Iatrogenic Cushings

RE: Iatrogenic Cushings

Julie Innes — Wed, 01 Nov 2017 22:37:10 GMT

Thank you, Rob and Richard! I knew I wasn't making these things up, but my brain refused to put a name to them- that's the 2 I was thinking of

RE: Iatrogenic Cushings

Richard Allport — Wed, 01 Nov 2017 21:31:49 GMT

[quote user="Julie Innes"]

Just thought- I seem to remember doing a CPD course where some weird skin cancers caused symptoms like this. Also that thing where liver issue causes intense pruritis (can't remember name now, brain has stopped!) I'd say its worth a biopsy

[/quote]

Epithelial cutaneous lymphoma, for instance.

RE: Iatrogenic Cushings

Rob Loxley — Wed, 01 Nov 2017 19:47:39 GMT

[quote user="Julie Innes"]Also that thing where liver issue causes intense pruritis (can't remember name now, brain has stopped!) I'd say its worth a biopsy[/quote]

Hepatocutaneous syndrome, have one at the moment, not much fun to try and manage!

RE: Iatrogenic Cushings

Anthony Todd — Wed, 01 Nov 2017 17:48:35 GMT

[quote user="Julie Innes"] worth a biopsy[/quote]

Yes, but take a plug from the centre of the worst patch and shave and get one from the periphery.

Doubt if a pyoderma ever presents like this???

RE: Iatrogenic Cushings

Julie Innes — Wed, 01 Nov 2017 17:33:26 GMT

RE: Iatrogenic Cushings

Roland Bulkyn-Rackowe — Wed, 01 Nov 2017 17:20:50 GMT

It would be good to have a biopsy from this skin. I've seen a few deep pyoderma cases that look like this, usually atopic (or suspected to be) and resolved with a good course of antibiotics - 4+ weeks of cephalexin or TMS if limited funds.

RE: Iatrogenic Cushings

mariette asselbergs — Tue, 31 Oct 2017 18:48:43 GMT

I am old enough to have seen thallium cases. By the time they are losing hair they are dying in an awful manner (inflammation of all mucosa/skin borders, and internally).

Mariette

RE: Iatrogenic Cushings

Julie Innes — Tue, 31 Oct 2017 09:02:59 GMT

Years ago I had a boxer presented with calcinosis cutis ( it too had been on steroids for years), and it's hair fell out in clumps just as you describe, and he was intensely pruritic, but the distribution was different- it was mainly from the back of his neck down his back. I suppose it's still a possibility. I diagnosed it on biopsy.

RE: Iatrogenic Cushings

Anthony Todd — Mon, 30 Oct 2017 21:56:10 GMT

It won't help, but I've never seen anything like that before....

Too random for contact derm [value of pictures!] and too diffuse and random for parasitic. No signs of self mutilation either. The picture of the hairs look like a response to a chemical liquid ie a "burn"??

Shave a test lesion and see if there are ominous signs and/or do histo on an edge lesion where the hair is still apparently vital?? If there are none I'd still go for something in contact with the skin??

Steroid response suggests some sort of insult response??

Last time I saw hairs coming out like that it was a rabbit when the heated pad burnt the skin and the hairs did just that.

The distribution of the lesion was confirmatory, but distribution in this case doesn't support that??

RE: Iatrogenic Cushings

Avril Mc Ginn — Mon, 30 Oct 2017 19:49:19 GMT

[quote user="Anthony Todd"]

PS Some pictures would be worth a thousand words.....

[/quote]

Sorry for a delay in replying,

the dog came back in last week, the owner reported he was much much more comfortable and noticed a dramatic decrease in the pruritis, this was noted in the consult also (phew:)

the plan is continue to taper out pred and continue with apoquel longterm as needed, continue antibiotics until better resolution, the skin was more lichenified/thickened when first presented.

RE: Iatrogenic Cushings

Bill Nolan — Mon, 23 Oct 2017 18:24:38 GMT

[quote user="Martin Atkinson"]No idea on costing but I don't imagine it will be any cheaper than Apoquel.[/quote]

It isn't. I think there's a marginal saving if you're dosing >25kd, but for smaller dogs its equivocal. Shame, thought we was on to a winner here! Except, you know, for those really hard to pill dogs...

RE: Iatrogenic Cushings

Joyce Whitehead — Mon, 23 Oct 2017 11:45:15 GMT

[quote user="Martin Atkinson"]

[quote user="Joyce Whitehead"]

Could be a candidate for Cytopoint?

[/quote]Have you tried it yet. I'm awaiting a visit from the Zoetis rep. Last time I looked on NVS it wasn't there. No idea on costing but I don't imagine it will be any cheaper than Apoquel.

[/quote]

No I haven't tried it but went to a Zoetis CPD last week. Upshot is on cost it's more than Apoquel, especially for small and very large dogs, not as big a difference for the medium ones. Certainly cheaper than Apoquel and Atopica together (we have a couple of dogs on this combo). Should now be available from wholesalers I think.

RE: Iatrogenic Cushings

Anthony Todd — Mon, 23 Oct 2017 11:00:43 GMT

[quote user="Anthony Todd"]Vaguely remember thallium doing something to hair loss??[/quote]

PS apparently thallium causes changes in human nails, so might pay to look at the claws in this dog.

https://www.ncbi.nlm.nih.gov/pubmed/15208382

RE: Iatrogenic Cushings

Martin Atkinson — Mon, 23 Oct 2017 09:51:12 GMT

[quote user="Joyce Whitehead"]

Could be a candidate for Cytopoint?

[/quote]Have you tried it yet. I'm awaiting a visit from the Zoetis rep. Last time I looked on NVS it wasn't there. No idea on costing but I don't imagine it will be any cheaper than Apoquel.

RE: Iatrogenic Cushings

Anthony Todd — Mon, 23 Oct 2017 00:06:12 GMT

[quote user="Virginia Campbell"] Just wondering what else could affect the follicles like this. [/quote]

Yes, me too. Chemical burn/damage?? Is it only in the "bald" areas?

I can't ever remember demodex only on the flanks???

Getting curiouser and curiouser and sounding more like some sort of contact with something nasty??

Environment needs a forensic search?? Vaguely remember thallium doing something to hair loss??

Anyone had case where the hair can be pulled out as opposed to "irritated" away??

This could be relevant re skin signs:

http://lib.dr.iastate.edu/cgi/viewcontent.cgi?article=2409&context=iowastate_veterinarian

RE: Iatrogenic Cushings

Virginia Campbell — Sun, 22 Oct 2017 23:00:33 GMT

[quote user="Avril mcginn"]When I pet him in the consult he is obviously pruritic, and his coat comes out in clumps.[/quote]

This is the strangest bit to me. Hair does not usually epilate that easily to the point of falling out in your hands even with hypot4, lots of pred, Cushings or bad atopy. What could be affecting the follicles? The last one I saw like this was a lab on immunesuppressive doses of pred who had hotspots on the side of his face. The hair was coming away in my hands. I skin scraped the lesions and he was hooching with Demodex. But your dog is on Bravecto and I believe it's good for treating Demodex. Just wondering what else could affect the follicles like this.

RE: Iatrogenic Cushings

Anthony Todd — Sun, 22 Oct 2017 21:47:15 GMT

[quote user="Beats"]It is common practice to use 3-5 day courses of preds, or equivalent corticosteroid, for allergy flares.[/quote]

Yes, but it's completely unnecessary!

One dose will last until the next one is needed, usually 3-5 days as a minimum.

Of course, hopefully in that time the allergen will have been discovered and eliminated so no further dose is needed.

RE: Iatrogenic Cushings

Beats — Sun, 22 Oct 2017 21:37:09 GMT

[quote user="Anthony Todd"][As an aside] I wonder why nobody seems to stretch the dosage interval to "repeat as necessary" thereby achieving the same relief and certainly avoiding any iatrogenic HAC in these sort of "chronic" cases?[/quote]

It is common practice to use 3-5 day courses of preds, or equivalent corticosteroid, for allergy flares.

RE: Iatrogenic Cushings

Anthony Todd — Sun, 22 Oct 2017 21:08:07 GMT

[quote user="Martin Atkinson"] I wonder why he's been on sid preds and no-one has tried to get him on alternate days which may well have avoided iatrogenic HAC.[/quote]

[As an aside] I wonder why nobody seems to stretch the dosage interval to "repeat as necessary" thereby achieving the same relief and certainly avoiding any iatrogenic HAC in these sort of "chronic" cases?

RE: Iatrogenic Cushings

Avril Mc Ginn — Sun, 22 Oct 2017 20:40:21 GMT

[quote user="Joyce Whitehead"]

Could be a candidate for Cytopoint?

[/quote]yes i would think so, but im worried about spending money on cytopoint when at the moment there is such a poor response to apoquel that im worried there is something else going on!

RE: Iatrogenic Cushings

Avril Mc Ginn — Sun, 22 Oct 2017 20:38:06 GMT

[quote user="Anthony Todd"]

PS Some pictures would be worth a thousand words.....

[/quote] thanks for your input Anthony, the client is back this tuesday, with her permission I'll take some pics and post

RE: Iatrogenic Cushings

Anthony Todd — Sun, 22 Oct 2017 19:45:41 GMT

[quote user="Martin Atkinson"]We used to have dinovet steroid king up the road, he 'worked miracles' with the flea allergies!![/quote]

Sounds like me. I surveyed 500+ fleas allergies back in the day when they were all "hormonal" and introduced Taskil [malathion] to the UK when all we had was pyrethrum. [sorry about the smell]

And no there isn't a paper. I just did it for me.

This doesn't sound like any allergy I've ever seen and it may just be a contact dermatitis which, of course, will be helped by corticosteroids but better to remove the contact, or indeed the allergen in "normal" allergic derms whilst giving symptomatic symptom relief if, and only if, necessary and when necessary in single doses.

Every time corticosteroids are mentioned and denigrated it is always when they have been grossly misused, and to excess, and every time I try and correct this.

But it's "turboposting" and again now......

RE: Iatrogenic Cushings

Joyce Whitehead — Sun, 22 Oct 2017 19:06:52 GMT

Could be a candidate for Cytopoint?

RE: Iatrogenic Cushings

Martin Atkinson — Sun, 22 Oct 2017 18:58:47 GMT

[quote user="Virginia Campbell"] I have also seen pruritic dogs with severe Demodex (assume due to 2ndry infection).[/quote]Ditto. We used to have dinovet steroid king up the road, he 'worked miracles' with the flea allergies!! Sadly I saw a fairly endless stream of iatrogenic HAC, DM and Demodex cases whose owners eventually were sensible to realise he was all bedside manner and bovine dung with few clinical skills!

RE: Iatrogenic Cushings

Michael Woodhouse — Sun, 22 Oct 2017 18:24:51 GMT

[quote user="Avril mcginn"]is an ACTH stim necessary when I plan to wean off pred anyway?[/quote]

Pred cross reacts in the cortisol assay (cf dex which doesn't). Keep that in mind.