2012 IVG Symposium

This session sponsored by:

The itchy patient:interactive cases

Michaela Austel, Dr. med. vet., DACVD

Never forget to round up the ‘usual suspects’: *

- Demodicosis- Cheyletiella- Dermatophytosis- Pyoderma

* diseases that may or may not be pruritic

- Bacterial infections/overgrowths- Fungal infections/overgrowths- Parasites- Allergies

Allergy tests are RARELY the first diagnostic procedure performed in pruritic patients

“Eike” German Shepherd, m, 3 y

Owner noticed dog scratching/biting around the base of the tail and the hind legs six weeks ago.Owner detected several fleas, treated Eike immediately with Frontline®.Pruritus decreased a lot at first, but then it returned plus problem “spread”.

Diagnostic tests:

- Flea comb (+ “water test”): negative- Wood’s lamp exam: negative

What is the next, most “reasonable” (considering the history) diagnostic step?

1. Skin scrapes2. Fungal culture3. Trial treatment for

Sarcoptes4. Bacterial culture5. Cytology6. 1 & 27. 3 & 48. Other

What is the next, most “reasonable” (considering the history) diagnostic step?

1. Skin scrapes2. Fungal culture3. Trial treatment for

Sarcoptes4. Bacterial culture5. Cytology6. 1 & 27. 3 & 48. Other

Treatment options

- shampoos - conditioners - oral antibiotics Cephalexin

Cefpodoxime Cefovecin inj. Enrofloxacin Ciprofloxacin Marbofloxacin

Orbifloxacin Clindamycin, Chloramphenicol, Rifampin Amoxicillin/Clavulanic Acid Trimethoprim/Sulfadiazine Ormethoprim/Sulfadimethoxime and more…

-> at least 3 weeks-> one week past resolution of clinical signs

Baseline: patient needs to be rechecked!

How long do you want to treat???

“Max” Labrador Retr., mn, 5 y

Started with facial pruritus 3 years ago. Problem got progressively worse plus spread to entire body. Any treatment resulted in temporary improvement but no resolution. RDVM treated mainly with oral antibiotics (for 3-4 weeks) and steroid shots (once monthly) -> ‘some’ improvement.No other animals in the household. Owner has no lesions.Owner mentions that dog has sometimes soft stool, but is not sure whether this is due to the previous treatment (antibiotics) or the fact that Max gets a lot of people food/treats on a regular basis.

Diagnostic tests:

- Flea comb/’water test’: negative- Wood’s lamp exam: negative- Fungal culture: negative- Cytology: no microorganisms- Skin scrapes: negative- Trial treatment for Sarcoptes: negative

- Food switched to ‘100% allergen free diet’ (Pinnacle duck, OTC diet), no treats, bones, etc.: no change- IDAT: no positive reactions

What would you do next?

1. Specific IgE test (‘blood allergy test)

2. Strict elimination diet for 10 weeks with hydrolyzed soy prescription diet

3. Start all over/repeat all tests, something was missed

4. Give oral cyclosporine A/Atopica

5. Switch to grain-free diet6. Other

What would you do next?

1. Specific IgE test (‘blood allergy test)

2. Strict elimination diet for 10 weeks with hydrolyzed soy prescription diet

3. Start all over/repeat all tests, something was missed

4. Give oral cyclosporine A/Atopica

5. Switch to grain-free diet6. Other

Treatment options

- Symptomatic ?

- Immunotherapy ?

- Strict (!!!) elimination diet for a minimum of 8-12 weeks

a) dry prescription diets (novel protein or hydrolyzed) + b) canned prescription diets ++ c) home cooked diets* +++

* may be necessary in up to 20% of food allergic patients

‘Beware of’

- uninformed household members, neighbors- flavored heartworm preventatives- vitamin or mineral supplements, fish oil- flavored tooth paste- flavored nylabones- cat litter boxes- empty food bowls of other dogs/cats- bones, raw hides, treats, pill pockets, etc.- medications in capsules

--> nothing in the mouth but the diet

Compliance approx. 20%

The owner is very unhappy about your suggestion and rather wants to pursue expensive symptomatic treatment instead. Your answer is

1. Sure, let’s give cyclosporine A; it is expensive but convenient and works for most dogs

2. This is most likely not going to work in Max’ case, because……

3. Other

The owner is very unhappy about your suggestion and rather wants to pursue expensive symptomatic treatment instead. Your answer is

1. Sure, let’s give cyclosporine A; it is expensive but convenient and works for most dogs

2. This is most likely not going to work in Max case, because……symptomatic treatment does not work in the majority of food allergic patients

3. Other

It can take several weeks of ‘dieting’ until symptoms improve……….

“Jimmy” from NY DSH, mn, 3.5 y

• Only cat in the household• Indoors/outdoor• “Fur mowing” for 2 ½ years• Nonseasonal problem• Advantage + Revolution every 3 weeks• Responds to injectable steroids (nearly 100%, owner concerned because cat needs more shots with larger dose)

Diagnostic tests:

- Flea comb/ paper towel test: negative- Wood’s lamp exam: negative- Fungal culture: negative- Cytology: negative- Skin scrapes: negative- Elimination diet (RC rabbit for 10 weeks, strict): negative- IDAT: positive*

* several pollen

What would you do now?

1. Desensitization2. Oral cyclosporine

A/Atopica3. 1) & 2)4. 1) & oral steroids5. Another food trial

with different brand6. Home-cooked food

trial7. Other

What would you do now?

1. Desensitization2. Oral cyclosporine A/Atopica3. 1) & 2)4. 1) & oral steroids5. Another food trial with different

brand6. Home-cooked food trial

(pollen are seasonal, Jimmy’s problem is non-seasonal!)

7. Other

Never forget to use common sense when you look at either IDAT or specific IgE level results

What if………….

Jimmy is not any better after a correct home-cooked elimination diet trial???

Up to 5% of atopic individuals do not show positive allergy test results (IDAT or specific IgE)

(Avoidance)

Symptomatic treatment(Immunotherapy)

“Prince” Labrador Retriever, mn, 5 y

Nonseasonal pruritus for almost 4 years (initially seasonal). He responded well to steroids in the past (not any more). Prince underwent extensive diagnostics and immunotherapy based on IDAT for 1.5 years without improvement. Most recent treatment consisted of raw chicken carcasses and herbal supplements for 4 months (no improvement). His level of itchiness right now is 10/10.

Diagnostic tests:- Flea comb/’water test’: 20x negative- Wood’s lamp exam: 5x negative- Fungal culture: 2x negative- Cytology: 25x various infections- Skin scrapes: 25x negative- Scabies trial treatment (inj. ivermectin, lime sulfur

dip, still on Revolution): 3x negative- Elimination diets (hydrolyzed prescription diet, home-cooked pork diet,

raw chicken diet): 3x negative- Blood allergy test/IgE: HDM I+II, beef, eggs- IDAT: HDM I+II & several pollen

No diagnostic tests (except for raw chicken elimination diet) during the past

3 months

What would you do?

1. Vegetarian elimination diet

2. Hydrolyzed elimination diet

3. Repeat IDAT

4. Injectable steroids

5. Oral cyclosporine/Atopica

6. Start from scratch (repeat ALL tests)

7. Check for infections

8. Other

What would you do?

1. Vegetarian elimination diet

2. Hydrolyzed elimination diet

3. Repeat IDAT

4. Injectable steroids

5. Oral cyclosporine/Atopica

6. Start from scratch (repeat ALL tests)

7. Check for infections

8. Other

StaphylococcusMalassezia

Trichophyton

Atopy

Immunotherapy:Desensitization, Hyposensitization

Goal: - increase the patients tolerance- reduce the patients sensitivity

- Success rate approx. 75% (final evaluation after 12 months)

What was missing in Prince’s case???

time

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SymptomaticTherapy

Desensitization

• No “universal” pruritus treatment

• Diagnostics are key

• “Banana” technique

Surgeons are sprinters….. Dermatologists are marathon runners………