Alopecia X? Allergy?

Re: Alopecia X? Allergy?

Anthony Todd — Sat, 16 Aug 2014 07:51:16 GMT

[quote user="Kara Gibson"]I saw the dog last week, her skin looks improved[/quote]

Sometimes, just occasionally, and with a total regard for lab. tests, God forbid, the old dinosaureal Mk1 eyeball, a bit of knowledge and common sense can, miraculously, very unlikely I know, disgusting to the slavish followers of test results, make a difference.

If it looks like a duck and quacks like a duck it probably is hypothyroid!

Pity it wasn't tried a lot of time and money ago......

[see thread on chronic haemorrhagic diarrhoea cat too, more tests than a NASA moon-shot! ]

Re: Alopecia X? Allergy?

Kara Gibson — Sat, 16 Aug 2014 07:26:05 GMT

Hi,

I saw the dog last week, her skin looks improved, no further papules or pustules and no erythema. The alopeia looks simialr btu I know it can take some time for hair to regrow after hormonal alopecia. The total T4 is back within the normal range. An ACTH stimulation test was in the grey area of may or may not be Cushings.

I will recheck him again in 2 month to further assess hair regrowth.

Re: Alopecia X? Allergy?

Anthony Todd — Wed, 13 Aug 2014 20:21:41 GMT

And again, how's the dog; should be a change by now, for better or same?

Re: Alopecia X? Allergy?

Anthony Todd — Mon, 04 Aug 2014 18:00:21 GMT

How's the dog?

Re: Alopecia X? Allergy?

Kara Gibson — Wed, 23 Jul 2014 03:00:27 GMT

I talked through all the options with the owner and she was keen to trial a month of levothyroxine at the lower end of the dose range. I will be seeing him back and checking his total T4 and an ACTH stimulation test now he is off Vetoryl. I will let you know the outcome!

Re: Alopecia X? Allergy?

Anthony Todd — Tue, 22 Jul 2014 17:33:13 GMT

[quote user="Kara Gibson"]I have a long standing alopecia case I need help with! 6yo MN miniature poodle with black coat.[/quote]

How's the dog?

Re: Alopecia X? Allergy?

Anthony Todd — Mon, 14 Jul 2014 21:58:54 GMT

[quote user="Andrew Kent"]I've read the paper.[/quote]

So have I and these are the doses as quoted:

(1) 32Kg golden retriever

dose rate L-thyroxine 0.04mg/Kg q12hrs

TT4 6hrs after morning L-thyrox = 11.4uG/dl [ref range 1.0 - 4.0 uG/dl]

(2) 41.3Kg Great Pyrenees cross

Diagnosed as hypothyroid 18 months previously TT4 4nmol/L ref.range 15-50nmol/L

Free T4 10 pmol/L range 12-33pmol

But this was 2 weeks after a course of corticosteroids.

Started on a course of L-thyroxine at 0.025mg/Kg q 12 hrs and showed symptoms of hyperthyroidism and a T4 24 hrs after discontinuence of L-thyroxine showed a level of 75nmols/L ref. 15-50!!

Turned out dog was receiving multiple medication from various people in the house....!!

7 months later dog was rechecked and normal.

The authors go on to discuss the effect on the heart and say it is not uncommon to find dogs on thyroxin to have values above the reference range and any cardiac exam should include thyroid tests as well as a summary of the cardiac changes seen.

Re: Alopecia X? Allergy?

Anthony Todd — Sun, 13 Jul 2014 14:14:21 GMT

[quote user="Kate Richardson"]Sorry if I caused you any confusion with my approach.[/quote]

Got it now, thanks. Actually it turns out to be about the same as my approach, although if pyoderma recurs I tended to look again at possible instigators.

Fortunately most of them turned out to be fleas; again!

Re: Alopecia X? Allergy?

Kate Richardson — Sun, 13 Jul 2014 13:01:49 GMT

If I was seeing a dog for the first time with pyoderma I would treat for 2 weeks then recheck etc. If it was resolved then I wouldn't give further antibiotics.

If I was seeing a dog (like this one) that had been seen repeatedly for recurrent pyoderma which had only had a history of having repeated 1-2 weeks of antibiotics at a time, I would be highly likely to recommend giving a 4-6 week course of treatment, but I would still recheck after 2 weeks to ensure it was doing what I wanted to do. It's just because in my experience some dogs with recurrent pyoderma simply aren't treated for long enough, hence it appears to go away but come back. Sometimes these dogs have an underlying cause, sometimes they don't. If the owners are keen to investigate underlying causes early on then I do, but I do feel with recurrent skin issues you kind have to get the secondary issues such as pyoderma, cleared up and then see them at the first sign of recurrence so you can try to work out what comes first, for example does the itch come first or the pustules? (Not related to this case as not itchy I appreciate). Other owners choose to go with the 2 weeks recheck 2 weeks recheck regime, until all signs resolved then 2-3 weeks beyond resolution. If it then recurs again, then some owners feel more justified in investigating further if they aren't keen initially. Skin cases take a lot of explaining to the owners and really need continuity of care and getting the owners on board and plenty of patience. I was always told or remember from somewhere that skin turnover is approximately 3 weeks hence the need to treat for 2-3 weeks beyond resolution in chronic cases.

Sorry if I caused you any confusion with my approach.

Re: Alopecia X? Allergy?

Anthony Todd — Sun, 13 Jul 2014 11:59:42 GMT

[quote user="Kate Richardson"] So I would have the dog on antibiotics for a minimum 4-6 weeks continuously and treat for 3 weeks beyond complete normality both visually and on cytology. Cephalexin would be my antibiotic of choice, and I would use 20-30mg/kg bid. Shorter lower dose course may make the skin look normal, but you really need to get really close, clip hair off if nec (although may not be nec in your poor dogs case!) but treat continuously for a long period. [/quote]

Not trying to be a smart-arse but this is what you said first, did you actually mean 2 weeks and reassess etc.

I'm interested because what you said first is the modern view and it is the view, not you, that I wish to query because my experience is of shorter courses which seemed effective. [hopefully with the precipitating cause eliminated concurrently]

Re: Alopecia X? Allergy?

Anthony Todd — Sun, 13 Jul 2014 11:36:35 GMT

[quote user="Kate Richardson"]I have seen it in a dog that was confirmed hypothyroid before starting treatment[/quote]

Fair enough, thanks, can't dispute that. Sounds like the old conception of safety is wrong.

It's still being propagated by some "authorities" though as I've quoted already.

Re: Alopecia X? Allergy?

Kate Richardson — Sun, 13 Jul 2014 09:58:07 GMT

I have seen it in a dog that was confirmed hypothyroid before starting treatment and was on standard formulary doses- luckily the dog was presented for regular rechecks and had an observant intelligent owner who brought the dog in due to concerns about the dog's behaviour (panting, nervous energy) and clinical exam revealed tachycardia and bloods confirmed the T4 level was too high. Dose reduction dog fine. But not all owners are as ideal as we would like them to be and some vets are happy handing out repeat prescriptions without rechecking the dog.

[quote user="Anthony Todd"]Trouble is with any long or over long course of antibiotics, or indeed any drug is that you can't know whether a shorter course would have sufficed. A long course would, or could, prevent recurrence of course. .[/quote]

If you go back to what I wrote, I said I give 2 weeks then recheck, and give a further 2 weeks if there are still signs of pyoderma present and then recheck again. So if after 2 weeks I am happy that the infection has resolved I don't give any more antibiotics, so yes sometimes a shorter course does suffice.

Re: Alopecia X? Allergy?

Andrew Kent — Sun, 13 Jul 2014 09:27:54 GMT

I've read the paper. If you compare the doses used to those suggested in the BSAVA formulary then one dog was on a standard dose, one dog was on twice that (as I said earlier). If you don't believe me then subscribe to the journal and look yourself.

and I have also seen it for myself, not infrequently, including a lovely golden retriever who died of HCM. in honesty I never considered writing it up because it seemed a no-brainer that this could occur.

Re: Alopecia X? Allergy?

Anthony Todd — Sat, 12 Jul 2014 23:41:38 GMT

[quote user="Andrew Kent"]I'm afraid it was your website that was misquoting.[/quote]

Cardiovascular Manifestations of Iatrogenic Hyperthyroidism
in Two Dogs

by D.M. Fine, A. H. Tobias, and J.D. Bonagura

Journal of Veterinary (Cardiology) [sic] 2010; 12: 141-146.

It sounds pretty definite, judging by the title! Did you check the full paper? Did you go to my link?

Search Dr Mark E. Peterson, seems unlikely that he would get it so wrong to say nothing of the authors??

I assume it would be peer reviewed?

Re: Alopecia X? Allergy?

Anthony Todd — Sat, 12 Jul 2014 23:38:27 GMT

[quote user="Yantha Smyth"]I would have thought a euthyroid dog with T4 at 25 could quite easily become thyrotoxic on standard doses[/quote]

But have you ever actually seen it, with values or without, because the only case I can find showed it occurred at 2-4 times standard does [unless the other comment is mistaken which seems unlikely]. All the others were gross overdoses for various reasons or dogs fed cows' thyroid glands!

I had never heard of iatrogenic thyrotoxicosis until this thread, certainly not at therapeutic doses.

Why would you get non-specific improvement in skin appearance with thyroid supplementation if the animal was not actually hypothyroid. Is it ever used just to improve dog's skin? Have you ever seen it or heard of it?

I take the point that negative feedback on the thyro regulation could be a theoretical problem but if it does cause an improvement in the condition why stop [assuming nothing else has]. Tends to suggest that the dog was hypothyroid despite the euthyroid value of 26.

Trouble is with any long or over long course of antibiotics, or indeed any drug is that you can't know whether a shorter course would have sufficed. A long course would, or could, prevent recurrence of course. I can only say that I found a short course of a week, or two at the most, was the longest necessary to control most pyodermas if there was no underlying precipitating factor.

Re: Alopecia X? Allergy?

Andrew Kent — Sat, 12 Jul 2014 22:35:32 GMT

I'm afraid it was your website that was misquoting. As I have already told you the doses the dogs were on you can see that one of them was on a standard dose, one of them was just above this. Hardly massive overdoses.

Re: Alopecia X? Allergy?

Yantha Smyth — Sat, 12 Jul 2014 21:18:50 GMT

Re the thyroid discussion. I would have thought a euthyroid dog with T4 at 25 could quite easily become thyrotoxic on standard doses, as the dogs T4 was not low to begin with. I also was under the impression that one of the other reasons a 'therapeutic trial' is not recommended is that as well as the non-specific apparent (short term, transient) improvement that will be seen anyhow, you are effectively switching off the dogs own thyro regulation by negative feedback, creating an iatrogenic hypothyroid! That could complicate the picture down the line somewhat! Re the OP. I confess to not being conversant with the various steroid hormone changes, but if they are indicative of atypical Cushings, and the trilostane tx has caused over suppression, it might be worth using the much lower doses described in Nelson and Couto. I agree with using a long course of skin dose cephalexin and shampooing as suggested before. Did you think the histopath agreed with your clinical impression? It sounds discordant in places...a re- biopsy or 2nd opinion on the originals? Some people use different labs for their dermatohistopath.

Re: Alopecia X? Allergy?

Anthony Todd — Sat, 12 Jul 2014 20:44:45 GMT

[quote user="David Mills"]Do you think someone harping on about thyroid toxicosis is helping the OP?[/quote]

Yes, I think someone was, all that stuff about hyperthyroid cats and how they are and apparently misquoting a paper.

[quote user="David Mills"]Do you think someone harping on about thyroid toxicosis is helping the OP?[/quote]

Well possibly, because the argument that thyroid supplement is (a) unnecessary, because the thyroid value is normal and (b) because excessive thyroid is cardiotoxic and all sorts of other nasties.

But, unless I am wrong, thyroid supplement is only toxic when given in doses of at least 2-4 times recommended and not at accepted dose rates and I have suggested that I would try something at the lower end of the dose rate as the dog is, at worst, only marginally thyrotoxic.

Have I missed something? Is thyroxine ever toxic at normal dose rates?

You never know, approach A may be superior and we could try it now 'cos it appears to be safe after all.

Re: Alopecia X? Allergy?

David Mills — Sat, 12 Jul 2014 16:59:48 GMT

[quote user="Anthony Todd"]You can answer below but do try to stick to the points please.[/quote]

Can anyone explain the logic in the following arguing style?

I think approach A to be superior.

You can't prove A is inferior with evidence.

Therefore A is superior.

Well, there isn't any. It's called a burden of proof fallacy, and its well practised in this thread. No-one has studied A because its either unethical or mind-numbingly <insert word>.

Do you think someone harping on about thyroid toxicosis is helping the OP?

Re: Alopecia X? Allergy?

Anthony Todd — Sat, 12 Jul 2014 15:25:47 GMT

Now you're just a wind up!

Re: Alopecia X? Allergy?

Evelyn Barbour-Hill — Sat, 12 Jul 2014 14:07:10 GMT

[quote user="Anthony Todd"]

[quote user="David Mills"]

Epistemologists would have a field day with this thread. What is the difference between belief and knowledge?

[/quote]

Either Google or Wikipedia?

[/quote]

But which is which?

Re: Alopecia X? Allergy?

Evelyn Barbour-Hill — Sat, 12 Jul 2014 14:04:11 GMT

[quote user="David Mills"] Relevant to this discussion?[/quote]

No.

Re: Alopecia X? Allergy?

Anthony Todd — Sat, 12 Jul 2014 13:22:25 GMT

[quote user="David Mills"]

Epistemologists would have a field day with this thread. What is the difference between belief and knowledge?

[/quote]

Either Google or Wikipedia?

Re: Alopecia X? Allergy?

David Mills — Sat, 12 Jul 2014 12:40:44 GMT

Epistemologists would have a field day with this thread. What is the difference between belief and knowledge?

Re: Alopecia X? Allergy?

Anthony Todd — Sat, 12 Jul 2014 11:12:41 GMT

[quote user="David Mills"]

Whilst locumming at a charity in the UK a little while ago, I worked with a vet who:

1. didn't 'believe' in premeds

2. said stray FIV cats were fine to go back out into the world

3. externally coapted every fracture (bar spinal)

4. though ultrasound was 'useless'

5. bemoaned the day pure penicillin couldn't be used for skin infections

6. Took pride in the fact he hadn't done CPD other than a 1974 book about 'pet medicine' in 10 years

He qualified 40 years ago. Relevant to this discussion?

[/quote]

Just to clear things up, my answers are

1. I do for sure, and there are better ones than Largactil now.....

2. No if possible. What if the alternative is euthanasia?

3. Sometimes, just as they do in young humans; eg simple mid-shaft radius/ulna #.

[funnily enough my next door neighbour's pom is limping around with a palpable plate put in as a pup a few years ago on the tiny radius/ulna and the screws are palpable as well....]

Putting a cast on is a lost art anyway, just watch the experts in a plaster room at a busy A&E, boy are they good to watch!

4. Often equivocal leading to delay and more investigations sometimes. Does anyone ever palpate an abdomen these days?

5. No, useless, always has been for skins. They all need at least six weeks of cephalexin I've recently learnt.

6. I'm on here aren't I?

I graduated 53 years ago [used a calculator though....]

So easy to respond by a veiled personal attack; not the sign of a discussion winner IMHO.

But back to the evidence of thyroxin "toxicity", at sensible dose rates in dogs, credible or distorted by careless association?

You can answer below but do try to stick to the points please.