Frustrating Atopy case

Re: Frustrating Atopy case

Anthony Todd — Sun, 06 Jul 2014 10:58:56 GMT

[quote user="robloxley"]There are some good written guidelines for managing canine atopic dermatitis at http://onlinelibrary.wiley.com/doi/10.1111/j.1365-3164.2010.00889.x/pdf that are well worth reading, and make relevent comments in relation to these points.[/quote]

Trouble is a lot of what the paper say is an extrapolation of human advice, particularly the use of topical steroids and other topicals.

I was going to copy and paste examples but I then I usually get accused of taking things out of context.

Even the reference talks of "irritation" after some shampoos or washes [in humans] and my experience is that virtually any shampoo on a dog with an inflamed skin makes the irritation and the dog's discomfit worse!

Unless you resort to physical restraint anything topical will be removed in no time or less and usually, merely by licking, the original irritation will be made worse. "Lick granuloma" illustrates my point.

The legendary steroid side effects, which are always exaggerated by most experts, relate only to prolonged or excessive use which, except in the chronic cases shown well in the paper, is unnecessary.

Side effects from a single but effective dose are rare and, if occurring, can usually be reduced or eliminated by reducing the dose at the next inevitable [unless you're very lucky, or an environmental change] flare.

Why the experts give continuous steroids for a condition with often a single trigger [let's say a single flea bite] is beyond me.

I suppose they take paracetamol for a week or two after a hangover?

Re: Frustrating Atopy case

Rob Loxley — Sat, 05 Jul 2014 12:59:35 GMT

[quote user="Anthony Todd"]So the pyoderma is secondary? No point in treating it then is there? [/quote]

[quote user="Anthony Todd"]I was always reluctant to bath "allergic" skin because I felt it might irritate the already sensitive skin unless the shampoo was "mild". it won't stop the allergic reaction, that's for sure[/quote]

There are some good written guidelines for managing canine atopic dermatitis at http://onlinelibrary.wiley.com/doi/10.1111/j.1365-3164.2010.00889.x/pdf that are well worth reading, and make relevent comments in relation to these points.

Re: Frustrating Atopy case

Anthony Todd — Fri, 04 Jul 2014 20:11:34 GMT

[quote user="Clare Smith"]The pruritis is always there even when there has been no signs of pyoderma [/quote]

So the pyoderma is secondary? No point in treating it then is there? Chase the primary.

Was the response to the itching good at the quoted dose rate if so try a reduced dose or, as I said a jab of Dex Q or bets but at the lower and of the dose rate.

Keep reducing the dose until you don't stop the itch ie get to the minimal effective dose as infrequently as is effective, almost certainly this will not be daily, which is where a lot of the problems of polydipsis etc comes from.

From the dog's point of view inappropriate urination is better than intolerable itching!!

Does polydypsia occur concurrently with the "polyuria"? Often boiled water reduces the water intake to physiological and hence the peeing everywhere.

If definitely no fleas, or contact with fleas then dietary trial sounds a good step but owner compliance, to say nothing of children, aunties and grannies dropping ice cream and god knows what makes it a tedious task.

A good steroid response, and I mean sudden and almost total remission, [apart from the peeing] is, IMHO, a pretty good indication of an allergic aetiology rather than any sort of infection.

I was always reluctant to bath "allergic" skin because I felt it might irritate the already sensitive skin unless the shampoo was "mild". it won't stop the allergic reaction, that's for sure.

I'll bet it's not parasitic [except the remote possibility of fleas]. Ever seen any fleas ever; neighbours, cats, visitors, etc.?

Re: Frustrating Atopy case

Clare Smith — Fri, 04 Jul 2014 19:07:36 GMT

Thanks for all the replies!

The pruritis is always there even when there has been no signs of pyoderma - the owenr reports that the only time the dog has been super itchy in years was when he was on BID Apoquel.

[quote user="Anthony Todd"]

"Polyuria" is steroid dose dependent and much worse with continuous doseage.

Try betamethasone instead . Dare I suggest depomedrone inj? [S/C is fine.]

And single effective doses by trial rather than continuous lower dose, but I know your aversion to steroids even the mention of the name......

[/quote]

In this case Anthony I would love to be able to use Preds, however the owner is very steroid averse after having a bad response at prev vets to 0.5m/kg SID (reported aggression as well as PU/PD) and urination in the house on 0.25mg/kg - think I will find it very difficult to convince her to try depo or another steroid at this stage. The pruritis is definately steroid responsive though - just the owner cannot tolerate the side effects (to be honest i am not sure in reality how much the low dose pred I tried affected the dog and how much is the owners preconceptions about steroids now)

[quote user="robloxley"]- cortavance topically?
- if regular shampooing, how effective is advantage/advocate for flea control? [/quote]

Good point! I quite like comfortis tin these cases so may get her to try that. the pruritis is pretty widespread so not sure about cortavance over such a wide area

Client is back in next week to check the pyoderma - will see if she is happy to repeat skin scrapes etc then will probably add EFAs etc if nothing found (really not convinced re sarcoptes in this case but will still consider stronghold). Will probably have to have the steroid discussion again with her

I had thought about referral but it would be more as a cop out - not sure they would do much different but would get her out of my hair!

Re: Frustrating Atopy case

Bob Russell — Fri, 04 Jul 2014 15:52:09 GMT

I consider Imidocloprid pretty good for basic flea control. Weaknesses - don't think it lasts even the four weeks with great reliability also owners are pretty rubbish at measuring four week intervals!

Works brilliantly in the form of Seresto but I tend to resist using a collar in a dog with existing lesions in case they aggravate the skin.

Stronghold for at least three consecutive months would be my recommendation.

Not evidence based of course but works for my patients!

Re: Frustrating Atopy case

Rob Loxley — Fri, 04 Jul 2014 13:43:39 GMT

- cortavance topically?
- if regular shampooing, how effective is advantage/advocate for flea control?

Re: Frustrating Atopy case

Suzanne Kelly — Thu, 03 Jul 2014 23:59:28 GMT

Treat the pyoderma first. A long course of a suitable antibiotic - at least 6 weeks with no immunosuppressive treatement. A lot of yorkies are itchy because of the pyoderma.

Re: Frustrating Atopy case

Anthony Todd — Thu, 03 Jul 2014 18:19:49 GMT

Does the pyoderma come before, during the itch or after the itch has been going for a while?

ie is the pyoderma the cause or the result?

Does the shampoo make it better or worse?

Are the owners doing anything else they haven't mentioned.

As far as a diet trial goes I reckon a single source of one protein is better than a manufactured mix

Where are the lesions, if any, or is it generalised? Where do they start?

Any other animals in the house or regular contact ie neighbour/relative's house etc?

Try one shot of dexQ to confirm steroid response.

Sorry, you've probably done all this.

"Polyuria" is steroid dose dependent and much worse with continuous doseage.

Try betamethasone instead . Dare I suggest depomedrone inj? [S/C is fine.]

And single effective doses by trial rather than continuous lower dose, but I know your aversion to steroids even the mention of the name......

Sorry, again you know, and have done all the above i'm sure.

Referral is just a cop-out surely [and it'll come back on steroids and something esoteric just to impress you]

Awaits red-star

Re: Frustrating Atopy case

Martin Atkinson — Thu, 03 Jul 2014 16:44:43 GMT

[quote user="Clare Smith"]My only other thoughts were to add in EFAs or anti histamines etc but don't have much faith that they will improve things in such a severe case[/quote]In these cases it is often the accumulation of marginal gains that works. So throw everything at it: hypoallergenic diet, Advocate + regular worming, EFA supplements (Viacutin Plus) Malaseb, moisturising spray (Ermidra), antibiotics, antihistamines (hydoxyzine) , as much preds as it will stand (once you're sure there's no Demodex), cyclosporin, and Apoquel when you can get it again. The clients need to know this is never going to be cheap so they have to be committed or you are going nowhere.

Alternatively cut your losses and refer it.

Re: Frustrating Atopy case

Andrew Kent — Thu, 03 Jul 2014 15:28:04 GMT

In dogs who are this pruritic, going back and repeating your investigations is usually a good plan in case the situation has changed (for example a mite has appeared!).

So I would repeat skin scrapes, hair plucks, surface cytology and would agree that a trial treatment with something that kills sarcoptes would be an excellent plan.

You don't talk about diet and again this would be high up on my list so starting an 8 week trial with a suitable diet based on dietary history

Andy

Re: Frustrating Atopy case

Clare Smith — Thu, 03 Jul 2014 15:25:12 GMT

Thanks for the quick reply:

Looking back at the history from the other vets he had a diet trial with Z/D for 8 weeks (notes convincing that was carried out correctly) a couple of years ago with no repsonse

I had thought about stronghold/advocate too just in case - think it less likely with the history but definitely worth a try i guess!

My only other thoughts were to add in EFAs or anti histamines etc but don't have much faith that they will improve things in such a severe case

Re: Frustrating Atopy case

Utlendigur — Thu, 03 Jul 2014 15:17:25 GMT

Two random thoughts

1. treat with stronghold just in case sarcoptes (and/or sarcoptes serology) - negative skin scrape doesn't rule it out (plus you can get cross reaction to dust mites)

2. elimination diet