Dermatology help please! scaling, crusting, nodular problem...

Re: Dermatology help please! scaling, crusting, nodular problem...

Richard Fox — Tue, 08 May 2012 15:49:56 GMT

Great news - preds should work a treat :)

Re: Dermatology help please! scaling, crusting, nodular problem...

Holly Lee — Mon, 07 May 2012 18:45:05 GMT

Pemphigus foliaceus on histopath.

Prednisolone started and fingers crossed.

Thanks again for everyones input.

Re: Dermatology help please! scaling, crusting, nodular problem...

Holly Lee — Mon, 30 Apr 2012 17:09:16 GMT

Thanks again all.

Biopsies taken this morning - under GA as wanted to do extensive ellipitcal excision biopsies rather than just punch biopsies to make sure I got good representative samples. Found an area of intact pustules to sample so reasonably optimistic that the answer will be in the histopath...

Will let you know what the result is...

Thanks again for the responses, much appreciated.

Re: Dermatology help please! scaling, crusting, nodular problem...

Richard Fox — Mon, 30 Apr 2012 09:06:26 GMT

[quote user="Holly Lee"]

Interested in the comment on furunculosis getting worse before better as this isn't something I had come across (and it gives me more hope!) - in what way/timescale does that tend to happen?

[/quote]

What I meant to say was that pyoderma with significant folliculitis often you see a delay in the the response to tx - this is because of furunculosis and this often makes it look worse as once the follicle ruptures the keratin and hair shafts induce a foreign body reaction - the lesions may very well be sterile but often looks worse as the inflammation is more intense - if that makes more sense?

However in this case I would still be inclined to do further work up - cytology, bacteriology or just go for bx - just doesn't strike me as a typical pyoderma/folliculitis given the gross and historical findings

Re: Dermatology help please! scaling, crusting, nodular problem...

Richard Fox — Mon, 30 Apr 2012 09:01:19 GMT

I agree Michael but I didn't suggest it myself as didn't want to be flamed

Re: Dermatology help please! scaling, crusting, nodular problem...

Michael Woodhouse — Sun, 29 Apr 2012 23:24:29 GMT

[quote user="Richard Fox"]Some cases are too chronic to be able to diagnose easily on histopath? However I can understand the cost issue i.e. GA + bx fee.[/quote]

You don't need a GA to take a biopsy. In the vast majority of cases I will take them fully conscious with a bleb of local introduced from a slight distance away. A brief swab with iodine and quick biopsy and a single suture or staple. Usually take 3-5 samples but never takes more than 10 minutes. How much do we need to charge for it? (we have an extended consult fee that I would use).

If dog difficult then I would keep in and sedate. Only GA if I was doing something else.

I don't really like skin, but have found biopsy a quick and very cost effective way of getting good answers. (got my name in VR doing one on a dead deer with demodecosis.........)

Re: Dermatology help please! scaling, crusting, nodular problem...

emma o'connor — Sun, 29 Apr 2012 19:26:46 GMT

Hi Holly

I would agree with some of the others that Pemphigus seems a likely fit for this, it certainly looks familiar in presentation to the last case I diagnosed. I find they generally form larger vesicles, rather than small pustules normally seen with pyoderma. These vesicles are very delicate and generally rupture very easily to form large adherent crusts. As Richard suggested, cytology of early lesions can be rewarding and easily performed if you have access to a microscope and diff quick, and if you do biopsy, take plenty of samples and again look for newer lesions with less crusting. I have seen pyrexia as a common feature in the few cases I have seen and diagnosed.

Good Luck

Re: Dermatology help please! scaling, crusting, nodular problem...

Simon Neuhoff — Sat, 28 Apr 2012 09:53:21 GMT

AT my prev practice we had a v similar sounding case (not my case though so details a little shaky) that turned out to be immune mediated - not pemphigus though IIRC, and responded well to steroids. I would definitely go with biopsies prior to the steroids though if at all poss!

Re: Dermatology help please! scaling, crusting, nodular problem...

Sarah Wheadon — Fri, 27 Apr 2012 17:51:45 GMT

Looks and sounds very much like a case I had recently which turned out to be pemphigus foliaceous. Biopsy was really essential as gave the diagnosis and the basis on which to start immunosuppressive meds which would never be used otherwise in a dog covered in pustules. Good luck!

Re: Dermatology help please! scaling, crusting, nodular problem...

Holly Lee — Fri, 27 Apr 2012 16:01:20 GMT

Thanks all for comments and help.

No recent drugs prior to this problem, had considered drug eruption, apart from regular advocate treatment so mites (other than demodex perhaps but have never seen it cause this kind of problem) unlikely, and especially with dogs in close contact not affected.

Amoxy-clav was started by my colleague, I did consider making a change to cephalexin rather than marbocyl but (rightly or wrongly - bracing myself for criticism) thought resistance was less likely to marbocyl as a second line. No mention of pruritus in initial consultation and certainly not apparent at present, although I might have expected pyoderma to cause some pruritus in it's own right anyway.

Interested in the comment on furunculosis getting worse before better as this isn't something I had come across (and it gives me more hope!) - in what way/timescale does that tend to happen?

As far as whether there are new lesions - honestly with so much of the dog affected I am finding it impossible to be certain. My impression is that yes, it is progressive, but I cannot honestly be 100% sure.

I am used to pyoderma taking time to resolve but not with such marked pyrexia previously.

Thanks again and I look forward to further comments..

Re: Dermatology help please! scaling, crusting, nodular problem...

John Rimmer — Fri, 27 Apr 2012 15:43:09 GMT

in a springer...could it not be primary keratoseborrhoeic disorder with secondary pyoderma? Interesting choice of antibiotics for skin - Why not cephalexin? Anyway FQ have fair skin penetration too so I would continue with Marbocyl. Sebolytic good for greasy KSD, Sebomild for flaky KSD.....but whilst pyoderma present, I would use Malaseb (this is what it is licensed for - seborrhoea with Malassexia or pyoderma) - then switch over to Sebomild/Sebolytic when infection resolved.

Re: Dermatology help please! scaling, crusting, nodular problem...

Richard Fox — Fri, 27 Apr 2012 15:24:58 GMT

No offence taken Mark

As above a close look at recent history/events and clinical signs will help you order your diagnostic tests i.e. is there prutitis? (ectoparasites unlikely in my opinion due to the several and generalised nature ) although sever demodecosis with furunculosis is a remote differential.

Re: Dermatology help please! scaling, crusting, nodular problem...

Martin Atkinson — Fri, 27 Apr 2012 15:18:39 GMT

You've not given us a time scale or any previous history of medication, vaccination etc. In this light I would add drug reaction to my list of differentials but you still need skin scrapes/tricogram, a skin swab for staining and culture then biopsies, allergy testing and food trials in that order.

Re: Dermatology help please! scaling, crusting, nodular problem...

Mark Hedberg — Fri, 27 Apr 2012 14:54:18 GMT

Absolutely agree, I was just going from the cost angle. :) Obviously proper diagnosis can actually reduce the cost of treatment, but sometimes it's hard to get the owners on board with this, especially if biopsy is presented as "I don't know what's wrong with it so let's cut out a piece" as opposed to "this procedure is very much in line with our diagnostic plan and will enable us to begin correct treatment so your pet begins healing as soon as possible".

(No offense intended to anyone with this and this post is not intentionally aimed at anyone, just an observation.)

Re: Dermatology help please! scaling, crusting, nodular problem...

Richard Fox — Fri, 27 Apr 2012 14:44:48 GMT

I agree somewhat but I am a great advocate in taking a biopsy or cytology early in the disease process not because I an a pathologist but if after 2 weeks the are new lesions forming? (are there?) despite (now) quite broad spectrum antimicrobials (should be effective against pseudomonas?). Some cases are too chronic to be able to diagnose easily on histopath? However I can understand the cost issue i.e. GA + bx fee.

I would agree that you'd prob be best to wait 3-4 weeks on Ab's as some infections can take that time and also as said before furunculosis often gets worse before it gets better?

Re: Dermatology help please! scaling, crusting, nodular problem...

Mark Hedberg — Fri, 27 Apr 2012 11:50:10 GMT

Malaseb might be a good choice here - good antiseptic properties, if it's a whacking great infection you'll need all the help you can get, inside and outside. Remember that really nasty skin infections may take up to 3-4 weeks to fully resolve. Patience is key here. Does the skin smell like anything?

I had a great dane with very severe skin infection last year in a charity clinic, it took a combination of amoxicillin and metronidazole to get it under control, and 3 weeks continuous therapy. (As you're on marbocyl, amoxicillin/clav can be used together synergistically.) Culture and sensitivity is a low cost possibility here - swab the purulent material and get a C&S done on it maybe the infectious agent simply wasn't susceptible to amox/clav. (It's an abused drug, I do see some germs that just laugh at it.) Biopsy is definitely a thought but there's room for exploration here before that.

Also, skin infection can be secondary - how is mite control in your patient?

Re: Dermatology help please! scaling, crusting, nodular problem...

Richard Fox — Fri, 27 Apr 2012 11:42:02 GMT

My thoughts:

Look crusting now but circular patches with pallor? If you have severe furunculosis this may take time to resolve even after effective antibiosis. That said I would bx. cutaneous epitheliotropic lymphoma seems unlikely d.t. the crusting and multifocal nature. Severe sebaceous adenitis probably unlikely d.t. the pyrexia and well demarcated scabs. AI / immune-mediated e.g. pemphigus/lupus I would consider the most if non-infectious - pemphigus folliacious would give you a pustular skin disease so look for new lesions? Are there andy new lesions? If so then you have progression. I would biopsy new lesions if possible.One other condition of not would be erythema multiforme especially if you have targetoid lesions.

You could to cytology on new wetish lesions and look for micro-organisms, leukocytes (degen/non-degen) and acantholytic cells:

Bx should hopefully give you and answer - I would take several biopsies from the newer lesions - punches or an ellipse through the border of normal and abnormal?

Give me a ring on 01626 353598 if you want to discuss it - happy to help (even if you don't use us !)