Distribution Patterns & Differential Diagnoses of Pruritus in Dogs Robert A. Kennis DVM, MS, DACVD Professor of Veterinary Dermatology Auburn University CVM
A little about me.
Objectives Review distribution patterns Develop differential diagnoses
Infectious Causes Bacteria Malassezia Scabies Dermatophyte? Biscuit M. canis
Buck: 3 yr M-C
Bacterial Infections Only treat infection Avoid antipruritic agents initially If recurrent Pruritic Non-pruritic
What is Pruritus Licking Biting Chewing Scratching Rubbing Rolling Cleaning Stanley
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
Steroid Dosage 1 mg/kg/day decreasing Avoid injectable Apoquel Cytopoint
History Seasonality Atopy: Seasonal usually Food allergy: Non- seasonal Scabies: Non-seasonal
Atopy: 1-3 years History Age of Onset Food allergy: <1 year or anytime Scabies: contagious
1 year F-sp English bulldog Distribution: feet, face First occurrence No infection
Diet selection Duration Circumstances Young dogs Seasonality Food Allergy Clinical Bias
Ears Atopy Food allergy Scabies Contact reactions Otitis Recurrent
Topical reaction to Tresaderm
Facial Pruritus Muzzle Periorbital Chin
Oral Allergy Syndrome Type I hypersensitivity Occurs after eating Muzzle Pixie
Periorbital Bacteria Malassezia Demodex Medications
Chin Deep skin infections Facial folds
Foreleg Pruritus Cranial elbow Elbow
Foot Pruritus Outside exacerbation Secondary infection
Foot Pruritus Food allergic: Why?
Malassezia Paronychia Variable numbers Variable pruritus Treatment options
Axillae Allergic Infectious
Ventrum Non-specific Scabies Contact allergy
Caudal 1/2 Flea allergy! Rear feet Hocks
Perianal Region Allergic Anal sac Fistulae CTL
Daisy 13 yr F-sp CTL
Bella 4 yr F-sp G. shep.
Atopy Face Feet Ears Axillae Forelegs
Food Allergy Face Feet Ears Axillae Forelegs Aubie 12 yr M-C
Flea Allergy Caudal 1/2 Foxboro 6 yr F-Sp
Scabies Ear margin Elbow Hock Ventrum
Contact Allergy Non- haired regions
Antipruritic therapy in Small Animal Practice Robert A. Kennis, MS, DVM, DACVD Professor of Dermatology Auburn University
Kahan BD. Individuality: the barrier to optimal immunosuppression. Nature Reviews. 2003 (3). 831-838.
Dosing Protocols
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?
Relapse? Tachyphylaxis? Switch type of steroid, equipotent Check for infection Consider additional meds
Drug Glucocorticoid potency Equivalent dosage (mg) Duration of Effect (hr) Alternate day? Short-Acting Cortisone 0.8 25 <12 Hydrocortisone 1 20 <12 Intermediate Prednisone 4 5 24-36 Yes Prednisolone 4 5 24-36 Yes Methylprednisolone 5 4 24-36 Yes Long-Acting Flumethasone 15 1.3 36-48 No Triamcinolone 40 0.5 36-48 No Dexamethasone 40 0.5 36-54 No Betamethasone 50 0.4 36-54 No Scott DW. Rational use of glucocorticoids in dermatology. Current Veterinary Therapy XII. 573-581
Temaril P Atopics Decreasing dosage Give BID, eod
Why Not? Onset same as oral Duration unpredictable Side effects not manageable
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
Key Points Use 5mg/kg until remission Use name brand product first Azoles cp450 enzymes Monitor for infections Side effects Frankie & Rebecca Sterile panniculitis
Oclacitinib APOQUEL Janus kinase inhibitor Inhibits JAK1-dependent cytokines involved in allergy Rapidly reduces itching NOT antiinflammatory Dogs only
Oclacitinib Dosing 0.4-0.6mg/kg/bid, then decrease Possible side effects Infection Hypercholesterolemia Neoplasia? Altered hematopoiesis
Neoplasia Deep pyoderma Demodex <1 year of age Cats Oclacitinib Containdications
Buster 13 yr Shih Tzu Oclacitinib My Experiences
Oclacitinib Recommendations Baseline CBC, Chem, UA CBC q3 months Full work-up every 6 months including urine culture Keri & Missy
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
Cytopoint Canine Atopic Dermatitis Immunotherapeutic IgG antibody targets IL-31 Prevents receptor binding Lasts 30 days Dogs only
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
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
Immunotherapy Use <16 allergens Use 20,000 PNU Use less, more often 0.25-0.5ml q7day Modify based on resp. Use concurrent meds. Give it time
Questions?
Feline Pruritic Skin Disorders Robert A. Kennis, DVM, MS, DACVD Professor of Veterinary Dermatology Auburn University
Albert: 14 yr MC DSH
Albert Clinical Findings 4+ cocci on cytology Scrapings: Neg Allergy test: Pending DTM: Pending Treatment Cefovecin Q14 days Prednisolone (decreasing)
5 Months Later Immunotherapy Alt. day prednisolone
Traumatic Induced Alopecia Allergic Parasitic Behavioral Miscellaneous Urinary cystitis Impacted anal sacs
Diagnostic Tools History Trichogram Intradermal flea antigen test
Allergic Alopecia Distribution pattern Seasonality
Allergic Alopecia Atopy Diagnostic options Treatment options Steroids Antihistamines Immunotherapy Cyclosporine Rio: 6 yr M-C, DSH
Food trial 8 weeks Diets Novel Protein Hydrolyzed Home cooked Allergic Alopecia Food Allergy
Distribution Back ½ Allergic Alopecia Flea Allergy Head & Neck Treatment Steroids Avoidance
Salem: F-sp DSH
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
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)
Missy Streicher LVT Salem post treatment
Demodex gatoi Short demodex mite Surface location Diagnosis Pruritus Contagious
Behavioral Diagnosis by exclusion History Treatment options
Neoplastic Mast cell tumors Solitary mass Diffuse
Miscellaneous Urinary cystitis Impacted anal sacs
Traumatic Induced Alopecia Allergic Parasitic Behavioral Neoplastic Miscellaneous
Eosinophilic Reactions Miliary dermatitis Eosinophilic plaque Eosinophilic granuloma Indolent ulceration
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
Miliary Dermatitis Crusted Papules
Hypersensitivity Flea Food Aeroallergens Miliary Dermatitis Differential Diagnoses Dermatophytosis Bacterial infection Ectoparasites
Diagnosis Fungal culture Impression cytology Skin scrapings Biopsy Flea antigen test
Symptomatic Treatment Methylprednisolone 2-4mg bid Depo Medrol 10-20mg SQ q14 days Fatty acids? Not effective: Antihistamines
Eosinophilic Plaque Intense pruritus 2 infections common
Eosinophilic Plaque Treatment Options Methylprednisolone Concurrent antibiotics if indicated Biopsy mast cell tumor
Eosinophilic Granuloma Linear Granuloma Variable clinical findings
Eosinophilic Granuloma Key Points Difficult to treat Biopsy to rule out other diseases Hypersensitivities (food, atopy)
Non-pruritic Indolent Ulceration Clinical Findings Hypersensitivities r/o S.C.C.
Cyclosporin A 6 mg/kg/day Inhibits T- helper cells Nephrotoxicity Infections
Walter 5yr MC DLH Pruritus!
History 2 years duration Non-seasonal, worse in summer / fall Responsive to steroids Oral Injected Intralesional
History Strictly indoors Fed Iams Frontline
Walter DDX? TX? Plan?
Treatment Food trial: Purina HA Depo Medrol injection x 2 Cyclosporine Cefovecin x 2
Walter 5 week recheck: Continue food Continue cyclosporine Consider allergy testing
Questions? Daisy Kennis
Skin Manifestations of Internal Disorders Robert A. Kennis, MS, DVM, DACVD Professor of Veterinary Dermatology Auburn University
Overview Hepatocutaneous syndrome Calcinosis cutis Hypothyroidism Zinc responsive dermatosis
Hepatocutaneous syndrome synonyms Superficial necrolytic dermatitis (SND) Necrolytic migratory erythema (NME) Diabetic dermatopathy
Hepatocutaneous syndrome Older dogs Cobalt 11yr M-c Italian greyhound
Clinical findings Scale Foot pads Bony prominences Perianal region Lips
Serum Chemistry Glucose Alk phos ALT Variable bile acids
Differential diagnoses Zinc responsive dermatosis Neoplasia Bacterial infection Insulinoma Zn Responsive Dermatosis
Biopsy Here
Histopathology
Ultrasonography
Treatment options Aminosyn: central line Oral AA s: 1-2 daily Oral Zinc Fatty acids? Eggs
Darby 9 yr M-c Mixed breed
Date Apr-05 Jul-06 May-07 Dec-07 Alk Phos 2251 358 227 283 ALT 403 287 142 40 Glucose 80 351 261 148
Darby 1996-2007
Prognosis Guarded to poor Quality of life
Zoe Grace Questions?
Calcinosis Cutis Deposition of Ca+ salt Causes Hyperadrenocorticism Iatrogenic steroids
Raised firm papules Red-pink color Coalescing Linear Calcinosis cutis clinical signs
Artie F redbone hound Oral pred for MUE
Captain
Edward
DDX: neoplasia
Hana: 11yr F/sp Boston terrier
Jake
Lexie 10 yr F-sp Golden
Mojo 10 yr M-c, Mixed breed Severe DLE, SLOD
Steroid removal DMSO Doxycycline hyclate Calcinosis cutis Treatment options
Hypothyroidism Lethargy Myxedema Tragic look
Hypothyroidism
Hypothyroidism
Hypothyroidism
Zinc Responsive Dermatosis Poor absorption
Zinc Responsive Dermatosis Breeds Siberian husky Alaskan malamute Bull terrier Others
Zinc Responsive Dermatosis Pathogenesis Poor absorption Deficient diets High Ca+ diets
Zinc Responsive Dermatosis Differential Diagnoses Hepatocutaneous Hypothyroidism Malassezia Vasculitis
Diagnosis on biopsy Failed: Zinc methionine Zinc gluconate Started Zinc sulfate Scarlett O hara 8 year F-sp Dachshund
Zinc Responsive Dermatosis Treatment Options Zinc sulfate 10mg/kg/day Zinc methionine 2mg/kg/day Zinc gluconate 5mg/kg/day Oral pred
Questions? Booger Kennis 15 th Birthday
Antimicrobial resistance: Where we stand and where we are going Robert A. Kennis, DVM, MS, DACVD Professor of Dermatology Auburn University
There would be no antibiotic resistance if we did not use antibiotics Dr. Dawn Boothe Professor of Pharmacology & Physiology Auburn University CVM
Objectives Bacteria of importance Culture procedures Antibiotic selection
Folliculitis Furunculosis Deep Pyoderma Terminology
Bacterial Pyoderma Staphylococcus intermedius Staphylococcus pseudintermedius
Staphylococcus pseudintermedius Current susceptibility patterns 1 st Generation Cephalosporins 3 rd Generation Cephalosporins Cefovecin Cefpodoxime Amoxicillin with Clavulanate Clindamycin (macrolides)
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
Staphylococcus pseudintermedius Resistance patterns Potentiated sulfas Chloramphenicol Amikacin/ Gentamicin Rifampin Doxycycline/ minocycline Fluorinated quinolones
Common Second Tier Pathogens Staphylococcus aureus Staphylococcus schleiferi E. coli Enterococcus Pseudomonas Anaerobes Corynebacteria Actinomyces Fungal pathogens
Diagnostic Procedures Culture techniques (aerobic/anaerobic/fungal) Swab collection Biopsy for macerated tissue culture Cytology Histopathology Laboratory work
Macerated Tissue Culture Aseptically collect sample Transfer: Sterile vacutainer Ear swab container Sterile petri dish Culture media Send chilled
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
4 yr, F-sp Labrador retriever
Diagnosis: Pseudomonas sp. Treatment with Enrofloxacin at 10mg/kg for 8 weeks resulted in complete resolution
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
6 year old M-C Dachshund TX: Cephalexin, Immune suppressive prednisone Cocci on cytology
How would you culture these lesions?
Staphylococcus schleiferi Subset of Staphylococcus aureus May be resistant to: Cephalosporins Fluorinated quinolones Amoxicillin w/ clavulanate Cocci on cytology!
Minimum Inhibitory Concentration Mutant Prevention Concentration
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
Treating deep pyoderma is neither cheap nor easy Select an antibiotic based upon culture and susceptiblity whenever possible
Now What?
Chloramphenicol 40-50 mg/kg TID Side effects cp450 Concerns
Sulfa Drugs Primor: 27 mg/kg/day Side effects: Drug rxn KCS Anemia
Doxycycline Static 10mg/kg bid Ca+ chelates Cats = esophageal strictures Resistance?
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
Rifampin 10 mg/kg/day Lipophilic cp450 enzymes Hepatotoxicity Stain urine/tears Monitoring
Ciprofloxacin 25-30 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) 2012. 1085-91 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.
Amikacin Bactericidal 15mg/kg qd Inactivated at low ph Patient discomfort Side effects VIII nerve toxicity Nephrotoxicity
Linezolid Human drug $23 / tab Ethics?
Questions?