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January 2008
Ketoconazole In Vet Derm
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Table of Contents
Lou Gotthelf's Small Animal Ear Diseases
Ketoconazole In Vet Derm
The following is edited from "Topical Ketoconazole Antifungal Therapy" by LOU
GOTTHELF, VPN, 8/07 (for a complete
unedited version go to www.dermapet.com)
Veterinarians have longed for a broad spectrum antibacterial and antifungal topical to handle those dermatitis cases where either mixed microbes are involved or as a broad spectrum treatment when they are not sure. Recently, (ed note: MalAKet and TrizUltra) containing traditional antibacterial agents have been introduced into the market that are mixed with the antifungal agent, ketoconazole in the form of shampoos and otics.
Shampoo therapy is an integral adjunctive part of the management of skin diseases in dogs and cats. Treating the skin requires TREATING-THE-SKIN; not just giving systemic medications such as steroids, antifungals, and antibiotics. Deciding which shampoo to use and which ingredients the shampoo should contain for a certain skin problem may be confusing.
Rather than just cleansing the dirt off of the skin and haircoat, when left in contact with the skin for 15 minutes or longer, these shampoos actually have beneficial effects on the skin cells. Newer shampoos contain topical pharmaceuticals as a part of their ingredients, so topical antimicrobial therapy in shampoos is now possible. Recently, 1% ketoconazole has been added to Mal-A-Ket, for dogs and cats used in treating Malassezia dermatitis and dermatophytosis/ringworm.
Ketoconazole is an azole antifungal agent that binds to the lipids in fungal cell membranes and interferes with the synthesis of ergosterol, an integral part of the fungus or yeast cell wall. When topically applied in a shampoo, ketoconazole should be used on a skin surface that is degreased because of its lipid affinity. The more lipid that is on the skin, the smaller the amount of ketoconazole that will be available to bind to the yeast or fungus. With some shampoos, a good degreasing shampoo should be used prior to the ketoconazole shampoo. Mal-A-Ket, 2% acetic acid, 2% chlorhexidine and 1% ketoconazole contains acetic acid which actually degreases the skin as the shampoo is working. Chlorhexidine gluconate 2%, an antimicrobial detergent that binds to skin proteins. seems to be a synergistic with the 1% ketoconazole when used topically. Like MalAKet, a product containing ketoconazole should have an even distribution of the drug and it should be a clear solution rather than a suspension. Ketoconazole is not very water soluble, so when using it in a shampoo, the less water dilution there is, the higher the concentration on the skin cells.
Using a topical ketoconazole shampoo for ringworm in cats may preclude the need for systemic antifungal drugs, like itraconazole and fluconazole which are expensive. A ketoconazole containing shampoo has a much less offensive odor than other topicals like lime sulfur, which can be used in conjunction to treat dermatophytosis. In addition, topical therapy for ringworm helps to reduce shedding of spores in the environment. Twice weekly 15-20 minute shampoos are required until a negative DTM culture is obtained.
Malassezia dermatitis results as a secondary complication from allergies or adverse food reactions in dogs. Atopic dermatitis dogs usually have Malassezia yeasts between the toes and results in foot licking and salivary discoloration of the hair. Atopics may also have hyperkeratosis and seborrhea, often with a very bad odor in the axillary, antecubital, pedal and ventral neck region. Of course Malassezia otitis occurs in most of these allergic dogs, too. Shampoo therapy alone may help many of these allergy dogs get relief from Malassezia dermatitis. However, systemic treatment with steroids, cyclosporine, antibiotics and antifungals may be necessary in more severe cases. Allergen specific immunotherapy and food elimination diets may decrease the incidence of Malassezia dermatitis. Initial skin treatment requires a 15-20 minute whole body shampooing every other day for 2 weeks, a total of 7 treatments. In foot lickers, make sure that the shampoo gets between the toes and in the foot pads.
Malassezia otitis often complicates allergic disease, hypothyroidism, and seborrheic conditions in dogs. Antifungal drugs such as nystatin, clotrimazole, miconazole, and thiabendazole have been available in otic preparations for a long time. Systemic ketoconazole does not seem to have good anti-yeast effects in the ear, most likely due to the ear canal's poor blood supply. Ketoconazole is now available in combination with tris-EDTA (TrizUltra/DermaPet). However, prior to using TrizUltra, a deep ear flush should be done using a wax dissolving cerumenolytic detergent (KlearWax, DermaPet) in the hospital, preferably with the dog sedated or anesthetized. Initial deep ear cleaning remains an essential part of good ear therapy. Twice daily application of the tris-EDTA/ketoconazole (TrizUltra) is recommended until negative cytology is obtained. Treatment is used for a minimum of 2 weeks. Unless the primary cause of the ear disease and/or the Malassezia dermatitis (atopy, adverse food reactions, and/or hypothyroidism) are addressed, when topical skin or otic therapy is stopped, the yeasts often return.
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 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.
For our Ketoconazole products flyer go to http://dermapet.com/articles/KetoFlyer6.pdf
For the 7 Steps to Ear Therapy go to http://dermapet.com/articles/7_steps.pdf
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?
5) Will the "new product" be marketed using the same name, not stressing to vet customers the significant change in concentration?
We will be at the:
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-DERMAPET.
For the TM nearest you please email, look at our web site or call us.
See our 1st Quarter 2008 flyer
Call your DermaPet Distributor or 800-755-4738 for ordering information.
TECHNICAL BULLETINS are at our web site.
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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Steve Melman VMD
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