Case of the Week: Dermatology

RE: Case of the Week: Dermatology

Rob Loxley — Wed, 06 Nov 2019 08:32:23 GMT

[quote user="Beats"]I've always been a skeptic of tet/nic treatment in dogs[/quote]

We've had some really good successes with niacinamide/oxytetracycline, particularly in some of these nasal cases.

[quote user="Beats"]finally nicotinamide is available at a very reasonable price from Lamberts[/quote]

I think we still buy from NVS, and I don't think it's particularly expensive

RE: Case of the Week: Dermatology

Anthony Todd — Wed, 06 Nov 2019 04:01:50 GMT

Please let me know how this case progresses.

I was pretty sure. from what I know and have seen and done, that Depomed,which is obviously as a trial as most treatments are in most conditions, should improve, if not clear, this sort of mass.

The response, or not, is the proof.

RE: Case of the Week: Dermatology

Beats — Tue, 05 Nov 2019 15:43:17 GMT

So was put on 500mg oxytetracycline and 500mg nicotinamide given together with food every 8 hours and after 3 months was in remission with no ulceration or crusting or lesions beyond some mild hypopigmentation on nose.

Continuing on these doses for another 3 months, then will consider reducing to twice daily.

I've always been a skeptic of tet/nic treatment in dogs, and of course spontaneous remission in this case cannot be ruled out.

Danny Scott has a small case series which involved some cases that relapsed when dose frequency was reduced and went into remission again on dose frequency increasing, so while it may be an anecdotal treatment without a huge amount of science behind it, given the lack of side effects (when drugs given with food) I thought it a worthwhile trial treatment in this case. This case series (and dosing suggestions, inclduing giving with food both drugs at same time - of practical importance!) can be found at https://www.jstage.jst.go.jp/article/jjvd/20/1/20_9/_pdf/-char/en

A very interesting podcast from Danny Scott where he discusses the historical beginnings of this dosing treatment entitled: "Tetracyclines and Niacinamide in Canine Dermatology: Over 20 Years Down the Road " can be found in BSAVA podcasts 2015 for members. Well worth a listen.

A recent review of cutaneous lupus erythematosus is available at : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5907183/

finally nicotinamide is available at a very reasonable price from Lamberts which will now sell direct to client rather than only through registered health professional as used to be the case: https://www.lambertshealthcare.co.uk/vitamins/vitamin-b/nicotinamide-250mg/

RE: Case of the Week: Dermatology

Beats — Mon, 04 Nov 2019 13:03:44 GMT

OK, so the dermatohistopathologist has added his two cents now:

“Thank you for the photographs. The differential diagnosis of the clinical lesions is localised cutaneous lupus or epitheliotropic lymphoma. I suspect that the diagnostic features of cutaneous lupus.wax and wane and that we often look at biopsies that lack the basal cell apoptosis at the time of biposy which may be the case here. It is still possible, but less likely, that this is a case of epitheliotropic lymphoma that has now progressed but I was unable to find evidence of neoplastic lymphocytes in the sections of biopsy collected [3 to 4 months ago when only nose was affected].”

Most up-to-date follow-up to come shortly.

RE: Case of the Week: Dermatology

Julie Innes — Mon, 04 Nov 2019 10:36:56 GMT

cytology not my strong point, but just to add to the "which steroid" discussion- my mum had SLE and was on pred at immunosuppresive doses for years. I would have gone for pred, I rarely use depo and when I do it seems to last for varying times in different individuals, so Im not sure what dose the dog will actually be on 2 weeks later. Also an expensive way of doing it, especially in a big dog!

RE: Case of the Week: Dermatology

Beats — Sat, 02 Nov 2019 08:21:55 GMT

OK, so the dog's not bothered by the lesions (not painful and not pruritic), there has been some progression over couple of months from first presentation (nose only) and nasal biopsies / trial with topical isaderm / trial with cefalexin.

Owner happy to wait on review of original biopsies in light of clinical progression [a free service] before deciding on further trial therapy or further biopsies.

Here's some impression smears while we wait:

Above: Front of nasal planum

Above: dorsal nasal planum

Above: ventral chin

Above: vulval tip

Any thoughts specifically on the cytology at this point? [I think that's enough chat on merits and approaches to trial therapy just for now, can come back to that once get the dermatohistopathology review posted]

RE: Case of the Week: Dermatology

Lucy Fleming — Fri, 01 Nov 2019 17:49:37 GMT

[quote user="Anthony Todd"]Sometimes Arlo, and others, a "turbo" response is required.[/quote]

I don't mean to be rude, Anthony, but in this case going back and re-reading the OP might have been more useful. This case is a dog with ulcers on multiple mucocutaneous junctions, and the dog is described as being "oblivious" to the lesions. That suggests to me that they are non-pruritic.

While I don't disagree with your points that [quote user="Anthony Todd"]

infrequent, only if necessary pred in a dose which, by trial, is easy to establish??

THESE NOT IMMUNOSUPPRESSIVE DOSES

[/quote] could be useful in a case of pruritis due to presumed allergic skin disease (though I don't agree that [quote user="Anthony Todd"]The diagnosis is, generally, established by the respose which is usually total and definite viz: the animal stops tearing itself apart![/quote]. That's not actually a diagnosis, it's just a response to treatment. I do agree with you that I wouldn't necessarily be chasing a definitive diagnosis in that situation, I would be establishing a managment plan based on the information I had.

However - THIS CASE IS NOT CLINICALLY CONSISTENT WITH ALLERGIC SKIN DISEASE (or atopic dermatitis, or food allergy, or FAD, or pollen allergy). If I was very suspicious of an auto-immune condition I probably would want to start at an immune-suppressive dose of prednisolone. I would not aim for immunosupressive doses of pred in a case of suspected atopy or FAD.

RE: Case of the Week: Dermatology

Anthony Todd — Fri, 01 Nov 2019 17:39:02 GMT

[quote user="Lucy Fleming"]If treatment trialling was needed (it would be nice to get a diagnosis first, especially if we are thinking of immunosuppresive doses!)[/quote]

The diagnosis is, generally, established by the respose which is usually total and definite viz: the animal stops tearing itself apart!

But I thought I had explained how you can do that AND give the animal [and the owner] symptomatic relief with infrequent, only if necessary pred in a dose which, by trial, is easy to establish??

THESE NOT IMMUNOSUPPRESSIVE DOSES, unless you read the dire exaggerated caveats in NOAH!!

[unless you postulate that anything that stops an allergic response is ipso facto immunosupressive....]

I very much doubt if immunosupression is realistic in minimal, but adequate, doses of pred at maximum intervals dictated only by the animal's adequate response.

It really is that simple!

Sometimes Arlo, and others, a "turbo" response is required.

RE: Case of the Week: Dermatology

Lucy Fleming — Fri, 01 Nov 2019 16:46:20 GMT

If treatment trialling was needed (it would be nice to get a diagnosis first, especially if we are thinking of immunosuppresive doses!) then I would be tempted to bite the bullet and go to 2mg/kg prednisolone per day, if I was particularly clinically suspicious of SLE or similar. Can start to taper the dose down if good response, but potentially harder to get owners on board for increasing the dose if starting at more of an anti-inflammatory dose isn't successful.

I probably wouldn't use depo-medrone in this case, as I feel it wanes in the body too quickly for an auto-immune condition (suspected at this stage, I appreciate). My colleagues and I tried to use it for a pemphigus case in a cat once, as the owner didn't think she would be able to tablet, but it wasn't very successful, did much better once it was on oral prednisolone.

RE: Case of the Week: Dermatology

Anthony Todd — Fri, 01 Nov 2019 15:57:13 GMT

[quote user="Nicola M"]

’Never seen a diabetic after Csteroids but then intermittent minimal dose of pred might help. Why give an injection of a long acting Csteroid rather than an easily-controlled-just enough-Pred’.

Obviously, I can see you’re using them in different situations (Auto-immune vs dermatitis) but they really are conflicting comments in terms of side effects (or not).

[/quote]

True, I was confusing and no, as far as I can see they are not if I explain the total difference in each condition.

In the mass on the dog's chin etc I think you will need a longer-acting Csteroid and you want to make sure the dose is at least adequate and at most at the high end so you can be sure if, or if not, you get a response.

The picture shows chronic changes in the skin, and beneath, which won't go away quickly, ideal for Dmed in my experience. [ideal for sub-lesional if the site is suitable, but not a lip, I suggest]

In the usual allergic skin you want to control the irritation but allow the Csteroid effect to wear off because, concurrently, you should have started flea control and the diagnosticelimination or discovery process of intermittent allergens. Also you may be able to reduce the "maintenance" or repeat dose to the minimal dose which controls the signs [eg when the grass pollen season dies away or the cat's flea control improves.

That is why a course of pred in these doesn't help with a possible diagnosis at all because the obvious signs are being supressed by the continuous pred. where a single dose lasts 5 days anyway and is only rrepeated if needed.

It may surprise some to find that, with intermittent only as necessary repeat doses [pred lasts for 5 days per dose, I think??] the owners sometimes twig the allergic trigger fairly quickly which will be masked by a course of pred or even more likely, a long acting prep. like Dmed.

Happy to start a tangent if needed and only trying to hopefully improveearly allergic skin disease resolution.

RE: Case of the Week: Dermatology

Neil Wheadon — Fri, 01 Nov 2019 15:20:23 GMT

[quote user="Anthony Todd"]

The evidence of Csteroid toxicity in rabbits is the real classic where the "evidence" is cruel, but irrelevant, and the total contraindication is perpetuated by no use at all... [not helped by NOAH's dire warnings which I have never seen in my hands.] and even totally contradicted in a sensible published trial!

If any drug is not used because of apparent, or claimed, contraindication the dogma is therefore, and obviously, perpetuated!

[/quote]

Maybe it's because steroids are by and large used responsibly that we don't see too many issues

Anecdote time, so here goes. 6 years ago i locummed in a practice where the clients had no money (I'm not naming the area, but it was renowned) The vet bless him/her was into cheap/control medication and I reckon 1/3 cases were on DMV or steroids. I have never seen so much pyoderma/bloated abdomens in all my life. Like everyone else on this forum I use them as part of a clinical armory and with caution, but sometimes, yes animals need it as costs involved and at the day we want to make them comfortable.

Now returning this thread back on track, no-one here is going to give this dog DMV as a trial medication, so can we return to the thread please?

Neil

RE: Case of the Week: Dermatology

Nicola Cole — Fri, 01 Nov 2019 12:55:30 GMT

Sorry Anthony, I’m confused (and I’m not taking the mick!)

You mention:

[quote user="Anthony Todd"]

Depomedrone [by injection] at the top end of the dose rate, reasoning being that, at that dose rate, you will either get a response or not.

....

If response is good repeat as necessary

[/quote]

But then you say:

’Never seen a diabetic after Csteroids but then intermittent minimal dose of pred might help. Why give an injection of a long acting Csteroid rather than an easily-controlled-just enough-Pred’.

Obviously, I can see you’re using them in different situations (Auto-immune vs dermatitis) but they really are conflicting comments in terms of side effects (or not).

P.s. I’m not averse to steroids at all-happily use them and personally have seen very few side effects (in fact apart from one case I can think of (diabetes) have only seen reversible PUPD)....as far as I’m aware

RE: Case of the Week: Dermatology

Arlo Guthrie — Fri, 01 Nov 2019 11:06:56 GMT

[quote user="Anthony Todd"]

The odd thing is that my turboing accusations are only [now] when I dispute the pure dogma based on my evidence of years and much usage with no problems.

[sorry about rambling on about the Gambia]

If any drug is not used because of apparent, or claimed, contraindication the dogma is therefore and obviously perpetuated![/quote]

One [of three]

And no, Tony, it's NOT because you dispute dogma. Emphatically not. The clue is in the name. It's because you turbo post and dominate the forum and take threads off topic. Like this one.

RE: Case of the Week: Dermatology

Anthony Todd — Fri, 01 Nov 2019 11:03:19 GMT

The odd thing is that my turboing accusations are only [now] when I dispute the pure dogma based on my evidence of years and much usage with no problems.

[sorry about rambling on about the Gambia]

If any drug is not used because of apparent, or claimed, contraindication the dogma is therefore, and obviously, perpetuated!

RE: Case of the Week: Dermatology

Arlo Guthrie — Fri, 01 Nov 2019 10:44:33 GMT

[quote user="Anthony Dennison"]Sigh. Arlo Guthrie, it's happening again.[/quote]

Well, I am trying a number of different possible solutions, the latest is that Tony (and this would go for any other turbo posters) is restricted to 3 posts per day. On this version of the website, that is something I have to keep an eye on manually. Hoping I can automate on the upgraded website!

RE: Case of the Week: Dermatology

Anthony Dennison — Fri, 01 Nov 2019 10:38:27 GMT

Sigh. Arlo Guthrie, it's happening again.

RE: Case of the Week: Dermatology

Anthony Todd — Thu, 31 Oct 2019 17:39:53 GMT

[quote user="Beats"]

[quote user="Anthony Todd"]oral pred isn't very potent[/quote]

I'm glad you brought up the question of potency, as I think that's a good discussion point and I don't think its a diversion to the discussion given that lots will treat with "steroids" at this point, but finding 2 vets to actually give the exact same steroid treatment could be challenging!

True, usually they read NOAH, see the exaggerated possible side effects, and steer away!

We often approach derm cases simply by saying "steroids" [not unreasonably!], without discussing the differences between the various options and dosages.

Potency, however, I would argue is irrelevant really. If "steroidX" is twice as potent as "steroidY", then taking twice as much of "steroidY" will have the same clinical effect as "steroidX".

"Potency" is quite my wrong word and "effective" is much better! Pred orally always worked well with me for long-term control of allergy after an initial jab of Bets or similar then the minimum effective oral dose of pred just before it was needed and most owners got very skilled at dose control, surprisingly a lot were seasonal or fleas and/or food related so many came off everything over time

Potency may be relevant for topical steroid applications, but for systemic treatments I believe the only relevance is in trying to ascertain a "dose-equivalence" for other types of steroids. For instance if we follow the assumed dogma that dexamethasone is 7 times as potent as prednisolone, then we can "think in pred" [e.g. 1mg/kg/day pred] and convert this dose to dex and hopefully have an equivalent effect.

Sure, see above.

Route of administration may be relevant, but in my experience I do not, for instance, see more GI side effects with oral steroids than SC/IM ones.

Strange, I don't recall any GI side-effects?? Are people getting this from the dire warnings in NOAH?

On a separate note re Depo-Medrone-V: How many injections a year for a dog at 2mg/kg IM before you get twitchy about it becoming diabetic? I would say more than 4 a year and I reckon I've got an increased risk of the dreaded diabetes - that's just a guess and in no way scientific.

Never seen a diabetic after Csteroids but then my intermittent minimal dose of pred might help??

Why give an injection of a long-acting potent Csteroid rather than an easily-controlled-just-enough Pred??

[/quote]

RE: Case of the Week: Dermatology

Beats — Thu, 31 Oct 2019 16:34:36 GMT

[quote user="Anthony Todd"]oral pred isn't very potent[/quote]

We often approach derm cases simply by saying "steroids" [not unreasonably!], without discussing the differences between the various options and dosages.

Potency, however, I would argue is irrelevant really. If "steroidX" is twice as potent as "steroidY", then taking twice as much of "steroidY" will have the same clinical effect as "steroidX".

Route of administration may be relevant, but in my experience I do not, for instance, see more GI side effects with oral steroids than SC/IM ones.

RE: Case of the Week: Dermatology

Anthony Todd — Thu, 31 Oct 2019 15:47:20 GMT

[quote user="Kate Richardson"]But please please don't dismiss everyones else's experiences[/quote]

I was just quoting mine, and I must say your unlikely scenario didn't add much to the discussion.

RE: Case of the Week: Dermatology

Kate Richardson — Thu, 31 Oct 2019 15:42:40 GMT

[quote user="Anthony Todd"]

Sorry I'll be in trouble again but:

i've never known depomed ever to make things worse, but I've known oral pred, at any dose, to have no effect at all, in the above type lesions and only effective, and except, in maintaining relief in atopy or allergic derm.

It was the maintenance drug of choice in intermittent minimum but effective dose every time the pet looked like itching.

I used all the time after an initial injection of a short-acting prep. to give an idea of response [or not!] and to reassure the owner quickly.

Trying to remember any side effects for either, perhaps increased thirst, but it's never been a problem?

Had one only deep muscle reaction ever with Dmed and never with anything else, so we gave lots S/C and particularly sub-lesion which seemed sensible andworked well.

[/quote]

And here we go again. Maybe you haven't (or weren't made aware of any side effects) but many of us have. Maybe oral pred didn't work for you because the owners went home, couldn't get Tiddles or Fido to take it, so flushed it down the toilet and then were too embarrassed to tell you they couldn't administer it so, then told you it didn't work, can you give him an injection please. But please please don't dismiss everyones else's experiences

RE: Case of the Week: Dermatology

Anthony Todd — Thu, 31 Oct 2019 15:25:38 GMT

[quote user="Joyce Whitehead"]

I specifically would not use depomed due to the fact that if it makes things worse it can’t be removed. I would start on prednisolone at around 0.5-1mg/kg. I always tend to start at a reasonable but not massive dose, I feel if you start really high the owner can be put off by side effects, and usually find that dose is amply sufficient. I would aim to reassess after a week and if improved then start to lower dose.

[/quote]

Sorry I'll be in trouble again but:

It was the maintenance drug of choice in intermittent minimum but effective dose every time the pet looked like itching.

I used all the time after an initial injection of a short-acting prep. to give an idea of response [or not!] and to reassure the owner quickly.

Trying to remember any side effects for either, perhaps increased thirst, but it's never been a problem?

Had one only deep muscle reaction ever with Dmed and never with anything else, so we gave lots S/C and particularly sub-lesion which seemed sensible andworked well.

RE: Case of the Week: Dermatology

Joyce Whitehead — Thu, 31 Oct 2019 14:26:12 GMT

RE: Case of the Week: Dermatology

Beats — Thu, 31 Oct 2019 14:07:10 GMT

So that's one vote for depo-medrone-V at 2mg/kg IM and repeat at first sign of relapse assuming remission achieved.

RE: Case of the Week: Dermatology

Anthony Todd — Thu, 31 Oct 2019 13:51:31 GMT

Depomedrone [by injection] at the top end of the dose rate, reasoning being that, at that dose rate, you will either get a response or not. Anything topical will obviously fail. [IMHO]

Whereas the usual oral pred isn't very potent and orally, in these sort of presentations, never worked for me.

If response is good repeat as necessary

RE: Case of the Week: Dermatology

Beats — Thu, 31 Oct 2019 13:33:47 GMT

OK, sorry for delay, wanted to post the dermatohistopathologists further comments on review before giving rest of follow-up, but I'm off this week so will have to wait to next week.

In the meantime if anyone advocating trial treatment options wants to specify these in more detail (say which corticosteroid, at what dose and whether you plan to taper or not etc; or what dose of nicotinamide [and brand / where you would get it from] and which tetracycline and dose and dosing schedule with relation to feeding) then that might keep the thread alive until I get back :-)