Professional Documents
Culture Documents
ADAM P. PATTERSON
EDITION 4
SMALLDERMATOLOGY
ANIMAL
A COLOR ATLAS AND THERAPEUTIC GUIDE
A DAM P. P ,
ATTERSON DVM, DACVD
Chief of Dermatology
College of Veterinary Medicine & Biological Sciences
Texas A&M University
College Station, Texas
3251 Riverport Lane
St. Louis, Missouri 63043
Chapter 14 by Amy Leblanc is the work of US Government employee. Hence, chapter 14 is in public
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Notices
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Printed in China
v
Favorite quotes from Keith’s children and Keith
To have pursued your dreams and fail is better than to have never pursued your dreams at all.
Max T.
Promise me that you will not spend so much time treading water and trying to keep your head
above the waves that you forget, truly forget how much you have always loved to swim.
Tyler Knott Gregson
Sam T.
It’s not about the size of the dog in the fight, it’s about the size of the fight in the dog.
Mark Twain
Caleb M.
I’ve seen a look in a dog’s eyes, a quickly vanishing look of amazed contempt, and I am con-
vinced that basically that dogs think humans are nuts.
John Steinbeck
Caroline M.
From its conception, this textbook was designed to be a practi- Also new in the fourth edition are critical updates on MRS
cal color atlas that also included current treatments for each infections and new ground-breaking therapies for the treat-
disorder. Great effort has gone into making this book an easy- ment of allergy. We have expanded the useful pattern-based
to-use reference for practicing small animal veterinarians and approach concept with additional outlines, charts, and graph-
students alike. This atlas began as a companion text for Muller ics. A breed predilection list has been incorporated for fast
and Kirk’s Small Animal Dermatology; however, it has grown in reference, and disease topographies have been added for the
use and popularity and become a useful, stand-alone textbook most common diseases to simplify the diagnostic process.
in its own right. Expanded Author’s Notes were incorporated to provide a
New to this fourth edition is Dr. Adam P. Patterson, who contemporary feeling for the most important issues surround-
has provided a fresh and enhanced perspective to the science ing select disorders. The Author’s Notes are ultimately the
and skill of practical veterinary dermatology. opinion of the authors; however, the information has been
A key feature of this text is the relevant clinical images. collected from many sources over many years and reflects an
Numerous new images have been added to provide a useful endless pursuit of practical knowledge, which truly makes a
perspective of the most common lesions and patterns caused difference in the diagnosis and treatment of each disease.
by each disease. By reviewing all of the images for a given I hope you find the special efforts taken to provide a practi-
disease, the practitioner should acquire a working knowledge cal approach to veterinary dermatology useful.
of the most common presentations for that disease. Dermatol-
ogy relies heavily on the identification of patterns in the Keith A. Hnilica, DVM, MS, MBA, DACVD
patient’s signalment, history, lesion type, and pattern. The TheItchClinic.com
images in each disease section were selected not for their
extreme nature but rather because each image demonstrates a
common feature of the disease.
ix
Acknowledgments
Keith A. Hnilica
Adam P. Patterson
xi
C H A P T E R || 1
Differential Diagnoses
■ Essential Questions ■ Papules
■ Ten Clinical Patterns ■ Miliary Dermatitis
■ What Are the Infections? ■ Plaques
■ Why Are They There? ■ Follicular Casts
■ Differentials Based on Body Region ■ Epidermal Collarettes
■ Diseases Primarily Limited to the Face ■ Comedones
■ Diseases of Nasal Depigmentation ■ Lichenification
■ Diseases with Oral Lesions ■ Inflammatory or Pruritic Alopecic Diseases
■ Ear Margin Dermatitis ■ Noninflammatory or Nonpruritic Alopecic Diseases
■ Nasodigital Hyperkeratosis ■ Cellulitis and Draining Lesions
■ Interdigital Pododermatitis ■ Nodular Diseases
■ Diseases of the Claw ■ Pruritic Diseases
■ Diseases of the Footpads ■ Seborrheic Diseases
■ Differentials Based on Primary and Secondary ■ Hyperpigmentation
Lesions ■ Hypopigmentation
■ Vesicular and Pustular Diseases ■ Breed Predispositions to Select Skin Conditions in
■ Erosive and Ulcerative Diseases Dog and Cats
Almost all dermatology patients have a primary or underlying After the origin of a patient’s dermatosis is known, it is a simple
disease that causes secondary infections. These infections must matter of therapeutic follow-through to resolve the problem.
be eliminated and prevented but will recur rapidly unless the Recognition of basic patterns allows a practical approach
primary disease is identified and controlled. to most of the common skin diseases.
Most skin cases seen in a veterinary practice can be success-
fully managed if two essential questions can be answered: Ten Clinical Patterns
(1) What are the secondary infections? and (2) Why are these What are the secondary infections? (always secondary)
secondary infections there? 1. Folliculitis: Folliculitis is the most common “pattern” of
disease mimicking other patterns. However, it is common
Essential Questions for it to be concurrent with other disease patterns (e.g.,
1. What are the infections? yeast dermatitis). The major differentials to consider for fol
■ Folliculitis liculitis are superficial staphylococcal pyoderma or bacterial
– Pyoderma folliculitis, demodicosis, and dermatophytosis. Pyoderma
– Demodex is the mostly likely cause in the dog, with demodicosis a
– Dermatophyte close second if not a concurrent factor. Juvenile-onset
■ Pododermatitis demodicosis may affect the patient in a symmetric fashion.
– Bacterial A good rule of thumb is to consider all dermatologic
– Yeast patients to have folliculitis until proven otherwise and
■ Otitis then search for predisposing underlying diseases (e.g.,
– Bacterial allergy, endocrinopathy, cornification disorder or defect).
– Yeast 2. Pododermatitis: Always scrape the dorsal pedal surface
■ Malassezia yeast dermatitis when it is alopecic because both demodicosis and allergic
2. Why are they there? skin disease may cause pododermatitis; steroids are not
■ Allergies appropriate for the former. Hemorrhagic bullae are mani-
– Atopy festations of deep pyoderma; therefore, they should be
– Food allergy cultured. A lesion on the paw pads is usually an indica-
– Scabies tion to biopsy. P3 digit amputation is rarely needed
■ Endocrinopathy to make a diagnosis of symmetric lupoid onychodystro-
– Hypothyroidism phy because the history with typical clinical findings is
– Cushing’s sufficient for a firm tentative diagnosis.
1
2 CHAPTER 1 ■ Differential Diagnoses
■ Single paw: trauma, foreign body, infection (e.g., bac- exfoliative dermatitis, plaques, nodules, depigmentation,
teria, yeast), localized demodicosis, cutaneous horn, +/- lesions affecting nonhaired skin, consider cutaneous
neoplasia, arteriovenous pedal fistula T-cell lymphoma (CTCL) and biopsy.
■ Multiple paws: infection (e.g., bacteria, yeast, hook- Distribution patterns and differential diagnoses for
worms, distemper, leishmaniasis), generalized demo pruritus:
dicosis, allergic skin disease, split paw pad disease, ■ Dorsum: pediculosis, cheyletiellosis, flea allergy der-
palmar or plantar interdigital comedones and follicu- matitis (FAD), +/- AD in terriers
lar cysts, autoimmune- or immune-mediated dermato- ■ Face, ears, paws, axillae, inguinum, and perineum: cuta-
sis (e.g., pemphigus foliaceus, vasculitis, symmetric neous adverse food reaction (CAFR), AD
lupoid onychodystrophy or onychomadesis), dermato- ■ Pinnal margins, elbows, hocks, and ventral trunk: sarcop-
myositis, metabolic dermatosis (e.g., hepatocutaneous tic mange
syndrome, zinc-responsive dermatosis, nasodigital ■ Rear or perineum: anal sacculitis, trichuriasis, FAD,
hyperkeratosis), and sometimes neoplasia (e.g., cuta- CAFR, AD, psychocutaneous disorder
neous lymphoma, subungual small cell carcinoma or ■ Sparsely haired body regions: allergic contact dermatitis
melanoma in heavily pigmented dogs) (rare)
3. Otitis: Because the ear is just an extension of the skin, 6. Nonpruritic alopecia (endocrine): Always exclude fol-
a good dermatologic examination of the skin may pro liculitis when confronted with alopecia (especially when
vide clues (other “patterns”) about potential causes of other typical lesions are present) because it is the most
ear disease. Resolution of otitis externa is achievable if common reason for it and often a resultant feature of
primary causes are identified and managed. Similarly, other diseases within the pattern of “nonpruritic sym-
otic cytology should be used on every case to initially metrical alopecia.” Consider an endocrinopathy as a
determine the infection(s) present, as well as monitor cause of recurring infection when pruritus resolves with
response to therapy during reexaminations. By and large, infection control. Exclude castration- or neuter-responsive
correctly administered topical antimicrobial treatments dermatosis, hypothyroidism, and hyperadrenocorticism
(volume and duration) are more effective for infected before considering alopecia X. Many alopecic conditions
canals than systemic therapy. Rigid palpable canals (ossi- have breed predilections, so consult a text for a listing of
fied) are usually beyond medical resolution and would these associations.
be better removed (total ear canal ablation and bulla ■ Endocrinopathy: hypothyroidism, hyperadrenocorti-
osteotomy). cism, sex hormone–related dermatoses
Is the pinna or canal affected? ■ Follicular dysplasias: color dilution alopecia, black hair
■ Pinnae: trauma, aural hematoma, sarcoptic mange, fly follicular alopecia, canine recurrent flank alopecia
bite or strike hypersensitivity, allergic skin or ear (CRFA), breed-related follicular alopecia
disease, ear margin seborrhea or dermatosis, vasculitis ■ Hair cycle arrest: Alopecia X, CRFA, defluxions, canine
or other autoimmune dermatoses, neoplasia pattern alopecia or baldness
■ Otitis externa: facets and differentials (chart below) 7. Autoimmune- or immune-mediated skin disease: Hepa-
4. Malassezia yeast dermatitis: The pattern is characteristic tocutaneous syndrome, zinc-responsive dermatosis, der-
of Malassezia yeast, but any chronic pruritic skin disorder matomyositis, eosinophilic dermatitis with edema (Well’s
may resemble it, including folliculitis (superficial pyo- syndrome), mucocutaneous pyoderma, and some forms
derma, demodicosis, dermatophytosis), ectoparasitism, of dermatophytosis may mimic this pattern of disease.
and allergic skin disease. Yeast dermatitis is often over- Skin biopsy is useful to correctly diagnose the disease so
looked as a cause of pruritic skin disease. The author’s a reasonable prognosis can be offered to the client and a
favorite way to find yeast is with the use of acetate tape treatment plan tailored to the patient can be developed
cytology. Just the finding of a single yeast from rep- (some autoimmune- or immune-mediated diseases do
resentative lesions is significant (yeast hypersensitivity?) not require systemic glucocorticoids).
and warrants topical or systemic (or both) treatment based Distribution patterns and differential diagnoses for
on the severity of pruritus. However, if cytology is “nega- autoimmune- or immune-mediated dermatoses:
tive” for yeast when confronted with this pattern, assume ■ Face, pinnae, or nasal planum: pemphigus foliaceus,
they are there, treat accordingly, and search for predispos- pemphigus erythematosus, discoid lupus erythemato-
ing underlying diseases (e.g., allergy, endocrinopathy, cor- sus, vasculitis, uveodermatologic syndrome, drug
nification defect). reaction, vitiligo
Why are they there? (the key to preventing relapse of ■ Oral cavity +/- other body areas: pemphigus vulgaris,
infections) subepidermal blistering dermatosis, systemic lupus
5. Pruritus (allergies, mites, fleas): When confronted with erythematosus, vasculitis, erythema multiforme, drug
pruritus, always exclude infection and parasites first! reaction
Many times pruritus is reassessed after controlling for ■ Pads and elsewhere on the body: basically any of the
microorganisms before determining the “next step.” aforementioned diseases
Atopic dermatitis (AD) is a clinical diagnosis based on 8. Keratinization defects: Exclude secondary reasons for a
the exclusion of other causes of pruritus; “allergy tests” scaling disorder before considering primary ones. Some
do not diagnosis it. If you see pruritic erythroderma, hereditary cornification defects are tardive, not being
So, What Is the Solution? 3
confronted with this pattern of disease because some ■ When is a fecal examination performed (before the doc-
present. Acral lick dermatitis (lick granuloma) is a form ■ Does the clinic charge for the fecal examination?
of deep pyoderma; tissue culture (deep dermis with epi- The answers to these questions should be the same for skin
dermis removed) is helpful. cytology: The minimum dermatologic database (skin scrap-
■ Infectious inflammatory: bacterial, atypical bacterial, ings, impression smears, tape preps, and otic swabs).
mycobacterial, fungal, oomycete, parasite The practical solution for determining the best method
■ Noninfectious inflammatory: cyst, xanthoma, hygroma, by which to answer the question, “What are the infections?”
cutaneous histiocytosis, pyogranuloma or granuloma is to implement a minimum database infection screening
syndrome, sterile nodular panniculitis, perianal procedure to be performed by the technician before the veteri-
fistula narian examines the patient. Every dermatology patient should
■ Neoplasia: benign, malignant undergo otic cytology, skin cytology (an impression smear or
■ Mineral deposition: calcinosis circumscripta, calcinosis a tape prep), and a skin scrape at every examination (initially
cutis and at every recheck visit). The three-slide technique (Figure
10. Weirdopathies: Commonly, this pattern is an unusual 1-1) can be performed easily and interpreted by a technician
manifestation of an aforementioned “pattern” or is before the doctor completes an evaluation, which is exactly
formed by several overlapping ones. After “folliculitis” how diarrhea and fecal examinations are handled in most
has been excluded, skin biopsy (± culture) is usually clinics. Moving the cytologic evaluation to the beginning of
warranted when confronted with an “oddopathy.” Several the dermatology appointment and thereby empowering the
skin biopsies of representative lesions will help better technical staff to accomplish the evaluation optimizes the
categorize the disease process—infectious, allergic,
autoimmune- or immune-mediated, endocrine or fol
licular abnormality, cornification defect, congenital, or
neoplasia—assuming the proper technique is used and
the pathologist is provided a detailed history with clinical
findings. Ideally, a dermatopathologist should be sought.
Calcinosis cutis often appears as an oddopathy. A patient
with an oddopathy might be best examined by a
dermatologist.
cultures because dogs can acquire MRS from humans. need the most aggressive diagnostic workup and treat-
If family members are immunosuppressed, monitor ments achievable to protect the entire family from con-
the patient for MRS pseudintermedius and MRS tagion and zoonosis. In these families, avoid the use of
schleiferi, which can be a source of contagious infection steroids or fluoroquinolone antibiotics, which can
to at-risk, immunosuppressed people. These patients increase the risk of MRS.
Text continued on p. 12
6 CHAPTER 1 ■ Differential Diagnoses
PHYSICAL EVALUATION
Please check any that describe your dog and circle problem areas on the drawing.
Hair loss
Foul odor
Inflammation or redness
Itching/Scratching CIRCLE PROBLEM AREAS
(Itching, hair loss, lesions, etc.)
Otitis (ear infections)
Licking/Chewing
Skin lesions (sores)
Changes in skin (reddish brown stains, discolorations and/or areas that are thick and leathery)
Other
• Has your dog ever had ear problems? Yes No
• Does your dog have any chronic gastrointestinal signs like diarrhea or vomiting? Yes No
SEVERITY OF SCRATCHING/LICKING/CHEWING
0 1 2 3 4 5 6 7 8 9 10
No signs Severe
FIGURE 1-2 Medical History and Information Forms (A–F) to be Filled Out by Owners. (Courtesy Novartis Animal Health US, Inc.)
Novartis Animal Health is now Elanco.
Why Are They There? 7
DIETARY EVALUATION
• What pet food are you feeding?
• Do you feed the same food all the time or provide a variety? ❑ Always same ❑ Variety
• Have you changed his or her diet recently? ❑ Yes ❑ No
• Do you give your dog packaged treats? ❑ Yes ❑ No
• Do you feed your dog “human” food? ❑ Yes ❑ No
ACTIVITY LEVEL
Inactive Much less active Somewhat less active No change
SOCIAL BEHAVIOR
Unsocial A lot less social Somewhat less social No change
RELATIONSHIP CHANGES
Fewer walks No longer sleeps in bed/same room Interacts less with family
PRIOR TREATMENTS
• Has your dog been treated for itching before? ❑ Yes ❑ No
• Indicate previous treatments administered to your dog: (CHECK ALL THAT APPLY)
❑ Steroids ❑ Shampoos ❑ Sprays ❑ Ointments ❑ Antibiotics ❑ Hypoallergenic food
❑ Essential fatty acids ❑ Antihistamines ❑ Immunotherapy
❑ Other (PLEASE SPECIFY)
Next Steps
Laboratory Testing:
Physical Exam:
Ear Swab–To identify any infections in the ear including yeast
A thorough physical evaluation and/or bacteria.
of your dog will help us
Skin Scrape/Hair Pluck–To detect scabies or demodex mites.
identify obvious problems and
conditions like parasites. Impression Smear/Tape Prep–To detect other parasites and
check for presence of yeast and/or bacteria.
DERMATOLOGY WORK-UP
SEVERITY OF ITCHING PET’S NAME:
1 2 3 4 5 6 7 8 9 10
Minor Severe
C. PERIANAL DERMATITIS
S D. FFOOT LICKING
Food Allergy: (less common but
ut Atopic
A
Atop Dermatitis:
1-5 increase probability) (1-5 are highly reliable)
(1-
1. Perianal dermatitis 1. Started at
2. GI symptoms; more than 6 months – 3 years of age
ting,
3 BM/day, diarrhea, vomiting, 2. Front feet affected
3. Inner ear pinnae erythema
3. Less than 1 year or older than
5 years at onset 4. Lives indoors
4. Labradors and German Breeds may 5. Ruling out Scabies (ear margin
be predisposed dermatitis) and Flea Allergy
(lumbar dermatitis)
5. Variable response to steroids
6. Seasonal symptoms progressing
Hypothyroidism: (can mimic allergic dermatitis) to year-round
1. Recurrent infection may cause pruritus
2. Lethargy, weight gain, dry coat, hypotrichosis
3. Nonpruritic when infections are resolved
2 PATTERN RECOGNITION
Flea Allergy Atopy Scabies
3
Food Allergy Yeast (Malassezia) Pyoderma (Bact)
4
Allergy Vaccine
Atopy
Atopica® (Cyclosporine
capsules, USP) MODIFIED
Thyroid Supplementation bid
© 2011 Novartis Animal Health US, Inc. 3-Slide Technique is a trademark of Novartis AG. ATO110020A
Keep track of how itchy your dog is for the next 30 PET’S NAME:
days. Measure the severity of itch on a scale of 1-10,
PET OWNER:
1 being mild and 10 being the most severe. Bring this
report card back on your next visit. START DATE:
SEVERITY OF ITCHING
DAY 1 1
Minor
2 3 4 5 6 7 8 9 10
Severe
DAY 2 1 2 3 4 5 6 7 8 9 10
DAY 3 1 2 3 4 5 6 7 8 9 10
DAY 4 1 2 3 4 5 6 7 8 9 10
DAY 5 1 2 3 4 5 6 7 8 9 10
DAY 6 1 2 3 4 5 6 7 8 9 10
DAY 7 1 2 3 4 5 6 7 8 9 10
DAY 8 1 2 3 4 5 6 7 8 9 10
DAY 9 1 2 3 4 5 6 7 8 9 10
DAY 10 1 2 3 4 5 6 7 8 9 10
DAY 11 1 2 3 4 5 6 7 8 9 10
DAY 12 1 2 3 4 5 6 7 8 9 10
DAY 13 1 2 3 4 5 6 7 8 9 10
DAY 14 1 2 3 4 5 6 7 8 9 10
DAY 15 1 2 3 4 5 6 7 8 9 10
SEVERITY OF ITCHING
DAY 16 1
Minor
2 3 4 5 6 7 8 9 10
Severe
DAY 17 1 2 3 4 5 6 7 8 9 10
DAY 18 1 2 3 4 5 6 7 8 9 10
DAY 19 1 2 3 4 5 6 7 8 9 10
DAY 20 1 2 3 4 5 6 7 8 9 10
DAY 21 1 2 3 4 5 6 7 8 9 10
DAY 22 1 2 3 4 5 6 7 8 9 10
DAY 23 1 2 3 4 5 6 7 8 9 10
DAY 24 1 2 3 4 5 6 7 8 9 10
DAY 25 1 2 3 4 5 6 7 8 9 10
DAY 26 1 2 3 4 5 6 7 8 9 10
DAY 27 1 2 3 4 5 6 7 8 9 10
DAY 28 1 2 3 4 5 6 7 8 9 10
DAY 29 1 2 3 4 5 6 7 8 9 10
DAY 30 1 2 3 4 5 6 7 8 9 10
Cats
Indolent ulcers
Eosinophilic granuloma
Pemphigus vulgaris
FIGURE 1-3 Facial Dermatitis. Bullous pemphigoid
Systemic lupus erythematosus
Cutaneous drug reaction
Diseases of Nasal Depigmentation Contact dermatitis
Dogs Vasculitis
Erythema multiforme or toxic epidermal necrolysis
Contact dermatitis Squamous cell carcinoma
Pemphigus erythematosus Epitheliotropic lymphoma
Pemphigus foliaceus
Pemphigus vulgaris
Bullous pemphigoid
Discoid lupus erythematosus
Systemic lupus erythematosus
Vesicular cutaneous lupus erythematosus
Uveodermatologic syndrome
Vitiligo
Neoplasia (cutaneous lymphoma)
Differentials Based on Body Region 13
Cats
Atopy
Food allergy
Mosquito bite hypersensitivity
Eosinophilic plaque
Feline scabies
Vasculitis
Pemphigus foliaceus
Pemphigus vulgaris FIGURE 1-7 Nasal Keratosis.
Bullous pemphigoid
Systemic lupus erythematosus Interdigital Pododermatitis
Drug reactions
Solar dermatitis
Dogs
Squamous cell carcinoma Bacterial infections
Malassezia
Dermatophytosis
Demodicosis
Trombiculiasis
Hookworm dermatitis
Pelodera dermatitis
Atopy
Food hypersensitivity
Contact dermatitis
Interdigital pyogranuloma
Neoplastic tumor
14 CHAPTER 1 ■ Differential Diagnoses
Cats
Plasma cell pododermatitis
Mosquito bite hypersensitivity
FIGURE 1-8 Interdigital Pododermatitis. Contact dermatitis
Pemphigus foliaceus
Diseases of the Claw Pemphigus vulgaris
Bullous pemphigoid
Dogs Systemic lupus erythematosus
Trauma Vasculitis
Bacterial infections Hepatocutaneous syndrome
Dermatophytosis
Leishmaniasis Cutaneous Horn
Vasculitis
Symmetrical lupoid onychodystrophy
Squamous cell carcinoma
Melanoma
Cats
Trauma
Bacterial infections
Dermatophytosis
Vasculitis
Pemphigus foliaceus
Squamous cell carcinoma
Trombiculiasis
Pediculosis
Feline immunodeficiency virus (FIV) infection
Atopy
Food hypersensitivity
Flea allergy dermatitis
Contact dermatitis
Cutaneous drug reaction
Pemphigus foliaceus
Pemphigus erythematosus
Pemphigus vulgaris
Cutaneous drug reaction
Epidermolysis bullosa
Squamous cell carcinoma
Early neoplasia
FIGURE 1-12 Ulcer Erosion.
Miliary Dermatitis
Papules
(Nonspecific lesions caused by a cellular infiltrate)
Cats
Superficial pyoderma
Dogs Dermatophytosis
Demodicosis
Chin pyoderma
Cheyletiellosis
Superficial pyoderma
Ear mites
Impetigo
Atopy
Dermatophytosis
Food hypersensitivity
Canine scabies
Flea allergy dermatitis
Cheyletiellosis
Pemphigus foliaceus
Ear mites
Lupus
Trombiculiasis
Cutaneous drug reaction
Pediculosis
FIV infection
Atopy
Flea allergy
Food allergy
Contact dermatitis
Pemphigus foliaceus
Pemphigus erythematosus
Pemphigus vulgaris
Bullous pemphigoid
Systemic lupus erythematosus
Vesicular cutaneous lupus erythematosus
Cutaneous drug reaction
Epidermolysis bullosa
Canine familial dermatomyositis
Subcorneal pustular dermatosis
Sterile eosinophilic pustulosis
Calcinosis cutis
FIGURE 1-13 Miliary Dermatitis.
Squamous cell carcinoma
Early neoplasia
Plaques
Cats (Larger lesions that usually are formed by numerous papules
Superficial pyoderma that coalesce)
Dermatophytosis
Demodicosis Dogs
Canine scabies Dermatophytosis
Cheyletiellosis Contact dermatitis
Ear mites Cutaneous drug reaction
Differentials Based on Primary and Secondary Lesions 17
Calcinosis cutis
Squamous cell carcinoma
Early neoplasia
Cats
Dermatophytosis
Demodicosis
Cheyletiellosis
Ear mites
Trombiculiasis
FIV infection
Contact dermatitis
Cutaneous drug reaction
Squamous cell carcinoma
FIGURE 1-16 Follicular Cast.
Epidermal Collarettes
(Specific lesions that develop subsequent to a pustule or
vesicle; most often found in association with folliculitis)
Dogs
Superficial pyoderma
Impetigo
Demodicosis
Dermatophytosis
Pemphigus foliaceus
Follicular Casts
(Specific lesions often associated with primary keratinization
defects)
Dogs
Primary seborrhea
Vitamin A–responsive dermatosis
Sebaceous adenitis
Comedones
(Specific lesions that are caused by plugging of the hair
follicles)
Dogs
Chin pyoderma
Demodicosis
Dermatophytosis
Canine hyperadrenocorticism
Schnauzer comedone syndrome
Vitamin A–responsive dermatosis
Hairless breeds
Color dilution alopecia
FIGURE 1-15 Excoriation. Follicular dysplasias
18 CHAPTER 1 ■ Differential Diagnoses
Dogs
Superficial pyoderma
Mucocutaneous pyoderma
Pyotraumatic dermatitis
Malasseziasis
Canine scabies
Cheyletiellosis
Ear mites
Trombiculiasis
Pediculosis
Hookworm dermatitis
Pelodera dermatitis
Atopy
Food hypersensitivity
Flea allergy dermatitis
FIGURE 1-18 Comedone.
Contact dermatitis
Pemphigus foliaceus
Acral lick dermatitis
Lichenification Subcorneal pustular dermatosis
(Characteristic lesion of yeast dermatitis in dogs but can also Sterile eosinophilic pustulosis
be caused by chronic inflammatory disease) Hepatocutaneous syndrome
Dogs Cats
Malasseziasis Superficial pyoderma
Chronic inflammation Pyotraumatic dermatitis
Parasitic infections Malasseziasis
Hypersensitivities Feline scabies
Keratinization diseases Cheyletiellosis
Ear mites
Trombiculiasis
Pediculosis
Atopy
Food hypersensitivity
Flea allergy dermatitis
Contact dermatitis
Idiopathic facial dermatitis of Persian cats
Psychogenic alopecia
Feline lymphocytic mural folliculitis
Eosinophilic plaque
Idiopathic ulcerative dermatosis
Feline paraneoplastic alopecia
Hepatocutaneous syndrome
Dogs Dogs
Hyperadrenocorticism Deep pyoderma
Hypothyroidism Actinomycosis
Sex hormone imbalance Nocardiosis
Alopecia X Opportunistic mycobacteriosis
Recurrent flank alopecia Tuberculosis
Congenital hypotrichosis Pythiosis
Color dilution alopecia Lagenidiosis
Black hair follicular dysplasia Zygomycosis
Canine pattern baldness Blastomycosis
Idiopathic bald thigh syndrome of greyhounds Coccidiomycosis
Anagen and telogen defluxion Juvenile cellulitis
Postclipping alopecia Blepharitis
Traction alopecia Perianal fistulae
Injection reaction
Alopecia areata Cats
Subcutaneous abscess
Cats Actinomycosis
Allergic alopecia L-form infection
Hyperadrenocorticism Nocardiosis
Congenital hypotrichosis Opportunistic mycobacteriosis
Feline preauricular and pinnal alopecia Tuberculosis
Anagen and telogen defluxion Plague
Injection reaction Phaeohyphomycosis
Alopecia areata Pythiosis
Feline lymphocytic mural folliculitis Lagenidiosis
Sporotrichosis
Zygomycosis
Blastomycosis
Coccidiomycosis
Blepharitis
Anal sac disease
20 CHAPTER 1 ■ Differential Diagnoses
Cats
Botryomycosis
Actinomycosis
Nocardiosis
Opportunistic mycobacteriosis
Subcutaneous abscess
Feline leprosy
FIGURE 1-22 Cellulitis. Plague
Tuberculosis
Nodular Diseases Dermatophytosis
Eumycotic mycetoma
(Nonspecific lesions caused by any cellular infiltrate; most
Phaeohyphomycosis
often associated with neoplasia or infection)
Protothecosis
Pythiosis
Dogs Lagenidiosis
Botryomycosis Sporotrichosis
Actinomycosis Zygomycosis
Nocardiosis Blastomycosis
Opportunistic mycobacteriosis Coccidiomycosis
Subcutaneous abscess Cryptococcosis
Tuberculosis Histoplasmosis
Canine leproid granuloma syndrome Cuterebra
Dermatophytosis Dracunculiasis
Eumycotic mycetoma Feline cowpox
Phaeohyphomycosis Viral papillomatosis
Protothecosis Leishmaniasis
Pythiosis Cutaneous neosporosis
Lagenidiosis Sterile nodular panniculitis
Sporotrichosis Eosinophilic granuloma
Zygomycosis Neoplastic tumors
Blastomycosis Follicular cyst–intraepidermal inclusion cyst
Coccidiomycosis
Histoplasmosis
Cuterebra
Dracunculiasis
Viral papillomatosis
Leishmaniasis
Cutaneous neosporosis
Systemic lupus erythematosus
Vesicular cutaneous lupus erythematosus
Cutaneous vesicular lupus erythematosus
Sterile nodular panniculitis
Idiopathic sterile granuloma and pyogranuloma
Tail gland hyperplasia
Acral lick dermatitis
Callus
Hygroma
Eosinophilic granuloma FIGURE 1-23 Nodules.
Differentials Based on Primary and Secondary Lesions 21
Pruritic Diseases
(Nonspecific symptoms caused by any inflammatory dermati-
tis; some diseases have characteristic patterns that are more
clinically relevant)
Dogs
Superficial pyoderma
Malasseziasis
Canine scabies
Cheyletiellosis
Ear mites
Trombiculiasis
Pediculosis
Hookworm dermatitis
Pelodera dermatitis
Atopy FIGURE 1-24 Pruritus.
Food hypersensitivity
Flea allergy dermatitis
Contact dermatitis Seborrheic Diseases
Pemphigus foliaceus (Nonspecific lesions that usually are secondary to a primary
Acral lick dermatitis dermatologic disease but can be caused by a primary keratini-
Subcorneal pustular dermatosis zation defect)
Sterile eosinophilic pustulosis
Hepatocutaneous syndrome Dogs
Cutaneous lymphoma
Superficial pyoderma
Malasseziasis
Cats Dermatophytosis
Superficial pyoderma Demodicosis
Malasseziasis Canine scabies
Feline scabies Cheyletiellosis
Cheyletiellosis Pediculosis
Ear mites Leishmaniasis
Trombiculiasis Food hypersensitivity
Pediculosis Pemphigus foliaceus
Atopy Pemphigus erythematosus
Food hypersensitivity Systemic lupus erythematosus
Flea allergy dermatitis Cutaneous drug reaction
Contact dermatitis Hyperadrenocorticism
Idiopathic facial dermatitis of Persian cats Hypothyroidism
Psychogenic alopecia Sex hormone imbalances
Feline lymphocytic mural folliculitis Canine primary seborrhea
Eosinophilic plaque Vitamin A–responsive dermatosis
Idiopathic ulcerative dermatosis Ichthyosis
Feline paraneoplastic alopecia Epidermal dysplasia of West Highland white terriers
Hepatocutaneous syndrome Sebaceous adenitis
Tail gland hyperplasia
Zinc-responsive dermatosis
Hepatocutaneous syndrome
Canine ear margin seborrhea
Neoplasia
22 CHAPTER 1 ■ Differential Diagnoses
Cats Hyperpigmentation
Superficial pyoderma (Common, usually nonspecific, change caused by inflamma-
Dermatophytosis tion of long duration)
Malasseziasis
Demodicosis Dogs
Feline scabies
Lentigo
Cheyletiellosis
Chronic trauma
Cat fur mite
Chronic inflammation
Pediculosis
Allergy
Pemphigus foliaceus
Post-infection
Pemphigus erythematosus
Cushing’s
Systemic lupus erythematosus
Sex hormone alopecia
Cutaneous drug reaction
Alopecia X
Hepatocutaneous syndrome
Recurrent flank alopecia
Tail gland hyperplasia
Melanoma
Idiopathic facial dermatitis of Persian cats
Neoplasia
Pruritic dog
Folliculitis
Otitis Pododermatitis Yeast dermatitis
Pyoderma, Demodex,
Bacteria, Malassezia
dermatophytosis
Aggressively treat all secondary infections for 30 days because they complicate case evaluation.
(Steroid therapy will make it difficult to evaluate the pruritus and its association with the secondary infections.)
Differential Diagnoses
Consider endocrine Consider food allergy. Lesions on the nasal Follicular casts, entire
diseases. planum, ear pinnae, skin surface affected
Food allergy is the one footpads
Hypothyroidism and allergic disease that can Primary keratinization
hyperadrenocorticism can be nonpruritic. Food Autoimmune skin defects (sebaceous
cause a relative allergy can change the diseases are usually not adenitis, primary
immunosuppression that normal function of the considered pruritic; seborrhea, ichthyosis,
predisposes the dog to skin, predisposing it to however, the cutaneous epidermal dysplasia)
secondary infections. The secondary infections inflammation and crusts change the normal skin
secondary infections can that are pruritic. If the can cause mild to defense functions,
be pruritic, mimicking pruritus resolves when the moderate pruritus. predisposing the dog to
allergy; however, if the infections are treated, secondary infections
pruritus resolves when the endocrine disease or food that may be pruritic
infections are controlled, allergy is most likely.
allergy is less likely. Atopy and scabies are
almost always pruritic.
Breed Predispositions to Select Skin Conditions in Dogs and Cats—cont’d
Feline dermatitis
Miliary dermatitis
CHAPTER 1
This is the most common clinical Alopecia with or without apparent Eosinophilic plaques, eosinophilic
presentation in cats and can be caused by cutaneous inflammation is common in granulomas, linear granulomas, indolent
numerous conditions. cats with allergies or ectoparasites. ulcers, and fat chin syndrome are all
manifestations of eosinophilic dermatitis
associated with numerous etiologies.
Biopsy, consider
Lime sulfur dip trial Food trial medical workup and
Allergy testing Atopica; abdominal
Ectoparasites such as cyclosporine ultrasound
Food allergy is one Environmental
Demodex gatoi, of the more common allergies, including Very well
Cheyletiella, and causes of feline Paraneoplastic
insect tolerated
Otodectes can cause dermatitis. Feeding a dermatitis caused by
hypersensitivity, can in cats
dermatitis and be novel protein source hepatic and pancreatic
occur in cats but are and treats
difficult to find on skin in an extreme limited- adenocarcinoma or
less common than most allergic
scrapes. Weekly dips ingredient diet for cutaneous lymphoma
flea and food etiologies,
with lime sulfur for 4–6 10–12 weeks will can mimic allergies but
allergies. Allergy except
weeks should resolve confirm or eliminate occurs in old cats that
testing of cats is flea allergy.
any infections. this differential. usually present with
difficult because of the
Treatment with weight loss and other
lack of specific
avermectins will kill evidence of metabolic
serum testing and the
Otodectes and disease.
poor reactivity of
Cheyletiella but are skin tests.
ineffective for D. gatoi.
Biopsy
This will identify the etiology or at least be able to suggest an infection (folliculitis or diffuse pyogranulomatous dermatitis),
hypersensitivity reaction (eosinophils and mast cells), autoimmune skin disease (interface dermatitis), neoplasia, or psychogenic
(complete absence of inflammation).
Diagnostic Techniques
■ Diagnostic Testing ■ Cultures
■ Skin Scrapes ■ Polymerase Chain Reaction Assays
■ Cutaneous Cytology ■ Serology
■ Acetate Tape Preparations ■ Immunostaining Techniques
■ Otic Swabs ■ Diascopy
■ Dermatophyte Test Medium Fungal Cultures ■ Allergy Testing
■ Trichoscopy ■ Patch Testing
■ Wood’s Lamp Examination ■ Therapeutic Trials
■ Biopsy
require biopsy for identification of mites within the hair fol a 10× objective). A search of the entire slide ensures that if only
licles. Hair plucks from an area of lesional skin may be used one or two mites are present (as is typical of scabies infection),
to help find follicular mites. This technique is especially the user will likely find them. It may be helpful to lower the
helpful in areas or situations when a skin scrape would be microscope condenser; this provides greater contrast to the
difficult: around the eyes or excited puppies. mites, thereby enhancing their visibility. (One must be sure to
Regardless of the collection technique used, the entire slide raise the condenser before looking for cells or bacteria on stained
should be searched for mites with the use of low power (usually slides.)
A B
D
C
AUTHOR’S NOTE
Cutaneous Cytology
There is no excuse for mistreating a patient who
has demodicosis. Lesions caused by demodicosis Cutaneous cytology is the second most frequently used der
matologic diagnostic technique (slide #2 in the three-slide
can look identical to folliculitis lesions caused by
technique). Its purpose is to help the practitioner to identify
bacterial pyoderma and dermatophytosis. Clinical
bacterial or fungal organisms (yeast) and assess the infiltrating
appearance is not an acceptable criterion for ruling
cell types, neoplastic cells, or acantholytic cells (typical of
in or ruling out demodicosis. When the technician
pemphigus complex).
performs a skin scrape as part of the infection
screen called the three-slide technique, demodico-
Procedure
sis can be identified and treated easily and
accurately. Direct Impression Smear. Moist exudate is collected from
pustules, erosions, ulcers, or draining lesions. Alternatively,
Cutaneous Cytology 33
A B
C D
crusts or the leading edge of an epidermal collarette can be identify individual cell types, as well as bacterial or fungal
lifted, revealing a moist undersurface. Papular lesions may be organisms.
traumatized by the corner of a glass slide or a needle and then
squeezed to express fluid. Yeast dermatitis can be sampled by Fine-Needle Aspirate Method. A needle (22–25 gauge)
repeated sticking of the slide onto lichenified lesions or and a 6-mL syringe should be used to aspirate the mass. The
through the use of a dry scalpel blade to collect material that area should be cleaned if necessary with alcohol or chlorhexi
is then smeared onto a dry slide. Regardless of which tech dine. The lesion is then immobilized. The practitioner should
nique is used, the moist exudate collected on the slide insert the needle into the nodule while aiming for the center
is allowed to dry. The slide is then stained with a commer of the lesion, pull back on the plunger to apply suction, release
cially available cytology stain (e.g., modified Wright’s stain and redirect, pull back on the plunger again, and stop if any
[Diff-Quik is the most common]), and it is gently rinsed. A blood is visible in the hub of the needle because this will
low-power objective is used to scan the slide to allow selection dilute the cellular sample. Negative pressure should be released
of ideal areas rich in basophilia for closer examination. A before the needle is removed from the lesion. An alternative
high-power (40× or, preferably, 100× oil) objective is used to technique involves repeated insertion of the needle without
34 CHAPTER 2 ■ Diagnostic Techniques
the syringe into the lesion while redirecting several times. This but false-negative results are common with all yeast collection
latter technique (without negative pressure), which decreases techniques.
the frequency of inadvertent dilution of the sample with
blood, works best for soft masses. After the sample has been Otic Swabs
collected, the material is expressed onto a microscope slide by
blowing a syringe-full of air through the needle to spray the Screening
cells onto the slide. The material is smeared gently to thin the Otic swabs are useful for determining whether a normal-
clumps of cells before staining, and finally the sample should appearing ear canal actually has exudate deep within the ear
be stained with cytology stain. The slide should be scanned (slide #3 in the three-slide technique). If a cotton swab is used
with low power (4×–10×) to reveal a suitable area for closer to gently collect a sample, and if it is relatively clean, then the
examination. A high-power (40×) objective may be used to ear most likely is normal. If the sample demonstrates a black
reveal the infiltrating cell type and the cellular atypia. waxy exudate, then a mineral oil prep should be performed
for identification of any mites (e.g., Otodectes or Demodex
spp.). If the sample is light brown or demonstrates a purulent
AUTHOR’S NOTE exudate, cytology should be performed for identification of
The infections are always secondary to a primary bacteria or yeast.
disease; however, all too often, the patient is not
evaluated or treated for the primary disease for Mites
three major reasons: Mineral oil can be used to dissolve the black waxy material
1. Only the secondary infections are treated collected from an otic swab. The swab should be stirred in the
repeatedly. oil to remove the exudate and to make the sample suitable for
2. The nature of the allergy is confusing. examination. The entire slide should be examined under low
3. Cheap steroids that have delayed repercussions power (4× or 10× objective) for identification of any mites.
are available. Usually, Otodectes mites are easy to visualize, but dropping the
condenser and scanning the entire slide may make the practi
tioner more certain of the diagnosis.
Acetate Tape Preparations
Bacteria and Yeast
Tape preps are used to evaluate a variety of different condi
Otic cytology is used to identify secondary yeast and bacterial
tions. The basic technique involves the use of crystal clear tape
otitis externa. Debris is collected with a cotton swab. An easy
(single- or double-sided tape) to collect a sample of hair or
and quick technique is to roll the swab from the right ear onto
superficial skin debris.
the right side of the slide and then swab from the left ear onto
the left side of the slide, assuming that the slide has markings
Tape Preps for Mites by which to identify which direction is up. If the material is
Tape preps can be an effective method of collecting and very waxy, the end of the slide should be heated to help melt
restraining Cheyletiella and lice for microscopic examination. the wax and allow the stain to penetrate the sample. The
The mites are usually large enough to be seen, so a piece of sample should be stained with cytology stain (modified
tape can be used to capture a specimen. The tape prevents the Wright’s stain [Diff-Quik]) and then examined under low
creatures from escaping. power (10× objectives), so that a cellular area likely to include
organisms can be identified. Then the high-power objective
Tape Preps for Hair (Trichoscopy) (40× or 100× oil immersion) should be used to identify the
Tape is used to secure the hair sample in position on a glass organisms that are causing the secondary otitis.
slide. The sample is examined under low power (4×–10×
objective). (See the “Trichoscopy” section for more informa AUTHOR’S NOTE
tion on analysis techniques.) Oil may be a better medium for When an owner brings the pet into the clinic for a
use with trichoscopy. small hairless spot, it would be appropriate to ques-
tion the necessity for an otic cytology when the
Tape Preps for Yeast hairless spot is the problem. However, the three-
Tape preps for yeast dermatitis are the most efficient and effec slide technique is most helpful in these exact types
tive methods of identifying Malassezia skin infections. The of cases. If focal pruritus occurs in a dog and the
lichenified lesion (elephant skin on the ventral neck or patient has a secondary otitis (which the technician
ventrum) or moist pedal erythematous skin is sampled by identified during the infection screen), the veteri-
repeated application of the sticky side of the tape onto the narian should more aggressively discuss and work
lesion. The tape is then adhered to a glass slide (sticky side up the patient for possible allergy. If the patient did
down) and is stained with a cytology stain (only the last dark not have otitis, the skin pruritus could be minimized
blue stain is needed). The tape serves as a coverslip and can in the hope that it was a short-term problem that
be examined under high power (100× oil immersion) for may self-resolve.
visualization of Malassezia organisms. This technique is useful,
35
A B
C D
E F
A B
C D
FIGURE 2-5 Tape Preps. A, Clear acetate tape is pressured repeatedly into the interdigital space for collection of a superficial sample. B, The tape is
processed with a modified Wright’s stain (Diff-Quik) with omission of the first light blue alcohol solution, which dissolves the tape adhesive. C, After
processing has been completed, the sample material is easily visible under the tape. D, Microscopic image of Malassezia organisms and keratinocytes,
as viewed with a 100× (oil) objective.
A B
C D
FIGURE 2-6 Otic Cytology. A, Before an otic sample is obtained for cytologic evaluation, the ear canal and the tympanic membrane should be
evaluated visually. B, A cotton swab is used to obtain a sample of exudates from the ear canal. C, The exudates collected on the swab are smeared
onto the slide. The left ear sample has been smeared onto the left half of the slide, and the right ear sample onto the right side of the slide.
D, Microscopic image of otic cytology demonstrating numerous neutrophils and mixed bacteria, as viewed with a 10× objective.
visible on the medium. Some contaminants (usually black, cultures. If such species are suspected, swab samples and tissue
gray, and green) will be able to change the medium to red but specimens should be submitted to and cultured by well-
only after growing for several days. If the culture plate has not equipped microbiology laboratories.
been evaluated daily, it will be impossible to determine when
the color change occurred in relation to the appearance of AUTHOR’S NOTE
fungal colony growth.
Macroconidia only come from the culture plate
After the fungal colony has been growing for several days,
it begins to produce macroconidia. Keeping the culture warm
colony and cannot be retrieved from the hair or
in a humid environment facilitates the formation of conidia. skin. Macroconidia-like structures found on the skin
The macroconidia should be sampled and microscopically or hairs are usually pollen or other species of mold
examined so that the dermatophyte species can be identified. and not dermatophyte macroconidia.
Clear acetate tape is touched to the surface of the white- or
buff-colored fluffy fungal colony to be evaluated. The tape is Trichoscopy
then adhered to a glass slide, and a drop of cytology stain
is applied. The macroconidia are usually apparent under a A trichoscopy is used to visualize the hair for evidence of
low-power (10×) objective. This is especially important in pruritus, fungal infection, and pigmentation defects and to
dogs because the identification of Microsporum canis may assess the growth phase (for evaluation of hair tips, roots, and
indicate the presence of an infected asymptomatic cat in the shafts).
immediate environment. Identification of Trichophyton or
Microsporum gypseum suggests an environmental source for the Procedure
dermatophyte infection (other than an infected cat). A small amount of hair to be examined is epilated. Tape or
Some fungal species that cause deep infection or cellulitis mineral oil is used to secure the hair sample in position on a
(e.g., blastomycosis, pythiosis, histoplasmosis, coccidioido glass slide. The sample is examined under a low-power (4× or
mycosis) represent a zoonotic hazard when grown as in-house 10×) objective.
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