One veterinarian's approach to skin allergies and ear disease explained.

1. Now what?
By Jacquelyn H. Burns, DVM
Copyright © Jacquelyn H. Burns 2012

4.  The main sign of allergies in pets
is itching, with or without hair loss
 This may be manifest in several
ways
◦ Scratching
◦ Chewing/gnawing
◦ Licking
 Feet
 Legs
 Rump or rectal area
◦ Rubbing
◦ Shaking head/scratching or rubbing
ears

5.  Hair loss
 Greasy coat
 Dry coat
 Erythema (redness)
 Red bumps
 Scabby spots
 Dandruff
 Ear infections
 Lichenification
◦ Thickened, rough/wrinkled or ―elephant skin‖
 Hyperpigmentation
◦ Dark pigment deposited in skin that is affected

6.  There are three
categories of allergy
in pet dermatology:
◦ Atopy
(environmental and
inhaled allergy)
◦ Food Allergy
◦ Flea allergy
dermatitis

7.  Age of onset  Pattern (where on the
◦ Young body the itch is)
◦ Middle age to older  Breed
 Time of year of onset  Playing the odds (only
◦ Summer-Fall 15 to 20% are food
◦ Winter-Spring allergy)
 Seasonal vs. all year  Primary Lesions
round  Secondary Lesions
 Response to previous
treatments
Physical
History
Exam/Observations

8.  Flea combing
 Skin scrapings
◦ Screen for mange
 Demodex
 Sarcoptes
 Skin cytology
◦ Bacteria?
◦ Yeast?
 Fungal cultures
◦ Screen for ringworm
 Skin biopsies

9.  Rate your pet‘s itchiness on a scale of 1 to 10
◦ 1‘s never scratch/chew/lick/rub
◦ 10‘s never stop scratching/chewing/rubbing
◦ Our vets consider
 1-3 to be normal
 4-5 mildly itchy
 6-7 moderately itchy
 8-10 severely itchy
You may be asked to grade your dog‘s
itchiness at the initial visit and again at
follow up visits

10.  Allergies are not curable
 Our goal is to manage the condition
◦ Reduce the itch/inflammation
◦ Reduce secondary changes to the skin
 Lichenification
 Skin gets thick and roughened
(like elephant skin)
 Hyperpigmentation
 Skin gets black-looking
 Secondary skin infection
 Scales/flakes/crusts/oily seborrhea
 Management may be
◦ As needed for flare-ups
◦ Long-term or for life

11.  There isn‘t a magic allergy
fairy who can wave her
magic wand and ―cure‖
allergies.
 Management will be as
needed for life
 Expect some symptoms
some of the time
 Expect flare ups

12.  Is an environmental allergy that is usually but
not always seasonal
 Formerly believed to be mostly inhaled, but
veterinary dermatologists have broadened
their outlook to include allergens being
absorbed through contact with the skin
 Can be allergic to
◦ Mold spores
◦ Dust mites
◦ Pollens
◦ A combination of several things

13.  Age of Onset
◦ Middle aged adult to senior
 Time of year of onset
◦ Often warmer months
 Seasonal vs. non seasonal
◦ Seasonal (unless allergic to dust mites)
 Pattern
◦ Not confined to waist down
◦ Itching can be all over
◦ Itching can be ears only, feet only
 Breed: ShihTzu, Westie, Lab, Daschund
 Playing the odds (FAD aside, about 80-85% of
itchy dogs are atopic)

14.  Immunotherapy
◦ Determine exactly what the pet is allergic to and
order an immunotherapy serum to be given by
injection as regular ―allergy shots.‖
◦ Gold standard of allergy testing is the intradermal
skin test
 Done mostly in veterinary dermatology specialty
practices, requiring a referral from your primary care
veterinarian to a board-certified dermatologist
◦ There are blood tests, but these are less reliable
than intradermal skin tests
 Can be done by most primary care veterinarians

15.  Atopica
◦ Cylcosporine
 Suppresses the
immune system
◦ Loading dose is
once daily for 30
days
◦ Maintenance dose is
every other day for
life

16.  Atopy was formerly attributed to inhaled
allergens. But dermatologists now recognize
that allergens also can be absorbed through
contact with the skin. They have broadened
the definition of Atopy to include inhaled
allergens and transdermal absorption of
other environmental allergen particles
◦ Wipe feet and legs off with a damp cloth whenever
your dog comes in from outside to remove
allergens
◦ Bathe once weekly—whether your dog ―needs‖ it or
not to remove surface allergens

17.  Topical
◦ Soothing Shampoos & Conditioners
◦ Soothing Sprays, creams or ointments
 Oral
◦ Prednisone
 Daily for several days tapering dose to an every 2 to 3 days
dose
◦ Antihistamines
 Sometimes help; sometimes don‘t
 Helpful in 10 to 30% of patients
 Several different ones so we can ―hunt & peck‖ for the best
one
◦ Essential Fatty Acid supplements
 May help up to 40% of dogs with itchy allergy skin
 Injectable ―cortisone‖ as last resort
◦ Vetalog during an acute flare up

18.  Corticosteroids
◦ Prednisone, prednisolone, Vetalog, Depomedrol,
dexamethasone
◦ Anti-inflammatory, anti-itch
◦ Are not the same as anabolic steroids abused by athletes
◦ Work very well on Atopy and FAD-related itching
◦ Do not work well on Food Allergy
◦ Have side effects so use in moderation
 Use as last resort
 Use lowest dose that helps control itching
◦ Do have a place in management of dogs with itchy skin,
again, in moderation

19.  Lethargy, panting
 Weight gain
 Increased thirst
 Increased urine volume
◦ Some pets urinate in the house
 Weaken muscles, tendons, ligaments
◦ Easier to injure an ACL or rupture a disk in the back
 Can cause fluid retention
◦ Can make heart disease worse
 Increase susceptibility to infection
◦ Easier to get infections (urinary tract, skin)
◦ Harder to clear up infections
 Iatrogenic Cushing‘s Syndrome
◦ Hormone inbalance
◦ Can ―crash‖ in an Addisonian crisis if drug is withdrawn
suddenly

20.  They work!
◦ Sometimes they are the only thing that works that is also
affordable
 Reduce itching, redness, swelling
 Acute flare-ups
◦ Intense itching with self-mutilation
 Some pets scratch/chew/rub until they create serious
bleeding sores or hotspots
 In these cases, it usually takes an injection to get the itch
under control so that healing can begin
 Chronic disease
◦ Reduce or reverse lichenification, hyperpigmentation,
thickening in ear canals, etc

21.  Atopica contains cyclosporine, an immune
suppressive drug that can be used to manage
atopy.
 Atopica is relatively expensive, which is the
main reason many people do not elect to
purchase it
 First month given once a day
 After this, usually given every other day
 Side effects
◦ Anorexia, vomiting
◦ Increased susceptibility to infection

22.  Since many patients are on long-
term management, we want to avoid
certain side effects
 It does not cause
◦ Weight gain
◦ Panting, sluggishness
◦ Increased thirst and urine output
◦ Weakening of connective tissue (muscle, tendon,
ligament) which increases risk of injury
◦ Does not increase liver size and ALP
◦ Does not suppress the adrenal cortical-pituitary axis
 Doesn‘t risk Cushing‘s Syndrome or Addisonian Crisis

23.  Doesn‘t work on
FAD or Food
Allergic Dogs
 It is simply cost-
prohibitive for
many clients

24.  Age of onset
◦ Many are younger (under 3 years)
 Time of year of onset
◦ Not applicable
 NONSEASONAL
 Pattern
◦ No special pattern
◦ ―Ears and rears‖: Some are itchy around the anus and in
the ears. May be itchy around lips and feet
 Breed
 Playing the odds: about 15 to 20 % of dogs with
skin allergies have food allergy

25.  Non seasonal itching
◦ These dogs itch all year ‗round
 Response to prednisone is marginal
 Do not respond to Atopica

26.  It‘s not that easy!!!!
 Pet foods are
heavily marketed
and you have to
analyze the label
ingredients
Pet food marketing ◦ For example, a food
is so good, it‘s labeled ―lamb and
surprising they rice‖ is likely to
don‘t have YOU contain lamb as well
as rice, but if you
eating their brand. read the ingredient
list, you may also see
poultry meal or
whey, which is in the
beef family
antigenically

27.  All natural
◦ All ingredients come from some type of original, natural
raw material
 Organic
◦ Your dog can be as allergic to organic beef as to non-
organic beef
 Grain-free
◦ Healthy pet foods do contain some carbohydrates
 Contains vegetables
◦ Misleading marketing! Often pet food manufacturers
add vegetables and artificial colors to represent
vegetables to appeal to buyers who see this as ―good‖

28. Beef Chicken
Grains and carbs get a
not always deserved bad rap!

29. Eat more  Includes all proteins from
chikin? cows
 Beef by-products
◦ Cow hooves
◦ Rawhides
◦ Jerky
 Beef flavorings
◦ Even in flavored pet
medications or vitamins
 Milk
 Milk by-products
◦ Whey, Casein
 Proteins antigenically
similar to beef
◦ Venison, Buffalo, Yak
Beef Not just the meat!

30.  Chicken meat
 Chicken by-products
◦ Chicken meal
 Nasty stuff any way—
contains ground up
feathers and beaks
◦ Chicken jerky
 Be very wary of any
chicken products
originating in China,
anyway!
 Eggs
More than just the bird! Chicken

31.  The ―real‖ test for food allergy
 A prescription food
◦ Contains only 1 novel protein source
◦ Contains only 1 novel carbohydrate source
 8 to 12 weeks of this only
◦ No treats or snacks other than this food
◦ No flavored heartworm pills, arthritis meds,
vitamins, etc.
◦ No visiting the neighbor‘s cat food bowl
 Reintroduce other foods one at a time to see
which one restarts itching

32.  ―Novel‖ in this sense means an unusual
ingredient that your pet has never been
exposed to before
 Therefore, the foods sound really funky:
◦ Duck and sweet potato
◦ Fish and potato
◦ Turkey and barley
◦ Kangaroo and Oatmeal

33.  No-compromise
commitment on the
part of all members
of the household for a
moderately lengthy
period of time
 Possible unhappiness
on the part of the pet
and owners
 Increased expenditure
for prescription food

34.  Some aren‘t really infections!
 Otitis externa is an itchy inflammation of the external ear
canal. It is not like an earache (otitis media), which is on
the inside of the eardrum. Otitis externa involves the ear
canal outside of the eardrum.
 Itches and burns
 Does not always include infection, but can
◦ Yeast
◦ Bacteria
 Often results from allergies
◦ Greater than 80% in this practice are caused by allergies
◦ Less than 20% other causes
 Mites
 Foreign bodies
 Trauma
 Tumors, polyps

35.  Shaking head
 Rubbing ears on floor or furniture
 Whining/crying when ears are rubbed
 Discharge from ears
 Odor from ears
◦ Sour most often means yeast infection
◦ Foul most often means bacterial infection
 Thickening or swelling of pinna (ear flap)
◦ Lichenification
◦ Aural hematoma

36.  Veterinarian looks at a  Veterinarian looks at a
sample of ear wax or stained slide of ear
discharge in mineral oil wax or discharge
under the microscope  Seeing whether there
 Screening for ear mites are
 Can be difficult to ◦ Yeast
interpret if you‘ve used ◦ Bacteria
an over-the-counter  Cocci
ear mite med prior to  Rods
seeing your ◦ Neutrophils (pus cells) vs
veterinarian simple epithelials
Oil Smear Ear Cytology

37.  Hygiene
◦ Pluck hair from inside ears if present
◦ Clean with veterinarian-recommended ear cleaner
◦ One to two times weekly initially
◦ Weekly or every other week as ―maintenance‖
 Topicals
◦ Ointments, drops, sprays
◦ Sometimes hunt and peck to see which works best
 Symptomatic Care
◦ Antihistamines
◦ Fatty acid supplements

38.  Outdoors or in shower/bathtub!
 Hold the pinna up over the top of the dog‘s head
 Fill the ear canal to overflowing with ear cleaning
solution
 Massage the base of the ear for 60 seconds
 Allow your dog to shake his head
 Wipe away grime that comes to the top and
solution with a plain cotton ball
 Repeat
Never use Q-tips! They can pack wax and discharge down deeper,
and make the problem worse!

39. I've come to
cure your ear
allergies.
Yeah, right!

40.  Allergic to a protein in flea saliva
 Owner may not see fleas
◦ 1 flea bite every 5 to 7 days keeps them itching
◦ Many are currently using flea control but it‘s not good enough
(Frontline, Over-the Counter flea products, flea shampoos)
 Age of onset: adult to senior
 Time of year of onset: summer to fall
 Seasonal: often history of coming back this time every
year
◦ In the South, may be seen year-round
 Pattern: very strong pattern!! Almost always from the
waist down. Rump, tail base, tail, around the rectal area,
inner thighs, flanks
 No breed predilection

41.  In Dogs with pattern  All Cats!
itching from the
waist down:
◦ Redness
◦ Hair loss
◦ Saliva Stain
◦ Thickened skin
 Called Lichenification
◦ Black looking skin
 Called
Hyperpigmentation
◦ Scabbiness

42.  Upgrade Flea Control  Topical
◦ Dogs ◦ Aloe & Oatmeal weekly
 Spinosad-based once a shampoo
month flea pill ◦ Soothing conditioner after
 Every 30 days bath
◦ Cats ◦ Pramasoothe Spray
 Advantage Multi once-a-  Oral
month flea topical
◦ Prednisone for dogs
 Every 21 days
◦ Other pets ◦ Antihistamines
 Treat all other pets,
 Injectible
whether itchy or not ◦ Vetalog for dogs
◦ Environment ◦ Depomedrol for cats
Primary (Specific) Secondary (Symptomatic)
Treatment Treatment

43.  Topical
◦ Aloe & Oatmeal Shampoo
◦ Aloe & Oatmeal Conditioner
◦ Soothing Sprays – Pramasoothe, Relief
 Oral
◦ Prednisone for dogs
 Tapering dose for 2 to 4 weeks
 Does have side effects
◦ Antihistamines
 May help some dogs/may not help some dogs
 Injectable
◦ Last resort!
◦ Vetalog for dogs
 Lasts 1 to 2 weeks
◦ Depomedrol for cats
 Lasts 4 to 8 weeks
 Side effects
 Serious side effects are rare but can be life-threatening

45.  Flea Allergy  Atopy
◦ Zero tolerance for ◦ Immunotherapy
fleas ◦ Atopica
◦ Upgrade flea control ◦ Prednisone if
◦ Not all flea products unavoidable
work equally well!!!!
Food Allergy
 Diet that eliminates
the problem
allergen

46.  Hygiene
◦ Keeping clean
◦ Short haircuts
◦ Ear cleaning solutions if needed
◦ Good flea control for all pets!!!!
 Soothing shampoos, conditioners and sprays
◦ Aloe & Oatmeal or Hypoallergenic (Hyliderm) weekly
◦ Pramasoothe or Relief Spray 2-3 times a day
◦ More specific shampoos if needed for
 Yeast infection (Ketochlor)
 Bacterial infection
 Scales, crusts, greasiness
 Anti-histamines
 Fatty acid/vitamin supplements
 Treat secondary problems
◦ Antibiotics for secondary skin infections
◦ Antifungals for secondary yeast infections
◦ Topicals (in ear) for otitis externa

47.  We are not going to cure your
pet‘s skin disease, but we
want to keep him as
comfortable as possible so
that he has a good quality of
life.
 Remember that we are not
going to be able to stop all of
the itching all of the time.
 Goal is to help your pet itch
less
 Goal is a good quality of life
for your pet

48.  Ask yourself if you are
compliant with all of your
family veterinarian‘s
prescriptions and advice.
 If you are not compliant,
ask yourself why…and try to
start doing EVERYTHING
your veterinarian
recommends
 If you are compliant and
things are not working out,
ask your veterinarian for a
referral to a board-certified
veterinary dermatologist

49.  Holmes Veterinary Hospital
1001 Church Street
Laurens, SC 29360
www.holmesvethospital.com
Material in this slide presentation is intended
to help veterinary clients understand one
practice‘s approach to skin disease. It is not
intended to be a substitute for assessment
and treatment by your pet‘s veterinarian.
Copyright © Jacquelyn H. Burns 2012
All rights reserved