wild crazy immune system - vetgirl · swollen pads, striae, and blue/violet discoloration ! bridge...
TRANSCRIPT
1/9/16%
1%
Sponsorship
Garret%Pach.nger,%VMD,%DACVECC%
COO,%VETgirl%
Introduc.on%
1/9/16%
2%
Jus.ne%A.%Lee,%DVM,%
DACVECC,%DABT%
CEO,%VETgirl%
Introduction
Conflict of Interest Disclosure
! The tech-savvy way to get online veterinary CE!
! A subscription-based podcast and webinar service offering veterinary RACE-approved CE
VETgirl…On-The-Run
1/9/16%
3%
50-60 podcasts/year plus 24+ hours of webinars!
! $199/year
! 30+ hours of RACE-CE
VETgirl ELITE
VETgirl TEAM memberships!
! Up to 5 members: $599/year
! Up to 10 members: $999/year
! > 10 members: $1399/year
! > 20 members: Ping us
1/9/16%
4%
Easier playback, less buffering – better!
New and improved video!
Download our iTunes podcasts free!
Social media and our blog!
1/9/16%
5%
Logistics: CE Certificates " No%need%to%raise%your%hand!%" Type%in%ques.ons%
" Emailed%to%you%48%hours%aPer%the%webinar%" Ac.ve%par.cipa.on%=%no%quiz%
" Watching%video%later,%must%complete%quiz%" ELITE%members%only%
" Email%/%contact%with%ANY%ques.ons%
" [email protected]%" [email protected]%
Call in from Smart Phone!
Dr. Amy Haarstad, DACVD ! North Carolina State University-
DVM 2001
! Purdue University Small Animal Internship 2001-2002
! Small animal private practice for 9 years
! Dermatology residency at McKeever Dermatology Clinics in Minnesota 2011-2014
! Diplomate of ACVD 2014
! Veterinary Dermatologist at McKeever Dermatology Clinics
1/9/16%
6%
The Wild and Crazy Immune System…and how it affects the
skin
Diseases ! Discoid Lupus Erythematosus (DLE)
! Symmetrical Lupoid Onychodystrophy (SLO)
! Pemphigus Foliaceus (PF)
! Sterile Nodular Panniculitis
! Perianal Fistulas
! Sebaceous Adenitis
! Dermatomyositis
! Ear Margin Vasculitis
Total cases in 9 years ! DLE=2
! SLO=1
! Pemphigus Foliaceus=1 in a cat
! Panniculitis=0
! Perianal Fistulas=1
! Sebaceous Adenitis=2
! Dermatomyositis=0
! Ear Margin Vasculitis=2
! Plasma Cell Pododermatitis=0
1/9/16%
7%
Why is this happening? ! Most cases are idiopathic
! Recent vaccination
! Medication history
Cutaneous adverse drug reactions in dogs and cats
Dogs
! Pemphigus foliaceus-sulfonamides, ampicillin, penicillin, cephalosporins, diethylcarbamazine, metaflumazone/amitraz
! Panniculitis-rabies vaccine, others
! Vasculitis-rabies vaccine, others
Cats
! Pemphigus foliaceus-ampicillin, cimetidine, doxycycline, cephalexin, sulfonamides
! Panniculitis-vaccines, glucocorticoids
! Vasculitis-vaccines, ivermectin, antibiotics
Diagnosis ! Clinical Appearance
! Dermatohistopathology
1/9/16%
8%
Quick Reminder ! Cytology
! Skin scrape
! Dermatophyte culture
! Bacterial culture and sensitivity
Tape IT! ! Tape prep
! Scotch 3M® packaging tape
! Microscope slide size
! Stain with orange and purple only
! Impression smear
! Use for moist lesions
My top 5 tips for performing a skin biopsy
1. Keep it DIRTY
2. Keep it HAIRY
“Do you feel lucky, well, do ya?”
1/9/16%
9%
My top 5 tips for performing a skin biopsy
3. Just say NO
! to ulcerated skin
! to normal skin
4. Keep that CRUST!
5. Get the FAT!
Drugs and Vitamins ! Glucocorticoids
! Azathioprine
! Atopica®
! modified cyclosporine
! Minocycline/Doxycycline
! with Niacinamide
! Topical tacrolimus
! Nutritional supplements (Omega-3s, Vitamin E, A)
Treatment Phases ! Induction
! Transition
! Maintenance
1/9/16%
10%
How Low Can You GO?
Glucocorticoids ! Every Other Day
! Transition and Maintenance phases
What’s up with that sore sniffer?
1/9/16%
11%
Discoid Lupus Erythematosus ! Most common immune-mediated dermatosis
! Localized, photoaggravated skin lesions
! Shetland Sheepdogs, Rough Collies, German Shepherds, and Siberian Huskies are predisposed
! Nose and nasal planum
! Alopecia, erythema, and varying depigmentation
! Absence of systemic signs
! Epitheliotropic lymphoma-Ddx
Biopsy Buzz Words
! DLE
! Interface basal cell degeneration
! Apoptotic keratinocytes only in the basal layer
! Lichenoid inflammation or band-like infiltrate
! Lymphocytes, plasma cells, histiocytes
! Pigmentary incontinence
! Melanin drops out into the dermis
Discoid Lupus Erythematosus
! Management
! *Minocycline or doxycycline/Niacinamide*
! *Topical 0.1% tacrolimus ointment (Protopic®)*
! Prednisone
! Modified cyclosporine A (Atopica®)
! Vitamin E
! Topical corticosteroids (ie. Betamethasone cream)
! *Topical sun-blocking creams and sun avoidance*
1/9/16%
12%
Symmetrical Lupoid Onychodystrophy
! SLO
! Sloughing of claws
! Early lesions 1-3 nails
! Remove loose nails
! Bandage if needed
! Treat secondary bacterial infection
SLO ! Diagnosis
! History
! Clinical appearance
! Biopsy-usually not
! Management
! *Minocycline or doxycycline/niacinamide*
! Atopica® (modified cyclosporine)
! Corticosteroids
! *Omega-3 fatty acids*
! Frequent nail trims
! Expectations-more nails to follow
Crusty Crusts on Crusts
1/9/16%
13%
Pemphigus Foliaceus ! Pathogenesis
! Type II Hypersensitivity
! Autoantibody (IgG) against desmocollin-1
! Signalment:
! Chow, Akita, Bearded Collie, etc.
! Many breeds
Pemphigus Foliaceus ! Clinical signs
! Pustular dermatitis
! Secondary erythema, scale, alopecia, erosion, crusts
! Dorsal muzzle, face, pinnae, pawpads, generalized
! Systemic signs
PF in cats
1/9/16%
14%
Acantholytic Cells
Pemphigus Foliaceus ! Diagnosis
! Cytology
! Neutrophils
! Acantholytic cells
! Dermatophyte culture
! R/O Trichophyton mentagrophytes
! Histopathology
! Keep those crusts
! Special stains
! GMS or PAS
Biopsy Buzz Words
! Pemphigus foliaceus
! Superficial epidermal pustules
! Acantholysis
! Lack of infectious organisms
1/9/16%
15%
Pemphigus Foliaceus ! Treatment
! *Glucocorticoids*
! *Azathioprine*
! Minocycline or doxycycline/niacinamide
! Atopica® (modified cyclosporine)
! Mycophenolate
Sterile Nodular Panniculitis
! Damaged lipocytes
! Solitary or multiple draining nodules
! Dachshunds most frequent breed affected
! Diagnosis
! Excisional or wedge biopsy
! Fungal and acid fast stains
! Rule out fungal disease (ie. blastomycosis), nocardiosis, mycobacterial infection)
Draining Lesions
1/9/16%
16%
Biopsy Buzz Words
! Sterile Nodular Panniculitis
! Epidermis may be normal or acanthotic (thick)
! Epidermis may be ulcerated in area of draining tract
! Pyogranulomas replacing adipose tissue
! Special stains are negative
Sterile Nodular Panniculitis
! Treatment
! *Minocycline or doxycycline/niacinamide*
! Atopica® (modified cyclosporine)
! Methylprednisolone or prednisone
! Vitamin E
Straining?
1/9/16%
17%
Perianal Fistulas ! Unknown cause
! German Shepherd Dogs
! Tenesmus
! Erythema, ulcers, fistulous tracts
! Diagnosis based on history and clinical findings
! Treatment of choice
! *Atopica® (modified cyclosporine)*
Treatment on a Budget ! Elimination Diet
! Limited ingredient or Hydrolyzed
! Sulfasalazine
! Prednisone
! 1 mg/kg once daily until resolution of lesions, then dose is reduced to 0.5 mg/kg Q24h for 6-8 weeks, then lowest every other day dose.
! Topical tacrolimus 0.1% twice daily
1/9/16%
18%
Sebaceous Adenitis ! Autoimmune destruction of sebaceous glands
! Young adult to middle aged
! Breeds--Standard Poodles, Vizslas, Akitas, Samoyeds, etc.
! Autosomal recessive
! Clinical
! Follicular casts, scaling, alopecia or poor coat
! Dorsum of neck and back, top of head, bridge of nose, ears
! In short coated dogs scales fine and non-adherent. Longer-coated have tightly adherent scales. Akitas may be greasy
! Diagnosis--clinical and histopathology
Biopsy Buzz Words
! Sebaceous adentitis
! Follicular plugging or casts
! Absence of sebaceous glands
Management ! *Bathe with Douxo Chlorhexidine PS shampoo weekly*
! *Propylene glycol or baby oil 50% in water weekly for 4-6 weeks then 1-2 times a month*
! *Vitamin A*
! *Atopica® (modified cyclosporine)*
! Can regrow sebaceous glands
! Prednisone or methylprednisolone
! Minocycline or doxycycline/niacinamide
! Retinoids (ie. Acitretin)
1/9/16%
19%
Dermatomyositis
Dermatomyositis ! Hereditary inflammatory disease
! Collies and Shetland Sheepdogs
! <6 months of age
! Symmetrical scarring alopecia of face and limbs
! Atrophy of muscles of mastication
! Waxing and waning
! Not pruritic or painful
Dermatomyositis ! Diagnosis
! Physical exam
! Electromyography (EMG)
! Histopathology
! Management
! *Pentoxifylline*
! *Vitamin E*
! Prednisone
! Atopica® (modified cyclosporine)
! Minocycline or doxycycline/niacinamide
1/9/16%
20%
Naked and Notched Ears
Ear Margin Vasculitis ! Ulcerative lesions affecting pinna
! Dachshunds predisposed
! Alopecia#Pigmented#Thickened#Necrosis
! Diagnosis—clinical findings and biopsy
! Management
! Sulfasalazine
! *Atopica® (modified cyclosporine)*
! Minocycline or doxycycline/Niacinamide
! Pentoxifylline
! Prednisone
Plasma Cell Pododermatitis
! Cats
! Plasma cell infiltration into one or more footpads
! Swollen pads, striae, and blue/violet discoloration
! Bridge of nose can be affected
! Diagnosis--clinical appearance or histopathology
! Treatment
! *Doxycycline*
! Atopica® (modified cyclosporine)
! Glucocorticoids
1/9/16%
21%
Medication doses ! Minocycline/doxycycline 5mg/kg BID-TID
! Niacinamide (with mino or doxy)
! <15 kg give 250 mg BID-TID
! >15 kg give 500 mg BID-TID
! Prednisone 1-4 mg/kg Q24 initially, then lowest effective EOD
! Atopica® (modified cyclosporine) 5 mg/kg Q24 then taper
! Azathioprine 2 mg/kg EOD
! Vitamin E 200-800 IU/day
Medication doses ! Omega-3 fatty acids 180mg EPA per 10lbs per day
! Sulfasalazine 10-20 mg/kg TID
! Pentoxifylline 10-15 mg/kg BID
! Vitamin A 8,000-10,000 IU/20 lb. PO Q24h
! Acitretin 1 mg/kg PO q 12-24h
References ! Scott, DW, et al. Immune mediated dermatoses in domestic animals: Ten
years after. Part I. Compend Contin Educ Small Anim Pract. 1987;9:423
! Scott, DW, Miller, WHJ. Idiosyncratic cutaneous adverse drug reactions in the cat: Literature review and report of 14 cases (1990-1996). Feline Pract. 1998;26(4):10-14
! Scott, DW, Miller, WHJ. Idiosyncratic cutaneous adverse drug reactions in the dog: Literature review and report of 101 cases (1990-1996). Canine Pract. 1999;24(5):16-22.
! Nuttall, T, Harvey, RG & McKeever, PJ. Skin Diseases of the Dog and Cat. 2nd edn, Manson Publishing Limited, 2009.
! Gross, TL, Ihrke, PJ, Walder, EJ, Affolter, AK. Skin Diseases of the Dog and Cat. 2nd edn, Blackwell Publishing, 2005.
! Miller, WJ, Griffin, C, Campbell, K. Muller and Kirk’s Small Animal Dermatology. 7th edn, Saunders-Elsevier, 2013.
1/9/16%
22%
Sponsorship
QUESTIONS?
#CPRwheel%
1/9/16%
23%
Check out our 2015 upcoming VETgirl appearances!
Dr. Justine Lee
! NAVC, Jan 2016
! IVS, Fiji, Feb 2016
! WVC, March 2016
! AAHA, March 2016
! AVMA, July 2016
Dr. Garret Pachtinger
! NAVC, Jan 2016
! WVC, March 2016
@VetGirlOnTheRun%
VetGirlOnTheRun%
This material is copyrighted by VETgirl, LLC. None of the materials provided may be used, reproduced or transmitted, in whole or in part, in any form or by any means, electronic or otherwise, including photocopying, recording or the use of any information storage and retrieval system, without the consent of VETgirl, LLC. Unless expressly stated otherwise, the findings, interpretations and conclusions expressed do not necessarily represent the views of VETgirl, LLC. Medical information here should be references by the practitioner prior to use. Under no circumstances shall VETgirl, LLC. be liable for any loss, damage, liability or expense incurred or suffered that is claimed to have resulted from the use of the information provided including, without limitation, any fault, error, omission, interruption or delay with respect thereto. If you have any questions regarding the information provided, please contact [email protected]