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ALLERGEN

• Pathophysiology of allergy and pruritus

• How it influences current treatment

• Treating AD: Practice Guidelines Summary

Douglas J. DeBoer, D.V.M., Diplomate A.C.V.D. • Practical clinical guidelines for treatment
School of Veterinary Medicine CLINICAL SIGNS
University of Wisconsin-Madison
DEGRANULATION
Release of histamine,
leukotrienes, etc.

Our View Today

• Old approach: managing
• AD has a very complex pathogenesis inflammation, reacting to the end
• Treatment approaches must combine several process of the disease
modes of therapy or “tools”

• Every patient is different and will require a • New approach: much broader,
different combination of “tools” to provide multifaceted approach; proactive to
correct actual disease pathogenesis
effective, affordable, convenient, and safe where possible; targeted anti-
treatment over a very long time. inflammatory and antipruritic
therapies

Ma rs e l l a e t al ., J Am Ve t Me d As so c. 20 12 Ju l 1 5;2 41 (2):1 94 -20 7

• Avoiding pollen allergens

• Avoiding dust mite allergens • Diet trial essential
• Avoiding concurrent üClear up infections first • Which Diet?
parasites, such as fleas üNo clear indication which diet • NOT a pet store brand!
is best to use • At least 50% are
• Evaluation for concurrent üMust be STRICT mislabeled
food allergy, and avoiding
food allergens üMust be at least 1-2 months
• Reducing microbial allergens

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 • Malassezia dermatitis Staphylococcal pyoderma
• Staphylococcal infection
Much of pruritus may be
bacterial infection
Over-rides drugs, diet trials,
• Which Diet? immunotherapy…
• What about crossreactivity between meats?
• Argument in favor of hydrolyseddiet?

• Diet?
• Fatty acid
supplementation? • Antihistamines
• Topical products? • Corticosteroids
• Fatty acid
supplements
• Ciclosporin

• Allergen-specific immunotherapy – by injection or

sublingual route

To provide evidence-based recommendations to assist

veterinary practitioners in choosing effective treatments
for common case presentations of atopic dermatitis in
dogs
ü Treatment of acute flares
ü Treatment of the chronic disease

• Targeting of the neuro-immunologic “vicious cycles”

that contribute to chronicity

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 • Flare Factors: Short-term alterations that cause
• Identification and dramatic worsening of clinical signs in a pet who was
elimination of flare factors previously under good control.
• Improvement of skin and
coat hygiene and care
Environmental Food Fleas Bacterial or
• Reduce pruritus and lesions Allergens
with medical therapy Allergens Mites Yeast Infections

üBathing with a non-irritating üNO: antihistamines (not

shampoo effective)
üNo good evidence of üNO: fatty acids,
superiority of any shampoo
ciclosporin A (too slow)
üNo evidence of efficacy of
shampoos containing oatmeal,
anaesthetics, antihistamines üYES: topical or oral
steroids; or Apoquel
Ah
Ah An tih istamin e

ü Identification and avoidance

of flare factors
ü Improvement of skin and
Gc coat hygiene and care
Gc ü Reduce pruritus and lesions
Gc with medical therapy
Gc
Gc
ü Implementation of strategies
Gc to prevent recurrence
Gc Consider therapies that will provide safer, longer lasting
Gc
control of the chronic disease
Gc
Gc Glu co co rtico id

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 üBathing with a non-irritating
shampoo Important, basic element
üTopical barrier augmentation
of treatment for human
products? AD Some veterinary products claim
Definitely results in that they “may help improve
üFatty acid supplementation barrier function”
improvement for patient
• Anti-inflammatory
Recently-developed lipid- Critical studies are in early stages
• Barrier augmentation?
• Effects on coat and skin might
ceramide combinations
take 2 months to be noticeable are very effective

üYES: Topical or oral steroids, oral

ciclosporin A; Apoquel
• Target for individual patient use,
considering variation in efficacy, Cs

cost, adverse effect profiles

Cs

üNO: antihistamines, misoprostol, Cs

Cs
pentoxifylline, nonsteroidal anti- Cs
inflammatory drugs…
Administration of fatty acid supplement can
improve chemical composition of skin lipid
Cs C yclo sp o rin e

• The only form of therapy for AD that is aimed

at, and can potentially reverse, the underlying • AD is a multifactorial disease
üAvoidance of flare pathogenesis of the disease with a complex pathogenesis
factors
• The only form of therapy for AD that can
potentially produce great benefit to the patient • Therapy is multimodal and
üAllergen-specific without the use of drugs individualized
immunotherapy
• Excellent safety profile • Practice guidelines are available
that provide specific steps for
• The only form of therapy for AD that can management
potentially produce permanent benefit, i.e.
“cure” of the disease