Clinical Therapeutics Flashcards
Name two common surface overgrowth skin problems
Pyotraumatic dermatitis (“hot spots”)
Fold dermatitis
How can you treat ‘hot spots’
Look for underlying cause e.g., allergy (FAD) or pruritic/painful trigger; predisposed breed?
- Happen overnight
- Will see an overgrowth of cocci
- Clip and clean with topical antiseptic/antimicrobial
- Systemic anti-inflammatory and pain relief
How would you treat fold dermatitis?
- Topical antiseptics/ anti-microbial and topical/systemic anti-inflammatories
- Look for underlying cause e.g., obese dogs causing a deep vulvar fold -> weight loss
- May progress to superficial or deep infection
- Can occur around the tail base, vulva, lips, etc
Which lesions are seen in superficial pyoderma
Pustules, papules, macules, crusts, erythema, staphylococcus, plaques, epidermal collarette
What is staphylococcal folliculitis?
Pustule of the hair follicle
How is superficial pyoderma treated?
Underlying cause – identify, treat/ manage
Topical treatment is most important
Systemic antibiotics ONLY if severe/ widespread proven infection and/or no response to above - Preferably chosen by swab culture
Topical therapy is the sole therpay for which conditions?
Surface infections, otitis externa and many cases of superficial pyoderma
Why is topical therpay used adjunct to systemic therpay?
improve efficacy and speed cure
How does Malassezia present?
Cobblestone appearance of the ventral neck – skin thickening
Extremely pruritic
What is the first line treatment for Malassezia dermatitis?
Shampoo first line treatment
- Chlorhexidine 2% + miconazole 2%
- Chlorhexidine >= 3%
What are the other treatment options for Malassezia dermatitis?
- Other topical preparations for skin and ears - Clotrimazole, miconazole, nystatin, terbinafine, selenium sulfide
- Systemic antifungals - Only if chronic or severe and underlying disease addressed
- Allergy vaccine
- If patient has atopic dermatitis and is hypersensitive
- Desensitise the patient against the yeast
Which factors help to select treatment for deep skin infections?
- Patient may be more painful that pruritic
- Can be systemically unwell
- Can have deep and superficial skin infections simultaneously but need to be treated differently as different parts of the skin are damaged
- What is the underlying cause?
- Localised: Topical antiseptics and antibiotics
- Severe/ widespread, especially if patient systemically unwell: systemic antibiotics always based on culture and susceptibility
When is antimicrobial use is indicated, how they are used appropriately?
- Choice based on cytology +/- culture and susceptibility testing
- Use correct drug, dose, frequency and duration
- Give good (written) instructions to owners
- Drug choice: Pharmacokinetics, pharmacodynamics, susceptibility of the organism, antimicrobial prescribing guidelines and drug cascade
How long are antibiotics needed for superficial pyoderma?
2-3 weeks
How long are antibiotics needed for deep pyoderma?
4+ weeks
For deep infections there may be an initial rapid response, but then improvement occurs quite slowly; if progress stops repeat culture
Describe the features of 1st line antibiotics
- Not restricted
- High index of suspicion of, or proven infection
- Based on likely microbe and C+S
Name some 1st line antibiotics
Amoxicillin +/- clavulanate
Tetracycline/doxycycline
Clindamycin
Cephalexin
Metronidazole
Describe the features of 2nd line antibiotics
- Semi-restricted, case by case
- Only if no 1st line drug
- Infection evident and C+S uploaded
- Consent from senior clinician
Name some 2nd line antibiotics
Minocycline
Cefovecin
Enrofloxacin/marbofloxacin
Gentamycin
Describe the features of 3rd line antibiotics
- Restricted, case by case
- Only if no 1st or 2nd line drug
- Infection evident (C+S)
- Consent from senior clinician
- Prescription completed
Describe the features of 4th line antibiotics
- Only option and good chance of successful outcome
- Consent from infection control lead
- Infection evident
- Prescription completed
How would you treat a staphylococcus pseudointermedius infection?
- Intense topical antiseptics
- Prednisolone
- Contact owner with culture results and only use antibiotics if needed e.g. cephalexin
- Re-examine in 2 weeks
What are the principles of treatment for immune-mediated skin disease?
- Removal or treatment of any external triggers - Drugs, UV light, confirmed infections, underlying neoplasia
- Control of inappropriate immune response
- Immunosuppressive/immunomodulatory drugs
- Topical therapy for mild or localised disease
Name the 3 phases of treatment for immune mediated skin disease
- Induction of remission
- Transition
- Maintenance
Describe the induction of remission phase of treatment for immune mediated skin disease
- Need to do biochem and haematology first to find out basal parameters
- Days to weeks
- Aggressive therapy: immunosuppressive doses of steroids
- May need to change/add treatments if minimal response after 2-4 weeks
- Try to avoid severe adverse effects
- Regular treatment monitoring
Describe the transmission phase of treatment for immune mediated skin disease
- Weeks to months
- Taper to lowest effective dose
- Taper drugs with most risk of adverse effects first
- Treatment monitoring frequency reduces with time and absence of adverse effects
- Bloods
- If no relapse with advanced dose tapering stop treatment to determine cures
Describe the maintenance phase of treatment for immune mediated skin disease
- Months to years
- Cases where relapses have occurred in transition phase
- Lowest effective dose and monitor for adverse effects
- Treatment monitoring as determined by treatment and dose
- Further tapering if disease in remission for many months
- For idiopathic cases that are lifelong and wont cure
How can you monitor patient during treatment and adjust therapy when needed?
- Baseline drug monitoring obtained prior to starting therapy
- Induction every 7-14 days
- Transition every 2-6 weeks
- Maintenance every 1-6 months (case dependant)
What is the primary treatment for immune mediated skin disease?
Steroids
E.g. Prednisolone 1-2mg/kg/day until stable (1-2 weeks), and then gradually taper every 1-2 weeks until reach minimal effective dose and frequency
If a steroid alone is producing a sub-optimal response which treatment might you add to the therpay?
Cytotoxic drug
May also need cytotoxic drug to achieve lowest effective steroid dose/frequency to reduce potential drug side effects
List some examples of immune mediated skin diseases that are treated with steroids
- Eosinophilic furunculosis of the face
- Juvenile sterile granulomatous dermatitis and lymphadenitis
- Vasculitis or vasculopathy (may respond to oclacitinib)
- Sterile pyogranulomatous dermatitis and panniculitis
- Pemphigus foliaceus (PF)
- Uveodermatological syndrome
- Erythema multiforme
- Sebaceous adenitis
- Anal furunculosis
Describe physiological dosing of steroids
Low dose
- Replace glucocorticoids that are absent in hypoadrenocorticism (adrenal insufficiency)
Describe anti-inflammatory dosing of steroids
Intermediate dose
Reduce inflammation and pruritus through a variety of mechanisms
Describe immunosuppressive dosing of steroids
High dose
Severely compromise immune responses to control immune-medicated disease
List some common side effects of steroids
- Polydipsia, polyphagia, polyuria
- Muscle weakness
- Breathlessness or panting
- Weight gain and/or abdominal enlargement
- Alopecia, secondary bacterial infections, calcinosis cutis
How long does ciclosporin efficacy take?
2-8 weeks
Ciclosporin is the main therapy of a number of IMSD - list some examples
- Anal furunculosis (AF)
- Symmetrical lupoid onychodystrophy (SLO)
- Cutaneous lupus erythematosus (CLE)
- Erythema multiforme (EM)
- Sebaceous adenitis (SA)
- Cutaneous histiocytosis
- Adjunct in Pemphigus foliaceus (PF)?
What are the side effects of Ciclosporin?
Vomiting and diarrhoea
Increased hair and gum growth due to increased TGFb
Immunosuppression
Papilloma growth
List some properties of topical agents used in skin disease
Cleansing
Keratoplastic - Antiseborrhoeic
Keratolytic - Antiseborrhoeic
Emollient
Antimicrobial
Anti-inflammatory
Define keratoplastic
Reduce cell turnover in the skin to reduce scale production
Define keratolytic
Shampoo removes the cells from the surface of the skin e.g. salicylic acid
Describe urea as a component of moisturisers
Binds water - promotes hydration, antibacterial, keratolytic
Describe glycerine as a component of moisturisers
Hygroscopic - absorbed into skin
Describe propylene glycol as a component of moisturisers
Potent softening and hydroscopic agent
How would you treat sebaceous adenitis?
- Ciclosporin to save residual sebaceous glands
- Prednisolone until ciclosporin takes effect and to reduce pruritus
- Commonly have secondary infections - Topical antiseptics
- Sebaceous glands destroyed so loss of oils to the skin and coat
- Remove thick scales
- Rehydrate
