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Now what?By Jacquelyn H. Burns, DVM                             Copyright © Jacquelyn H. Burns 2012
   The main sign of allergies in pets    is itching, with or without hair loss   This may be manifest in several    ways...
   Hair loss   Greasy coat   Dry coat   Erythema (redness)   Red bumps   Scabby spots   Dandruff   Ear infections...
   There are three    categories of allergy    in pet dermatology:    ◦ Atopy      (environmental and      inhaled allerg...
   Age of onset               Pattern (where on the    ◦ Young                     body the itch is)    ◦ Middle age to ...
   Flea combing   Skin scrapings    ◦ Screen for mange      Demodex      Sarcoptes   Skin cytology    ◦ Bacteria?    ...
   Rate your pet‘s itchiness on a scale of 1 to 10    ◦ 1‘s never scratch/chew/lick/rub    ◦ 10‘s never stop scratching/c...
   Allergies are not curable   Our goal is to manage the condition    ◦ Reduce the itch/inflammation    ◦ Reduce seconda...
   There isn‘t a magic allergy    fairy who can wave her    magic wand and ―cure‖    allergies.   Management will be as ...
   Is an environmental allergy that is usually but    not always seasonal   Formerly believed to be mostly inhaled, but ...
   Age of Onset    ◦ Middle aged adult to senior   Time of year of onset    ◦ Often warmer months   Seasonal vs. non se...
   Immunotherapy    ◦ Determine exactly what the pet is allergic to and      order an immunotherapy serum to be given by ...
   Atopica    ◦ Cylcosporine      Suppresses the       immune system    ◦ Loading dose is      once daily for 30      da...
   Atopy was formerly attributed to inhaled    allergens. But dermatologists now recognize    that allergens also can be ...
   Topical    ◦ Soothing Shampoos & Conditioners    ◦ Soothing Sprays, creams or ointments   Oral    ◦ Prednisone      ...
   Corticosteroids    ◦ Prednisone, prednisolone, Vetalog, Depomedrol,      dexamethasone    ◦ Anti-inflammatory, anti-it...
   Lethargy, panting   Weight gain   Increased thirst   Increased urine volume    ◦ Some pets urinate in the house   ...
   They work!    ◦ Sometimes they are the only thing that works that is also      affordable   Reduce itching, redness, ...
   Atopica contains cyclosporine, an immune    suppressive drug that can be used to manage    atopy.   Atopica is relati...
 Since many patients are on long-term management, we want to avoidcertain side effects It does not cause    ◦ Weight gai...
   Doesn‘t work on    FAD or Food    Allergic Dogs   It is simply cost-    prohibitive for    many clients
   Age of onset    ◦ Many are younger (under 3 years)   Time of year of onset    ◦ Not applicable   NONSEASONAL   Patt...
   Non seasonal itching    ◦ These dogs itch all year ‗round   Response to prednisone is marginal   Do not respond to A...
   It‘s not that easy!!!!                         Pet foods are                          heavily marketed               ...
   All natural    ◦ All ingredients come from some type of original, natural      raw material   Organic    ◦ Your dog c...
Beef                   Chicken Grains and carbs get a not always deserved bad rap!
Eat more      Includes all proteins from        chikin?       cows                     Beef by-products                 ...
   Chicken meat                              Chicken by-products                               ◦ Chicken meal           ...
   The ―real‖ test for food allergy   A prescription food    ◦ Contains only 1 novel protein source    ◦ Contains only 1...
   ―Novel‖ in this sense means an unusual    ingredient that your pet has never been    exposed to before   Therefore, t...
   No-compromise    commitment on the    part of all members    of the household for a    moderately lengthy    period of...
   Some aren‘t really infections!   Otitis externa is an itchy inflammation of the external ear    canal. It is not like...
   Shaking head   Rubbing ears on floor or furniture   Whining/crying when ears are rubbed   Discharge from ears   Od...
   Veterinarian looks at a       Veterinarian looks at a    sample of ear wax or           stained slide of ear    disch...
   Hygiene    ◦   Pluck hair from inside ears if present    ◦   Clean with veterinarian-recommended ear cleaner    ◦   On...
    Outdoors or in shower/bathtub!    Hold the pinna up over the top of the dog‘s head    Fill the ear canal to overflo...
Ive come tocure your ear   allergies.          Yeah, right!
   Allergic to a protein in flea saliva   Owner may not see fleas    ◦ 1 flea bite every 5 to 7 days keeps them itching ...
   In Dogs with pattern              All Cats!    itching from the    waist down:    ◦   Redness    ◦   Hair loss    ◦  ...
   Upgrade Flea Control            Topical    ◦ Dogs                           ◦ Aloe & Oatmeal weekly      Spinosad-ba...
   Topical    ◦ Aloe & Oatmeal Shampoo    ◦ Aloe & Oatmeal Conditioner    ◦ Soothing Sprays – Pramasoothe, Relief   Oral...
   Flea Allergy                 Atopy    ◦ Zero tolerance for          ◦ Immunotherapy      fleas                       ...
   Hygiene    ◦   Keeping clean    ◦   Short haircuts    ◦   Ear cleaning solutions if needed    ◦   Good flea control fo...
   We are not going to cure your    pet‘s skin disease, but we    want to keep him as    comfortable as possible so    th...
   Ask yourself if you are    compliant with all of your    family veterinarian‘s    prescriptions and advice.   If you ...
   Holmes Veterinary Hospital    1001 Church Street    Laurens, SC 29360    www.holmesvethospital.com    Material in this...
My pet has allergies!  What now?
My pet has allergies!  What now?
My pet has allergies!  What now?
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My pet has allergies! What now?

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

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My pet has allergies! What now?

  1. 1. Now what?By Jacquelyn H. Burns, DVM Copyright © Jacquelyn H. Burns 2012
  2. 2.  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
  3. 3.  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
  4. 4.  There are three categories of allergy in pet dermatology: ◦ Atopy (environmental and inhaled allergy) ◦ Food Allergy ◦ Flea allergy dermatitis
  5. 5.  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 PhysicalHistory Exam/Observations
  6. 6.  Flea combing Skin scrapings ◦ Screen for mange  Demodex  Sarcoptes Skin cytology ◦ Bacteria? ◦ Yeast? Fungal cultures ◦ Screen for ringworm Skin biopsies
  7. 7.  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
  8. 8.  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
  9. 9.  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
  10. 10.  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
  11. 11.  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)
  12. 12.  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
  13. 13.  Atopica ◦ Cylcosporine  Suppresses the immune system ◦ Loading dose is once daily for 30 days ◦ Maintenance dose is every other day for life
  14. 14.  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
  15. 15.  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
  16. 16.  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
  17. 17.  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
  18. 18.  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
  19. 19.  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
  20. 20.  Since many patients are on long-term management, we want to avoidcertain 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
  21. 21.  Doesn‘t work on FAD or Food Allergic Dogs It is simply cost- prohibitive for many clients
  22. 22.  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
  23. 23.  Non seasonal itching ◦ These dogs itch all year ‗round Response to prednisone is marginal Do not respond to Atopica
  24. 24.  It‘s not that easy!!!!  Pet foods are heavily marketed and you have to analyze the label ingredientsPet 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 youeating their brand. read the ingredient list, you may also see poultry meal or whey, which is in the beef family antigenically
  25. 25.  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‖
  26. 26. Beef Chicken Grains and carbs get a not always deserved bad rap!
  27. 27. 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, YakBeef Not just the meat!
  28. 28.  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!  EggsMore than just the bird! Chicken
  29. 29.  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
  30. 30.  ―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
  31. 31.  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
  32. 32.  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
  33. 33.  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
  34. 34.  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 epithelialsOil Smear Ear Cytology
  35. 35.  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
  36. 36.  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!
  37. 37. Ive come tocure your ear allergies. Yeah, right!
  38. 38.  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
  39. 39.  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
  40. 40.  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 catsPrimary (Specific) Secondary (Symptomatic)Treatment Treatment
  41. 41.  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
  42. 42.  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
  43. 43.  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
  44. 44.  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
  45. 45.  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
  46. 46.  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

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