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September 2007
Topical Therapy 101
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Table of Contents
Lou Gotthelf's Small Animal Ear Diseases
Topical Therapy plays an important role in small animal dermatology. When it
is not the primary treatment, it is almost always used in conjunction with systemic
therapy. Selection of the right chemicals and products is of vital importance.
Factors such as consistency, clarity, odor, viscosity and functionality are
all very important. A product that is incompatible may require dye or not be
clear or transparent. Are the ingredients used the best available or USP? Does
the product require too much alcohol or other solvent like propylene glycol
(PG) to solubilize non-compatible ingredients? For example, in the US, TrizEDTA
is protected by patent as the only product to use USP quality ingredients so
a copycat product using non-USP ingredients required alcohol, PG and other unnecessary
components to solublize it.
Clear products with pleasant natural fragrances are more aesthetic, work better
and have better client compliance. Most shampoos (ALL by DermaPet) are soapless.
Soapless shampoos are alleged to not remove the residual insecticide applied
from most flea control products. Still, any shampoo (soapless or not) containing
benzoyl peroxide will remove/reduce the efficacy of topical residual flea control
products.
Selection of topical therapy depends upon your goals with the primary objective
being "above all do no harm."
The key functions desired are resolution of infection and symptoms and management
of recurrent infections and/or symptoms. For example, skin "infections" most
likely will be from Staph or Malassezia whereas "symptoms" such as pruritus,
seborrhea sicca or oleosa may co-exist. Symptoms and infections may co-exist
and may vary according to severity. For example, it is not unusual for a Staph
pyoderma to be cross-infected with Malassezia and for this dog to be have a
mild seb sicca with mild to moderate pruritus.
Specific topical therapeutic suggestions are offered to assist in the treatment
of the main diagnoses facing small animal veterinarians. This often will include
multiple shampoos followed by leave-on, dry-on conditioners.
For those cases that require frequent bathing such as to treat environmental
allergy where the coat is like a dust mop carrying the allergic antigen, an
all natural hypo-allergenic shampoo like DermaLyte Shampoo is selected. This
is a soapless, dye free, clear, shampoo containing no animal protein with EFAs
allowing it to be used as often as daily. It also may be used as a primer or
first cleansing bath making it easier to more thoroughly apply the second shampoo
or therapeutic agent.
Symptomatic Therapy
Symptoms include varying amounts of pruritus, seb oleosa and sicca.. The use
of a symptom relieving shampoo preceding the use of the therapeutic one will
also prime the skin and coat for the 2nd shampoo.
Pruritus
Preceding or immediately after your choice of therapeutic topical therapy, use
an oatmeal based shampoo (DermAllay) or leave-on dry-on Conditioner (DermAllay).
For more serious cases of pruritus, a topical corticosteroid and/or antihistamine
shampoo or Conditioner can be uses. Allow the suds to sit for at least 5 minutes
before rinsing the shampoo. Ideally, pruritic pets should be bathed in cold
water.
Seborrhea Oleosa
Preceding or immediately after your choice of therapeutic topical therapy, should
there be one, for moderate cases, use an acetic and boric acid containing shampoo
and/or Conditioner, ( MalAcetic Shampoo, MalAcetic Conditioner). The acetic
acid is an excellent degreaser while boric acid is an excellent desiccating
agent. For severe cases, I suggest preceding with a benzoyl peroxide synergized
with sulfur and salicylic acid (DermaBenS). Where severe Seb oleosa, degreasing
or deskunking is your primary objective, use MalAcetic Shampoo first, followed
by the DermaBenS with a MalAcetic Conditioner spray as an after bath.
Seborrhea sicca
Preceding or immediately after your choice of therapeutic topical therapy, should
there be one, for moderate cases, use a mild, clear, sulfur/salicylic acid shampoo
(DermsSebs), immediately after using a moisturizing, humectant, emollient conditioner
(DermAllay).
It is possible for symptoms to be integrated by combining treatments. For example,
for a pruritic, oily dog one could "prime" with MalAcetic shampoo and condition
with DermAllay Conditioner.
Therapeutic uses
Therapeutic uses include assisting in the treatments of numerous diagnoses including
various types of skin diseases (pyoderma) caused by bacteria, most likely Staphylococcus,
and fungi, most likely yeasts (Malassezia) and dermatophytes (most likely M.
canis).
Pyoderma
Pyodermas occur in various forms.
Superficial folliculitis.
This is the most common diagnosis. The old way to treat these was to use a benzoyl
peroxide shampoo (DermaSebS) for it's follicular flushing capabilities as well
as it's ability to eliminate Staph effectively. The side effect of drying out
the coat could be dealt with using an after bath leave-on dry-on Conditioner
(DermAllay or MalAcetic Conditioner).
An acetic acid/boric acid shampoo and/or Conditioner (MalAcetic) offer a more
modern, gentle approach while still having the necessary antibacterial effects
.
A chlorhexidine/acetic acid product containing an azole compound-ketoconazole-(Mal-A-Ket)
offers the flexibility of potent antibacterial effects (chlorhexidine), coat
conditioning (acetic acid which is also antimicrobial) and an antifungal component
(keto) should there be a need.
It is possible for combinations of products to be used in the event of an oily,
dry or pruritic pyoderma. An after bath leave on Conditioner (MalAcetic Conditioner)
should be used for it's anti-microbial, coat conditioner and deodorizing functions.
Hot spots
A classic "hot spot" aka pyotraumatic dermatitis is an acute, ulcerative, erythematous,
exudative alopecic foci on which there is a surface pyoderma. Some breeds (Golden
Retrievers) develop a deeper pyoderma, usually on the side of the face, that
requires systemic antibiotics. Generally, only a short acting course of systemic
corticosteroids is all that is necessary in terms of systemic treatment.
Topically,
Clip a circle to healthy skin around the lesion with a #40 surgical blade
Bathe the dog in an antimicrobial shampoo such as MalAcetic Shampoo and the
lesion in DermaBenSs Shampoo.
Daily, remove the sero-necrotic debris physically with a mild antimicrobial
wet wipe (MalAcetic Wet Wipes or MalAcetic HC Wipes).
Intertrigenous and interdigital pyodermas
Skin fold pyodermas usually affect the neck, back, axillary, lip, face, anal
area and lips. These areas are dark, moist and have surface infections usually
with Staph +/- Malassezia. Often, topical therapy, consists of keeping the affected
areas dry, using a product that also has antimicrobial properties against both
Staph and Malassezia. Wet wipes are designed for the convenience of not requiring
unnecessary wetting a large or local area of the body and having to rinse. MalAcetic
Wet Wipes, MalAcetic HC Wipes and Mal-A-Ket Wipes all serve this purpose and
can be selected according to the specific case.
Deep pyodermas
These cases are often immune compromised and/or seen with mixed bacterial infections,
+/- Malassezia +/- demodex.. They all require long term doses of an antibiotic,
my preference being cephalexin 10 mg/#/BID LONG term.
The same rules apply to mixing treatment of symptoms with a specific diagnosis.
Use DermaBenSs shampoo, rinse and then apply Mal-A-Ket shampoo followed by MalAcetic
Conditioner and repeat this process at least 2 times weekly.
Malassezia dermatitis
There is a 3 Step treatment for this. Most often these cases have an associated
Staph pyoderma that requires the use of cephalexin 10 mg/#/BID.
-Shampoo Therapy alone. Bathe in Mal-A-Ket Shampoo followed by MalAcetic Conditioner
-Shampoo Therapy + ketoconazole 10 mg/kg/bid/21 d.
-Shampoo therapy + itraconazole 5-10 mg/kg/qd. This is the safest method, although
somewhat expensive. Itraconazole persists in the epidermis and does not have
the adverse side effects on the liver like ketoconazole.
Dermatophytes
Lime-sulfur dips (LimePlus Dip) are the treatment of choice. The dip should
be preceeded with Mal-A-Ket Shampoo and, if focal areas, Mal-A-Ket Wipes.
6th Banfield Industry Summit, Portland
"Even if you are on the right track, you'll get run over if you just sit there," Will Rogers.
On a gloriously sunny day, JOHN PAYNE, who organized the golf tournament and chaired the entire meeting, led the winning team in a "shamble" while TOM CORCORAN (Ft Dodge) won low score. MARK CUSHING, Banfield lawyer, offered to sue himself on behalf of SCOTT CAMPBELL, who he nearly hit with an errant golf shot. Mulligans were cheap and plentiful with the proceeds going to "Future Veteriarians"
Attending were a virtual Who's Who of the veterinary industry and a few wannabees. The Foresight Report, how to meet the needs of increasing demands for vets, was presented and discussed in detail. At the airport, the new AVMA Exec VP, RON DeHAVEN, and BRUCE LITTLE, the retiring one, as well as STEPHEN SUNDLOF (CVM director) and YT got to know each other a little better since weather in Chicago forced a flight cancellation and search for a hotel in a sold-out city.
ESVD, Mainz, Germany
HA-JO SCHAEFFER (Albrecht/Eurovet) manned the DermaPet booth. SUE PATERSON pointed out that our LIMEPLUS DIP (lime sulfur) is the treatment of choice for Dermatophilus in horses (as written in the Equine Derm book by Scott et al) and is effective against virtually all surface parasites Since we just introduced that product in the EU, many were so curious that the seal broke on our only real sample (we only show empty bottles in the US due to the easily identifiable strong odor of lime sulfur). Surprising this American, the odor actually "attracted" European vets who were pleased the product is now available. To paraphrase ROBERT DUVALL in "Apocalypse Now", it appeared the ESVD attendees "loved the smell of lime sulfur in the morning."
BABETTE BADDAKY (our distributor in Norway), CLAUDIA NETT (Switzerland), REGINA WAGNER (Austria), ILAN SKORINSKY (Israel), HANS KOCH (Germany), PETER HILL, IAN MASON and RICHARD HALLIWELL (UK) were amongst the many who attended. CRAIG HARRISON nearly gave me the WCVD shirt off his back. The Europeans warmly received the few of us who attended from the states namely KAREN BEALE, DAVE DUCLOS, ROSARIO CERUNDOLO, THIERRY OLIVRY and BARB ATLEE. DermaPet's UK staff members, LYDIA PAYNE, won a Flat Screen and a Swiss Army watch, while LAUREN BUCKLY also won a watch.
In the tradition of all derm meetings, there was many free refreshments constantly available with music and dancing at nite. The Spanish contingent seemed particularly willing to party with the promise that the SEVC in BARCELONA next month will be a fun time. Europeans appeared to require no particular partner to dance.
See at our web site "Topical Ketoconazole Antifungal Therapy" by LOU GOTTHELF, VPN, 8/07 (for a complete unedited version go to www.dermapet.com)
Ketoconazole has been used to extend the MalAcetic line making Mal-A-Ket Shampoo, a 2% Acetic Acid, 2% Chlorhexidine and 1% ketoconazole clear, elegant and pleasant smelling shampoo. This product has mixed microbial efficacy and should be helpful in your Malassezia, dermatophyte (and other cutaneous fungal orders), Staphylococcus and other microbial associated cutaneous disorders. It has excellent coat conditioning, degreasing and deodorizing qualities.
TrizULTRA+KETO uses Ketoconazole to extend our patented TrizEDTA line by adding .15% ketoconazole. This broad spectrum product is designed to benefit those cases where Malassezia otitis co-exists or is associated with bacterial ear disease. This product is low viscosity, totally soluble and in solution to better access difficult areas of infection. It combines the best topical antifungal with the best topical and ONLY PATENTED antibacterial, TrizEDTA. Of course, our MalAcetic Otic line is still the best approach towards Malassezia otitis with or without associated bacterial cocci involvement.
TrizPLUS with .15% chlorhexidine is available for your difficult bacterial cases, combining the gram negative merits of TrizEDTA with the gram positive effects of chlorhexidine.
Go to KetoFlyer6.pdf
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We will be at the:
- ACVC in Atlantic City on Oct 9-11
- SEVC in BARCELONA on October 18-21
- Great Smokies in Asheville, NC,Oct 26-29
- Muller meeting in Maui in the first week of November and
-Barbados, the 4th Pan Commonwealth Veterinary Conference, November 4-8 where LOU GOTTHELF and YT lecture.
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BOB MARSHALL handles the Northwest. Bob can be contacted at bob.dermapet@sbcglobal.net, and 916-290-3557.
DOTTIE ASMUSSEN handles IL, IA, WI, MN, NE, KS, MO, ND, and SD. Dottie lives in Hannibal, MO and can be reached at dottie.asmussen@gmail.com or 573-406-8616.
ROB CONN handles the southern region of the West Coast. Rob can be reached at 818.585.0632 (Cell) or rob.dermapet@sbcglobal.net
Al LINGUA is in the NE from New Jersey north. Al can be reached at 860-810-7280 or ajlingua@aol.com.
JAY MAIDEN is our TM for the SE US (FL MS, AL, TN, KY) . Jay can be reached at 727-560-2325
or jaymaiden@verizonmail.com .
The "old work-horse" CHUCK MICHAELS fencepostcharlie@yahoo.com or 240-447-7248, works the Middle eastern US, PA, WV, DC, MD, VA and DE.
PATRICK RAYBURN (SW TM) ducks2003@suddenlink.net
or 817-559-7878, continues to ride with distributor reps.
All our sales are guided by the capable JACK WHITE jag6410@aol.com or call 866-3376 or 866-DERMAPE.
For the TM nearest you please email, look at our web site or call us.
3rd Quarter 2007 -Buy any 3 cases of our popular Otics and receive a FREE case of either TrizUltra or MalAKet.
3Q Specials Link
Call your DermaPet Distributor or 800 755 4738 for ordering information.
TECHNICAL BULLETINS are at our web site.
Previously, we showed how our LIME PLUS Dip has 29% more lime sulfur than the
new LymDip. The new LymDip is a much weaker formula that has not survived the
test of time (neither for efficacy or stability). Despite their citing literature,
there is not one refereed publication supporting the use of this substantially
diluted product. There also is reason to believe that fragrances used in this
product (the addition of which required the dilution from a 97.8% like LimePlus
to 76.9% in LymDip) will cause contact irritation/dermatitis.
The LimePlus Dip formula, like all DermaPet products, offers the desired ingredient,
undiluted lime sulfur, packaged at an FDA inspected facility under strict cGMP
regulations.
Since Lime Plus Dip contains 98% lime sulfur and the "new" LymDip only 76.9%,
several questions beg asking:
1) What exactly has been substituted for the effective ingredient?
2) Could the missing 21% be fragrance or alcohol or some unknown heretofore
non-functional (except for marketing) excipient?
3) What function could these substitute ingredients possess?
4) Will testimonials of efficacy from "allied experts" convince vets that DECADES
of previously refereed papers were wrong about the effective concentration?
Lou Gotthelf's Small Animal Ear Diseases
Lou Gotthelf's Small Animal Ear Diseases 2nd Ed is out. There is a chapter by YT as well as many others. At $64.95 this is a great deal considering all the color photos and the fact that ears represent up to 20% of your business.
MedRx is offering CE with EAR Seminars
by LOU GOTTHELF. For more information call 888-392-1234
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