Flat coat with widespread lesions

Re: Flat coat with widespread lesions

Anthony Todd — Wed, 15 Jan 2014 05:07:23 GMT

[quote user="robloxley"]

[quote user="Anthony Todd"] if that is fine, try reducing it a bit[/quote]

[quote user="Anthony Todd"]no taper[/quote]

???

[/quote]

As I said, one adequate, probably high by today's standards, dose or a jab, [enough to give relief of signs within 24 hours] and don't taper the dose off with reducing amounts over a week or so.

If the irritation returns you could try a smaller single dose as often the amount needed to relieve the irritation reduces over time.

Owners get the idea in the end...

Keep trying to find the trigger between the "attacks".

Re: Flat coat with widespread lesions

Rob Loxley — Wed, 15 Jan 2014 00:23:22 GMT

[quote user="Anthony Todd"] if that is fine, try reducing it a bit[/quote]

[quote user="Anthony Todd"]no taper[/quote]

???

Re: Flat coat with widespread lesions

Anthony Todd — Tue, 14 Jan 2014 18:49:40 GMT

[quote user="Rebecca Benge"]What do you mean by an adequate single dose?[/quote]

Sorry, I'll try again.

Try the usual initial dose of pred which has worked in the past, repeat in 24 hours but only if no response, and the response should be obvious and nearly perfect ie after 24 hours, not a week. Owners usually are the best judge.

Then repeat at the first sign of recurrence, same dose initially then, if that is fine, try reducing it a bit. Sometimes you'll find that the "curative" or symptom relieving dose seems to reduce and there's a sort of natural taper of the dose rate.

Key thing is enough, as one single dose, at the first definite sign of recurrence, no taper, 'cos it's only a single dose and the adrenals [?] can cope with that.

Flareups don't coincide with a bath or some event to give us a clue as to the trigger ???

Re: Flat coat with widespread lesions

Rebecca MacMillan — Tue, 14 Jan 2014 18:00:08 GMT

I don't understand? What do you mean by an adequate single dose?

My concern is that after finishing a 10 day course of preds on the 28th Nov, he flared up from what looked like nearly normal skin to the same state (if not worse) than before within 6 days after coming off of them. He re-presented to us on 6th Dec with my colleague's notes reporting that 'skin has rapidly deteriorated after discontinuing'. Hence this time I thought I would keep him on them longer and very gradually taper off so we can get a good idea at what dose of preds the lesions make a reappearance if at all.

If I'm doing it all wrong, then I apologise, but as you said yourself this doesn't appear as a typical allergy case. This case is getting me down as much as it is the dog I think!

Re: Flat coat with widespread lesions

Anthony Todd — Mon, 13 Jan 2014 18:22:06 GMT

PS: it's nothing like anything I recognise as "allergic", to be honest.....

Re: Flat coat with widespread lesions

Anthony Todd — Mon, 13 Jan 2014 18:17:10 GMT

[quote user="Rebecca Benge"]how long he really needs to be on steroids for as we don't have a diagnosis....[/quote]

Just give an adequate single dose when necessary, no taper just one adequate dose, and you can scratch your head and get opinions whilst the dog is, undiagnosed but comfortable.

Which would you prefer yourself??

You may find that the allergen/irritant or whatever goes away and, horror of horrors, shame on you and your family, the dog gets better and everyone is happy, particularly the patient, but without a DIAGNOSIS.

God, what am I suggesting.....I can hardly believe myself....soak my keyboard in bleach.

Re: Flat coat with widespread lesions

Rebecca MacMillan — Mon, 13 Jan 2014 17:46:35 GMT

Update!

I saw the dog last week, much improved on preds. Just scurf in the areas where there were once lesions. No new lesions and even the crusts on the bridge of his nose have improved. He is still licking at his legs occasionally though, but on the whole less itchy.

My aim was to do a more prolonged steroid course, gradually tapering down over a good few weeks and monitoring for any recurrence of lesions. It's just tricky because obviously the owner is concerned that if we get him off steroids again that he'll just flare up like he did the first time. But equally it's hard to say how long he really needs to be on steroids for as we don't have a diagnosis....

Re: Flat coat with widespread lesions

Anthony Todd — Tue, 31 Dec 2013 21:21:53 GMT

A picture is worth 1000 words. Definitely worth exploring. Would there be a steroid response?

Re: Flat coat with widespread lesions

mariette asselbergs — Tue, 31 Dec 2013 20:21:14 GMT

Really if this dog has been out of the country, or if it lives on or near a farm or TB area, then look seriously into the last JSAP (the one you get as a BSAVA member). If you are near Bristol discuss with the vet facuilty there the chance of diagnosing Leishmania or cutaneous mycobacterial infections (not necessarily bovine TB). The article described how the diagnoses had been made with a new technique multiplying tiny amounts of TB DNA in slides and tissue samples. The photographs showed skin lesions with a fresh bloody surface under scabs. The lesions on dogs' ears looked just like the ones we in Mozambique always blamed on biting flies.......In retrospect I wish I had made impression smears and stained them with Ziehl Neelson.!

Mariette

Re: Flat coat with widespread lesions

Anthony Todd — Tue, 31 Dec 2013 19:40:08 GMT

Couldn't the "pyoderma," be just a secondary change and the culture results what you would expect from insulted skin which would always be colonised?

I can't see it as a primary pyoderma and why would it resolve with steroids alone?

Because the pictures are so distinctive someone is going to know exactly what it is.

Take some more but clip the hair first and see if you can get the lesions as the progress from the start.

Re: Flat coat with widespread lesions

Rebecca MacMillan — Tue, 31 Dec 2013 18:01:58 GMT

I agree that they don't look like a typical pyoderma, especially as they don't seem to come up like pustules first, but that was the only thing that really came up on the lab results - chronic ulcerative dermatitis, which is consistent with chronic pyoderma according to the biopsy results. So this is what I went with! Especially as the dog was initially improving on the second course of antibiotics. The feet just seem to be licked rather than having any lesions on them. The lesions around the eyes and bridge of the nose are much smaller and more crusty than on the body. They are like small raised crusty bumps

Re: Flat coat with widespread lesions

Anthony Todd — Tue, 31 Dec 2013 17:10:02 GMT

I must admit the pictures[ which are quite good enough] don't look anything like I can remember or recognise and certainly nothing like a typical "allergic" skin to me.

Neither do they look like a pyoderma, but if pred is the only thing that works what options are you left with?

Can you clip an area with a real fresh lesion and get a picture?

Do you see these lesions on the feet or are the feet just licked??

Steroids do make most bacterial and most parasitic things worse though??

Better a comfortable dog than nothing.

Re: Flat coat with widespread lesions

Rebecca MacMillan — Tue, 31 Dec 2013 16:55:31 GMT

Sorry, photos probably aren't the best quality! I took them on my new Christmas present (tablet!) as I didn't have my proper camera with me when he came in yesterday. He is better than on initial presentation. But new sores are still opening up on him, with marked crusting/scurf. O is worried to brush him in case she opens a new sore up. He is now grumpy and fed up. This has been after 4 weeks of antirobe.

I took bloods yesterday to check for hypoT, waiting on results, and have started him on a course of preds as we discussed that he is actually feeling down and chewing his back feet. I've continued the antirobe whilst we initiate steroids, to make sure any immunosuppressive effects from preds don't cause a big pyoderma flare up (I doubt that this will happen, I'm not using immunosuppressive doses of preds! But thought I'd best cover myself).

I'm aiming to see him back in 7-10 days to see what difference the preds make. DO you think it's worth switching to cephorum if things still aren't resolving at this stage?? I also discussed novel protein diets with her. She's already put him on a 'hypoallergenic diet' for dogs with itchy skin, but brand escapes me at the mo.

Re: Flat coat with widespread lesions

Rebecca MacMillan — Fri, 27 Dec 2013 15:30:15 GMT

No I didn't actually - sounds interesting! Any more information?

I'm due to see this dog again soon, so if there are still lesions, I'll try and get some photos!

Re: Flat coat with widespread lesions

mariette asselbergs — Tue, 24 Dec 2013 15:38:57 GMT

Did you see the photographs in the last JSAP about the various Mycobacteria causing skin lesions in dogs. Round red surface under pealed off scab.......

Mariette

Re: Flat coat with widespread lesions

Anthony Todd — Fri, 20 Dec 2013 17:13:18 GMT

[quote user="Rebecca Benge"]The 'easiest' option probably would be to start him back on steroids and see how he goes[/quote]

Nice for the patient too.... but they only need to be given as one adequate dose and only when necessary so there's no need to "start him back on steroids" which implies a course, with all the long term potential effects.

It may well be that all these lesions are just the secondary result of self-trauma or secondary infection and if you eliminate that the lesions will resolve?

Similar to multiple lick granulomas.

What about the questions I asked? All can be answered or explored whilst you are controlling the recurrences of irritation with the single dose of pred or whatever.

It's easier to put the dog on a single protein source than a manufactured hypoallergenic diet, say chicken and water only for a fortnight and see.

Re: Flat coat with widespread lesions

Rebecca MacMillan — Fri, 20 Dec 2013 16:49:39 GMT

[quote user="Anthony Todd"]

Geez, all this time the dog's in all sorts of anguish whilst all the experts vacillate and theorise.

[/quote]

The dog is occasionally itchy at the moment and had an episode of chewing it's foot recently which has resolved again, so I don't consider him to be in anguish at present.

The 'easiest' option probably would be to start him back on steroids and see how he goes, but I was worried that as this is such a severe/unusual presentation that perhaps I was missing something obvious. Also having read others posts, I'm worried about the affect that steroids may have on any further testing we may want to do and it'll screw that up. Plus I was always told at uni that you should treat with either steroids or antibiotics (otherwise how do you know if the itchiness has improved because the pyoderma is resolving or because of the preds?). In fairness as a general rule, I don't abide by this all that often and find short courses of preds useful! But in this case as there was initial improvement after starting on the antirobe I decided to continue without adding preds back in whilst we awaited lab results.

The last lot of results are back now - NEGATIVE for dermatophyte culture.

I will try and post photos when he comes in for another check up soon. I think I'll suggest T4 sampling to the owner at that stage too. When I spoke to her recently she had already changed the dogs diet to something higher quality to see if that helps (but don't think it was a proper hypoallergenic diet), but again we discuss trying novel protein etc too. Also might test the water to see how she feels about preds again if the dog is still showing any signs of pruritus....

Re: Flat coat with widespread lesions

Rob Loxley — Fri, 20 Dec 2013 00:25:32 GMT

a 7.5yo dog is not a typical signalment for onset of alergic skin disease
there are underlying systemic diseases that can result in recurrent pyoderma
antibiotics and appropriate medicated bathing will go a long way to alleviating initial discomfort

Re: Flat coat with widespread lesions

Anthony Todd — Thu, 19 Dec 2013 23:32:37 GMT

[quote user="Utlendigur"]So all of those silly RCVS Specialist dermatologists are wrong for wanting animals off corticosteroids before they investigate and try to get a diagnosis?[/quote]

Of course not but these animals have been on continuous steroids sometimes for yonks. And, yes, there are some vets that bung everything on steroids on day one and do no diagnosis at all. I say do them concurrently so that the symptoms are relieved whilst diagnosis id pursued.

[quote user="Utlendigur"]And you won't get one if you just bung everything on 'steroids to make the symptoms disappear ....until the magic tablets run out and they come back again....[/quote]

Too true, but I'm not suggesting that . I'm suggesting that you take your samples, do your allergy eliminations and give steroids as necessary in adequate single doses to give symptomatic relief while you do this

[quote user="Utlendigur"]but I'd rather do that later in the process rather than as a first line treatment. [/quote]

So no relief until when? Why not give relief at the same time, but only as and when?

Re: Flat coat with widespread lesions

Anthony Todd — Thu, 19 Dec 2013 23:17:33 GMT

[quote user="robloxley"]hmm[/quote]

Ok, let's see how this case ends up. All the possibilities seem to have been explored. meanwhile, apart from a brief and promising spell on the dreaded steroids, the dog remains in no little distress.

Just how long does this pursuit of a diagnosis go on for and is it likely that a cure will result?

Re: Flat coat with widespread lesions

Rob Loxley — Thu, 19 Dec 2013 22:30:00 GMT

[quote user="Anthony Todd"]Use adequate steroids whilst you do this to...
... t won't influence any diagnosis you come up[/quote]

hmm

Re: Flat coat with widespread lesions

Utlendigur — Thu, 19 Dec 2013 22:24:03 GMT

[quote user="Anthony Todd"]Use adequate steroids whilst you do this to, at least, give the dog adequate relief, it won't influence any diagnosis you come up with[/quote]

So all of those silly RCVS Specialist dermatologists are wrong for wanting animals off corticosteroids before they investigate and try to get a diagnosis?

[quote user="Anthony Todd"]After all, a diagnosis is necessary to dictate treatment[/quote]

And you won't get one if you just bung everything on 'steroids to make the symptoms disappear ....until the magic tablets run out and they come back again....

[quote user="Anthony Todd"]What if you never get a diagnosis, let alone a treatment that leads to a resolution?[/quote]

At least some of us try to get a diagnosis, which in some cases may lead to a resolution, in some cases better management, and in a few cases, yes, they end up on 'steroids - but I'd rather do that later in the process rather than as a first line treatment.

Re: Flat coat with widespread lesions

Anthony Todd — Thu, 19 Dec 2013 21:52:21 GMT

"I guess the other option is to just go back to preds, as he responded so well last time, but I'd really like to try and get a diagnosis!"

"Have seen a couple of epitheliotrophic lymphoma cases that looked like the lesions you describe."

What, tumours that go away and then start somewhere else??

Geez, all this time the dog's in all sorts of anguish whilst all the experts vacillate and theorise.

Use adequate steroids whilst you do this to, at least, give the dog adequate relief, it won't influence any diagnosis you come up with if you ever do.

After all, a diagnosis is necessary to dictate treatment, not some sort of theoretical intellectual exercise.

What if you never get a diagnosis, let alone a treatment that leads to a resolution?

Re: Flat coat with widespread lesions

Utlendigur — Thu, 19 Dec 2013 20:49:21 GMT

[quote user="Andrew Kent"]

Would the owner let you biopsy again now the dog has been off steroids for a while? And can you try to get some photos? I always worry about neoplasia in flat coats.

Andy

[/quote]

Ditto. Have seen a couple of epitheliotrophic lymphoma cases that looked like the lesions you describe. Also find the quality of report you get on skin lesions varies with the lab - I always use Abbey for skin cases rather than our usual lab

Re: Flat coat with widespread lesions

Mark Hedberg — Thu, 19 Dec 2013 17:58:04 GMT

[quote user="Rebecca Benge"]

*sigh*

Just spoke to the owner on the phone, and as well as older lesions drying up, new ones are still appearing on his chest!! Plus he had an episode of really bothering at his foot again recently. I've said to continue with the antirobe and malaseb bathing and we'll assess again in about a week and a half before the antibiotic course finishes.

Should I switch to a different antibiotic?? I did discuss testing for T4 and re-sampling if things weren't improving...

I guess the other option is to just go back to preds, as he responded so well last time, but I'd really like to try and get a diagnosis!

[/quote]

Maybe there's an underlying allergy that's tickling things - what about trying a hypoallergenic food for a few weeks? Also, could go with cephalexin instead of clinda in case the spectrum's not quite right.