Your next consult: 9 year old Staffie with bad skin

RE: Your next consult: 9 year old Staffie with bad skin

Richard Carter — Sun, 14 Aug 2022 10:51:22 GMT

Impressed you could get vetoryl for under £50!

Anyone tried the ketoconizole oral to suppress the adrenals?

RE: Your next consult: 9 year old Staffie with bad skin

Beats — Sat, 13 Aug 2022 13:53:56 GMT

Probably got a vetoryl 30mg maybe 5 days out of 7 and drinking was noted markedly decreased. Skin never fully resolved, but did improve somewhat and didn't worsen at least. Also put on DMSO gel (https://www.triequestrian.ie/dmso-gel-99.html)

Photo about 2 years later.

No biopsies or further testing, so can't give any definitive answers - sorry!

RE: Your next consult: 9 year old Staffie with bad skin

Beats — Sat, 13 Aug 2022 13:45:48 GMT

[quote userid="2675" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/30385/your-next-consult-9-year-old-staffie-with-bad-skin/238644#238644"]this can still be false positive from stress/ agitation in kennels[/quote]

I've never fully understood this line of thinking: You give an injection to supra-maximally stimulate the adrenal glands to produce everything they can and then take another blood sample, I can't see how stressing the patient for an hour should result in a higher output of cortisol than your massive ACTH injection would alone. That said, I typically ask the owner to bring the dog back in an hour rather than keep it in a kennel - if nothing else I'm more likely to remember the second blood sample when I see the owner back in the waiting room than forget about a dog I put in a kennel...

[quote userid="2675" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/30385/your-next-consult-9-year-old-staffie-with-bad-skin/238644#238644"]alkp levels, stress leukogram, dilute urine to back up the suspicion of HAC?[/quote]

None done, I'm afraid, but would agree would help to increase or decrease suspicion of HAC (hyperadrenocorticism / Cushings).

I thought the skin looked like calcinosis cutis - photos might not do justice, but here are some more:

Suspicion was increased when phoned second owner with results who said had been drinking a lot more, and (rightly or wrongly) decided to try some vetoryl 30mg once daily.

RE: Your next consult: 9 year old Staffie with bad skin

Richard Carter — Sat, 13 Aug 2022 13:24:47 GMT

So exaggerated cortisol response- this can still be false positive from stress/ agitation in kennels - alkp levels, stress leukogram, dilute urine to back up the suspicion of HAC?

suppose you said female middle aged terrier

Not aware of vetoryl costing less than £50 a month, never mind further testing/ monitoring.

I would go back to plan a- control secondary infections, your favourite fatty acids, possibly check TT4 / tsh if any budget left or look at incurin eod to improve metabolism, repair of skin, weight loss

RE: Your next consult: 9 year old Staffie with bad skin

Beats — Sat, 13 Aug 2022 12:48:56 GMT

I'll see if I have a few more photos from that visit to go with ones above. Photos are never quite as good as the real thing in front of you though! I settled for a chat and ACTH stim test (rightly or wrongly).

Cortisol 139nmol/L (50-250)

1hr post ACTH cortisol 706nmol/L (150-550)

RE: Your next consult: 9 year old Staffie with bad skin

Delia Richter — Sat, 13 Aug 2022 12:19:52 GMT

Also, I can't get a really close look at the photos, but I wonder if there is some post-inflammatory hyperpigmentation going on - so maybe there was a ripping pyoderma that is settled a bit

RE: Your next consult: 9 year old Staffie with bad skin

Delia Richter — Sat, 13 Aug 2022 12:14:06 GMT

Thanks for the extra info! So, could be either allergic or hypothyroid! I would treat what you can to start with, which is the secondary infections, and ruling out parasites. Was the bravecto the dog had oral or spot-on? I don't trust spot-ons! Also check their shampooing method. If they can't bath every second day, then consider mousse (eg Douxo Pyo) or spray (eg vetruus clorexyderm) instead. Then recheck in 2 weeks and see how things are going.

At that point you could do a 2 week trial with prednisolone at say 1mg/kg and check the response. If no response then check for hypothyroidism... except you then have to wait for the effect of the pred to wear off.... But such is life. You could take blood before the pred trial and put it on hold - maybe just check with your lab first about whether that's doable.

You could pluck a little hair from the margins of those lesions and check for broken hairs as well. If they are broken the dog is secretly scratching, if they are falling out whole then that's more likely hypoT.

Cheers,

Delia

RE: Your next consult: 9 year old Staffie with bad skin

Clive Ansell — Sat, 13 Aug 2022 10:10:50 GMT

[quote userid="2675" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/30385/your-next-consult-9-year-old-staffie-with-bad-skin/238636#238636"]Actually you can recommend anything. You may be under cascade restrictions if you sell it.[/quote]

No, not according to our code of conduct.

FAQs – Common medicines pitfalls - Professionals (rcvs.org.uk)

Can I advise that a client use over the counter human medicines for their animal?

This would count as a veterinary prescription, even where the human-licenced medicine is not itself prescription-only.

Human-licensed medication could be prescribed under step (c)(i) (in Great Britain) or (b)(i) (in Northern Ireland) of the prescribing cascade, however, the justification in this case would also need to account for why a veterinary medicine (authorised for that species and condition, or for another species or condition) could not be used.

Also as an aside:

Prescribing human-licensed paracetamol

Veterinary professionals should be mindful that advising a client to administer human-licensed paracetamol to their animal is considered to be a veterinary prescription, and therefore the prescribing cascade should be followed as is clearly set out as a requirement in the Code of Professional Conduct.

The only authorised veterinary form of paracetamol for companion animals is Pardale-V (Oral Tablets). This authorisation is only for use in dogs.

[quote userid="2675" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/30385/your-next-consult-9-year-old-staffie-with-bad-skin/238636#238636"]Would like to see who wins the court case when press get hold of a cost of living/ animal welfare vs EU legacy[/quote]

Agree, me too.

I don't like the cascade nonsense anymore than anyone else, but given it is a professional requirement, we have little choice.

RE: Your next consult: 9 year old Staffie with bad skin

Richard Carter — Sat, 13 Aug 2022 09:12:10 GMT

Actually you can recommend anything. You may be under cascade restrictions if you sell it. Would like to see who wins the court case when press get hold of a cost of living/ animal welfare vs EU legacy legislation.

Also think we way underestimate the effect of neutering on thyroid and the other steroid based hormones.

In humans post menopause hrt a common supplement/ treatment for things from hypothyroid to osteoporosis

RE: Your next consult: 9 year old Staffie with bad skin

Beats — Sat, 13 Aug 2022 09:06:41 GMT

Has got apoquel infrequently and intermittently for itch since age of 5, mainly, but not exclusively, in the summer (but has not needed any apoquel this summer).

One flare of otitis at age of 6.

No regular parasite treatment, but did have a bravecto (and some malaseb and topical surolan) at a consult a couple of months ago (May). Had not improved on preds and sebolytic dispensed a week prior, but reported by phone to be improved a week after the Bravecto, Malaseb and topical surolan.

2 months after this still appears as per photos above. Malaseb bathing has probably been infrequent.

RE: Your next consult: 9 year old Staffie with bad skin

Clive Ansell — Sat, 13 Aug 2022 08:48:40 GMT

With such a restrictive budget, little room for any or much investiagtion, so meds and kick to touch.

Given not pruritic, would avoid preds and dish out Bravecto and Malaseb, suck it and see.

Could do skin skin scrapes and microscopy, but I tend to treat with Bravecto even if the scrapes are negative

[quote userid="2675" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/30385/your-next-consult-9-year-old-staffie-with-bad-skin/238627#238627"]You can buy ketoconizole shampoo off the shelf in supermarkets these days- Morrison’s sells it[/quote]

If we recommend that, we fall foul of the cacade regs given that the likes of Malaseb are licenced.

RE: Your next consult: 9 year old Staffie with bad skin

Delia Richter — Sat, 13 Aug 2022 08:19:37 GMT

Oh and cover for demodex with an oral isoxazoline! (Eg nexguard, credelio, brave to)

RE: Your next consult: 9 year old Staffie with bad skin

Delia Richter — Sat, 13 Aug 2022 07:52:24 GMT

Ever any previous history of skin problems?

If completely new skin problem at 8 years of age, then this is more likely secondary to hypothyroidism or another systemic disease.

If the dog has ever had a skin problem before (even a single ear infection or rubs her bottom), then more likely an underlying atopy.

Either way, there will be a secondary bacterial or yeast infection. So I would start with an antimicrobial shampoo (I use Douxo Pyo, but there's a million out there), every second day, or at least twice a week. Give the owners an itch tracker (zoetis do a good one you can hand out to the client) and find out if there is any itch. Once you have rid of the secondary infection, then reassess. If you are sure this isn't allergy/atopy, then check T4.

Thyroid tablets are pretty cheap these days.

Would love to hear how she goes!

Cheers,

Delia

RE: Your next consult: 9 year old Staffie with bad skin

Beats — Sat, 13 Aug 2022 06:50:40 GMT

Not noticed to be pruritic.

General doggy smell (sorry, I genuinely have a poor sense of smell).

Skin dry.

Drinks quite a bit.

No change reported in appetite.

RE: Your next consult: 9 year old Staffie with bad skin

Richard Carter — Sat, 13 Aug 2022 04:47:46 GMT

ok I’ll bite..

Pruritic or not?

smell of yeasts or clean?

skin thin or flexible/ good thickness/ oil content not dry or excessive?

alopecia traumatic or falling out? Other HAC signs (ppp?)

non pruritic- start with cleaning, discuss testing for hypoT4, non thyroidal illness, adenitis other skin degenerative conditions, budget for skin biopsy

There is a protocol for skin biopsy under local with standard poodle breeding so ga not essential

pruritic- bravecto; pred 5 mg sid / eod; your favourite ketoconizole shampoo etd until yeast under control then once a week. You can buy ketoconizole shampoo off the shelf in supermarkets these days- Morrison’s sells it

if really pruritic discuss cytopoint