Itching, Scratching, Atopy Oh My! Diagnosis and Treatment of the Allergic Patient

DIAGNOSIS AND TREATMENT OF THE ALLERGIC PATIENT
ITCHING, SCRATCHING, ATOPY OH MY!
Amy Schnedeker, DVM, MS, DACVD
Upstate Veterinary Specialties
Latham, NY

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 How to perform diagnostics to confirm secondary
infections
 Discuss treatment options for managing pruritus
 Diagnostic steps to rule in/out allergic dermatitis
 Flea allergies vs. food allergies vs. atopic dermatitis
LEARNING OBJECTIVES
9/26/2023
All trademarks are the property of their respective companies unless otherwise noted.

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 One of the most common clinical conditions presenting in
practice
 Remember, allergies are managed, never cured
 These patients will return for frequent rechecks
 This can cause frustration for both veterinarians and
clients
ALLERGIC DISEASE
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 Pruritus
 Most common complaint from owners
 Can affect patient’s quality of life
 Patient-owner bond
CLINICAL SIGNS
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 Secondary lesions
 Alopecia
 Erythema
 Excoriation
 Hyperpigmentation
 Lichenification
CLINICAL SIGNS
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 Recurrent infections
 Superficial/deep pyoderma
 Recurrent otitis externa
CLINICAL SIGNS
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PRESENTATION
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 Is there secondary skin infection?
 Is there otitis externa?
 Are there parasites?
DIAGNOSTIC STEPS
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 Is there secondary skin
infection?
 Pyoderma can contribute to
pruritus and patient discomfort
 Pustules, papules, crusts,
collarettes
 Skin cytology
 +/- Bacterial culture
DIAGNOSTIC STEPS
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 Frequent antibiotic use
 History of resistant infections
 New lesions while on current
systemic therapy
 Important to recheck patient while on
therapy
WHEN TO CULTURE?
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 Systemic antibiotics
 Common empirical
options
 Cephalexin
 Clindamycin
 Cefpodoxime
 Cats  Convenia®
SECONDARY SKIN INFECTIONS
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 Topical therapy
 Important step!
 Can be targeted therapy
 In some cases, sole therapy
SECONDARY SKIN INFECTIONS
9/26/2023
DOUXO®, the DOUXO® S3 logo, OPHYTRIUM®, the OPHYTRIUM® logo, and Seboliance™ trademarks are the property of Ceva Santé Animale S.A.
.

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 Medicated shampoo
 Mousse
 Spray
 Medicated wipes
 Client education helps
compliance
TOPICAL THERAPY
9/26/2023
DOUXO®, the DOUXO® S3 logo, OPHYTRIUM®, the OPHYTRIUM® logo, and Seboliance™ trademarks are the property of Ceva Santé Animale S.A.
.

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 Is there secondary skin infection? ✅
DIAGNOSTIC STEPS
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 Lesions near/around the ears
 Head shaking, otic pruritus,
odor
 History of otitis externa
DIAGNOSTIC STEPS
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 Ear cytology ALWAYS
 Cannot diagnose otitis by odor
alone
 Crucial to help guide appropriate
treatment
 Also needed to determine
resolution
DIAGNOSTIC STEPS
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 Treatment with topical
therapy based on ear
cytology
 Systemic therapy not
as effective
 Otitis media
 Neurologic signs
present
OTITIS EXTERNA
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 Is there secondary skin infection? ✅
 Is there otitis externa? ✅
DIAGNOSTIC STEPS
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 Fleas
 Up to date on prevention?
 Consider active ingredients
 Flea comb
DIAGNOSTIC STEPS
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 Distribution
 Dogs ”pants” region
 Not as helpful in cats
 Cutaneous reaction patterns
DIAGNOSTIC STEPS
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 Indoor only cats can still have
flea allergy dermatitis
 Recommend flea prevention
year-round for all patients
 Easy to rule out
FLEAS
9/26/2023
Catego® is a registered trademark of Ceva Santé Animale S.A

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 Oral preventatives
 Simparica®, Simparica®
Trio, Nexgard®,
Bravecto®
 Revolution® Plus,
Frontline® Plus,
Advantix®,
Advantage®, Catego®,
Vectra® 3D
FLEA TREATMENT
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 Sarcoptic mange
 Acutely pruritic
 Distribution
 Ear margins, elbows, hocks,
ventral abdomen
DIAGNOSTIC STEPS
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 Pinnal-pedal reflex
 Consider patient’s environment
 Exposed to wildlife?
 Superficial skin scrape
 Multiple sites
 Remember, only see 30-50% of the
time
 Treatment trial
SARCOPTIC MANGE
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REMEMBER THIS PATIENT?
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 Simparica®, Simparica® Trio**, Nexgard®, Bravecto®
 All off-label
 Revolution® or Revolution® Plus (cats only)
 Every 2 weeks for 3 treatments (off-label)
SARCOPTIC MANGE TREATMENT
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 Superficial pyoderma ✅
 Otitis externa ✅
 Parasites ✅
NOW WHAT?
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 What is the most common clinical sign and client
complaint?
 PRURITUS!
 We need to address the patient’s pruritus
REMEMBER….
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 Treatments can take 1-2 weeks to see significant
improvement
 Short-term goals
 Want patient to look and feel better fast
REMEMBER….
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 Ideal medication
 Safe
 Effective
 Works fast!
GOALS FOR CONTROLLING PRURITUS
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 Apoquel®
 Cytopoint®
 Glucocorticoids
 Atopica®
TREATMENT OPTIONS FOR PRURITUS
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ADVANTAGES OF APOQUEL ®
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•How it works
• Blocks IL-31 (also IL-2, 4,
6 and 13) blocks ITCH
• Works fast
• 1-3 hours of onset
• High efficacy
• Great for both short-term and
long-term use

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 Cost $$$
 Short half-life
 Daily dosing
 Contraindicated in dogs
less than 12 months or
with historical neoplasia
DISADVANTAGES OF APOQUEL®
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 How it works
 Degraded by normal pathways for
protein degradation
 Unlikely to affect kidney or liver
 Dose
 Dosing chart
 Minimum 2mg/kg SQ every 4 to 8
weeks
CYTOPOINT®
9/26/2023
Reference: https://www.zoetis.be/fr/excellenceindermatology/assets/downloads/SYMPOSIUM_PROCEEDINGSv4.pdf

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 Advantages
 30-60 day dosing
 Minimal side effects reported
 Concurrent medications
CYTOPOINT ®
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 Advantages
 Rapid acting
 1 to 3 days
 No age restriction
 No pills needed
CYTOPOINT®
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 Disadvantages
 Expense ($$ if small dog; $$$ large dogs)
 Given in-hospital
CYTOPOINT ®
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 Prednisone, prednisolone,
dexamethasone, Temaril-
P®
 Dosing
 Prednisone: ~0.5 mg/kg/day
 Dexamethasone: 0.07-
0.1mg/kg/d
 Cats start with 0.25 mg q24h
per cat
GLUCOCORTICOIDS
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 Advantages
 Fast
 Effective
 Inexpensive ($)
 Multiple routes of
administration
 Caution with long acting
injectable
GLUCOCORTICOIDS
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 Disadvantages
 Side effects!!
 Polyuria/polydipsia
 Polyphagia/weight gain
 Anxiety/aggression
 Panting
 Muscle atrophy
 Elevated liver enzymes
 UTI predisposition
 Pot belly
 Calcinosis cutis
 Etc...
GLUCOCORTICOIDS
9/26/2023

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 Yes! (in some cases)
 Stenotic ears
 Patient age
 Might be the only thing that
works
SO…. DO WE STILL NEED THEM??
9/26/2023

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 How it works
 Calcineurin inhibitor
 Blocks production of IL-2, IL-4,
TNF-α
 Inhibits eosinophils and mast
cell function/degranulation
ATOPICA® (MODIFIED CYCLOSPORINE)
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 Dose
 Dogs: 5mg/kg PO once
daily
 Cats: 7mg/kg PO once
daily
 Taper after 60 days
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 Advantages
 Labeled for cats (liquid
formulation)
 Less side effects than steroids
(ish?)
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 Disadvantages
 Expensive ($$$)
 Duration to efficacy
 4 to 6 weeks
ATOPICA (MODIFIED CYCLOSPORINE)
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 Disadvantages
 Side effects
 Vomiting (up to 30%)
 Diarrhea
 Nausea
 Contraindicated with neoplasia
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 Remember our goals
 Look and feel better fast
 Not first choice for this goal
 May be more long-term option if other treatments fail
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 Control pruritus
 Apoquel®, Cytopoint®, glucocorticoids
 Treating these things can already make a big difference in
the quality of life for your client and patient
 Can take time just to achieve short-term goals
SHORT-TERM GOALS
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 These are all secondary issues
 Need to control the primary problem
 If we don’t address the allergy, secondary issues will
return
LONG-TERM GOALS
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 Set up client expectations
 Allergies are life-long
 Not about cure, about
management with safest long-
term therapy
 Goal for pruritus  3 out of 10
LONG-TERM GOALS
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 Three big categories of allergies
 Flea allergy dermatitis
 Cutaneous adverse food reaction (CAFR)
 Atopic dermatitis
 Diagnosis is ruling out each one step-by-step
ALLERGIC DISEASE
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 Clinical distribution can help
 Appropriate systemic or
topical therapy
 All pruritic patients should be
on year-round flea control
 This is the diagnosis you
want!!
FLEA ALLERGY DERMATITIS
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 Cannot distinguish by clinical
signs alone
 Both can have pruritus,
recurrent infection, recurrent
otitis, etc.
CUTANEOUS ADVERSE FOOD REACTION VS. ATOPIC
DERMATITIS
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 History can be helpful
 Non-seasonal pruritus
 Can also be seasonally non-seasonal
 Diagnosis with 8-12 week elimination diet trial
CUTANEOUS ADVERSE FOOD REACTION
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 Work with your client
 Will diet trial be possible?
 Cost
 Lifestyle of owner and patient
 Multiple animals
 Children/family members
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 All patients with non-
seasonal clinical signs
 “Better” allergy to have
 Not possible in every patient
and household
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 Prescription diet will take minimum of 8 to 12 weeks to
work
 Start medication to keep them comfortable
 Apoquel®
 Cytopoint®
 Glucocorticoids
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 Relapse after stopping medications failed diet trial
 Diagnosis = atopic dermatitis
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 This is how you get to the diagnosis of atopic dermatitis
 Diagnosis of exclusion
 Serum and/or intradermal testing does NOT diagnose
atopic dermatitis
 Seasonal pruritus  can diagnose atopic dermatitis
ATOPIC DERMATITIS
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 Definitive therapy
 Allergy testing and
immunotherapy
 Symptomatic therapy
 Apoquel®
 Cytopoint®
 Glucocorticoids
 Atopica®
ATOPIC DERMATITIS TREATMENT
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 Intradermal testing (IDT)
 Disadvantages
 Sedation and shaving required
 Drug washout periods
ALLERGY TESTING
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 Serum allergy testing
 Advantages
 Blood draw only
 Can stay on some
medications
ALLERGY TESTING
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 Serum allergy testing
 Disadvantages
 Measuring circulating
immunoglobulins
 Not all skin specific
 Variable between different
labs
ALLERGY TESTING
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 How it works
 Allergen tolerance
 Desensitization
 Dose
 Varies with dermatologist
 Induction period 
maintenance
ALLERGEN SPECIFIC IMMUNOTHERAPY (ASIT)
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 Two different forms
 Subcutaneous immunotherapy
(SCIT)
 Every 3 days for first 45 days
 Then every 7-10 days
 Sublingual immunotherapy (SLIT)
 Once to twice daily
 FOREVER
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 Advantages
 Treats underlying disease
 Patient specific
 Minimal long-term side
effects
 70% effective
 SLIT or SCIT
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 Disadvantages
 Up to 1 year for full efficacy
 Moderate expense ($$)
 Atopic patients only
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 Goal of ASIT is ultimately
reduce or stop
symptomatic therapy
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 Not treating the allergy
 Treating the symptoms
 Patient comfort
 Needed for atopic patients to prevent relapses
SYMPTOMATIC THERAPY
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 Apoquel®
 Cytopoint®
 Glucocorticoids
 Atopica®
SYMPTOMATIC THERAPY
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 Very effective to help
treat and prevent
secondary infections;
protect skin barrier
 Chlorhexidine
 Antibacterial, antifungal
 OPHYTRIUM®
 Soothing, moisturizing
 Supports the 3 skin
barriers
TOPICAL THERAPY
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 Maintenance bathing
 Once weekly (more often if
needed)
 Alternating shampoos
 DOUXO® S3 PYO
 DOUXO® S3 CALM
 Localized therapy with
wipes/mousse
TOPICAL THERAPY
9/26/2023

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 Take a breath
 Treat the things you know they have
 Skin cytology, ear cytology, bacterial culture
 Treat the pruritus
 Goes a long way to comfort for patient AND owners
 Don’t forget about topical therapy
 Great and safe way to manage skin long-term
KEY THINGS TO REMEMBER
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 Dermatology is difficult
and frustrating
 Client education
 Set up expectations
 Referral
KEY THINGS TO REMEMBER
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MEMORIAL FUND
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QUESTIONS?
9/26/2023

Itching, Scratching, Atopy Oh My! Diagnosis and Treatment of the Allergic Patient

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