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DERMATOLOGY

German Shepherd Dog Pyoderma:

An Overview and Antimicrobial Management
Peter J. Ihrke, VMD, Diplomate ACVD
Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, California, USA

Terese C. DeManuelle, DVM, Diplomate ACVD

Animal Allergy and Skin Clinic, Beaverton, Oregon, USA
Adjunct Assistant Professor of Dermatology, Washington State University, Pullman, Washington, USA

The term German Shepherd dog py-
oderma has been used to connote a
clinically distinct, aggressive, deep bac-
terial infection of the skin characterized
by folliculitis, furunculosis, and cellulitis
seen predominantly in the German
Shepherd dog and related crossbreeds
(Figures 1 and 2).1–11 The syndrome typ-
ically begins over the lateral surface of
the hindlimbs and the lumbosacral re-
gion and then progresses to become
more generalized (Figure 3).1,3,5,8 Mor-
bidity is variable, but German Shepherd
dog pyoderma can be a severe, poten-
tially life-threatening disease.9–11
Etiology and
Pathogenesis
A familial predisposition for this syn-
drome has been documented by Wis-
selink and associates, and an autoso-
mal recessive mode of inheritance has
been hypothesized.2,12 German Shep-
herd dogs can acquire other pyoder-
mas, both superficial and deep, that do
not meet the criteria for German Shep-
herd dog pyoderma. Interestingly,
Denerolle and others recently have
shown in a controlled study that the
German Shepherd dog, in general, is
predisposed to develop deep rather
than superficial pyoderma.8
Most dermatologists agree as to the
clinical history, clinical symptomatology,
and therapeutic difficulties seen with
German Shepherd dog pyoderma.
However, some disagreement exists re-
garding the underlying etiology of this
syndrome. Immunologic defects have
been noted in a number of stud-
ies.2,5,8,13,14 In most studies, however, it is
unclear whether these defects lead to
the genesis of the pyoderma or occur as
sequelae to persistent, severe bacterial
infection.
Clinically remarkable inflammatory
halos may surround early lesions, and
unusually florid tissue necrosis usually
characterizes more chronic disease (Fig-
ure 4). This striking and inappropriate
magnitude of inflammation may offer a
clue to the pathogenesis of this syn-
drome. Perhaps the heritable defect
seen in German Shepherd dog pyoder-
ma is associated with an exaggerated
tissue response to staphylococcal bac-
teria characterized by an inappropriate
release of cytokines and other media-
tors of inflammation.
Defects in cell-mediated immunity,
assayed predominantly by lymphocyte
blastogenesis studies, have been docu-
mented in a small number of dogs with
German Shepherd dog pyoderma.
However, underlying immunologic ab-
normalities were not documented in
the majority of evaluated dogs.2,5,13 A
recent prospective study of 23 German
Shepherd dogs with the syndrome indi-
cated high levels of IgG and low levels
of IgA as assayed by radial immunodif-
fusion. In addition, flow cytometry was
used as an indicator of cell-mediated
immune competence and showed that
CD8 T-lymphocyte subsets were abnor-
mally elevated, while CD4 subsets were
decreased.8
In addition to defects in the immune
system, associations have been made
between German Shepherd dog pyo-
derma and both flea allergy dermatitis
and hypothyroidism.1,2,3,5,15 In a recent
prospective study, Rosser also docu-
mented atopic dermatitis and food hy-
persensitivity as initiators of German
Shepherd dog pyoderma.5 The authors
also have noted flea allergy dermatitis,
food hypersensitivity, and hypothy-
roidism as documented underlying trig-
gers for this syndrome. However, every
study investigating underlying causes for
this syndrome has shown German Shep-
herd dog pyoderma to be idiopathic in
varying numbers of cases.1,3–5,8
Other underlying diseases also may
occur in conjunction with German Shep-
herd dog pyoderma. Chronic ehrlichiosis
has been determined as an initiator in a
small case study from southern Italy.16
However, a larger study of German
Shepherd dog pyoderma also performed
in an endemic area for ehrlichiosis
(southern France) did not identify any
dogs with coexistent ehrlichiosis.8
Available data suggest that German
Shepherd dog pyoderma is a distinct
syndrome seen predominantly in mem-
bers of one breed of dog at apparent
increased risk. Rather than looking at
German Shepherd dog pyoderma as a
disease of multifactorial etiology, it may
be more useful to view it as a charac-
teristic clinical syndrome that can be

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Figure 1—Severe German Shepherd dog pyoderma. Lesions in-
volved the lateral thighs, lateral thorax, and dorsal lumbosacral re-
gion in a partially bilateral symmetric manner. The severity of the le-
sions was not obvious until the dog was clipped prior to shampoo
and whirlpool. (Photograph courtesy of Dr. Barbara Atlee. Case ma-
terial, University of California.)
Figure 2—Closer view of lesions of the dog shown in Figure 1. Ar-
eas of dramatic hyperpigmentation represent older lesions from
previous episodes of infection. (Photograph courtesy of Dr. Barbara
Atlee. Case material, University of California.)

triggered by a variety of other diseases
in susceptible individuals. Steps taken
to minimize the clinical symptomatol-
ogy of potentially triggering diseases
may prevent the occurrence or recur-
rence of German Shepherd dog pyo-
derma.
Signalment Predilections
German Shepherd dog pyoderma is
seen predominantly in the German
Shepherd dog and related crossbreeds.
Recently, Rosser mentioned that a sim-
ilar syndrome has been seen in similar
herding breeds such as the Belgian Ma-
linois, the Belgian Sheepdog, and the
Belgian Tervuren.6 One of the authors
(Ihrke) has also noted this syndrome in
Belgian herding breeds. Clinically and
histologically similar infections also
have been seen much less commonly in
the Dalmatian and in “Pit Bulls”
grouped under the breed name Bull
Terriers.10
Although marked gender pre-
dilections have not been noted in most
studies,1,3,5 two recent, larger studies in-
dicated that 24 of 27 and 20 of 23 af-
fected dogs, respectively, were male.4,8
The reported age of onset is quite vari-
able, ranging from 3 months to 13
years. Mean and median age of onset in
the two larger studies was noted as 6.6
and 7.5 years, respectively.4,8 Rosser’s
study indicated a mean of 3.44 years,
leading to his speculation that the “con-
tinued inbreeding of German Shepherd
dogs has allowed this condition to be
expressed at an earlier age over time.”5
However, the study by Denerolle and
colleagues in France was done at ap-
proximately the same time.8
Clinical History and
Clinical Findings
A recent review article indicates that

Figure 4—Close-up of a lesion of German Shepherd dog pyo-

Figure 3—Severe German Shepherd dog pyoderma in a predom-
inantly white German Shepherd dog. Lesions predominantly in-
volved the dorsal lumbosacral region and the lateral thighs. Lesion
severity was less obvious before clipping. (Photograph courtesy of
Dr. Susan Reinke. Case material, University of California.)
derma. Infected plaques are coalescing. (Photograph courtesy of
Dr. Carlo Vitale. Case material, University of California. Reprinted
from Ihrke PJ: Bacterial Skin Disease in the Dog—A Guide to Ca-
nine Pyoderma, Figure 8-18, Trenton, NJ, Veterinary Learning Sys-
tems, 1995, with permission.)

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Figure 5—Somewhat bilaterally symmetric well-demarcated le- Figure 6—Close-up of the lesion on the groin of the dog shown
sion on the groin of a dog with German Shepherd dog pyoderma. in Figure 5. Note the suppurative, devitalized tissue and the mot-
tled hyperpigmentation.

pruritus is the most common initial
chief complaint.6 Pruritus and pain are
both common presenting signs and
may be confused with each other by
pet owners. If potentially seasonal skin
diseases such as flea allergy dermatitis
and atopic dermatitis are underlying
triggers, German Shepherd dog pyo-
derma may be presented initially as a
syndrome with seasonal predilections
or recurrences.
German Shepherd dog pyoderma is
characterized clinically by erythema-
tous papules, pustules, furuncles, and
fistulous tracts. Early lesions may be
surrounded by strikingly circular erythe-
matous halos. Lesions may develop
rapidly, forming confluent plaques of
ulcerated and eroded, friable, and devi-
talized skin (Figures 5, 6, and 7). Tena-
ciously adherent crusting occurs in
heavily haired regions and may shield
the lesions such that extent and severi-
ty are not recognized by the owner or
the veterinarian (Figure 8). Hyperpig-
mentation usually occurs with chronicity.
The skin lesions of German Shepherd
dog pyoderma may be disproportion-
ately severe in comparison to most oth-
er pyodermas, with the exception of
cellulitis seen secondary to generalized
demodicosis. Regional lymphadenopa-
thy is noted in most dogs with German
Shepherd dog pyoderma. Systemic in-
volvement is not present in most dogs
but may be seen in more severe cases.
Severely affected dogs may be anorec-
tic, cachectic, and lethargic. The clinical
course is chronic. Occasionally, this syn-
drome may be seen in conjunction with
either perianal fistulas or sterile pedal
panniculitis of the German Shepherd
dog. It is not known whether a link ex-
ists between these syndromes.
The clinical distribution pattern of
German Shepherd dog pyoderma is dis-
tinctive. The lateral thighs, rump, dorsal
back, ventral abdomen, elbows, and dis-
tal extremities are most frequently affect-
ed.5,8,10 The syndrome may become gen-
eralized, with the chest wall and neck
being additional severely affected sites.
The perioral region also may be affected.
Partial bilateral symmetry is common.
Differential Diagnoses
and Diagnosis
Deep pyoderma secondary to under-
lying demodicosis is the major clinical dif-

Figure 7—Perioral lesions present in the dog shown in Figures 5
and 6. Note the suppurative and ulcerated plaques.
Figure 8—Area of deep furunculosis and cellulitis on the lateral
thigh of a German Shepherd dog with German Shepherd dog py-
oderma. The regions of cellulitis were friable and devitalized. Le-
sions were much more obvious after clipping. (Photograph cour-
tesy of Dr. Ralf Mueller. Case material, University of California.)

46 Third International Veterinary Symposium on Fluoroquinolones Proceedings

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ferential diagnosis for German Shepherd
dog pyoderma in the German Shepherd
dog. In addition, subcutaneous and deep
mycosis and opportunistic fungal dis-
eases could conceivably mimic this syn-
drome. As indicated previously, German
Shepherd dog pyoderma is clinically dis-
tinctive and, hence, diagnosis is rarely a
problem. Physical examination, cytology
obtained from fistulous tracts, and nega-
tive skin scrapings should confirm the
presence of deep pyoderma without un-
derlying demodicosis. If indicated, skin
biopsy may be performed to rule out
other diseases and to evaluate for the
presence of underlying diseases. Histo-
pathologic findings include severe bacte-
rial deep folliculitis, furunculosis, and cel-
lulitis with severe pyogranulomatous
inflammation.10
Therapeutic Overview
German Shepherd dog pyoderma is a
severe, frustrating, aggressive skin dis-
ease. Because long-term therapeutic re-
sponse is problematic in idiopathic cases,
every effort must be made to identify and
manage possible underlying triggering
diseases, such as flea allergy dermatitis,
food hypersensitivity, atopic dermatitis,
and hypothyroidism. In addition, evalua-
tion for immunologic incompetence as a
predisposing cause is recommended if
appropriate testing is available. Unfortu-
nately, testing for immunologic compe-
tence must be performed using fresh sera
in research facilities.
Successful initial and long-term
management of German Shepherd dog
pyoderma requires the use of systemic
antibiotics, usually in conjunction with
adjunctive topical shampoo and
whirlpool therapy. Topical antibacterial
therapy is beneficial as an adjunct to
systemic antibiotics because it may of-
fer both enhanced speed of recovery
and improved general well-being.17 Use
of appropriate nonsteroidal antiinflam-
matory drugs may diminish pain sub-
stantially and thus also improve quality
of life.
Initially, hospitalization is advisable
to initiate vigorous topical therapy. Be-
cause the magnitude of the disease
may be masked by matted debris in
dogs with a dense hair coat, clipping a
“window” is recommended before
hospitalization so that the owner can
visualize the extent and severity of in-
fection. Clipping of the entire body is
usually required, as a dense hair coat
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may impede drainage. Sedation may
be required for clipping because pain
may be severe. During hospitalization,
antibacterial shampoos should be used
daily, followed by either whirlpools or
soaks.17
Currently available antibacterial
shampoos contain either benzoyl perox-
ide, benzoyl peroxide and sulfur,
chlorhexidine, ethyl lactate, or triclosan.
In addition to antibacterial effect, sham-
poo therapy also offers removal of in-
flammatory products and other debris
that can prevent drainage and encour-
age additional inflammation. Pain and
pruritus also may be reduced substan-
tially by shampooing. Contact time
should be a minimum of 10 minutes.
After close clipping and shampoo-
ing, the dog should be either soaked or
whirlpooled in warm water containing
antibacterials such as chlorhexidine or
povidone-iodine. If feasible, the agita-
tion provided by a whirlpool is superior
to the effect of simple soaking. Hospi-
talized dogs benefit from daily or twice
daily treatment for 15 to 30 minutes.
Unfortunately, soaks and whirlpools
are labor intensive.
Appropriate systemic antibiotic
therapy is integral to successful man-
agement of this syndrome. The basic
principles of successful systemic anti-
biotic therapy apply to the manage-
ment of German Shepherd dog pyo-
derma. These include choice of the
proper antibiotic, establishment of an
effective dosage, and maintenance of
the therapy for a sufficiently long peri-
od to ensure cure rather than only tran-
sient remission. Systemic antibiotic
therapy must be maintained long term.
In most cases, a minimum of 10 to 12
weeks of antibacterial therapy is re-
quired. Higher antibiotic dosages may
Enrofloxacin
should be
considered the
antibiotic of
choice in the
management of
German
Shepherd dog
pyoderma.
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be beneficial because sequestered foci
of infection may impede antibiotic pen-
etration. Caution should be exercised
before therapy is withdrawn, as relaps-
es may be swift and aggressive.
The chronic, refractory, deep infec-
tion seen in German Shepherd dog py-
oderma frequently requires an antibiot-
ic with superior penetrating ability
because extensive scar tissue with
granulomatous inflammation separat-
ing and protecting sequestered foci of
infection may prevent access of the an-
tibiotic to the actual sites of infection.
Fluoroquinolones, such as enrofloxacin,
and first-generation cephalosporins,
such as cephalexin, have been consid-
ered drugs of choice in these circum-
stances, because both drugs exhibit a
broad spectrum of bactericidal activity.
Enrofloxacin offers excellent tissue pen-
etration and cephalexin offers good
penetrating ability.17 Previous studies
have also shown enrofloxacin to be
very efficacious in a wide variety of ca-
nine pyodermas.18,19
Fluoroquinolones accumulate intra-
cellularly within phagocytic cells such
as macrophages and neutrophils in the
dog.20–22 A recent study also has
demonstrated that enrofloxacin is con-
centrated within inflammatory cells in
dogs with pyoderma and is unimpeded
by granulomatous inflammation, fi-
brosis, and purulent debris.23 Statistical-
ly significant higher skin levels of en-
rofloxacin were seen in deep pyoderma
versus superficial pyoderma, indicating
the likelihood that inflammatory cells
transport enrofloxacin into areas of
deep pyoderma.23
Koch and Peters have reported an
unusually high success rate in the man-
agement of German Shepherd dog py-
oderma using enrofloxacin adminis-
tered orally once daily at a dose rate of
5 mg/kg.4 In this study of 25 dogs with
German Shepherd dog pyoderma, ex-
cellent results were obtained in 23
dogs.4 Despite this remarkable degree
of success, results may have been even
better; the rigorous protocol followed
by Koch and Peters caused two dogs to
be listed as failures because one dog
did not show response within 2 weeks
and a second dog showed only partial
response in conjunction with less than
optimal adjunctive flea control. The
lower range of the current flexible dos-
ing was also used. The last four dogs
with this syndrome managed by one of
the authors (DeManuelle) have all re-
47
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sponded to enrofloxacin as well.
Currently, enrofloxacin should be
considered the antibiotic of choice in
the management of German Shepherd
dog pyoderma. Dosages between 5
mg/kg and 10 mg/kg given once daily
are initially recommended. If scar tissue
is extensive, higher dosages may be
used.
The striking success of enrofloxacin
in the management of a syndrome that
has previously been quite antibiotic re-
sistant requires explanation. It is known
that subinhibitory concentrations of
quinolones can make bacteria more
susceptible to phagocytosis and
killing.24 It also is known that fluoro-
quinolones such as ciprofloxacin, but
not ofloxacin, can enhance interferon
production.25 Because ciprofloxacin is
one of the metabolic products of enro-
floxacin, this may explain the success of
enrofloxacin. In the presence of
ciprofloxacin, lymphocytes from hu-
mans demonstrate increased synthesis
of interleukin-2.26 These mechanisms
may offer enhanced bacterial killing.
The effectiveness of enrofloxacin in
the management of German Shepherd
dog pyoderma also may be partially ex-
plained by beneficial antiinflammatory
properties. Quinolones have been
shown to diminish tumor necrosis fac-
tor production and suppress induced
leukotriene generation from neu-
trophils, lymphocytes, monocytes, and
basophils.27,28 If German Shepherd dog
pyoderma is associated with a predilec-
tion for an exaggerated tissue response
to staphylococcal bacteria characterized
by an inappropriate release of cytokines
and other mediators of inflammation,
the antiinflammatory properties of
quinolones may partially explain the de-
gree of success seen with enrofloxacin.
In addition to systemic antibiotic
therapy, clinicians must vigorously at-
tempt to identify triggering underlying
diseases and use appropriate dosages
of bactericidal antibiotics at least 3
weeks beyond apparent clinical cure. It
is important to remember that chronic,
deep lesions may heal superficially be-
fore deep infection is ameliorated. The
clinical course of German Shepherd
dog pyoderma is protracted and clini-
cally frustrating, and recrudescence is
common.
In the past, long-term shampoo and
immunomodulatory therapy were usu-
ally recommended as initial attempts to
prevent recurrence before initiation of
48 Third International Veterinary Symposium on Fluoroquinolones Proceedings
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extended antibiotic regimens.17 Howev-
er, in the German Shepherd dog pyo-
derma subgroup of pyoderma, long-
term shampoo therapy has not been
effective in preventing relapses. In ad-
dition, frequent, aggressive shampoo
therapy with products such as benzoyl
peroxide would preclude the regular
use of newer, highly effective flea con-
trol products such as imidacloprid and
fipronil. Because flea allergy dermatitis
is a prominent trigger of recurrent Ger-
man Shepherd dog pyoderma, it is not
reasonable to rely on older, less effec-
tive flea control products.
Immunomodulation is controversial
but has been beneficial in a limited
number of cases. A product consisting
of bacterial antigen made from human
strains of Staphylococcus aureus,
serotypes I and III (Staphage Lysate
[Delmont Laboratories, Swarthmore,
Pennsylvania]), has been used success-
fully to manage underlying cell-
mediated immunodeficiency.5
Extended Regimens of
Antibiotic Therapy
Long-term, extended regimen ther-
apy using systemic antibiotics may be
necessary in circumstances in which
underlying causes cannot be identified
or in which pyoderma consistently re-
curs despite investigation of and at-
tempted management of triggering
underlying diseases. It should be em-
phasized again that extended regimens
should not be used until the pyoderma
has been brought under complete con-
trol by a standard course of appropriate
antibiotic therapy.
In extended regimen or “pulse”
therapy, antibiotic dosages convention-
The
antiinflammatory
properties of
quinolones may
partially explain
the degree of
success seen
with
enrofloxacin.
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ally considered to be subtherapeutic
are utilized to control cost and to di-
minish the frequency of administration.
Extended antibiotic regimens using
subtherapeutic dosages should be con-
sidered as a last resort. This therapeutic
modality should be reserved for circum-
stances in which underlying causes ei-
ther cannot be identified or cannot be
managed successfully.
Drawbacks associated with extend-
ed regimen therapy include possible
undesirable effects in the patient, in-
duction of antibiotic resistance, forma-
tion and possible dissemination of re-
sistant strains of bacteria in the
environment, and relatively high cost.17
A variety of antibiotics commonly
recommended for extended regimen
therapy include first-generation ceph-
alosporins, such as cephalexin and beta-
lactamase–resistant synthetic penicillin,
oxacillin, clavulanate-potentiated amoxi-
cillin, and fluoroquinolones, such as
enrofloxacin.17 However, based on the
efficacy of enrofloxacin in the manage-
ment of German Shepherd dog pyo-
derma, enrofloxacin is recommended
for extended regimen therapy for this
syndrome.
Many different regimens for long-
term, extended antibiotic usage have
been recommended. Some of the most
common options include dosing every
other week or 2 to 3 consecutive days
per week at full daily dosage.17 Clinical
experience has not shown a difference
in induced resistance with any of the
aforementioned regimens.
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