Distribution Patterns & Differential Diagnoses of Pruritus in Dogs
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1 Distribution Patterns & Differential Diagnoses of Pruritus in Dogs Robert A. Kennis DVM, MS, DACVD Professor of Veterinary Dermatology Auburn University CVM
2 A little about me.
3 Objectives Review distribution patterns Develop differential diagnoses
4 Infectious Causes Bacteria Malassezia Scabies Dermatophyte? Biscuit M. canis
5 Buck: 3 yr M-C
6
7 Bacterial Infections Only treat infection Avoid antipruritic agents initially If recurrent Pruritic Non-pruritic
8 What is Pruritus Licking Biting Chewing Scratching Rubbing Rolling Cleaning Stanley
9 Response to Steroids Why? Atopy (+) Type I Flea allergy (+/-) Type I, IV Food allergy (+/-) Type I, III, IV Scabies (-) Type IV Contact allergy (-) Type IV CTL (-) Unknown
10 Steroid Dosage 1 mg/kg/day decreasing Avoid injectable Apoquel Cytopoint
11 History Seasonality Atopy: Seasonal usually Food allergy: Non- seasonal Scabies: Non-seasonal
12 Atopy: 1-3 years History Age of Onset Food allergy: <1 year or anytime Scabies: contagious
13 1 year F-sp English bulldog Distribution: feet, face First occurrence No infection
14 Diet selection Duration Circumstances Young dogs Seasonality Food Allergy Clinical Bias
15 Ears Atopy Food allergy Scabies Contact reactions Otitis Recurrent
16 Topical reaction to Tresaderm
17
18 Facial Pruritus Muzzle Periorbital Chin
19 Oral Allergy Syndrome Type I hypersensitivity Occurs after eating Muzzle Pixie
20 Periorbital Bacteria Malassezia Demodex Medications
21
22 Chin Deep skin infections Facial folds
23 Foreleg Pruritus Cranial elbow Elbow
24 Foot Pruritus Outside exacerbation Secondary infection
25 Foot Pruritus Food allergic: Why?
26 Malassezia Paronychia Variable numbers Variable pruritus Treatment options
27 Axillae Allergic Infectious
28 Ventrum Non-specific Scabies Contact allergy
29
30
31 Caudal 1/2 Flea allergy! Rear feet Hocks
32 Perianal Region Allergic Anal sac Fistulae CTL
33 Daisy 13 yr F-sp CTL
34 Bella 4 yr F-sp G. shep.
35 Atopy Face Feet Ears Axillae Forelegs
36 Food Allergy Face Feet Ears Axillae Forelegs Aubie 12 yr M-C
37 Flea Allergy Caudal 1/2 Foxboro 6 yr F-Sp
38 Scabies Ear margin Elbow Hock Ventrum
39 Contact Allergy Non- haired regions
40 Antipruritic therapy in Small Animal Practice Robert A. Kennis, MS, DVM, DACVD Professor of Dermatology Auburn University
41 Kahan BD. Individuality: the barrier to optimal immunosuppression. Nature Reviews (3)
42 Dosing Protocols
43 Prednisone / Prednisolone Anti-inflammatory / Antipruritic 0.5mg/kg bid x 7 0.5mg/kg qd x 7 0.5mg/kg eod x 14 Provide calendar Stomach protectants?
44 Relapse? Tachyphylaxis? Switch type of steroid, equipotent Check for infection Consider additional meds
45 Drug Glucocorticoid potency Equivalent dosage (mg) Duration of Effect (hr) Alternate day? Short-Acting Cortisone <12 Hydrocortisone 1 20 <12 Intermediate Prednisone Yes Prednisolone Yes Methylprednisolone Yes Long-Acting Flumethasone No Triamcinolone No Dexamethasone No Betamethasone No Scott DW. Rational use of glucocorticoids in dermatology. Current Veterinary Therapy XII
46 Temaril P Atopics Decreasing dosage Give BID, eod
47 Why Not? Onset same as oral Duration unpredictable Side effects not manageable
48
49 Cyclosporine Blocks intracellular transmitter calcineurin Inhibits signal transduction Prevents production of IL-2, TGF-α Blocks Th1 response Inhibits IFN-γ Additive effects with steroids Increases TGF-β
50 Key Points Use 5mg/kg until remission Use name brand product first Azoles cp450 enzymes Monitor for infections Side effects Frankie & Rebecca Sterile panniculitis
51 Oclacitinib APOQUEL Janus kinase inhibitor Inhibits JAK1-dependent cytokines involved in allergy Rapidly reduces itching NOT antiinflammatory Dogs only
52 Oclacitinib Dosing mg/kg/bid, then decrease Possible side effects Infection Hypercholesterolemia Neoplasia? Altered hematopoiesis
53 Neoplasia Deep pyoderma Demodex <1 year of age Cats Oclacitinib Containdications
54 Buster 13 yr Shih Tzu Oclacitinib My Experiences
55 Oclacitinib Recommendations Baseline CBC, Chem, UA CBC q3 months Full work-up every 6 months including urine culture Keri & Missy
56 Oclacitinib Modifications If not working adequately qd: Consider full dose a.m., ½ dose p.m. Consider alt Temaril-P / Apoquel Stop using it! If it stops working Lauren, Tricia & Shep
57 Cytopoint Canine Atopic Dermatitis Immunotherapeutic IgG antibody targets IL-31 Prevents receptor binding Lasts 30 days Dogs only
58 Zoetis Receives USDA License for CYTOPOINT First monoclonal antibody licensed to help control the clinical signs associated with atopic dermatitis in dogs Targets and neutralizes interleukin- 31 (IL-31), a key itch-inducing cytokine (protein) in canine atopic dermatitis
59
60 Cytopoint experiences Works fast, few side effects Can be used concurrently with pyoderma Clients have balked at cost for big dogs Future: May be effective for canine CTL Use with starting immunotherapy
61 Immunotherapy Use <16 allergens Use 20,000 PNU Use less, more often ml q7day Modify based on resp. Use concurrent meds. Give it time
62 Questions?
63 Feline Pruritic Skin Disorders Robert A. Kennis, DVM, MS, DACVD Professor of Veterinary Dermatology Auburn University
64 Albert: 14 yr MC DSH
65
66 Albert Clinical Findings 4+ cocci on cytology Scrapings: Neg Allergy test: Pending DTM: Pending Treatment Cefovecin Q14 days Prednisolone (decreasing)
67 5 Months Later Immunotherapy Alt. day prednisolone
68 Traumatic Induced Alopecia Allergic Parasitic Behavioral Miscellaneous Urinary cystitis Impacted anal sacs
69 Diagnostic Tools History Trichogram Intradermal flea antigen test
70 Allergic Alopecia Distribution pattern Seasonality
71 Allergic Alopecia Atopy Diagnostic options Treatment options Steroids Antihistamines Immunotherapy Cyclosporine Rio: 6 yr M-C, DSH
72 Food trial 8 weeks Diets Novel Protein Hydrolyzed Home cooked Allergic Alopecia Food Allergy
73 Distribution Back ½ Allergic Alopecia Flea Allergy Head & Neck Treatment Steroids Avoidance
74 Salem: F-sp DSH
75 Salem Clinical Findings 1-2+ Malassezia Malassezia otitis Lesions were gently cleansed under sedation Treatment Methylprednisolone acetate injection Cyclosporine Fluconazole Miconazole drops Purina HA trial
76 Salem 2 Months Later Relapsed when out of HA Ate duck and green pea Cocci on cytology Doing well with Cyclosporine Signs worsened when stopped Pruritus level 4/10 (was 10/10)
77 Missy Streicher LVT Salem post treatment
78 Demodex gatoi Short demodex mite Surface location Diagnosis Pruritus Contagious
79 Behavioral Diagnosis by exclusion History Treatment options
80 Neoplastic Mast cell tumors Solitary mass Diffuse
81 Miscellaneous Urinary cystitis Impacted anal sacs
82 Traumatic Induced Alopecia Allergic Parasitic Behavioral Neoplastic Miscellaneous
83 Eosinophilic Reactions Miliary dermatitis Eosinophilic plaque Eosinophilic granuloma Indolent ulceration
84 Key Points Reaction pattern NOT a diagnosis Ectoparasites most common cause May be assoc. with allergies Biopsy after resolving infections Relapse likely unless the underlying cause is identified
85 Miliary Dermatitis Crusted Papules
86 Hypersensitivity Flea Food Aeroallergens Miliary Dermatitis Differential Diagnoses Dermatophytosis Bacterial infection Ectoparasites
87 Diagnosis Fungal culture Impression cytology Skin scrapings Biopsy Flea antigen test
88 Symptomatic Treatment Methylprednisolone 2-4mg bid Depo Medrol 10-20mg SQ q14 days Fatty acids? Not effective: Antihistamines
89 Eosinophilic Plaque Intense pruritus 2 infections common
90
91 Eosinophilic Plaque Treatment Options Methylprednisolone Concurrent antibiotics if indicated Biopsy mast cell tumor
92 Eosinophilic Granuloma Linear Granuloma Variable clinical findings
93 Eosinophilic Granuloma Key Points Difficult to treat Biopsy to rule out other diseases Hypersensitivities (food, atopy)
94 Non-pruritic Indolent Ulceration Clinical Findings Hypersensitivities r/o S.C.C.
95 Cyclosporin A 6 mg/kg/day Inhibits T- helper cells Nephrotoxicity Infections
96 Walter 5yr MC DLH Pruritus!
97 History 2 years duration Non-seasonal, worse in summer / fall Responsive to steroids Oral Injected Intralesional
98 History Strictly indoors Fed Iams Frontline
99
100
101 Walter DDX? TX? Plan?
102 Treatment Food trial: Purina HA Depo Medrol injection x 2 Cyclosporine Cefovecin x 2
103 Walter 5 week recheck: Continue food Continue cyclosporine Consider allergy testing
104 Questions? Daisy Kennis
105 Skin Manifestations of Internal Disorders Robert A. Kennis, MS, DVM, DACVD Professor of Veterinary Dermatology Auburn University
106 Overview Hepatocutaneous syndrome Calcinosis cutis Hypothyroidism Zinc responsive dermatosis
107 Hepatocutaneous syndrome synonyms Superficial necrolytic dermatitis (SND) Necrolytic migratory erythema (NME) Diabetic dermatopathy
108 Hepatocutaneous syndrome Older dogs Cobalt 11yr M-c Italian greyhound
109 Clinical findings Scale Foot pads Bony prominences Perianal region Lips
110
111 Serum Chemistry Glucose Alk phos ALT Variable bile acids
112 Differential diagnoses Zinc responsive dermatosis Neoplasia Bacterial infection Insulinoma Zn Responsive Dermatosis
113 Biopsy Here
114 Histopathology
115 Ultrasonography
116 Treatment options Aminosyn: central line Oral AA s: 1-2 daily Oral Zinc Fatty acids? Eggs
117 Darby 9 yr M-c Mixed breed
118
119 Date Apr-05 Jul-06 May-07 Dec-07 Alk Phos ALT Glucose
120 Darby
121 Prognosis Guarded to poor Quality of life
122 Zoe Grace Questions?
123 Calcinosis Cutis Deposition of Ca+ salt Causes Hyperadrenocorticism Iatrogenic steroids
124 Raised firm papules Red-pink color Coalescing Linear Calcinosis cutis clinical signs
125 Artie F redbone hound Oral pred for MUE
126 Captain
127 Edward
128 DDX: neoplasia
129 Hana: 11yr F/sp Boston terrier
130 Jake
131 Lexie 10 yr F-sp Golden
132 Mojo 10 yr M-c, Mixed breed Severe DLE, SLOD
133 Steroid removal DMSO Doxycycline hyclate Calcinosis cutis Treatment options
134 Hypothyroidism Lethargy Myxedema Tragic look
135 Hypothyroidism
136 Hypothyroidism
137 Hypothyroidism
138
139
140 Zinc Responsive Dermatosis Poor absorption
141 Zinc Responsive Dermatosis Breeds Siberian husky Alaskan malamute Bull terrier Others
142 Zinc Responsive Dermatosis Pathogenesis Poor absorption Deficient diets High Ca+ diets
143 Zinc Responsive Dermatosis Differential Diagnoses Hepatocutaneous Hypothyroidism Malassezia Vasculitis
144 Diagnosis on biopsy Failed: Zinc methionine Zinc gluconate Started Zinc sulfate Scarlett O hara 8 year F-sp Dachshund
145 Zinc Responsive Dermatosis Treatment Options Zinc sulfate 10mg/kg/day Zinc methionine 2mg/kg/day Zinc gluconate 5mg/kg/day Oral pred
146 Questions? Booger Kennis 15 th Birthday
147 Antimicrobial resistance: Where we stand and where we are going Robert A. Kennis, DVM, MS, DACVD Professor of Dermatology Auburn University
148 There would be no antibiotic resistance if we did not use antibiotics Dr. Dawn Boothe Professor of Pharmacology & Physiology Auburn University CVM
149 Objectives Bacteria of importance Culture procedures Antibiotic selection
150 Folliculitis Furunculosis Deep Pyoderma Terminology
151 Bacterial Pyoderma Staphylococcus intermedius Staphylococcus pseudintermedius
152
153 Staphylococcus pseudintermedius Current susceptibility patterns 1 st Generation Cephalosporins 3 rd Generation Cephalosporins Cefovecin Cefpodoxime Amoxicillin with Clavulanate Clindamycin (macrolides)
154 Recommended Dosages Cephalexin 30mg/kg bid x 30 Cefpodoxime 10mg/kg qd x 30 Amoxi /clav 22mg/kg tid x 30 Clindamycin 11mg/kg/bid x 30
155 Staphylococcus pseudintermedius Resistance patterns Potentiated sulfas Chloramphenicol Amikacin/ Gentamicin Rifampin Doxycycline/ minocycline Fluorinated quinolones
156 Common Second Tier Pathogens Staphylococcus aureus Staphylococcus schleiferi E. coli Enterococcus Pseudomonas Anaerobes Corynebacteria Actinomyces Fungal pathogens
157 Diagnostic Procedures Culture techniques (aerobic/anaerobic/fungal) Swab collection Biopsy for macerated tissue culture Cytology Histopathology Laboratory work
158 Macerated Tissue Culture Aseptically collect sample Transfer: Sterile vacutainer Ear swab container Sterile petri dish Culture media Send chilled
159 What would be an indication to do a bacteria culture? Presence of bacteria on histopathology Rod bacteria on cytology Poor response to empiric therapy Recurrent infections
160 4 yr, F-sp Labrador retriever
161
162 Diagnosis: Pseudomonas sp. Treatment with Enrofloxacin at 10mg/kg for 8 weeks resulted in complete resolution
163 Tips for Culture 1. Off antibiotics for at least 48 hrs. 2. Consider anaerobic culture and fungal 3. Always submit for histopathology 4. Shop for a good laboratory
164 6 year old M-C Dachshund TX: Cephalexin, Immune suppressive prednisone Cocci on cytology
165 How would you culture these lesions?
166 Staphylococcus schleiferi Subset of Staphylococcus aureus May be resistant to: Cephalosporins Fluorinated quinolones Amoxicillin w/ clavulanate Cocci on cytology!
167 Minimum Inhibitory Concentration Mutant Prevention Concentration
168 Key Points of Therapy 1. When Staph are present, always treat for it initially 2. Do not be forced to treat all the bacteria with one antibiotic 3. Treatment will last 2 weeks beyond clinical remission 4. Repeat culture may be needed
169 Treating deep pyoderma is neither cheap nor easy Select an antibiotic based upon culture and susceptiblity whenever possible
170 Now What?
171 Chloramphenicol mg/kg TID Side effects cp450 Concerns
172 Sulfa Drugs Primor: 27 mg/kg/day Side effects: Drug rxn KCS Anemia
173 Doxycycline Static 10mg/kg bid Ca+ chelates Cats = esophageal strictures Resistance?
174 Minocycline Static 5-10mg/kg bid Tissue levels Minocycline pharmacokinetics and pharmacodynamics in dogs: dosage recommendations for treatment of meticillin-resistant Staphylococcus pseudintermedius infections Marit G. Maaland 1, Luca Guardabassi 1 Mark G. Papich 2,* Article first published online: 20 MAY 2014 Veterinary Dermatology
175 Rifampin 10 mg/kg/day Lipophilic cp450 enzymes Hepatotoxicity Stain urine/tears Monitoring
176 Ciprofloxacin mg/kg qd/bid Inconsistent absorption Ciprofloxacin pharmacokinetics and oral absorption of generic ciprofloxacin tablets in dogs Mark G. Papich, DVM, MS AJVR vol 73(7) The availability of inexpensive generic ciprofloxacin tablets formulated for use in humans combined with the poor oral systemic availability increases the risk that animals given these tablets may receive inadequate antimicrobial exposure, which may increase the emergence of bacterial resistance. The variable oral absorption in the dogs in the present study illustrates the difficulty of determining an effective dose for oral administration of ciprofloxacin tablets.
177 Amikacin Bactericidal 15mg/kg qd Inactivated at low ph Patient discomfort Side effects VIII nerve toxicity Nephrotoxicity
178 Linezolid Human drug $23 / tab Ethics?
179 Questions?
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