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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