My Pet Has AllergiesNow what?

By Jacquelyn H. Burns, DVM

Copyright © Jacquelyn H. Burns 2012

Material in this presentation is intended to help clients understand one veterinary practice’s approach to skin allergies. It is not intended to be a substitute for a visit to your veterinarian.

Allergies? But she isn’t sneezing or having a runny nose or runny eyes!

The main sign of allergies in pets is itching, with or without hair loss

This may be manifest in several ways◦ Scratching◦ Chewing/gnawing◦ Licking

Feet Legs Rump or rectal area

◦ Rubbing◦ Shaking head/scratching or rubbing

ears

Itching!

Hair loss Greasy coat Dry coat Erythema (redness) Red bumps Scabby spots Dandruff Ear infections Lichenification

◦ Thickened, rough/wrinkled or “elephant skin” Hyperpigmentation

◦ Dark pigment deposited in skin that is affected

Sometimes there are other signs

There are three categories of allergy in pet dermatology:◦Atopy (environmental and inhaled allergy)

◦Food Allergy◦Flea allergy dermatitis

So, what is my pet allergic to?

How Veterinarians Differentiate the Types of Allergy in Pets

History Physical Exam/Observations

Age of onset◦ Young◦ Middle age to older

Time of year of onset◦ Summer-Fall◦ Winter-Spring

Seasonal vs. all year round

Response to previous treatments

Pattern (where on the body the itch is)

Breed Playing the odds (only

15 to 20% are food allergy)

Primary Lesions Secondary Lesions

Flea combing Skin scrapings

◦ Screen for mange Demodex Sarcoptes

Skin cytology◦ Bacteria?◦ Yeast?

Fungal cultures◦ Screen for ringworm

Skin biopsies

Diagnostic Testing

Rate your pet’s itchiness on a scale of 1 to 10◦ 1’s never scratch/chew/lick/rub◦ 10’s never stop scratching/chewing/rubbing◦ Our vets consider

1-3 to be normal 4-5 mildly itchy 6-7 moderately itchy 8-10 severely itchy

Grading itching

You may be asked to grade your dog’s itchiness at the initial visit and

again at follow up visits

Allergies are not curable Our goal is to manage the condition

◦ Reduce the itch/inflammation◦ Reduce secondary changes to the skin

Lichenification Skin gets thick and roughened (like elephant skin)

Hyperpigmentation Skin gets black-looking

Secondary skin infection Scales/flakes/crusts/oily seborrhea

Management may be◦ As needed for flare-ups ◦ Long-term or for life

Goals of Treatment

Regardless of cause, have realistic expectations… There isn’t a magic

allergy fairy who can wave her magic wand and “cure” allergies.

Management will be as needed for life

Expect some symptoms some of the time

Expect flare ups

Is an environmental allergy that is usually but not always seasonal

Formerly believed to be mostly inhaled, but veterinary dermatologists have broadened their outlook to include allergens being absorbed through contact with the skin

Can be allergic to◦ Mold spores◦ Dust mites◦ Pollens◦ A combination of several things

Atopy

Age of Onset◦ Middle aged adult to senior

Time of year of onset◦ Often warmer months

Seasonal vs. non seasonal◦ Seasonal (unless allergic to dust mites)

Pattern◦ Not confined to waist down◦ Itching can be all over◦ Itching can be ears only, feet only

Breed: ShihTzu, Westie, Lab, Daschund Playing the odds (FAD aside, about 80-85% of itchy

dogs are atopic)

Atopy - EnvironmentalAllergy

Immunotherapy◦ Determine exactly what the pet is allergic to and

order an immunotherapy serum to be given by injection as regular “allergy shots.”

◦ Gold standard of allergy testing is the intradermal skin test Done mostly in veterinary dermatology specialty

practices, requiring a referral from your primary care veterinarian to a board-certified dermatologist

◦ There are blood tests, but these are less reliable than intradermal skin tests Can be done by most primary care veterinarians

Specific Treatment for Atopy

Atopica◦ Cylcosporine

Suppresses the immune system

◦ Loading dose is once daily for 30 days

◦ Maintenance dose is every other day for life

Atopy-specific Oral Medication

Atopy was formerly attributed to inhaled allergens. But dermatologists now recognize that allergens also can be absorbed through contact with the skin. They have broadened the definition of Atopy to include inhaled allergens and transdermal absorption of other environmental allergen particles◦ Wipe feet and legs off with a damp cloth

whenever your dog comes in from outside to remove allergens

◦ Bathe once weekly—whether your dog “needs” it or not to remove surface allergens

Wipe those feet off!

Topical◦ Soothing Shampoos & Conditioners◦ Soothing Sprays, creams or ointments

Oral◦ Prednisone

Daily for several days tapering dose to an every 2 to 3 days dose

◦ Antihistamines Sometimes help; sometimes don’t Helpful in 10 to 30% of patients Several different ones so we can “hunt & peck” for the best one

◦ Essential Fatty Acid supplements May help up to 40% of dogs with itchy allergy skin

Injectable “cortisone” as last resort◦ Vetalog during an acute flare up

Non-specific Treatment for AtopySymptomatic Care

Corticosteroids ◦ Prednisone, prednisolone, Vetalog, Depomedrol,

dexamethasone◦ Anti-inflammatory, anti-itch◦ Are not the same as anabolic steroids abused by

athletes◦ Work very well on Atopy and FAD-related itching◦ Do not work well on Food Allergy◦ Have side effects so use in moderation

Use as last resort Use lowest dose that helps control itching

◦ Do have a place in management of dogs with itchy skin, again, in moderation

What’s the deal about “steroids?”

Lethargy, panting Weight gain Increased thirst Increased urine volume

◦ Some pets urinate in the house Weaken muscles, tendons, ligaments

◦ Easier to injure an ACL or rupture a disk in the back Can cause fluid retention

◦ Can make heart disease worse Increase susceptibility to infection

◦ Easier to get infections (urinary tract, skin)◦ Harder to clear up infections

Iatrogenic Cushing’s Syndrome◦ Hormone inbalance ◦ Can “crash” in an Addisonian crisis if drug is withdrawn suddenly

What kind of side effects do corticosteroids have?

They work!◦ Sometimes they are the only thing that works that is also

affordable Reduce itching, redness, swelling Acute flare-ups

◦ Intense itching with self-mutilation Some pets scratch/chew/rub until they create serious

bleeding sores or hotspots In these cases, it usually takes an injection to get the itch

under control so that healing can begin Chronic disease

◦ Reduce or reverse lichenification, hyperpigmentation, thickening in ear canals, etc

So why do you use corticosteroids?

Atopica contains cyclosporine, an immune suppressive drug that can be used to manage atopy.

Atopica is relatively expensive, which is the main reason many people do not elect to purchase it

First month given once a day After this, usually given every other day Side effects

◦ Anorexia, vomiting◦ Increased susceptibility to infection

What About Atopica?

Since many patients are on long-term management, we want to avoidcertain side effects It does not cause

◦ Weight gain◦ Panting, sluggishness◦ Increased thirst and urine output ◦ Weakening of connective tissue (muscle, tendon,

ligament) which increases risk of injury◦ Does not increase liver size and ALP◦ Does not suppress the adrenal cortical-pituitary axis

Doesn’t risk Cushing’s Syndrome or Addisonian Crisis

Advantages of Atopica

Doesn’t work on FAD or Food Allergic Dogs

It is simply cost-prohibitive for many clients

Why don’t you prescribe Atopica for all dogs with skin allergies?

Age of onset◦ Many are younger (under 3 years)

Time of year of onset◦ Not applicable

NONSEASONAL Pattern

◦ No special pattern◦ “Ears and rears”: Some are itchy around the anus and in

the ears. May be itchy around lips and feet Breed Playing the odds: about 15 to 20 % of dogs with

skin allergies have food allergy

Food Allergy

Non seasonal itching ◦ These dogs itch all year ‘round

Response to prednisone is marginal Do not respond to Atopica

Hallmarks of food allergy

It’s not that easy!!!! Pet foods are heavily

marketed and you have to analyze the label ingredients◦ For example, a food

labeled “lamb and rice” is likely to contain lamb as well as rice, but if you read the ingredient list, you may also see poultry meal or whey, which is in the beef family antigenically

So I should just put my dog on (insert popular dog food here) and he will be okay?

Pet food marketing is so

good, it’s surprising they don’t have YOU

eating their brand.

All natural◦ All ingredients come from some type of original, natural raw

material Organic

◦ Your dog can be as allergic to organic beef as to non-organic beef

Grain-free◦ Healthy pet foods do contain some carbohydrates

Contains vegetables◦ Misleading marketing! Often pet food manufacturers add

vegetables and artificial colors to represent vegetables to appeal to buyers who see this as “good”

Popular Dog Food Marketing words to beware of…

In my experience the most likely ingredients dogs are allergic to are:

Beef Chicken

Grains and carbs get anot always deserved bad rap!

Beef

Beef Not just the meat!

Includes all proteins from cows Beef by-products

◦ Cow hooves◦ Rawhides◦ Jerky

Beef flavorings◦ Even in flavored pet medications or

vitamins Milk Milk by-products

◦ Whey, Casein Proteins antigenically similar to

beef◦ Venison, Buffalo, Yak

Eat more chikin?

Chicken

More than just the bird! Chicken

Chicken meat Chicken by-products

◦ Chicken meal Nasty stuff any way—

contains ground up feathers and beaks

◦ Chicken jerky Be very wary of any

chicken products originating in China, anyway!

Eggs

The “real” test for food allergy A prescription food

◦ Contains only 1 novel protein source◦ Contains only 1 novel carbohydrate source

8 to 12 weeks of this only◦ No treats or snacks other than this food◦ No flavored heartworm pills, arthritis meds,

vitamins, etc.◦ No visiting the neighbor’s cat food bowl

Reintroduce other foods one at a time to see which one restarts itching

Elimination Diets

“Novel” in this sense means an unusual ingredient that your pet has never been exposed to before

Therefore, the foods sound really funky:◦ Duck and sweet potato◦ Fish and potato◦ Turkey and barley◦ Kangaroo and Oatmeal

Novel Protein; Novel Carbohydrate Diet

No-compromise commitment on the part of all members of the household for a moderately lengthy period of time

Possible unhappiness on the part of the pet and owners

Increased expenditure for prescription food

Elimination Diets Require:

Some aren’t really infections! Otitis externa is an itchy inflammation of the external ear canal.

It is not like an earache (otitis media), which is on the inside of the eardrum. Otitis externa involves the ear canal outside of the eardrum.

Itches and burns Does not always include infection, but can

◦ Yeast◦ Bacteria

Often results from allergies◦ Greater than 80% in this practice are caused by allergies◦ Less than 20% other causes

Mites Foreign bodies Trauma Tumors, polyps

What about ear infections?Otitis Externa

Shaking head Rubbing ears on floor or furniture Whining/crying when ears are rubbed Discharge from ears Odor from ears

◦ Sour most often means yeast infection◦ Foul most often means bacterial infection

Thickening or swelling of pinna (ear flap)◦ Lichenification◦ Aural hematoma

Signs of Otitis Externa

Tests to determine causes of Otitis Externa

Oil Smear Ear Cytology

Veterinarian looks at a sample of ear wax or discharge in mineral oil under the microscope

Screening for ear mites Can be difficult to

interpret if you’ve used an over-the-counter ear mite med prior to seeing your veterinarian

Veterinarian looks at a stained slide of ear wax or discharge

Seeing whether there are◦ Yeast◦ Bacteria

Cocci Rods

◦ Neutrophils (pus cells) vs simple epithelials

Hygiene ◦ Pluck hair from inside ears if present◦ Clean with veterinarian-recommended ear cleaner◦ One to two times weekly initially◦ Weekly or every other week as “maintenance”

Topicals◦ Ointments, drops, sprays◦ Sometimes hunt and peck to see which works

best Symptomatic Care

◦ Antihistamines◦ Fatty acid supplements

Management for Otitis Externa

Outdoors or in shower/bathtub! Hold the pinna up over the top of the dog’s head Fill the ear canal to overflowing with ear cleaning

solution Massage the base of the ear for 60 seconds Allow your dog to shake his head Wipe away grime that comes to the top and solution

with a plain cotton ball Repeat

How to clean your dog’s ears

Never use Q-tips! They can pack wax and discharge down deeper, and make the problem worse!

Like all other allergies, allergies affecting the ears have no magic cure!

I've come to cure your ear

allergies.

Yeah, right!

Allergic to a protein in flea saliva Owner may not see fleas

◦ 1 flea bite every 5 to 7 days keeps them itching◦ Many are currently using flea control but it’s not good enough

(Frontline, Over-the Counter flea products, flea shampoos) Age of onset: adult to senior Time of year of onset: summer to fall Seasonal: often history of coming back this time every year

◦ In the South, may be seen year-round Pattern: very strong pattern!! Almost always from the

waist down. Rump, tail base, tail, around the rectal area, inner thighs, flanks

No breed predilection

Flea Allergy Dermatitis aka FAD

In Dogs with pattern itching from the waist down:◦ Redness◦ Hair loss◦ Saliva Stain◦ Thickened skin

Called Lichenification◦ Black looking skin

Called Hyperpigmentation

◦ Scabbiness

All Cats!

It’s flea allergy unless proven otherwise!

How do you treat FAD?

Primary (Specific) Treatment

Secondary (Symptomatic)Treatment

Upgrade Flea Control◦ Dogs

Spinosad-based once a month flea pill Every 30 days

◦ Cats Advantage Multi once-a-

month flea topical Every 21 days

◦ Other pets Treat all other pets, whether

itchy or not◦ Environment

Topical◦ Aloe & Oatmeal weekly

shampoo◦ Soothing conditioner after

bath◦ Pramasoothe Spray

Oral◦ Prednisone for dogs◦ Antihistamines

Injectible◦ Vetalog for dogs◦ Depomedrol for cats

Topical◦ Aloe & Oatmeal Shampoo◦ Aloe & Oatmeal Conditioner◦ Soothing Sprays – Pramasoothe, Relief

Oral◦ Prednisone for dogs

Tapering dose for 2 to 4 weeks Does have side effects

◦ Antihistamines May help some dogs/may not help some dogs

Injectable◦ Last resort!◦ Vetalog for dogs

Lasts 1 to 2 weeks◦ Depomedrol for cats

Lasts 4 to 8 weeks Side effects

Serious side effects are rare but can be life-threatening

Symptomatic Care for Itching

Recap…

Flea Allergy◦ Zero tolerance for

fleas◦ Upgrade flea control◦ Not all flea products

work equally well!!!!

Atopy◦ Immunotherapy◦ Atopica◦ Prednisone if

unavoidable

Specific Care if Possible…

Food Allergy Diet that

eliminates the problem allergen

Hygiene◦ Keeping clean◦ Short haircuts◦ Ear cleaning solutions if needed◦ Good flea control for all pets!!!!

Soothing shampoos, conditioners and sprays◦ Aloe & Oatmeal or Hypoallergenic (Hyliderm) weekly◦ Pramasoothe or Relief Spray 2-3 times a day◦ More specific shampoos if needed for

Yeast infection (Ketochlor) Bacterial infection Scales, crusts, greasiness

Anti-histamines Fatty acid/vitamin supplements Treat secondary problems

◦ Antibiotics for secondary skin infections◦ Antifungals for secondary yeast infections◦ Topicals (in ear) for otitis externa

Regardless of cause, symptomatic care for any allergy…

We are not going to cure your pet’s skin disease, but we want to keep him as comfortable as possible so that he has a good quality of life.

Remember that we are not going to be able to stop all of the itching all of the time.

Goal is to help your pet itch less Goal is a good quality of life for your pet

In short…

Ask yourself if you are compliant with all of your family veterinarian’s prescriptions and advice.

If you are not compliant, ask yourself why…and try to start doing EVERYTHING your veterinarian recommends

If you are compliant and things are not working out, ask your veterinarian for a referral to a board-certified veterinary dermatologist

If you are frustrated beyond belief…

Holmes Veterinary Hospital1001 Church StreetLaurens, SC 29360www.holmesvethospital.com

Slide presentation courtesy of Jacquelyn H. Burns, DVM

Material in this slide presentation is intended to help veterinary clients understand one practice’s approach to skin disease. It is not intended to be a substitute for assessment and treatment by your pet’s veterinarian.

Copyright © Jacquelyn H. Burns 2012All rights reserved