paws with little distance between the digital pads. provide evidence for weight bearing and interdigital
In contrast, the Labradors had wide-based paws with trauma as contributing causes for lesions in the dogs in
greater distance between pads.9 This latter characteristic the present study.
suggests the possibility that weight bearing, especially in Laser surgery was a useful method for resolving lesions
a heavy dog, might be more likely to be distributed to because it was effective in 25 of 28 dogs in which follow-
haired interdigital skin adjacent to digital pads. Interestingly, up of at least 1 year was available. As the laser cauterizes
the four dogs with the thick, firm, rough tissue covering the small capillaries and prevents bleeding, it facilitates
callus-like areas in interdigital skin in the present study differentiation between affected and normal tissue. In
were Labrador retrievers (three dogs) and a Labrador super pulse mode it allows removal of minute amounts
retriever husky crossbred. of tissue with each pass, thereby avoiding unnecessary
Finally, callus formation with dermatitis (callus pyoderma) damage to the surrounding tissue and making the laser an
of the skin over the sternum, elbow, or hock joints has ideal surgical tool for this condition. Moreover, the CO2
clinical, histological, and aetiological similarities to the cases laser ablation procedure facilitates removal not only of the
of chronic interdigital dermatitis and follicular cyst forma- follicular comedones and cysts, but also the adjacent
tion in the dogs in the current study.2 Clinically, calluses hair follicles, which may help prevent recurrences. Even
are alopecic thickened areas of skin subject to repeated so nine dogs required two laser surgical procedures, two
pressure or frictional trauma.2 Histologically, they frequently required three procedures, and two of the dogs continued
contain dilated hair follicles filled with keratin (e.g. come- to develop interdigital cysts.
dones and follicular cysts).2 These dilated follicles can rupture The reason why interdigital cysts in the palmar or plantar
causing furunculosis, a foreign body response to the skin recurred in some dogs but not others is unclear.
released follicular contents and a secondary bacterial No other contributory disease process was identified. The
infection. Fistulas may develop in some cases. It has also most likely explanation is development of comedones and
been suggested that friction or other trauma to interdigital follicular cysts in remaining hair follicles near the surgical

© 2008 The Authors. Journal compilation © 2008 ESVD and ACVD. 139
Duclos et al.

site or between other digits due to continued external clearly identified as having the palmar plantar interdigital
trauma. The capacity to develop ventral cysts in other digits cyst syndrome before having this invasive laser surgery
was demonstrated in three dogs in the present study where performed.
such cysts developed in a previously unaffected paw.
Because there are many causes of interdigital dermatitis
that can successfully be treated medically or with less Acknowledgements
extensive surgical procedures, prior to contemplating The authors acknowledge H. Denny Liggitt for pathology
laser surgery, it is necessary to evaluate and exclude those consultations, and Benjamin J. Weigler and Ronald F.
cases that are not due to the ventrally developing comedo DiGiacomo for statistical consultations.
and follicular cyst syndrome. Clinical evaluation of the
palmar and plantar interdigital skin for alopecia, come-
dones, and callus-like lesions; thorough dermatological References
evaluation for other aetiological factors (bacterial, para- 1. Scott DW, Miller Jr. WH, Griffin CE. Muller and Kirk’s Small Animal
sitic, yeast, fungal infections, exogenous foreign bodies, Dermatology, 6th edn. Philadelphia, PA: W.B. Saunders, 2001:
inflammation associated with allergies, etc.); an appropriate 304–6.
antibiotic trial; and/or skin sampling of ventral interdigital 2. Gross TL, Ihrke PJ, Walder EJ, Affolter VK. Skin Diseases of the
areas should enable identification of dogs with interdigital Dog and Cat Clinical and Histopathologic Diagnosis, 2nd edn.
cyst syndrome. Also, as presenting signs in dogs with Ames, IA: Blackwell Science Ltd, 2005: 184–5, 431–5.
3. Breathnach RM, Baker KP, Quinn PJ et al. Clinical, Immunological
the comedo and follicular cyst associated interdigital
and histopathological findings in a subpopulation of dogs with
dermatitis include pain manifested as lameness and pododermatitis. Veterinary Dermatology 2005; 16: 364–72.
sometimes licking, it is also important to exclude dogs in 4. Swaim SF, Lee AH, MacDonald JM et al. Fusion podoplasty for the
which lameness is due to involvement of other tissues treatment of chronic fibrosing interdigital pyoderma in the dog.
such as the bones or joints. In this study, one dog with the Journal of the American Animal Hospital Association 1991; 27:
interdigital cyst syndrome also had orthopaedic lameness 264–74.
5. Moore DS, McCabe GP. Introduction to the Practice of Statistics,
involving the elbow joint. This dog was euthanatized 1
5th edn. New York: W.H. Freeman, 2005: 581–609.
month after laser surgery of interdigital skin when it was 6. Peavy GM. Lasers and laser–tissue interaction. Veterinary Clinics
realized that a significant proportion of the lameness was of North America Small Animal Practice 2002; 32: 517–34.
orthopaedic in origin; although the interdigital lesions had 7. Calhoun ML, Stinson AW. Integument. In: Dellmann HD, Brown EM,
healed, the dog remained lame and in pain. eds. Textbook of Veterinary Histology. Philadelphia, PA: Lea &
In summary, the results reveal that the ventral interdigital Febiger, 1987: 382–415.
skin in some dogs develops follicular cysts, which can 8. Kovacs MS, McKiernan S, Potter DM et al. An epidemiological
study of interdigital cysts in a research beagle colony. Contemporary
rupture, cause inflammation and bacterial infection, and
Topics in Laboratory Animal Science 2005; 44: 17–21.
form fistulas that drain onto the dorsal interdigital surface. 9. Besancon MF, Conzemius MG, Evans RB et al. Distribution of
The lesions appear to arise from external trauma to the vertical forces in the pads of greyhounds and Labrador retrievers
ventral interdigital skin. Most lesions can be successfully during walking. American Journal of Veterinary Research 2004; 65:
treated by laser surgery, but affected dogs should be 1497–501.

Résumé Cette étude rapporte la présence de comédons et de kystes folliculaires au niveau de la peau
palmaire et plantaire interdigitée comme une cause de dermatose récidivante, et décrit l’utlilisation d’un
laser au dioxyde de carbone pour éliminer surgicalement les lésions. Les 28 chiens inclus dans cette étude
avaient: 1) une boiterie récurrente douloureuse et des nodules ou des fistules au niveau interdigité, 2) une
absence de réponse à l’antibiothérapie et 3) absence de Demodex et de dermatophytes. les 28 chiens
ont eu une chirurgie au laser, neuf ont eu deux chirurgies et deux trois chirurgies à cause de récidives. Un
examen histopathologique a été réalisé pour 15 chiens. Les signes cliniques en zone interdigitée ventrale
incluaient alopécie, épaississement et comédons. Les signes histopathologiques regroupaient une
hyperkératose, une acanthose, la formation de comédons et de kystes folliculaires, une furonculose, des
fistules et une fibrose. Des traumatismes de surface à la peau interdigitée semblaient aggraver les lésions.
Le laser a permis l’élimination de nombreuses couches kystiques et l’élimination des follicules adjacents
et des fistules. Un chien a été euthanasié pour boiterie un mois après le laser, mais une résolution a été
observée chez 25 cas après un suivi de (1.0 à 8.0 ans – moyenne 3 ans). Deux chiens ont présenté des
récidives.

Resumen Este estudio demuestra la presencia de comedones y quistes foliculares en la piel intedigital
palmar y plantar como causa de dermatitis recurrente y describe el uso de láser de dióxido de carbono para
retirar las lesiones quirúrgicamente. Los 28 perros incluidos en el estudio tenían: 1) cojera recurrente, dolor
y nódulos o senos de drenaje en la piel interdigital dorsal, 2) no respondieron a tratamiento con antibióticos,
y 3) fueron negativos para Demodex y dermatofitos. Todos los perros se trataron con cirugía de láser; nueve
perros tuvieron dos procedimientos quirúrgicos y dos perros tuvieron tres debido a lesiones recurrentes.
Se tomaron muestras de piel para histopatología de quince perros. Las características clínicas en la piel
interdigital ventral incluyeron alopecia, engrosamiento tipo callosidad y formación de comedones. Las
características histopatológicas incluyeron hiperqueratosis, acantosis, formación de quistes y comedones,
furunculosis, senos de drenaje y cicatrización. Trauma superficial en la piel interdigital ventral parecía

140 © 2008 The Authors. Journal compilation © 2008 ESVD and ACVD.
Palmar and plantar interdigital follicular cysts

contribuir al desarrollo de las lesiones. La cirugía con láser permitió retirar niveles múltiples de quistes y los
folículos adjacentes así como la localización y extirpación de los senos de drenaje. Un perro fue eutanasiado
debido a cojera ortopédica un mes después de la cirugía con láser, pero el seguimiento post-operatorio
(1–8 años, media 3 años) del resto de los 27 perros indicó que el tratamiento con láser de la piel afectada
y los folículos adjacentes produjo resolución de las lesiones interdigitales en 25 perros. Dos perros continuaron
desarrollado quistes interdigitales.

Zusammenfassung In dieser Studie wird das Auftreten von Komedonen und follikulären Zysten der
palmaren und plantaren Zwischenzehenhaut als zugrunde liegende Ursache einer wiederkehrenden
Dermatitis dokumentiert. Die Verwendung eines Kohlendioxidlasers zur chirurgischen Entfernung dieser
Veränderungen wird beschrieben. Die 28 Hunde, die in die Studie aufgenommen wurden, hatten: 1)
rezidivierende Lahmheit, Schmerz und Knoten oder abfließende Sinusse in der dorsalen Zwischenzehenhaut,
2) reagierten nicht auf Antibiose und 3) waren negativ für Demodexmilben und Dermatophyten. Bei allen
28 Hunden wurde Laserchirurgie durchgeführt; neun Hunde hatten zwei und zwei Hunde hatten drei
chirurgische Interventionen aufgrund von erneutem Auftreten der Läsionen. Bei fünfzehn Hunden wurden
Hautproben für eine histopathologische Untersuchung genommen. Der klinische Befund der ventralen
interdigitalen Haut bestand aus Alopezie, kallusartiger Verdickung und Komedonenbildung. Der histologische
Befund bestand aus Hyperkeratose, Akanthose, Komedonen und follikulärer Zystenbildung, Furunkulose,
abfließenden Sinussen und Narbenbildung. Ein oberflächliches Trauma der ventralen Zwischenzehenhaut
schien zur Entstehung der Läsionen beizutragen. Die Laserchirurgie ermöglichte das Entfernen von Zysten
in zahlreichen Schichten und der angrenzenden Haarfollikel und das Auffinden und die Entfernung der
Sinusse. Ein Hund wurde einen Monat nach der Laserchirurgie aufgrund von orthopädischer Lahmheit
eingeschläfert, aber die Kontrolluntersuchung nach der Chirurgie (1.0 bis 8.0 Jahre – Durchschnitt 3 Jahre)
der übrigen 27 Hunde zeigte, dass die Laserchirurgie der betroffenen Haut und der angrenzenden Haarfollikel
bei 25 Hunden in einer Heilung der interdigitalen Veränderungen resultierte. Zwei Hunde entwickelten
weiterhin interdigitale Zysten.

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