That s Not Normal! Changing Client Misconceptions Jennifer L. Matousek, DVM, MS, DACVD

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1 That s Not Normal! Changing Client Misconceptions Jennifer L. Matousek, DVM, MS, DACVD Misconception #1: The redness / odor from my English Bulldog s skin folds are normal for the breed. Skin folds are a normal feature of some breeds, such as the English Bulldog and Chinese Shar-Pei. Clients realize that their pet can be prone to infection in the skin folds, but often accept this as a normal part of the breed and do not seek medical advice or therapy for the infections. It is important to educate people about the ways that we can try to prevent and control skin fold infections! Skin fold dermatitis is called intertrigo. Skin folds, not just for English Bulldogs! Skin folds can occur on the face (nasal, muzzle, lip), legs, body, tail base, or vulvar areas. While skin folds on the face and tail of bulldogs are common, other breeds can be affected by skin folds examples include facial folds in Persian cats or lip fold dermatitis in St. Bernards. Skin folds can be problematic in obese animals and patients with lichenification from chronic dermatitis (i.e. ventral neck of a Cocker Spaniel with allergies). Why do the skin folds get infected? Skin folds result when two skin surfaces are closely apposed. The skin surfaces rub against each other, causing inflammation. Add poor air circulation and increased moisture in the fold (excess glandular secretions, tears, urine), and an environment is created that favors bacterial and yeast overgrowth. These micro-organisms are irritating, which contributes to a vicious cycle of inflammation. As long as the fold is present, management of the area will be required to prevent recurrence. Clients should be informed that as long as the skin fold is present, the area will be prone to recurrence of inflammation and over-growth of surface micro-organisms. In some patients, the fold can be surgically corrected this is probably most commonly considered for vulvar fold dermatitis and tail fold dermatitis. Cytology helps guide management of intertrigo A cytology sample from a swab of the fold should be obtained and examined microscopically for the presence of inflammatory cells, bacteria (cocci or rod shaped) and yeast. Treatment options differ, depending cytology findings. Treatment of intertrigo Carefully clean the area to remove surface exudates and debris this can be uncomfortable or painful in severely affected patients. Surface cleaning can be done with moistened gauze pads (water / dilute chlorhexidine) or by using manufactured wipes containing chlorhexidine, miconazole/ketoconazole, or acetic acid/boric acid. An alternative is to use an ear cleaner to moisten gauze squares.

2 Clean the fold for the client while the patient is in the clinic, then teach the client how to clean the area at home. Continued cleaning at home is necessary to resolve the dermatitis, and to prevent recurrence. For mild intertrigo, cleaning may be sufficient. For moderate to severe intertrigo, other medications may be needed. Although systemic therapy is sometimes indicated, topical therapy should almost always be integrated into the therapeutic plan. Topical hydrocortisone % ointment/cream, or a low dose of systemic prednisone may be used for patients with severe inflammation. Topical and/or systemic antibiotics may be needed if there is evidence of bacteria on cytology. Good options for topical therapy include silver sulfadiazine 1% and mupirocin 2%. Systemic therapy is beneficial for patients with deep folds, and those that are painful. Topical and/or systemic antifungal therapy may be needed if there is evidence of Malassezia yeast. Miconazole is often effective when used topically. Systemic antifungal medications are not commonly required. Pets with inflammation, bacteria and yeast often benefit from a combination ointment/cream containing a steroid, antibiotic and antifungal medication can be useful. Prevention of intertrigo Routine cleaning of the skin fold is often required to prevent recurrence. The frequency of cleaning needed should be individualized for each pet some will require daily cleaning, while others will be stable with weekly cleaning. It is optimal to control the intertrigo with cleaning, and reserve medications containing steroids and antibiotics for acute flare ups. Misconception #2: He licks his paws because he is bored. Although occasional paw licking can be normal behavior, persistent paw licking suggests an underlying disorder. Common causes of excessive paw licking are allergies and secondary infections. Other causes include arthritis or foreign bodies these are more likely if only one paw is affected. A psychogenic cause of licking should only be diagnosed after excluding other possible causes. Obtain a good history from the owner Ask about environmental exposure (backyard, walks) to help determine if the dog may be at increased risk for trauma or foreign bodies. Determine if there has been an injury to the paw(s) recently or in the past. Investigate if there is a pattern to the behavior is it worse during different times / seasons of the year? Finally, are there any other symptoms lameness, generalized pruritus or other skin lesions, ear infections?

3 Cytology and skin scrapings of the paws are helpful. Cytology samples should be obtained from the paws to investigate for secondary infections. Malassezia yeast and bacteria can be present, which can greatly exacerbate pruritus for some patients. Demodex infections can be limited to the paws, and are often complicated by secondary infections. If an infection is present, topical and systemic antimicrobial treatment can lead to significant improvement in the patient s symptoms and lesions. It is important to note that bacterial and yeast infections are usually secondary to an underlying disorder the infections are likely to recur if that disorder is not identified and managed. It could be an allergy! Allergic dermatitis varies in severity diagnostic and treatment options should be tailored to each individual patient and client Initial symptomatic therapy Wiping or cleaning the paws can help prevent secondary infections, and can help remove pollen and mold spores if the patient has atopic dermatitis Antihistamines Essential fatty acid supplements, or diets with high amounts of fatty acids Topical therapies that help strengthen skin barrier properties Systemic antibiotic and antifungal medications, if indicated for secondary infections Advanced symptomatic therapy may include low dose glucocorticoid therapy (Temaril-P, prednisone), modified-cyclosporine (Atopica ), or oclacitinib (Apoquel ). When symptomatic therapy is not adequate, or the symptoms are persistent, it is wise to identify the type of allergy and provide specific therapy. Atopic dermatitis (environmental allergies) can be seasonal or nonseasonal. Intradermal allergy testing can identify pertinent allergens for each patient. These pets can benefit from allergen immunotherapy. There are two options for immunotherapy subcutaneous injections and sublingual allergy drops. Adverse food reactions typically cause symptoms year-round. An elimination diet trial can be used to diagnose an adverse food reaction. If a patient has food allergies, the symptoms can be controlled long-term with diet alone.

4 Misconception #3: My cat grooms excessively because of anxiety. Although grooming is a normal behavior in cats, grooming that leads to hair loss or skin lesions is abnormal. Common causes of excessive grooming are allergies and parasites; hyperthyroidism and dermatophytosis are less common causes. A psychogenic cause of over-grooming should be diagnosed only after exclusion of other possible causes. Obtain a good history from the owner Determine if there is a seasonal pattern to the excessive grooming (i.e. worse in the fall). Ask if there are any other animals in the house over-grooming or if any seem itchy. Check to see if there been any recent stressful events for the patient (i.e. moving to a new home). Investigate whether treatment has been tried, and if there was any response to those medications (i.e. steroid therapy, behavior modifiers). Diagnostic tests are helpful for determining the cause of the over-grooming. Skin scrapes are useful for identification of parasites such as Cheyletiella or D. gatoi. Fungal cultures (DTM) are indicated to evaluate for the possibility of ringworm. CBC, Chemistry, Urinalysis, and T4 tests are particularly helpful in older patients to help determine if there is an underlying systemic disorder. Parasite treatment trials are important to rule out potential parasite infections. Parasite infections cannot be completely ruled out based on lack of evidence of fleas on physical examination, or negative skin scrapings for parasitic mites. To rule out these possibilities, a treatment trial should be prescribed. There are many options for routine flea control, but it is optimal to choose a parasiticide that will kill the adult flea. It can be more challenging to rule out D. gatoi infections this can be done with lime sulfur dips or off-label use of some parasiticides. It could be an allergy! Both food and environmental allergies are causes of excessive grooming in cats. Cats with nonseasonal symptoms of over-grooming should undergo an elimination diet trial for food allergies. Although environmental allergies are usually considered seasonal, many cats have allergies to house dust and therefore have symptoms year round. Intradermal allergy testing with subsequent allergen immunotherapy is a good option for cats that do not respond to an elimination diet trial, or for those with seasonal symptoms in which flea allergy has been ruled out. Symptomatic therapy can be given to control allergy symptoms, and includes antihistamines, glucocorticoid therapy, and modified-cyclosporine. What if it is psychogenic alopecia?! Consultation with a veterinary behaviorist should be recommended. Behavior modifying medications, such as clomipramine or amitriptyline have been effective in some cats.

5 Misconception #4: She has ear infections because she is a Bassett Hound with big floppy ears! Clients often believe that all dogs with pendulous ears have ear infections due to a lack of air circulation in the ear canal. There is currently little evidence to support that pendulous ear pinnae predispose to infection, for example, the temperature of the external ear canal is the same in dogs with erect or pendulous ears. It is more likely that these patients have a primary reason for the ear infections most commonly, an allergy! Otoscopic examinations are required to evaluate for underlying causes of recurrent otitis. An otoscopic examination can provide a lot of information about the ear canal. Ear infections can be recurrent if there is a foreign body or mass in the ear canal. Additionally, chronic inflammatory changes (stenosis, glandular hyperplasia) and excessive waxy exudates can make an animal more prone to otitis. Ear swab cytology is important for determine if the infection is resolving with therapy. Cytologic evaluation of an ear swab is an important tool in the diagnosis of otitis externa. It is helpful to note if yeast, bacteria (rod and/or cocci) or inflammatory cells are present on the slide. After treatment with an appropriate ear medication, the ear cytology should be rechecked, which will help assess the response to therapy. Some patients will improve significantly with treatment for ear disease, but still have microorganisms present in the ear canal. If medications are discontinued too early, the symptoms of otitis will recur. Food allergy is a common cause of otitis when there are no other dermatologic symptoms. Both atopic dermatitis and food allergies are common underlying causes of otitis externa. Atopic dermatitis is often associated with other symptoms, most notably pruritus. For patients whose only symptom is recurrent otitis externa, an elimination diet trial to investigate for underlying food allergies should be pursued. Routine ear cleaning may help decrease recurrent infections. Ear cleaning helps to remove excess wax and debris from the ear canal, and can decrease the presence of bacteria and yeast in the ear canal. It is helpful to demonstrate how to clean the ear for the client.