my pet has allergies! what now?
DESCRIPTION
One veterinarian's approach to skin allergies and ear disease explained.TRANSCRIPT
My Pet Has AllergiesNow what?
By Jacquelyn H. Burns, DVM
Copyright © Jacquelyn H. Burns 2012
Material in this presentation is intended to help clients understand one veterinary practice’s approach to skin allergies. It is not intended to be a substitute for a visit to your veterinarian.
Allergies? But she isn’t sneezing or having a runny nose or runny eyes!
The main sign of allergies in pets is itching, with or without hair loss
This may be manifest in several ways◦ Scratching◦ Chewing/gnawing◦ Licking
Feet Legs Rump or rectal area
◦ Rubbing◦ Shaking head/scratching or rubbing
ears
Itching!
Hair loss Greasy coat Dry coat Erythema (redness) Red bumps Scabby spots Dandruff Ear infections Lichenification
◦ Thickened, rough/wrinkled or “elephant skin” Hyperpigmentation
◦ Dark pigment deposited in skin that is affected
Sometimes there are other signs
There are three categories of allergy in pet dermatology:◦Atopy (environmental and inhaled allergy)
◦Food Allergy◦Flea allergy dermatitis
So, what is my pet allergic to?
How Veterinarians Differentiate the Types of Allergy in Pets
History Physical Exam/Observations
Age of onset◦ Young◦ Middle age to older
Time of year of onset◦ Summer-Fall◦ Winter-Spring
Seasonal vs. all year round
Response to previous treatments
Pattern (where on the body the itch is)
Breed Playing the odds (only
15 to 20% are food allergy)
Primary Lesions Secondary Lesions
Flea combing Skin scrapings
◦ Screen for mange Demodex Sarcoptes
Skin cytology◦ Bacteria?◦ Yeast?
Fungal cultures◦ Screen for ringworm
Skin biopsies
Diagnostic Testing
Rate your pet’s itchiness on a scale of 1 to 10◦ 1’s never scratch/chew/lick/rub◦ 10’s never stop scratching/chewing/rubbing◦ Our vets consider
1-3 to be normal 4-5 mildly itchy 6-7 moderately itchy 8-10 severely itchy
Grading itching
You may be asked to grade your dog’s itchiness at the initial visit and
again at follow up visits
Allergies are not curable Our goal is to manage the condition
◦ Reduce the itch/inflammation◦ Reduce secondary changes to the skin
Lichenification Skin gets thick and roughened (like elephant skin)
Hyperpigmentation Skin gets black-looking
Secondary skin infection Scales/flakes/crusts/oily seborrhea
Management may be◦ As needed for flare-ups ◦ Long-term or for life
Goals of Treatment
Regardless of cause, have realistic expectations… There isn’t a magic
allergy fairy who can wave her magic wand and “cure” allergies.
Management will be as needed for life
Expect some symptoms some of the time
Expect flare ups
Is an environmental allergy that is usually but not always seasonal
Formerly believed to be mostly inhaled, but veterinary dermatologists have broadened their outlook to include allergens being absorbed through contact with the skin
Can be allergic to◦ Mold spores◦ Dust mites◦ Pollens◦ A combination of several things
Atopy
Age of Onset◦ Middle aged adult to senior
Time of year of onset◦ Often warmer months
Seasonal vs. non seasonal◦ Seasonal (unless allergic to dust mites)
Pattern◦ Not confined to waist down◦ Itching can be all over◦ Itching can be ears only, feet only
Breed: ShihTzu, Westie, Lab, Daschund Playing the odds (FAD aside, about 80-85% of itchy
dogs are atopic)
Atopy - EnvironmentalAllergy
Immunotherapy◦ Determine exactly what the pet is allergic to and
order an immunotherapy serum to be given by injection as regular “allergy shots.”
◦ Gold standard of allergy testing is the intradermal skin test Done mostly in veterinary dermatology specialty
practices, requiring a referral from your primary care veterinarian to a board-certified dermatologist
◦ There are blood tests, but these are less reliable than intradermal skin tests Can be done by most primary care veterinarians
Specific Treatment for Atopy
Atopica◦ Cylcosporine
Suppresses the immune system
◦ Loading dose is once daily for 30 days
◦ Maintenance dose is every other day for life
Atopy-specific Oral Medication
Atopy was formerly attributed to inhaled allergens. But dermatologists now recognize that allergens also can be absorbed through contact with the skin. They have broadened the definition of Atopy to include inhaled allergens and transdermal absorption of other environmental allergen particles◦ Wipe feet and legs off with a damp cloth
whenever your dog comes in from outside to remove allergens
◦ Bathe once weekly—whether your dog “needs” it or not to remove surface allergens
Wipe those feet off!
Topical◦ Soothing Shampoos & Conditioners◦ Soothing Sprays, creams or ointments
Oral◦ Prednisone
Daily for several days tapering dose to an every 2 to 3 days dose
◦ Antihistamines Sometimes help; sometimes don’t Helpful in 10 to 30% of patients Several different ones so we can “hunt & peck” for the best one
◦ Essential Fatty Acid supplements May help up to 40% of dogs with itchy allergy skin
Injectable “cortisone” as last resort◦ Vetalog during an acute flare up
Non-specific Treatment for AtopySymptomatic Care
Corticosteroids ◦ Prednisone, prednisolone, Vetalog, Depomedrol,
dexamethasone◦ Anti-inflammatory, anti-itch◦ Are not the same as anabolic steroids abused by
athletes◦ Work very well on Atopy and FAD-related itching◦ Do not work well on Food Allergy◦ Have side effects so use in moderation
Use as last resort Use lowest dose that helps control itching
◦ Do have a place in management of dogs with itchy skin, again, in moderation
What’s the deal about “steroids?”
Lethargy, panting Weight gain Increased thirst Increased urine volume
◦ Some pets urinate in the house Weaken muscles, tendons, ligaments
◦ Easier to injure an ACL or rupture a disk in the back Can cause fluid retention
◦ Can make heart disease worse Increase susceptibility to infection
◦ Easier to get infections (urinary tract, skin)◦ Harder to clear up infections
Iatrogenic Cushing’s Syndrome◦ Hormone inbalance ◦ Can “crash” in an Addisonian crisis if drug is withdrawn suddenly
What kind of side effects do corticosteroids have?
They work!◦ Sometimes they are the only thing that works that is also
affordable Reduce itching, redness, swelling Acute flare-ups
◦ Intense itching with self-mutilation Some pets scratch/chew/rub until they create serious
bleeding sores or hotspots In these cases, it usually takes an injection to get the itch
under control so that healing can begin Chronic disease
◦ Reduce or reverse lichenification, hyperpigmentation, thickening in ear canals, etc
So why do you use corticosteroids?
Atopica contains cyclosporine, an immune suppressive drug that can be used to manage atopy.
Atopica is relatively expensive, which is the main reason many people do not elect to purchase it
First month given once a day After this, usually given every other day Side effects
◦ Anorexia, vomiting◦ Increased susceptibility to infection
What About Atopica?
Since many patients are on long-term management, we want to avoidcertain side effects It does not cause
◦ Weight gain◦ Panting, sluggishness◦ Increased thirst and urine output ◦ Weakening of connective tissue (muscle, tendon,
ligament) which increases risk of injury◦ Does not increase liver size and ALP◦ Does not suppress the adrenal cortical-pituitary axis
Doesn’t risk Cushing’s Syndrome or Addisonian Crisis
Advantages of Atopica
Doesn’t work on FAD or Food Allergic Dogs
It is simply cost-prohibitive for many clients
Why don’t you prescribe Atopica for all dogs with skin allergies?
Age of onset◦ Many are younger (under 3 years)
Time of year of onset◦ Not applicable
NONSEASONAL Pattern
◦ No special pattern◦ “Ears and rears”: Some are itchy around the anus and in
the ears. May be itchy around lips and feet Breed Playing the odds: about 15 to 20 % of dogs with
skin allergies have food allergy
Food Allergy
Non seasonal itching ◦ These dogs itch all year ‘round
Response to prednisone is marginal Do not respond to Atopica
Hallmarks of food allergy
It’s not that easy!!!! Pet foods are heavily
marketed and you have to analyze the label ingredients◦ For example, a food
labeled “lamb and rice” is likely to contain lamb as well as rice, but if you read the ingredient list, you may also see poultry meal or whey, which is in the beef family antigenically
So I should just put my dog on (insert popular dog food here) and he will be okay?
Pet food marketing is so
good, it’s surprising they don’t have YOU
eating their brand.
All natural◦ All ingredients come from some type of original, natural raw
material Organic
◦ Your dog can be as allergic to organic beef as to non-organic beef
Grain-free◦ Healthy pet foods do contain some carbohydrates
Contains vegetables◦ Misleading marketing! Often pet food manufacturers add
vegetables and artificial colors to represent vegetables to appeal to buyers who see this as “good”
Popular Dog Food Marketing words to beware of…
In my experience the most likely ingredients dogs are allergic to are:
Beef Chicken
Grains and carbs get anot always deserved bad rap!
Beef
Beef Not just the meat!
Includes all proteins from cows Beef by-products
◦ Cow hooves◦ Rawhides◦ Jerky
Beef flavorings◦ Even in flavored pet medications or
vitamins Milk Milk by-products
◦ Whey, Casein Proteins antigenically similar to
beef◦ Venison, Buffalo, Yak
Eat more chikin?
Chicken
More than just the bird! Chicken
Chicken meat Chicken by-products
◦ Chicken meal Nasty stuff any way—
contains ground up feathers and beaks
◦ Chicken jerky Be very wary of any
chicken products originating in China, anyway!
Eggs
The “real” test for food allergy A prescription food
◦ Contains only 1 novel protein source◦ Contains only 1 novel carbohydrate source
8 to 12 weeks of this only◦ No treats or snacks other than this food◦ No flavored heartworm pills, arthritis meds,
vitamins, etc.◦ No visiting the neighbor’s cat food bowl
Reintroduce other foods one at a time to see which one restarts itching
Elimination Diets
“Novel” in this sense means an unusual ingredient that your pet has never been exposed to before
Therefore, the foods sound really funky:◦ Duck and sweet potato◦ Fish and potato◦ Turkey and barley◦ Kangaroo and Oatmeal
Novel Protein; Novel Carbohydrate Diet
No-compromise commitment on the part of all members of the household for a moderately lengthy period of time
Possible unhappiness on the part of the pet and owners
Increased expenditure for prescription food
Elimination Diets Require:
Some aren’t really infections! Otitis externa is an itchy inflammation of the external ear canal.
It is not like an earache (otitis media), which is on the inside of the eardrum. Otitis externa involves the ear canal outside of the eardrum.
Itches and burns Does not always include infection, but can
◦ Yeast◦ Bacteria
Often results from allergies◦ Greater than 80% in this practice are caused by allergies◦ Less than 20% other causes
Mites Foreign bodies Trauma Tumors, polyps
What about ear infections?Otitis Externa
Shaking head Rubbing ears on floor or furniture Whining/crying when ears are rubbed Discharge from ears Odor from ears
◦ Sour most often means yeast infection◦ Foul most often means bacterial infection
Thickening or swelling of pinna (ear flap)◦ Lichenification◦ Aural hematoma
Signs of Otitis Externa
Tests to determine causes of Otitis Externa
Oil Smear Ear Cytology
Veterinarian looks at a sample of ear wax or discharge in mineral oil under the microscope
Screening for ear mites Can be difficult to
interpret if you’ve used an over-the-counter ear mite med prior to seeing your veterinarian
Veterinarian looks at a stained slide of ear wax or discharge
Seeing whether there are◦ Yeast◦ Bacteria
Cocci Rods
◦ Neutrophils (pus cells) vs simple epithelials
Hygiene ◦ Pluck hair from inside ears if present◦ Clean with veterinarian-recommended ear cleaner◦ One to two times weekly initially◦ Weekly or every other week as “maintenance”
Topicals◦ Ointments, drops, sprays◦ Sometimes hunt and peck to see which works
best Symptomatic Care
◦ Antihistamines◦ Fatty acid supplements
Management for Otitis Externa
Outdoors or in shower/bathtub! Hold the pinna up over the top of the dog’s head Fill the ear canal to overflowing with ear cleaning
solution Massage the base of the ear for 60 seconds Allow your dog to shake his head Wipe away grime that comes to the top and solution
with a plain cotton ball Repeat
How to clean your dog’s ears
Never use Q-tips! They can pack wax and discharge down deeper, and make the problem worse!
Like all other allergies, allergies affecting the ears have no magic cure!
I've come to cure your ear
allergies.
Yeah, right!
Allergic to a protein in flea saliva Owner may not see fleas
◦ 1 flea bite every 5 to 7 days keeps them itching◦ Many are currently using flea control but it’s not good enough
(Frontline, Over-the Counter flea products, flea shampoos) Age of onset: adult to senior Time of year of onset: summer to fall Seasonal: often history of coming back this time every year
◦ In the South, may be seen year-round Pattern: very strong pattern!! Almost always from the
waist down. Rump, tail base, tail, around the rectal area, inner thighs, flanks
No breed predilection
Flea Allergy Dermatitis aka FAD
In Dogs with pattern itching from the waist down:◦ Redness◦ Hair loss◦ Saliva Stain◦ Thickened skin
Called Lichenification◦ Black looking skin
Called Hyperpigmentation
◦ Scabbiness
All Cats!
It’s flea allergy unless proven otherwise!
How do you treat FAD?
Primary (Specific) Treatment
Secondary (Symptomatic)Treatment
Upgrade Flea Control◦ Dogs
Spinosad-based once a month flea pill Every 30 days
◦ Cats Advantage Multi once-a-
month flea topical Every 21 days
◦ Other pets Treat all other pets, whether
itchy or not◦ Environment
Topical◦ Aloe & Oatmeal weekly
shampoo◦ Soothing conditioner after
bath◦ Pramasoothe Spray
Oral◦ Prednisone for dogs◦ Antihistamines
Injectible◦ Vetalog for dogs◦ Depomedrol for cats
Topical◦ Aloe & Oatmeal Shampoo◦ Aloe & Oatmeal Conditioner◦ Soothing Sprays – Pramasoothe, Relief
Oral◦ Prednisone for dogs
Tapering dose for 2 to 4 weeks Does have side effects
◦ Antihistamines May help some dogs/may not help some dogs
Injectable◦ Last resort!◦ Vetalog for dogs
Lasts 1 to 2 weeks◦ Depomedrol for cats
Lasts 4 to 8 weeks Side effects
Serious side effects are rare but can be life-threatening
Symptomatic Care for Itching
Recap…
Flea Allergy◦ Zero tolerance for
fleas◦ Upgrade flea control◦ Not all flea products
work equally well!!!!
Atopy◦ Immunotherapy◦ Atopica◦ Prednisone if
unavoidable
Specific Care if Possible…
Food Allergy Diet that
eliminates the problem allergen
Hygiene◦ Keeping clean◦ Short haircuts◦ Ear cleaning solutions if needed◦ Good flea control for all pets!!!!
Soothing shampoos, conditioners and sprays◦ Aloe & Oatmeal or Hypoallergenic (Hyliderm) weekly◦ Pramasoothe or Relief Spray 2-3 times a day◦ More specific shampoos if needed for
Yeast infection (Ketochlor) Bacterial infection Scales, crusts, greasiness
Anti-histamines Fatty acid/vitamin supplements Treat secondary problems
◦ Antibiotics for secondary skin infections◦ Antifungals for secondary yeast infections◦ Topicals (in ear) for otitis externa
Regardless of cause, symptomatic care for any allergy…
We are not going to cure your pet’s skin disease, but we want to keep him as comfortable as possible so that he has a good quality of life.
Remember that we are not going to be able to stop all of the itching all of the time.
Goal is to help your pet itch less Goal is a good quality of life for your pet
In short…
Ask yourself if you are compliant with all of your family veterinarian’s prescriptions and advice.
If you are not compliant, ask yourself why…and try to start doing EVERYTHING your veterinarian recommends
If you are compliant and things are not working out, ask your veterinarian for a referral to a board-certified veterinary dermatologist
If you are frustrated beyond belief…
Holmes Veterinary Hospital1001 Church StreetLaurens, SC 29360www.holmesvethospital.com
Slide presentation courtesy of Jacquelyn H. Burns, DVM
Material in this slide presentation is intended to help veterinary clients understand one practice’s approach to skin disease. It is not intended to be a substitute for assessment and treatment by your pet’s veterinarian.
Copyright © Jacquelyn H. Burns 2012All rights reserved