Skin case any ideas

Re: Skin case any ideas

Charlotte Marshall — Sun, 28 Oct 2012 17:02:22 GMT

He did improve with the course of antibiotics to a certain degree. Turns out that he had not had a skin scrape and when one was done surprise surprise there were demodex present. He also turned out to have ringworm I believe! Last i heard he was on ivermectin orally and I think griseofulvin and was improving.

Re: Skin case any ideas

Anthony Todd — Thu, 04 Oct 2012 23:10:25 GMT

[quote user="Charlotte Marshall"] in this particular dog [/quote]

How's the dog doing; any diagnosis etc.?

Re: Skin case any ideas

Charlotte Marshall — Wed, 12 Sep 2012 15:02:11 GMT

On the steroid front in this particular dog it had been tried to give short doses when needed but it got to the point where it needed continuous therapy. I can't recall all the details. I know he is probably the most frustrating atopic dog on our books and I am pretty sure a lot of owners would have given up ages ago. He has been seeing my boss again lately so I have not seen him since I posted. apparently there has been very minor improvement only and my boss is perhaps coming around to the idea of biopsy. He did say the 'blood blisters' had dried up and gone scabby.

Re: Skin case any ideas

Anthony Todd — Tue, 11 Sep 2012 17:28:42 GMT

How's the dog; any progress??

Re: Skin case any ideas

Anthony Todd — Sat, 08 Sep 2012 13:06:46 GMT

[quote user="robloxley"] it's what works for them.[/quote]

Ah, the key at last, I'll bet they only found out by experience, and didn't go straight to daily use.

I'll bet they have to use the inhaler daily in the summer, or even certain times in the summer, and not so much in the winter depending on their particular asthmatic profile and allergens.

Re: Skin case any ideas

Rob Loxley — Sat, 08 Sep 2012 12:17:37 GMT

[quote user="Anthony Todd"]Do hay-fever sufferers use their meds continuously??[/quote]

Some asthma sufferers need to take a corticosteroid inhaler daily as a preventative; it's what works for them.

Re: Skin case any ideas

Anthony Todd — Sat, 08 Sep 2012 11:36:46 GMT

[quote user="Anthony Todd"]Have you looked at [/quote]

Now I've looked at the full paper and they do say:

For example, an early crossover trial reported that a

combination of the antihistamine trimeprazine and the

glucocorticoid prednisolone [Vanectyl-P (Temaril-P), Pﬁzer

Animal Health, Kirkland, Canada] had a higher antipruritic

efﬁcacy than trimeprazine or prednisolone given alone

(COE IIa).

Whether or not such steroid-sparing effect

would be seen with other antihistamines has not bee

So, in the interests of not being selective ,there it is.

[sorry for the formatting]

Here's the full paper.

http://onlinelibrary.wiley.com/doi/10.1111/j.1365-3164.2010.00889.x/pdf

Re: Skin case any ideas

Anthony Todd — Sat, 08 Sep 2012 09:08:58 GMT

[quote user="robloxley"]You've been advocating against continuous low dose steroids[/quote]

Geez, I've been advocating against continuous steroids in atopy or allergy at any, that's high, medium or low dose rates. And yes, that's a different advocacy from lymphoma where continuous steroids are used because the effect is required constantly.

Do hay-fever sufferers use their meds continuously?? They use them when needed.

Clients used to have difficulty with the concept of tailored doses to effect when necessary but I didn't think vets did.

And I do pick sentences out of the literature when they relate to my argument, I haven't edited out anything relating to continuous steroids 'cos it isn't there to edit out.....

How's the dog, that's really the point; we're all just trying to get it better?

Re: Skin case any ideas

Rajat — Fri, 07 Sep 2012 23:58:49 GMT

[quote user="Anthony Todd"]Never ever seen any serious side effects with that one or two doses. Do get PU/PD but that is almost independent of dose eg Westies.[/quote]

It's interesting to hear your experience because I do use that dose (lower end) typically in lymphoma cases but it is continuous not one off.

[quote user="Anthony Todd"]They use massive doses in humans and animals for shock with no[?] side effects.[/quote]

Even if the risk of s/e is low I'd rather use a lower dose than 2-4mg/kg as it seems to have a good effect (so far) in my patients. Pred's short life means I can't see why dosing higher means it would be used for less time..

Anyhoo its not a discussion about steroids rather the case at hand, wonder how the dog is getting on..

Re: Skin case any ideas

Rob Loxley — Fri, 07 Sep 2012 23:57:37 GMT

[quote user="Anthony Todd"]The dose and frequency of administration of these drugs should be tailored to each patient considering each drug's efficacy, adverse effects and cost. Just what I've been saying?[/quote]

You've been advocating against continuous low dose steroids, which are supported by this review. You can't just pick the sentences out of the literature that you like and agree with your point of view and edit out the rest

Re: Skin case any ideas

Anthony Todd — Fri, 07 Sep 2012 20:24:09 GMT

[quote user="Rajat"]that is 2-4mg/kg, [/quote]

That's one single dose or, at the most 2 doses. They use massive doses in humans and animals for shock with no[?] side effects. It's the continuous dose that does the damage.

Er, look where the low,high, or medium dose has got us in the present case.....

Never ever seen any serious side effects with that one or two doses. Do get PU/PD but that is almost independent of dose eg Westies.

Re: Skin case any ideas

Rajat — Fri, 07 Sep 2012 19:11:02 GMT

Ok - got it.

Personally, find stopping the steroids (and I start at higher doses) in many cases leads to flare ups - where it doesn't the owners stop them ( I get em to wean em off - try to find the lowest effective dose- where it reaches near physiological levels or bit sooner if a first time case- I ask them to stop and monitor). Many atopic dogs however need ongoing steroids to control their CS_- but bottom line is the therapy should be tailored to each patient (As per the guidelines which were quoted previously). A blanket approach to a heterogenous disease such as Atopy is unlikely to be effective for all patients suffering from it, whatever you or I say or believe. So I am not dogmatic about this.

[quote user="Anthony Todd"]giving around 1-2mg/lb in one dose,[/quote]

that is 2-4mg/kg, which is an immunosuppressive dose, much more likely to result in GI ulceration, I would not use preds at thise dose in atopic dogs..ever..sorry no insult intended.

Re: Skin case any ideas

Anthony Todd — Fri, 07 Sep 2012 18:49:50 GMT

[quote user="Rajat"]Yes totally- and it sounds like you were advocating against a low dose[/quote]

No, I always have been totally completely and utterly against a continuous dose whether it's high, low or in between.

Obviously the effects of a high continuous dose are going to be more pronounced than a low dose .

This is why steroids have such a bad press, I mean what other group of drugs gets vets saying things like "I use them more than I should"?

High doses intermittently ,as necessary and to effect, as the reference above alludes to, gives much better results without any long term effects.

My views have not changed, I'm not bending arguments not selectively quoting from references.

Mind you the above reference didn't seem to be big on anti-histamines........

I wager your dogs on the low continuous dose with the "occasional flare-ups" would do better on a single high dose at each "flare-up"and nothing in-between.

Obviously the low dose doesn't stop the "flare-ups" which I suggest are the atopic insult which only occurs occasionally making continuous treatment unnecessary.

My standard regime, having eliminated allergens if possible [fleas, food, etc] was 30 Pred 5mg, giving around 1-2mg/lb in one dose, repeat in 24-48hrs only if necessary. Most atopics got away with 4-6 "flare-ups" a year and total relief of symptoms within 24hrs.

I wonder how many of the "modern" treatments can claim that, and don't even mention cost or itch control during diagnosis....?

Re: Skin case any ideas

Rajat — Fri, 07 Sep 2012 18:16:55 GMT

[quote user="Anthony Todd"] there are lesions and areas that could well be pyoderma,[/quote]

true but nothing that SAYS pyoderma on the epidermis- no primary lesions.Like I said earlier I suspect it, but cannot be sure. I agree with you and everyone else we need more dx: on this one.

[quote user="Anthony Todd"]And a high continuous dose is even more likely to confuse pathology, surely?[/quote]

Yes totally- and it sounds like you were advocating against a low dose- but now sounds like you are advocating against a high dose- what I was trying to say is the dog had been on a low dose according to OP(which we have no clue what it was but sounds like it was controlling clinical signs) before its relapse. We still don't know what caused the relapse- marked exposure to an existing or new allergen a parasite or something else. I don't see how we can comment on the dose being inappropriate with the info we have, that's all..

For me a low dose of CS is < 0.4mg/kg eod. Most of my atopic dogs that cannot afford tx with anything other than steroids and topicals are on at or just <0.5mg/kg eod or sid. Some have occasional flareups, most are very well controlled.But I know for many ppl that is too low a dose and for others they would like to see it lower- I have seen 30kg dogs being given 5mg preds per day for a severe O externa- now that's a low dose eh, bet you can agree with me on that !

Re: Skin case any ideas

Anthony Todd — Fri, 07 Sep 2012 14:28:39 GMT

[quote user="Rajat"]Mites in a blood blister, really? I need to study more derm by the sounds of it, never heard of that![/quote]

Yeah well, if no one looks.....and could today's blood blister be tomorrow's pustule??

Looking at the picture, there are lesions and areas that could well be pyoderma, especially if their appearance is modified by high,low or medium doses of steroids continuously?

[quote user="Rajat"]I didn't see a dose mentioned, just that a low maintenance dose was used..one person's low dose is another's high[/quote]

And a high continuous dose is even more likely to confuse pathology, surely?

Re: Skin case any ideas

Anthony Todd — Fri, 07 Sep 2012 14:18:32 GMT

[quote user="robloxley"]Have you looked at [/quote]

Well here's the abstract:

Atopic dermatitis (AD) is a common chronic relapsing pruritic skin disease of dogs for which treatment has varied over time and geographical location. Recent high quality randomized controlled trials and systematic reviews have established which drugs are likely to offer consistent benefit. The International Task Force for Canine AD currently recommends a multi-faceted approach to treat dogs with AD. Acute flares should be treated with a combination of nonirritating baths and topical glucocorticoids, once an attempt has been made to identify and remove the suspected causes of the flare. Oral glucocorticoids and antimicrobial therapy must be added when needed. In dogs with chronic AD, a combination of interventions should be considered. Again, factors that trigger flares of AD must be identified and, if possible, avoided. Currently recognized flare factors include food, flea and environmental allergens, Staphylococcus bacteria and Malassezia yeast. Skin and coat hygiene and care must be improved by bathing with nonirritating shampoos and dietary supplementation with essential fatty acids. The severity of pruritus and skin lesions can be reduced with a combination of anti-inflammatory drugs. Currently, medications with good evidence of high efficacy include topical and oral glucocorticoids, and calcineurin inhibitors such as oral ciclosporin and topical tacrolimus. The dose and frequency of administration of these drugs should be tailored to each patient considering each drug's efficacy, adverse effects and cost. Allergen-specific immunotherapy should be offered, whenever feasible, in an attempt to prevent recurrence of clinical signs upon further exposure to environmental allergens to which the patient is hypersensitive.

topical glucocorticoids come on, how many of us have had any success with the usually hopelessly impractical topical glucocorticoids?

Oral glucocorticoids and antimicrobial therapy must be added when needed just what I've been saying but usually, with good management ABs aren't needed.

Currently, medications with good evidence of high efficacy include topical and oral glucocorticoids I'm in the game still I reckon.

The dose and frequency of administration of these drugs should be tailored to each patient considering each drug's efficacy, adverse effects and cost. Just what I've been saying?

Re: Skin case any ideas

Rob Loxley — Fri, 07 Sep 2012 13:45:52 GMT

[quote user="Anthony Todd"]

where steroids have been used at low, ineffective doses with poor results. This is what gets steroids such a bad name. And I say again, give them intermittently at effective doses as necessary.
They're hopeless, IMHO, at low continuous dosage rates

[/quote]

Have you looked at "Treatment of canine atopic dermatitis: 2010 clinical practice guidelines from the International Task Force on Canine Atopic Dermatitis"?

Re: Skin case any ideas

Anthony Todd — Fri, 07 Sep 2012 09:04:15 GMT

[quote user="Rajat"]Mites in a blood blister, really? I need to study more derm by the sounds of it, never heard of that![/quote]

I still think it can't hurt to look; if you don't look you can't know and as the lesions have been compromised by the prolonged steroids, who knows?

Same with culturing and cytology. Can't believe a pyoderma wouldn't have the bugs in the blood blister but the expert says not??

Re: Skin case any ideas

Rajat — Fri, 07 Sep 2012 00:47:47 GMT

[quote user="Anthony Todd"]Er, why doesn't someone culture and do cytology on the blood blisters, FFS, lovely culture medium and wouldn't have surface contaminants. Should give an insight, at least, as to pyoderma and might surprise everyone with mites floating around in it......and the cytology would give pointers too.[/quote]

As Richard pointed out - not on a blood blister. Pustule yes. I don't see a blood blister (rightly or wrongly) as a sign of pyoderma. And I suspect pyoderma but don't see screaming evidence for it.

Mites in a blood blister, really? I need to study more derm by the sounds of it, never heard of that!

[quote user="Anthony Todd"]Not criticising steroid use per se, only the low dose for ever with poor results, as in this case.[/quote]

I didn't see a dose mentioned, just that a low maintenance dose was used..one person's low dose is another's high..unless I missed something.

How is the dog Charlotte?

Re: Skin case any ideas

Richard Fox — Thu, 06 Sep 2012 16:48:34 GMT

No I doubt it TBH - will prob reveal blood and culture commenals and then you none-the -wiser. I would suggest bx but its chronic and so may or may not give you and answer but it may still help give a direction?

Re: Skin case any ideas

Anthony Todd — Thu, 06 Sep 2012 14:57:14 GMT

[quote user="Richard Fox"]I wonder if teh skin "blood blisters" and areas of phlebectasia - perhaps after prolonged steroid tx?[/quote]

Richard, would you think culture and cytology of the phlebectasia might be fruitful, 'cos no one else seems to....

Re: Skin case any ideas

Richard Fox — Thu, 06 Sep 2012 11:52:24 GMT

I wonder if teh skin "blood blisters" and areas of phlebectasia - perhaps after prolonged steroid tx?

http://onlinelibrary.wiley.com/doi/10.1046/j.1365-3164.1997.d01-3.x/abstract

Re: Skin case any ideas

Bob Russell — Thu, 06 Sep 2012 11:05:53 GMT

As far as parasites are concerned as a cost and corner cutting exercise I would second the use of Promeris Duo (which can be repeated two weeks later). I find it beats the pants off advocate for demodex. Side effects (sedation and/or vomiting) are fairly common but none of my patients have come to any real harm from it.

Does anyone really believe that Advocate kills demodex? None of my cases responded in any way to it so I stopped using it years ago.

Has it had a T4 done?

Re: Skin case any ideas

Anthony Todd — Thu, 06 Sep 2012 10:47:06 GMT

[quote user="Rajat"]I am sure there 'may' be infection but like I say could not spot a primary lesion screaming pyoderma.[/quote].

Er, why doesn't someone culture and do cytology on the blood blisters, FFS, lovely culture medium and wouldn't have surface contaminants. Should give an insight, at least, as to pyoderma and might surprise everyone with mites floating around in it......and the cytology would give pointers too.

Not criticising steroid use per se, only the low dose for ever with poor results, as in this case. Not disputing the original atopy diagnosis, just the very obvious failure of the treatment regime.

Re: Skin case any ideas

Moira Hamilton — Wed, 05 Sep 2012 23:56:54 GMT

What breed, age is it, could it be that the dog is developing an immune component? Have you done skin scrapes to see if any mites have infiltrated the skin barrier. Have you topically treated it for fungal infections perhaps with surolan topically? Does the dog were a collar to stop it self mutilating, for longterm use the blow up ones are much less intrusive for the dog.

Good luck, skin cases are soooo frustrating

Moira