Help needed with a skin case please!

RE: Help needed with a skin case please!

Nicola Cole — Wed, 04 Jul 2018 13:31:09 GMT

[quote user="Martin Atkinson"]

[quote user="Nicola M"]Yes, there will be some vets that always want a diagnosis, but this will be a small percentage.[/quote]Do you really mean that? Not: 'the vast majority want a diagnosis but in a percentage of cases this may not be practical or possible and as the only realistic alternative may advise a therapeutic trial'. If not then I, and I presume everyone else who has contributed to this thread (excluding Anthony), are in your small percentage which has then become a rather large percentage!

[/quote]

Well yes, you’ve put it much better than me!

What I was trying to say was that the view that had been expressed that ‘modvets’ will never give treatment without a confirmed diagnosis was, IMO, incorrect.

I was including the kind of things we treat all the time eg dog with vomiting and diarrhoea, young dog with a hacking cough for 24 hours that we would initially treat therapeutically (or not treat) unless specific cause for concern from clin exam/history and only investigate if not resolving.

Not sure if that explains my point better-just trying to refute the oft-quoted ‘modvets’ won’t treat anything without a blood sample, X-ray and MRI scan!

RE: Help needed with a skin case please!

Anthony Todd — Wed, 04 Jul 2018 11:58:06 GMT

[quote user="Martin Atkinson"]I don't know why I'm wasting my time but you have deliberately manipulated what I wrote for your own ends and further comment is beneath me.[/quote]

I only showed that what you wrote can easily be reversed into my contra-argument....

I doubt if Prof May has ever been involved in any dodgy surveys??

RE: Help needed with a skin case please!

Martin Atkinson — Wed, 04 Jul 2018 10:03:11 GMT

[quote user="Anthony Todd"]the vast majority want a diagnosis but in a percentage of cases this may not be practical or possible and as the only realistic alternative may advise a therapeutic trial[/quote]I don't know why I'm wasting my time but you have deliberately manipulated what I wrote for your own ends and further comment is beneath me.

RE: Help needed with a skin case please!

Anthony Todd — Wed, 04 Jul 2018 09:54:58 GMT

the vast majority want a diagnosis but in a percentage of cases this may not be practical or possible and as the only realistic alternative may advise a therapeutic trial

At last, the rub! The vast majority, probably all [of owners] , just want the animal to get better.

The vast majority of dinovets knew what would make the animal better,

but in a percentage of cases this may not be practical or possible and as the only realistic alternative may

be tests which were done......

Or should we all have scraped the thousands of obvious dorsal flea allergy for demodex?

Sorry, quotes don't work, sometimes for me.

RE: Help needed with a skin case please!

Martin Atkinson — Wed, 04 Jul 2018 09:33:47 GMT

RE: Help needed with a skin case please!

Gillian Mostyn — Wed, 04 Jul 2018 07:22:19 GMT

[quote user="Anthony Todd"]Summarises well my approach as opposed to the modvet approach and I don't think the twain will ever meet.....[/quote]

It also summarises the opinion of 12 new grads, and then extrapolates that to the whole profession!

RE: Help needed with a skin case please!

Nicola Cole — Wed, 04 Jul 2018 05:59:05 GMT

[quote user="Anthony Todd"]

[quote user="Gillian Mostyn"]

snap

[/quote]

https://www.vetsurgeon.org/news/b/veterinary-news/archive/2018/07/03/happiness-is-a-non-clinical-problem.aspx

Summarises well my approach as opposed to the modvet approach and I don't think the twain will ever meet.....

[/quote]

With all due respect: as has been said before, the cases on here are generally the more unusual ones and therefore often a diagnosis would be a good idea. There will be a huge number of cases that just get treated empirically as it’s ‘likely to work’ so most would just get on with a therapeutic trial for them.

Yes, there will be some vets that always want a diagnosis, but this will be a small percentage.

RE: Help needed with a skin case please!

Anthony Todd — Tue, 03 Jul 2018 22:16:57 GMT

[quote user="Gillian Mostyn"]

snap

[/quote]

https://www.vetsurgeon.org/news/b/veterinary-news/archive/2018/07/03/happiness-is-a-non-clinical-problem.aspx

Summarises well my approach as opposed to the modvet approach and I don't think the twain will ever meet.....

RE: Help needed with a skin case please!

Gillian Mostyn — Tue, 03 Jul 2018 11:58:13 GMT

RE: Help needed with a skin case please!

Anthony Todd — Tue, 03 Jul 2018 09:37:29 GMT

[quote user="Gillian Mostyn"]

Anthony...you can certainly cause long term harm with glucocorticoids if used inappropriately. I had a second opinion that developed some small, patchy, itchy skin lesions on its flanks, which the previous vet treated with antibiotics and preds. They continued to progress, and over 6-12 months the dog got more itchy, got more roids again, etc etc...when I saw it, the poor dogs skin was covered in itchy bleeding ulcers along both flanks.

One biopsy confirmed calcinosis cutis. (The skin was so crispy, histopathology just told me what I suspected...some areas had then transformed to become neoplastic.) The biopsy was done conscious with a bleb of local anaesthetic.

Whilst I agree that corticosteroids are a valuable resource, and trial therapy is justified in some cases, it is difficult to argue that a full and definitive diagnosis is always preferable before starting any therapy...no?

[/quote]

I'm sure you don't mean what you have written??

So I do agree, that it is difficult to argue that a full and definitive diagnosis is always preferable before starting any therapy...er, yes?

And, the "difficult" argument is always "confirmed" on every occasion, either by gross misuse, or gross overuse, as in your example quoted.

[and my 5000 Betsolan tablet boxer....]

RE: Help needed with a skin case please!

Gillian Mostyn — Tue, 03 Jul 2018 08:01:23 GMT

RE: Help needed with a skin case please!

Anthony Todd — Mon, 02 Jul 2018 17:20:35 GMT

No, some would say I should join cortico [or whatever is the approved name on vetsurgeon.org] -steroids anonymous

RE: Help needed with a skin case please!

Julie Innes — Mon, 02 Jul 2018 14:17:24 GMT

You are nothing if not tenacious, Anthony! If you went on Mastermind, I bet your specialist subject would be the use of corticosteroids

RE: Help needed with a skin case please!

Anthony Todd — Mon, 02 Jul 2018 12:30:41 GMT

[quote user="Lucy Fleming"]What would you use?[/quote]

True.

in this case probably a "rapid" short-acting like dex, mightn't give the usual 12 hour response you get from it in an itchy dog, so probably methylpred, would be my choice as you'll need an obvious response for a while.

Then go on your intermittent, but therapeutic level, pred when necessary and never continuous, at any dose level.

Sorry another reflex turbo, [can't help myself]

RE: Help needed with a skin case please!

Lucy Fleming — Mon, 02 Jul 2018 11:57:53 GMT

[quote user="Anthony Todd"]

There are much more effective steroids than pred, and therefore results are quicker and more definite.

[I don't know why pred, on vetsurgeon.org, seem always to be the steroid quoted??]

[/quote]

What would you use?

From this type of lesion, I don't think I would expect to see much improvement from a single dose of steroid - not enough to really gauge whether the treatment was working or not. I can see how, for very pruritic skin disease that approach can be useful (as the owner can report back whether the pruritus is improved, even before secondary lesions from self trauma heal) - for other types of skin disease where pruritus isn't a feature, the amount of improvement after a single, short acting injection would be negligible, I would have thought.

I don't think the dog in this case is particularly itchy?

RE: Help needed with a skin case please!

Anthony Todd — Mon, 02 Jul 2018 10:29:25 GMT

Given the site of the lesions, and the probable sensitivity, sedation only" would be risky, IMHO.

There are [from the pictures] no signs of infection??

There are much more effective steroids than pred, and therefore results are quicker and more definite.

[I don't know why pred, on vetsurgeon.org, seem always to be the steroid quoted??]

RE: Help needed with a skin case please!

Michael Woodhouse — Mon, 02 Jul 2018 00:33:57 GMT

[quote user="Anthony Todd"]I assume the biopsy would require a GA for a start?[/quote]

We'd sedate for biopsies usually.

I think I agree with everyone, it would be best to get a diagnosis, but if the owner was unwilling then I would happily try preds at an immunosuppressive dose and see what happened.

Steroids in the presence of infection being a 'disaster' is a myth. If signs worsen with pred then add in suitable antimicrobial/antifungal drugs. It's quite simple.

RE: Help needed with a skin case please!

Anthony Todd — Sun, 01 Jul 2018 13:53:20 GMT

[quote user="Aine Seavers"]With the caveat that -Yes no dog should ever go to its grave suffering a dex or a pred deficiency;

[/quote]

So true, because that maybe what's happened elsewhere and already?

I'd feel suitably squashed if a trial of some potent steroid had been given with poor results, or even some immunosuppressive.

Someone should ring and find out??......

Cortovance will be difficult to spray on the nose I reckon but a topical 'roid is, I think a great option with boots, as suggested, with those damaged paws.

Just out of interest, and if folk can be bothered, and assuming the biopsy was positive for an auto-immune disease what would be the treatment protocol given that this seems pretty mild.

I assume the biopsy would require a GA for a start?

RE: Help needed with a skin case please!

Nicola Cole — Sun, 01 Jul 2018 13:24:33 GMT

I’m more than happy with ‘therapeutic trials’ for a lot of conditions but I think one of this nature which may well end up lifelong and may involve harder hitting immunosuppressive drugs should have a diagnosis if possible.

If the owners can’t/don’t want to achieve a diagnosis then that’s a different matter. However, I think the delay/cost to get the diagnosis is definitely warranted on a case like this.

RE: Help needed with a skin case please!

Aine Seavers — Sun, 01 Jul 2018 01:46:52 GMT

With the caveat that -Yes no dog should ever go to its grave suffering a dex or a pred deficiency; in this case, there are enough factors to equally validate the trialing of other therapies that would then either preclude or eliminate the need for preds. By putting preds as the first cab off the rank then you set the case up to gain bad press for pred trials if it goes wrong. If there is a mucocutaneous pyoderma, this dog needs antibiotics not preds, if the lesion are a cutaneous lupus variant then topical Cortavance (yes a steroid but not preds) will do just as well-if its a GSD and you suspect fungal or internal renal neoplastic conditions throwing external cutaneous markers then finding both of those out before the preds would be beneficial and less painful to both the dog and the vet as the owners of latter not happy to discover dog had renal lesions whilst skin was the red herring. Its a larger breed dog so also more likely to have side effects on the preds. So for me, to avoid giving the use of preds as a therapeutic trial for other dogs a bad name (and the trials are a valid option), this dog has enough causes for concern that we really need to get some more diagnostic data information on the table at the start before starting ANY therapy

RE: Help needed with a skin case please!

Anthony Todd — Sat, 30 Jun 2018 11:13:02 GMT

[quote user="Thomas Johnson"]It is possible[/quote] etc

Thanks for a sensible response and sorry to troll again but, in this case there may be a tendency to overtreat at this stage of the condition in this patient.

Looking at the many [gruesome] pictures of secondary infection etc. etc. on a simple net search, it seems that this, even if confirmed, is right at the "minimal" end of the pemphigus spectrum.

As spontaneous resolution is possible it seems reasonable at this stage to treat with, not a course or continuously, but pulse single dosing of an adequate single dose of glucocorticoids, as and when necessary.

It appears that some pemphigus doesn't progress.

RE: Help needed with a skin case please!

Thomas Johnson — Sat, 30 Jun 2018 10:00:23 GMT

[quote user="Anthony Todd"]Can most all of you never accept that sometimes, and this, IMHO, is one of them, the diagnosis, even if you get a label, doesn't necessarily change or obviate the need for a treatment which in this case, I wager, will be steroids in adequate doses only as and when symptoms or signs dictate.[/quote]

It is possible that you are right, but I think this presentation is unusual enough, and because it has the potential to be an immune-mediated condition, such as pemphigus or lupus, that would need immune-suppressive doses of steroids, possibly combined with other potentially harmful drugs like azathioprine or cyclosporine, for a substantial period of time, that it would be better to get a diagnosis before treating, both because not treating adequately if it is an immune-mediated condition could lead to a dog that goes in cycles of improving with symptomatic steroid treatment and then getting worse again, but generally being on a downward trajectory; and if it doesn't require such intensive treatment, but you do it just in case, there is quite a high risk of putting it through unnecessary side-effects.

RE: Help needed with a skin case please!

Anthony Todd — Fri, 29 Jun 2018 20:34:26 GMT

[quote user="robloxley"]Can you never accept that it may be desirable to get a diagnosis in order to be able to fix the animal?[/quote]

Can most all of you never accept that sometimes, and this, IMHO, is one of them, the diagnosis, even if you get a label, doesn't necessarily change or obviate the need for a treatment which in this case, I wager, will be steroids in adequate doses only as and when symptoms or signs dictate.

Furthermore can most of you on here accept that a diagnosis, however obtained, however sophisticated, rare or common, doesn't ever, ever, cure even the simplest of conditions.

Be good if somehow, someone, could do a follow-up phone call and see what happened, a technique which some on here say is successful and client-friendly.

RE: Help needed with a skin case please!

Sarah Keir — Fri, 29 Jun 2018 20:03:44 GMT

I don't know the mechanism of vasculitis due to drug therapy so I looked it up. Human only source but seems likely:

A large number of drugs, particularly antibiotics (β-lactams), can induce vasculitis which is mainly cutaneous. The incidence of antibiotic-induced vasculitis is probably underestimated, but drug-induced vasculitides are encountered more frequently than those secondary to infections. Among the drugs most frequently implicated have been sulphonamides, penicillin, allopurinol, thiazides, hydantoins, aspirin and propylthiouracil [139, 140]. Penicillin causes vasculitis by conjugating to serum proteins and mediating immune complex vasculitis as in type III hypersensitivity reactions [141].

and elsewhere:

Immune and autoimmune mechanisms are both responsible for vasculitis.

RE: Help needed with a skin case please!

Martin Atkinson — Fri, 29 Jun 2018 18:44:40 GMT

Thomas, Niall, Sarah, Robs x 2: