a 'd :'e ,'' sponsorship& topic ermatitis tiopathology ... · 3/9/15&...
TRANSCRIPT
3/9/15&
1&
ATOPIC'DERMATITIS:'ETIOPATHOLOGY,''CASE'MANAGEMENT'AND'CLIENT'
COMMUNICATION'
Dr.&Tim&Strauss,&DVM,&Diplomat&ACVD&Rocky&Mountain&Veterinary&Dermatology&
Sponsored'by'ALK'
Sponsorship&
Thanks&to&ALK&&&the&ACTT&Allergy&Program&for&sponsoring&tonight�s&
VETgirl&webinar!&
IntroducMon&
JusMne&A.&Lee,&DVM,&
DACVECC,&DABT&
CEO,&VetGirl&
Garret&PachMnger,&VMD,&DACVECC&
COO,&VetGirl&
IntroducMon&
VETgirl…on&the&RUN!&
• The&techUsaavy&way&to&get&CE&credit!&• A&subscripMonUbased&podcast&and&webinar&service&offering&veterinary&RACEUapproved&CE&
SubscripMon&plans&
• VETgirl&Standard:&50U60&podcasts/year&&– $99/year&&– 4&hours&of&RACEUCE&&
• VETgirl&ELITE:&50U60&podcasts/year&plus%20&hours&of&webinars!&
– $199/year&– 20+&hours&of&RACEUCE&
3/9/15&
2&
Subscribers:&iTunes&Download!!!& Find&us&on&social&media&and&our&blog!&
LogisMcs:&CE&CerMficates&
! No&need&to&raise&your&hand!&
! Type&in&quesMons&
! Emailed&to&you&48&hours&acer&the&webinar&
! AcMve&parMcipaMon&=&no&quiz&
! Watching&video&later,&must&complete&quiz&
! ELITE&members&only&
! Email&/&contact&with&ANY&quesMons&
Call&in&from&Smart&Phone!&
IntroducMon&
Dr.&Tim&Strauss,&DVM,&Diplomat&
ACVD&
Rocky&Mountain&Veterinary&
Dermatology&
Overview&of&today’s&presentaMon&
• Understanding&new&concepts&for&an&old&disease&
• Secondary&condiMons/presentaMons&• Clinical&insights&
– Emphasis&on&managing&immunotherapy&paMents&
• Newer&treatments&
• How&to&approach&cases/examples&
3/9/15&
3&
A&New&DefiniMon&
• “A&geneMcally&predisposed&inflammatory&and&pruriMc&allergic&skin&disease&with&characterisMc&clinical&features&associated&with&IgE&most&commonly&directed&against&environmental&allergens”&1&
• Why&does&it&maper?&
1.&Halliwell&R:&Revised&nomenclature&for&veterinary&allergy.&Vet&Immunol&Immunopathol&114&(3U4):&207U208,&2006&Dec&15&
Old&versus&New&Pathogenisis&
Old'Theory'
• Type&I&hypersensiMvity&• Exclusively&IgE&and&mast&cell&
mediated&
New'Understanding'
• IgE&is¬&different&in&most&atopic&dogs&
• Innate&immune&system&&– T&helper&cell&responses&– Different&cytokines&(ILU3,&5)&
• Impaired&barrier&funcMon&
• NonUhistamine&pruritus&mediators&– ILU31,<&
Delayed/Innate&HypersensiMvity&& Clinical&PresentaMon&
• Erythema,&pruritus&• Pinnae,&paws,&axillae,&groin,&perianal,&perioccular&
• Signs&start&between&6&months&and&3&years&of&age&• Otherwise&healthy&• Chronic,'relapsing,&someMmes&seasonal&condiMon&• Any&Mme&allergen&exposure&occurs&we&should&expect&clinical&signs&to&reUoccur&&&
Don’t&Miss&these&“LookUAlikes”&
• Flea&allergic&dermaMMs&
• Sarcoptes&mange&
• Pyoderma&
• Malassezia&DermaMMs&
• Cutaneous&lymphoma&(rare)&
• Dermatophytosis&(uncommon)&
• Demodicosis&
&DiagnosMcs&
• History&and&good&physical&exam&
• Skin&scrapings&• Skin&cytologies&• Biopsies&• Fungal&culture&• Diet&trial&• Allergy&tesMng&
3/9/15&
4&
Cytologies&
• Great&for&diagnosing&infecMon&– Malassezia&
– Staphylococcus&– Ear&infecMons&
• Should&be&done&in&most&derm&cases&
• All&ear&cases&• Clients&don’t&mind&cytologies&
Use&oil&immersion&(100x)&Look&for&yeast,&bacteria&
Secondary&CondiMons/Lesions&
• Pyoderma&
• Malassezia&dermaMMs&
• OMMs&• ExcoraMons,&lick&granulomas&
• Alopecia&• LichenificaMon&• HyperpigmentaMon&&
Pyoderma&
• Staphylococcus%pseudintermedius%• Oral&anMbioMcs&
– Cephalosporines&(first&line)&• Topical&anMsepMcs/anMbioMcs&
– Chlorhexedine&(2U4%)&– Benzyol&peroxide&(2U4%)&– Mupirocin&2%&
• SPL&injecMons&&
Malassezia&DermaMMs &&
• Malassezia%pachyderma55s%• Topical&therapies&
– Ketoconazole&– Acidic&preparaMons&
• Oral&anMfungal&azoles&– Ketoconazole&5mg/kg&BID&
– Fluconazole&5mg/kg&SID&
OMMs &&
• Clean&(flush)&the&ears&to&remove&debris&
• Treat&inflammaMon/pain&
• Treat&secondary&infecMons&• Treat&underlying&allergy&• Recheck&progress®ularly&
3/9/15&
5&
Acral&Lick&Granulomas&
• Ocen&allergy&related&– Especially&mulMple&lesions&
• Can&be&deeply&infected&– 30&days&of&oral&anMbioMcs&
• Don’t&usually&respond&to&topical&medicaMons&
• Behavioral&modifying&medicaMons&– Clomipramine&–&2U4&mg/kg&SID&
– FluoxeMne&–&1U2&mg/kg&SIDUBID&
– ParoxeMne&–&0.5U1.0&mg/kg&SID&
Management&
Common&Management&DifficulMes&
• UnrealisMc&expectaMons&– There&is&no&cure&– NonUaggressive&treatments&
• Lack&of&long&term&treatment&plan&
• Lack&of&follow&up&• Failure&to&idenMfy/treat&complicaMng&disease&
Diagnosis&of&Atopic&DermaMMs&• Exclude&other&causes&of&pruritus&
• Food&allergy&• Parasites&• InfecMons&• Cutaneous&lymphoma&(rare)&
• Age,&breed,&history&• GlucocorMcoid&responsive&• No/minimal&response&to&diet&trial&
Diet&Trials &&
• Difficult&to&perform&• Works&in&about&15%&of&cases&
– 85%&failure&rate&• Must&be&strict&to&work&• The&food&must¬&contain&allergen&
– Novel&Protein&&– Hydrolyzed&– Pure&
• 6&Weeks&MINIMUM&Hydrolyzed&and&home&cooked&novel&protein&diets&
3/9/15&
6&
Treatment&of&Atopic&DermaMMs&MedicaMons&• AnMhistamines&• Steroids&• Cyclosporine&(atopica)&• OclaciMnib&(apoquel)&
NonUpharm&treatments&• Allergen&avoidance&• Immunotherapy&• Improve&skin&barrier&
Pharmacological&Therapy&
• AnMhistamines&– Chlorpheniramine&2U12mg&TID&(4mg,&12mg)&– Diphenhydramine&2mg/kg&TID&(25mg,&50mg)&– LoraMdine&2mg/kg&BID&(10mg)&– Hydroxyzine&0.5mg/kg&BID&(25mg,50mg)&– CeMrizine&1mg/kg&BID&(20mg)&
• Fast&onset,&very&marginal&effect&• SedaMon,&agitaMon,&pollakiuria,&dry&mouth&
GlucocorMcoids&
• 0.5U1mg/kg&prednisone&U&BID&to&EOD&tapering&&• Fast&onset&• Reliable&control&of&pruritus&• Many&side&effects&
– PU/PD/PP&– AgitaMon,&lethargy&– Catabolic,&glucogenic&– UTI&– Calcinosis&cuMs&
Cyclosporine &&• Atopica,&Neoral,&Gengraf,&Compounded &&
– 5mg/kg&SID&slow&taper&
– Can&be&reduced&to&2.5mg/kg&SID&with&KTZ&
• GI&upset,&papillomatosis,&hirsuMsm,&hepatotoxicity,&gingival&hyperplasia&
• Works&in&about&80%&of&cases&
• Slow&onset&of&acMon&(up&to&6&weeks)&
OclaciMnib&(Apoquel)&
• 0.4U0.6mg/kg&BID&x&14&days,&then&SID&
• JAK&inhibitor&• Reduces&IL&producMon&• Fast&onset,&but&rapid&with&drawl&too&• Immunosuppressive&&
• Dogs&must&be&>1&year&of&age&
• 75%&effecMve,&well&tolerated&
IdenMfying&significant&allergens&
Serum'allergy'tesIng'
• InUvitro&method&
• Less&sensiMve&to&medicaMon&interference&
• Very&pracMcal&in&most&sezngs&
• Delayed&results&(7U14&days)&
Intradermal'allergy'tesIng'
• InUvivo&method&
• SensiMve&to&medicaMon&interference&
• Not&pracMcal&in&most&pracMces&
• Immediate&results&(20U30&minutes)&
3/9/15&
7&
Intradermal&allergy&tesMng&
• Requires&specialized&materials&
• Important&drug&withdrawal&Mmes&
• Requires&shaving,&sedaMng,&Mme&
• Tricky&to&interpret&
Serum&allergy&tesMng &&
• Simple&blood&draw&(~4cc&of&serum)&• Usually&have&less&stringent&drug&withdrawl&Mmes&• No&specialized&equipment&required&• Results&take&about&1U2&weeks&
NonUpharmacological&therapies&
• Allergen&idenMficaMon &&
• Allergen&avoidance&• Immunotherapy&
• Improved&skin&barrier&funcMon&
Serum&allergy&tesMng&• Repeatability&• Agreement&between&labs&and&batches&
• Does¬&mimic&“natural&disease&pathogenesis”&
• Flat&test&results&
Perils&of&serum&allergy&tesMng&
Lab Heated FBS
Human ALB
Pooled SPFS
Totals
A 0/144 (0%)
48/144 (33%)
0/144 (0%)
48/432 (11%)
B 0/144 (0%)
1/144 (1%)
5/144 (4%)
6/432 (1%)
C 49/159 (31%)
44/159 (28%)
46/159 (29%)
139/477 (29%)
D 6/120 (5%)
2/120 (2%)
4/120 (3%)
12/360 (3%)
InterpreMng&Allergy&Test&Results&
• Good&or&Bad&test?&– PosiMve&reacMons?&– More&than&2U3&allergens?&
– Fits&with&exposure?&– Fits&with&seasonal&hx?&
• What&to&do&for&a&Bad&test?&– Try&another&method&
– Retest&– Reconsider&diagnosis?&
3/9/15&
8&
Now&you&know&U&Allergen&Avoidance?&
• Pollens&– Close&windows&– Avoid&outdoor&acMviMes&– Wipe&pets&down&&
– Bathing&
• Indoor&allergens&&– Beper&furnace&filter&– Avoid&carpet&– Open&windows&– Dust&mite&wraps&
– Frequent&washing &&
Immunotherapy&OpMons&Oral'Immunotherapy''
• SIDUBID&dosing&• Very&safe&• More&difficult&to&adjust&
• Faster&onset&of&effect?&• Beper&client&compliance&
• Beper&for&small&paMents&
Injectable'Immunotherapy'• Weekly&to&monthly&dosing&
• Safe&• Easier&to&adjust&• Slower&onset&of&effect?&• Poor&client&compliance&
• Beper&for&larger&paMents&
General&IMTX&ConsideraMons&
• Protein&rich&extracts&– Need&to&be&refrigerated&– Some&allergens&may&interact&with&each&other&
• Contained&in&glass&vials&– Fragile&
StarMng&Injectable&Immunotherapy&
• Many&programs&for&iniMaMng&therapy&– All&start&with&lower&doses&and&work&higher&– Some&use&more&diluted&serum&(200&PNU)&vials&
– There&have&been&no&direct&comparisons&between&these&schemes’&safety&
• Rush&immunotherapy&– Hospitalized&paMents&get&hourly&injecMons&– Achieve&‘maintenance’&level&acer&1&day&
Managing&injectable&IMTX&
Frequency&• BiUweekly&to&monthly&• Based&on&duraMon&of&effect&Volume&(dose)&• 0.05ccU1.0cc&(typically&20,000&PNU)&• Based&on&clinical&effect&• Increase&if&no&effect&• Decrease&if&side&effects¬ed&
Injectable&Immunotherapy&
• Lower&client&compliance?&
• Side&effects&– Worsening&of&allergy&signs&
– Tenderness&at&site&of&injecMons&– Swelling&at&site&of&injecMons&– UrMcaria&– Angiodema &&
3/9/15&
9&
Managing&oral&IMTX&
• Start&with&a&lower&volume&SID&
• Increase&volume&acer&14&days&
• SID&dosing&for&2U3&months&– If¬&effecMve&increase&to&BID&dosing&
Oral&Immunotherapy&
• Faster&onset&of&effect?&• Beper&client&compliance?&
– probably&• Fewer&side&effects?&
– GI&upset&(rare)&– Angioedema,&uriMcaria&
– Mild&lethargy&
– Rubbing&the&face/mouth&
Improving&skin&barrier&funcMon&
• Topical&fapy&acids&• Oral&fapy&acids&• Bathing&• Clinical&effect&is&mild&and&slow&to&develop&
The&Importance&of&CommunicaMon&
• Atopy&is&a&chronic&relapsing&condiMon&• No&perfect&treatment&
• Explaining&opMons&• Being&realisMc&• Offering&guidance&• Emphasizing&long&term&management&plan&
• EffecMve&treatment&vs.&Managing&side&effects&
Case&Studies& Simple&OMMs?&
“Bubba”'3&yr,&MN,&31kg,&Golden&Retriever&&• Presents&for&recurrent&ear&infecMons&• Was&treated&with&otomax&BID&x&10&days&• Problem&has&come&back&2&weeks&post&tx&
3/9/15&
10&
Bubba&ExaminaMon&
• Erythema&AU&(marked),&paws,&axillae,&under&the&tail&
• Moderate&pale&debris&AU,&TMs¬&visible&
• Ear&canals&very&erythematous,&mildly&hyperplasMc&
Bubba&DiagnosMcs,&Plan&
• Ear&cytologies&–&2+&cocci,&3+&yeast&
• Flush&ears&2x/week&• Posatex&SID&x&10&days&• Start&novel&protein&diet&trial&
• Prednisone&30mg&SID&tapering&dose&
• Recheck&3&&&6&weeks&
Bubba&conMnued&
3&week&follow&up&
• Owner&reports&doing&great&(1/10)&&
• Ears&beper&• Erythema&AU,&paws&
• Diet&trial&conMnued&• Flush&ears&weekly&
6&week&follow&up&
• Owner&reports&increased&pruritus&(6/10)&
• Erythema&AU,&paws,&axillae,&under&the&tail&
• No&discharge&AU&
Bubba&
Diagnosis&=&Atopic&dermaMMs&(failed&diet&trial)&
Plan&&
• Apoquel&16mg&BID&x&2&days,&then&SID&
• Changed&back&to&original&diet&• ConMnued&ear&flushing&weekly&• Recheck&1&month&for&chemistry/CBC&
PruriMc&despite&therapy&
• “Hobson”,&4&yo,&42.5kg,&MN,&Boxer&
• History&of&chronic,&nonUseasonal&pruritus&• Diagnosed&as&allergies&(failed&a&food&trial)&• Currently&on&16mg&apoquel&BID,&100mg&diphenhydramine&BID&
• Owner&rates¤t&pruritus&8/10&
Serum&allergy&tesMng&
PosiMve/borderline&reacMons&&• one&tree&• three&weeds&• five&mold&spores&• Dust&mites,&storage&mites&
• Insects&
3/9/15&
11&
Results&
• Hobson&was&started&on&oral&immunotherapy&
• Acer&6&weeks&reduced&apoquel&to&SID&• Acer&11&weeks&apoquel&reduced&to&occasional&use&(8U10&doses/month)&
Stella&
Progressive&alopecia&
• ‘Stella’,&8&yo,&F/S,&21.8&kg,&boxer&• Chronic,&nonUseasonal,&pruritus&diagnosed&as&atopic&dermaMMs&(failed&diet&trial)&
• Therapy&has&been&20mg&prednisone&SID&
• Pruritus&is&worsening&(8/10)&• Now&has&areas&of&alopecia&
DiagnosMc&work&up&
• Skin&scrapings&• Skin&cytologies&• Thyroid&panel&
• Diagnosis&=&pyoderma,&secondary&to&AD&or&iatrogenic&hyperadrenocorMcisim&&&
• No&mites/ova&
• 1U2+&cocci&• fT4&by&ed&=&3.2&mg/dl&(normal)&
Treatment&plan&
• Cephalexin&500mg&BID&x&21&days&
• 4%&chlorhexidine&shampoo&weekly&
• Atopica&50mg&SID&
• Ketoconazole&100mg&SID&
• Taper&pred.&over&3&weeks&
Stella,&1&month&recheck&
• Owner&reports&mild&pruritus&(3/10)&
• Alopecia&resolving&• GI&upset&for&the&first&week&of&therapy,&but&then&she&did&fine&
• Plan&–&chemistry/CBC,&conMnue&medicaMons,&taper&to&5&days/week,&taper&bathing&to&monthly,&recheck&6&months&
3/9/15&
12&
Treatment&opMons&summary&
• Primary&Treatments&– Avoidance&– Barrier&funcMon&– Fapy&acids&– AnMhistamines&
– Steroids&– Atopica&– Apoquel&– Immunotherapy&
• Secondary&treatments&– Topical&anMsepMcs&– AnMbioMcs&– AnMfungals&– Topical&steroids&– Ear&flushes&– Allergen&avoidance&
DiagnosMcs&Summary&
• Cytologies &&
• Skin&scrapings&• Biopsies&• Bacterial&cultures&• Fungal&cultures&• Blood&screening&• Thyroid&tesMng&• Diet&trial&
• Allergy&tesMng&• Referral&
Working&with&skin&cases&
IdenIfy'
Problems'
Diagnose'
Disease'
Evaluate'
Response'to'
Therapy'
DiagnosMcs&ReUexam&
Client&CommunicaMon&
Sponsorship&
Thanks&to&ALK&&&the&ACTT&Allergy&Program&for&sponsoring&tonight�s&
VETgirl&webinar!&
Check&out&our&2015&upcoming&VETgirl&appearances!&
Dr.'JusIne'Lee'• SAVMA,&Minneapolis,&March&2015&• InternaMonal&Veterinary&Seminars&(IVS),&
Kiwah&Island,&April&2015&• Merck,&NYC,&April&2015&• IVS,&Vancouver,&June&2015&
Dr.'Garret'PachInger'
• CVC&–&Washington,&DC,&April&2015&• Hills&Global&Symposium,&Miami,&April&
2015&• North&Carolina&Academy&of&Small&
Animal&Medicine&(Asheville,&NC)&–&October&2015&
3/9/15&
13&
QUESTIONS?'