Log of the Rounds Room session

Many thanks go to VIN for allowing us to reproduce this at our web site. This is a variation of the article "Itchy, Head-to-toe, year-round." I hope you will find it helpful in your approach to itchy dogs. Names have been changed at the request of VIN.

© COPYRIGHT 1998 - Veterinary Information Network, Inc. No portions of this text may be reproduced or distributed for any purpose without the written consent of the Veterinary Information Network, Inc.

Log of the Rounds Room session of October 4th 1998. Tonight Steve Melman the aptly named DermaPet leads as discussion on Atopy -- Diagnosis and Treatment. Frustrated by that itchy dog? Nothing seems to work?? Need a fresh approach??? Then join Steve and the rest of the VIN gang as we explore this interesting, challenging, and very common problem!

Vet1:	Welcome everyone to Sunday night rounds. Tonight Atopy -- diagnosis and management -- with our own Steve Melman (DermaPet) as a special guest presenter.
Dr. Melman:	The treatment of derm cases is #1 in terms of freq of complaints and income prod in almost every SA pract in the world...... Pruritus is the most common initial symp, with allergy being the most common Dx. The treatment of derm cases is #1 in terms of freq of complaints and income prod in almost every SA pract in the world...... Pruritus is the most common initial symp, with allergy being the most common Dx. :) Bear with me as I am unsure of this new program
Vet1:	doing great Steve...
Dr. Melman:	I will anticipate certain basic knowledge on the part of VINers and thus will omit many impt points in an effort to make this a clinical discussion useful in everyday practice.... Steve Young has promised to answer certain dosage and unaddressed questions on the derm boards. It is impt to note that the Dx and appropriate Tx of allergy dooms the client (and patient) to an $$$ work-up and regular lifelong therapy during the relevant clinical season...... It is the obligation of the vet to justify both the $$$ and Tx...... And make the client understand the goal. ..... Allergy testing is very expensive...... We all have experienced a nearby colleague who has made us look bad (after recommending an allergy w/u) by inappropriately using a shot of long acting steroid..... They cured 'em; why couldn't we? am I going too fast? We are going to take a hypothetical case and work it up...... We will apply a Pruritic Clinical Trial as reported in the July 1997 issue of Vet Forum, "Itchy Dog, Head to Toe." ...... This article may be found in it's entirety at my web site http://www.dermapet.com. You will not see this method describe in the ivory towers of academic medicine....... Rather, it may be condemned as a "shotgun" treatment plan...... But, clinically, in the pressured world of SA practice, this practical method will cure most (stop pruritus) and lead to a Dx when it fails. We will justify each comp of this plan and see where success and failure leads us based on the timing of when or if the symptoms (mainly pruritus) disappear and return.... We will often find that pruritus will return after stopping short acting pred (which is a component in this plan); THESE cases need allergy testing and "therapy." Let's take, as our patient, a HW negative, 2 year old, male Golden Retriever, living on a lake in South Carolina, with recurrent "hot spots" (it now has one on the lateral aspect of the face and neck), bilateral otitis externa and pruritus..... VINners, please give me a DD (Differential Dx).
Vet2:	Staph pyoderma, atopy, food allergy
Vet3:	Hypothyroidism
Vet4:	atopy, food allergy, flea bite allergy
Vet5:	iad
Vet6:	fleas
Dr. Melman:	any other bugs?
Vet4:	malassezia
Vet2:	Malassezia, maybe?
Vet8:	!
Dr. Melman:	Vet8
Vet8:	scabies
Dr. Melman:	YES! Vet2 got the Malassezia right OK We should have allergy (inhalant, food, insect and contact), Malassezia and Staph pyoderma (with or without hypersensitivity), intestinal parasitism, ectoparasitism (Scabies, Cheyletiella, other insects such as mosquitoes) on most lists. Any questions on this DD?
Vet9:	?
Dr. Melman:	Vet9
Vet9:	Don't see how intestinal parasites cause pruritis?
Dr. Melman:	it is a not uncommon cause in dogs under the age of one
Vet2:	?
Dr. Melman:	Vet2
Vet2:	Is it because of migrating larvae?
Vet10:	?
Dr. Melman:	not sure of the pathogenesis..possibly increased levels of IgE, migrating larva, debilitati, stress Vet10
Vet10:	Are all parasites likely to do this or only certain kinds?
Dr. Melman:	Good Q...I look for whips mainly..and the sign I look for is a pruritic flank The above named diagnoses WILL BE INCLUDED in the following trial......The results of the trial will guide us to other exclusions..... For example, if cephalexin (and topical therapy) do not stop the pyoderma then ..... we biopsy the pustules or epidermal collarettes and so forth with other DD exclusions like keratinization defects, mycosis fungoides and other less common diagnoses. Remember every good derm work-up starts with a thorough history, skin scrapes and fungal culture. The Pruritic Clinical Trial is: 1. Begin a flea program, preferably either Frontline or Advantage. Keep in mind the shampoo therapy you are doing; try to create a 48 hour break between appl and Shamp..... Maybe best to start this in the exam room before discharge AFTER the first bath (if done in the clinic)... erm, miconazole) may be all that is needed for the next 48 hours. 2. Shampoo Therapy. Shamp DAILY with a hypoallergenic shampoo... If a pyoderma, follow twice weekly with MalAcetic (acetic/boric acid) Shampoo, Benzoyl Peroxide (BP) and/or chlorhexidine followed by MalAcetic Shampoo then Conditioner.... For Malassezia, use MalAcetic Shampoo or a miconazole shampoo followed by one or the other in conditioner form, as instructed........ If pruritus is significant preceed with an oatmeal based shampoo and/or close with an oatmeal conditioner.........
Vet1:	?
Dr. Melman:	In this case, I would use a hypoallergenic shampoo daily for at least 3 weeks starting day one with a MalAcetic Shampoo and followed with an Oatmeal Conditioner. Vet1
Vet1:	Independent of product promotion. can you tell me why I want to bath my pruritic. dog with vinegar and cereal?
Dr. Melman:	yes.
Vet2:	!
Dr. Melman:	the use of the oatmeal is as an antipruritic
Vet1:	-- why is oatmeal antipruritic?
Vet4:	?
Dr. Melman:	the vinegar /boric acid gives you the combined effect of controling Staph and Malassezia -- both in the DD -- both delat with elsewhere as well Vet2
Vet2:	In a dog with hot spots, removing the caustic effect of the serum exudate helps soothe the skin.
Vet1:	?
Dr. Melman:	good Q--we don't know the M of A (Mode of Action)
Vet1:	ah. Vet4
Vet4:	do you add something for skin moisturizer..would think daily bath would dry GA
Vet8:	?
Dr. Melman:	of Oatmeal,yet it is used in the halls of NIH for chickenpox depends on the shampoo, but, yes, usually, in this case we added the oatmeal in the form of a Conditioner Vet8
Vet8:	Does it also help in rinsing of aeroallergens that can be absorbed percutaneously?
Dr. Melman:	EXACTLY as well as inhaled and carried on the coat for you or them or anyone that might be allergic In this case, I would use a hypoallergenic shampoo daily for at least 3 weeks starting day one with a MalAcetic Shampoo and followed with an Oatmeal Conditioner.... I would skip shampoo therapy again until day 3 to let the flea control product get absorbed..... BP will wash off Advantage. Any more Q's on the shampoo therapy?
Vet2:	?
Vet4:	?
Dr. Melman:	Vet2
Vet2:	In our case of the GOlden Retriever, shouldn't we shave the lesion AND initiate shampoos?
Dr. Melman:	good point..we will get to that when we discuss the "hot spot" Vet4
Vet4:	how about owner compliance with daily baths for 3 weeks? ga
Dr. Melman:	:) no kidding..I mention later on about this. I tell them this is a TRIAL if it proves what their pet has and improves the dog then I leave the freq up to them...call it a little jewish guilt! complaince is always the biggerst problme in my practice Ok..we'll go on to the rest of the trial 3. Use an omega 3 and 6 FAs supplement, preferably with antioxidants....... Some cases (up to 15% according to some studies) respond to this.... At least, coats shine better giving a sense of healing.
Vet8:	?
Dr. Melman:	any questions on using fatty acids?
Vet11:	?
Dr. Melman:	Vet8
Vet8:	Doesnt the omegas take at least 30 days to begin to work
Vet13:	?
Dr. Melman:	21 days is what most people use for these with ..... or without antihistamines...but to give them a fair chance I use them any way in all cases Vet11
Vet11:	Do you have a pref - dietary (eg: eukanuba), vs. supplements ?
Dr. Melman:	we will get to the diet for the trial for the time being I prefer FAs in stable caps Vet13
Vet13:	same ? as Vet11, ie, what about if the diet has the proper "ratio" of omega fa's
Dr. Melman:	This ratio Q has been bandied and prepetuated by Iams we will let Steve (Drdog) and I deal with it in the folder. OK?
Vet13:	y
Dr. Melman:	any more on FAs? At least, coats shine better giving a sense of healing. Now diets 4. Follow a strict homemade HA diet for 30 days..... there are many.. I will fax people a copy of the following if they want See p 125 of my book, Skin Diseases of Dogs and Cats, chapter on Food Allergy by Kevin Byrne.......
Vet14:	?
Dr. Melman:	This is a good time, to discuss the phenomenon of "allergic breakthrough" In simple terms, it is when the sum of all insults (AG load, vacc, viruses, parasites, envi stress) occur. The patient is "primed" , thus allergy CS are more easily elicited by less and less AG..... Thus, I suggest a HA (Hypoallergenic) diet to all my atopics during their allergy season...... For Diagnostic purposes I like a homecooked one if compliance is there
Vet15:	?
Dr. Melman:	This is a good time to share experiences with other commercial diets Vet15?
Vet15:	are commercial diets ok? like duck and rice etc? venison etc? opps i am trigger happy!
Vet14:	?
Dr. Melman:	Vet14
Vet14:	CNM-HA is a truly HA diet. Why would you not start with that rather than asking the client to make a diet for a 6-8 week trial? ga
Dr. Melman:	I like it also and would recommend that IF they were ot not be willing to cook
Vet2:	? for Vet14
Dr. Melman:	Vet2
Vet2:	Please tell us about your experience with the CNM diets
Vet14:	Okay.... :-) As I only see cats and NO dogs, I haven't had the cahnce to use their HA diet, but have read a lot of the supportive paperwork on it and wish it were available for cats... I use a lot of en-formula and NF in my practice though (obviously not for skin atopy) ga
Dr. Melman:	Vet2, why do you ask?
Vet14:	opppps. we also use some CV and UR ga
Vet2:	Purina salesman is very persistant. I have 4 hypo diets now.
Dr. Melman:	my trial is for 30 days ONLY..not 6-8 wks. I am not a 8-10 wk believer
Vet11:	?
Dr. Melman:	Vet11
Vet16:	?
Vet11:	30 days? As a part of atopy therapy, or as a food allergy trial?
Dr. Melman:	as part of the pruritic w/u to determine the cause I also use a commercial HA maintenance diet in atopics we get to that later If this animal is non-pruritic after the 30 days then I would challenge the diet..... If pruritus occurs within 48 hours then you have a diagnosis of primary food allergy..... next is the most impt corticosteroids Some people use antihistamines which are possibly OK for maintenance purposes but not in a trial..... If the pruritus goes away and returns after 12 days then you have a Dx of non-OFA responsive, non-shampoo therapy responsive Inhalant and need to allergy test and start on a vaccine. I will move to the other parts and discuss this later
Vet8:	?
Vet4:	?
Dr. Melman:	Vet8
Vet8:	What about ivermectin imperical therapy for persistant pruritis
Dr. Melman:	coming..
Dr. Melman:	Vet4
Vet4:	just to clarify, do you do the pred after the baths then? ga
Dr. Melman:	this is a simulataneous Tx plan...with the baths
Vet4:	thanks
Vet16:	your e-mail address? Dermapet
Dr. Melman:	Vet16..yes..dermapet@aol
Vet4:	?
Dr. Melman:	6. Antibiotics are only used if a pyoD (seen in as many as 68% of atopics) is present.... I generally prefer cephalexin 10 mg/1 pound/bid/21 days......
Vet1:	simply Dermapet from AOL :) Dermapet@aol.com from non AOL.. best to post discussions on the boards --:) ga
Dr. Melman:	The presumption with epidermal collarettes and/or pustules and/or lichenification is Staph pyoderma or Malassezia...
Vet17:	?
Dr. Melman:	Vet17
Vet17:	Do you not think this diagnosis protocal is excessive in the case of one or tow recurrent hot spots?
Dr. Melman:	if you are looking for allergy... it is an expensive proposition in tems of the w/u this is a way to maybe avoid the big bucks for the test and vaccine
Vet4:	?
Dr. Melman:	or justify the expense Vet4
Vet4:	just wondering if you have tried different bathing frequencies such as EOD or weekly... and your experience/reason for selecting daily baths? ga
Dr. Melman:	my experience is they respond better when you get rid of.. the source of the problem
Vet6:	/
Dr. Melman:	the allergen on their coat
Vet6:	?
Dr. Melman:	Vet6
Vet6:	What dose of pred are u using
Dr. Melman:	start at 1 mg/kg split daily, then 1/2 qd, then eod let's move on If it responds to antibiotics then it was superficial. If it is incomplete then further Tx may be necessary. If no response then you must consider autoimmune diseases and biopsy. ........ If there was a complete response and a recurrence then one must consider the many causes of pyoderma from incompete Tx, to recurrent pyoderma and Staph hypersensitivity and immune deficiency. next Vitamin I
Vet18:	! I use dexamethazone .25 to .125 mg bid for 1 week Its more potent with less side effects
Dr. Melman:	I don;t use dex orally in allergy nor do most experts..not necessarily wrong
Vet18:	why we can discuss that on the boards. OK?
Vet18:	sure
Dr. Melman:	7. Treat ectoparasites with Ivermectin (bovine Ivomec) at .1 ml/10 pounds/weekly/4 Txs.... Remember contact animals......The extralabel use of this should be noted.... .. Do not use in Collies or mixed Collies with whom I use "alternative methods" to eliminate Scabies and Cheyletiella..... The increasing prevalence of Scabies is, perhaps, the single most important reason why the pruritic clinical trial can be curative. this is the ivermectin trial asked about any Q's on this? 8. Treat endoparasites (phantom?) with an anthelminthic that also targets whipworms.... 9 . Tx other symp such as "hot spots".... Clip lesion with a #40 blade.... While I use systemic corticosteroids. they are already a part of this plan... Shampoo the entire body with a med shamp that does not put at risk your flea control like MalAcetic and chlorhexidine.. again already a part of the plan Usually these can be treated without using antibiotics;.... however, in this case, the location on the side of the goldens face seems to be often complicated with a deeper pyoderma requiring use of antibiotics. as described in the 6th step..... Treat the affected area topically daily for about 1 week. any Q's on hot spots?
Vet2:	?
Dr. Melman:	10. Tx other symptoms such as otitis externa which is seen in up to 50% of atopics. Vet2 and while at it answer 10.
Vet2:	Is it your feeling that hot spots are a manifestation of allergy
Dr. Melman:	yes.
Vet2:	I begin the workup of otitis externa (OE) with a roll swab to identify organisms (or not)
Dr. Melman:	Vet2.Tx? or Dx? :). What do you see on this smear?
Vet2:	If I find Malassezia, which accounts for 75% of my allergic dogs, I begin with daily cleanic cleaning for 1 week. If there are bacteria, then I use daily cleaning along with an antibiotic such as injectible Baytril in artificail tears or synotic The pruritis of Malassezia usually subsides in 1 week with acetic/boric treatment.
Dr. Melman:	OK. we Tx the Malassezia. People should know how to Tx that. If not, see you on the boards thanks Vet2 :)
Vet2:	I always get a good look with the patient sedated to see if there is additional ear patholog
Dr. Melman:	of course, you are using that fancy Vet scope Ears are an entire subject by themselves which is why Vet2 is writing a book on them
Vet1:	How we doing Steve? Getting late for you east coasters :)
Dr. Melman:	Ok we've done the trial now let's see what happened not sleepin yet :) If the pruritus does not go away then you have topical therapy unresponsive Malassezia (you may want to try ketoconazole 10 mg/kg/qd with an acidic food +/- a 'conazole topically).. I have not needed this systemic Tx in almost a year ivermectin resistant Scabies..... or a Zebra (biopsy and further w/u are necessary). We have now eliminated FA, Malassezia and Staph pyoderma (with or without hypersensitivity), intestinal parasitism, ectoparasitism (Scabies, Cheyletiella). maybe not the recurrent pyodermas WE HAVE a dog that is not FA and has an increased pruritus gradually after stopping the prednisone...... We have justified the allergy test, tested by elisa and received a vaccine with appropriate instructions to build up to full strength....... anybody awake enuff to follow how we got here? questions?
Vet2:	?
Dr. Melman:	Ok let's test for allergies Vet2
Vet2:	I was going to ask your preference for ELISA
Dr. Melman:	we can discuss that in the folder Testing..... With the exception of dermatology referral practices, blood tests, mainly Elisa, are the best way to test for inhalant allergy... When doing allergy testing, be sure that the lab you are sending serum has a profile for YOUR area.. Food allergy should not be tested by Elisa or IDST since the results are unrelaible...... The best FA(Food Allergy) test (and only reliable one that I know of) is the elimination diet
Vet19:	?
Dr. Melman:	Vet19 GA
Vet19:	any preference on labs? GA
Dr. Melman:	trying to avoid that Q as I am prejudiced there are many...we deal with this in the folder.. OK?
Vet19:	K
Dr. Melman:	the issue is that IDST is NOT a better test except for dermatologists and then only maybe
Dr. Melman:	so do your Elisa and hyposens and feel confident with the following Tx plan
Vet1:	sounds like a message board folder discussion to me :)
Dr. Melman:	right :) Tx plan "Summation of effect"= a subclinical pet may become symptomatic if any comb of fleas, antigen load, pyoderma or dry skin occur. 1. Vaccine- necess if avoidance of Ag is not poss. I like to increase the freq of the vacc to 10,000 PNUs (1/2 dose) weekly during the clinical (pruritic season).... Maintenance is usually 20,000 PNUs bimonthly..... Be sure to conentrate on the antigens seen during the symptomatic season.... the last point is most impt.. Vaccine Q's? usually a specialist is associated with the lab to choose the specific antigens as well as the number to use 2. Shampoo Therapy... if the dog does better with freq shampoos and the client sees this then tell them to bath as often as possible-DAILY is best!... keep up the guilt trips! 3. Pred., if necessary to break the cycle..... if properly used EOD then it can be used longer term, if necessary. 4.Antihistamines. 10-30% effective esp w OFAs....assess efficacy in 3 wks...... dosages...hydoxyxine and diphenhydramine (2.2 mg/kg/tid)......clemastine (.05-.1 mg/kg/BID)..... chlorpheniramine (.4 mg/kg/tid).......amitriptyline (1 mg/kg/BID) I rarely use these. we'll finish the Tx plan and then field Q's. 5. OFA caps..... 6.Feed a low antigen/hypoallergenic diet.. maintenance diet..commercially made and that passed provocation after the 30 day trial 7. Flea control..... 8. Treat symptoms and recurrences... If recurrent pyoderma then biweekly baths in MalAcetic.... If OE then clean ear/Q/2x/wkly..... If Malassezia then MalAcetic Shampoo and/or Conditioner/eod for Tx and 1-2x wk/prevention I tell my clients they should expect to visit me early on, annually, when symptoms start, to get them under control to receive a tune up and then maybe once or twice should an outbreak of symptoms occur. Now is the time to ask ANY thing you want on allergy, this trial, anything GA
Vet1:	Thanks Steve! we'll take a few short ? but then let's direct it to boards
Vet6:	?
Vet1:	I can see the group is very interested -- hanging in there
Dr. Melman:	Vet6
Vet1:	Great stuff :)
Vet6:	If you can controll allergies with pred short term is that acceptable
Dr. Melman:	thanks Paul..I think they'll sleep well now it is IF the symptoms are no longer than one month a year, give or take a few wks problme is they get worse as they get older and the pred dose goes higher and lasts longer
Vet7:	?
Dr. Melman:	and the liver gets worse..you know the rest :) Vet7
Vet7:	How long do you wait after pred to do Elisa? ga
Dr. Melman:	Good Q... it depends on the elisa..that is a big reason I didn't want to touch that Q
Vet2:	!
Dr. Melman:	generally an elisa is less likley to have drug interference except for, notably, one Vet2
Vet2:	If I think it is atopy, I'll draw a pre-steroid blood sample good for 30 days
Dr. Melman:	Which is what i am doing and should have mentioned it is good if frozen for much longer than 30 days thanks, Vet2
Vet1:	OK -- I think that wraps it up THANK YOU STEVE and all for coming
Dr. Melman:	I want to offer my sincerest sympathy to Steve (DrDog) who I am sure would have done a great job with this seminar..... Thanks go out to Paul (PDP1), Duncan (DuncanF), Nate (NateDVM) and Becky (Watusi) who gave me a cram course and support in the short time we had to prepare this..... Special thanks go to Vet2 for handling the Malassezia and otitis sections.... Any questions you may have regarding this presentation should be emailed to DermaPet@aol.com or call me, Steve Melman, at 800-755-4738....
Vet20:	It was my first time here. Sorry I logged on late

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