Exam 3 Flashcards
Lecture 1 Introduction to clinical dermatology
What are the two most essential questions to answer for any dermatology patient of any species?
- What are the infections?
- Why are they there?
How do breakdowns in the normal structure and function of the skin lead to disease?
Physical barrier - Roof house analogy
Stratum corneum
-Major barrier layer
-Keratinocytes: dehydrated “shingles”
-Lipid bilayer: “Glue”
-Brick and mortar model: keratinocytes = brick, lipid bilayer = mortar
What is the Goo?
Epidermal lipid envelope
-Cholesterol, phospholipids
-Free fatty acids, ceramides: Sphingosine - cholesterol complex; triggered dissolution of complex. Antimicrobial, promotes cell growth
-Sebum: triglycerides, wax esters, cholesterol. Squalene, sebaleic acid, linoleic acid
Epidermal turnover
-Stratum corneum 14 days
-Stratum basale 14 days
-Mitosis - basal layer
-Differentiate as cells move up: lose mitotic ability, nucleus and organelles, and aggregate keratin.
Keratinization defects
-Rice paper thin layer, peeling off in pieces
The velcro analogy
-Desmosomes: velcro proteins
-Autoimmune disease: destroys desmosomes = dermis peels away. Pattern non-haired parts, nose footpads.
Dermis
-Support and nourishes epidermis
-Interact with epidermis during embryogenesis
-Wound repair
-Thickness of skin
-Contains cells, fibers, ground substance
-Fibroblast cells: make collagen, elastin, reticulum, ground substance, fibronectin.
- Collagen: Dynamic, constantly being synthesized and degraded. 90% tensile strength
-Elastin: 10% elasticity
-Reticulin: 1% surround appendages, vessels, nerves
-Mast cells: Histiocytes (dermal macrophages), melanocytes (only in some species)
Ehlers-Danlos Syndrome
-Hyperelastosis cutis
-Congenital defect in collagen
Other structures
-Blood vessels ex: post rabies vaccine vasculitis.
-Lymphatics
Sensation
-Thermoreceptors
-Tylotrich pads: Merkel’s cells, mechanoreceptors
-Pacinian corpuscles: vibration and deep pressure
-Meissner or Ruffini corpuscles: velocity of skin movement
-Penicillate nerve endings
Hair - Protection
-UV light protection
-Contact irritants
-Physical damage
-Heat/cold
-Camouflage
-Social interactions
-Appearance
-Pheromones
-Anagen: growing
-Telogen: dormant, non-shedding dog breeds
Glands
-Sebaceous: sebum, oily film, antimicrobial
-Epitrichial: apocrine, chin, feet, rump
-Atrichial: footpads, thermoregulation
Sweat
-Water evaporation
-Salts, ammonia, urea
-Lubricants
-Histamine, prostaglandin, proteases
-Glucose
-Pheromones
Antimicrobial properties, IgA, IgG, Langerhan’s cells
Primary Diseases Alter the Skin
-Temperature: warm = inflammation, bacteria, yeast loves incubator
-Glandular secretions: rancid fat
-Moisture: moist and clammy
-Antibodies: IgE = pruritic due to licking
-Licking: spreads bacteria, increases moisture
-Scratching: excoriations
-Staph binding: more parking for bugs
Examples
-Acne a gland dz: enlargement of sebaceous glands. Vitamin A helps, cats have it
-Sebaceous Adenitis: body attacks glands = dry flaky skin entire body, poodles predisposed
Melanocytes
-Protection from UV light
-Absorbs radiation
-Scavenges free radicals
-Camouflage
-Decorative
-Melanocytes - melanosomes - keratinocytes
-Melanin transferred to keratinocyte required copper. Eumelanin and phenomelanin
Pigmentation
-Pigmentation promoters:
-MSH: synthesis and activation of tyrosinase
-ACTH
-Androgens
-Estrogens
-Progesterone
-UV light
-Inflammation
-Friction
Examples: pyoderma can become darker (black). UVeodermatologic syndrome, albino
How do secondary bacterial pyoderma or yeast infections occur?
Secondary infection triggered by allergy or hormones (endocrine disease)
What are the infections?
1. Folliculitis major ddx:
-Pyoderma: staphylococcus
-Demodex
-Dermatophyte
Major cause: allergy, endocrinology, cornification disorder or defect.
- Pododermatitis
-Bacterial
-Yeast - Otitis
-Bacterial
-Yeast
Why are they there?
1. Allergies
-Atopy
-Food allergy
-Scabies
- Endocrinopathy
-Hypothyroidism
-Cushingn’s
Why are they there?
-Pruritus leads to licking, damage on skin barrier, adding moisture, bacterial and yeast love the incubator. Loss of adequate antimicrobial defenses on the skin.
How do autoimmune skin diseases cause blisters or ulcers?
Pattern
-Face, pinnae, nasal planum
-Oral cavity
-Pads
Damage to the skin barrier by destruction of the desmosomes, which are the “velcro” proteins maintaining the stratum corneum and stratum granulosum together.
The outermost barrier peels away from the dermis leaving it exposed and damaged
How do T helper cells benefit or cause disease in the skin?
Why are mast cells and eosinophils especially important in dermatology?
What are the 10 core patterns in dermatology?
Secondary
1. Folliculitis
2. Pododermatitis
3. Yeast dermatitis
4. Otitis
Primary
5. Pruritus - allergy
6. Auto immune skin disease
7. Non pruritic alopecia
8. Keratinization defects
9. Lumps, bumps, and draining tracts
10. Weirdopathies
Secondary infections
-Pyoderma
-Demodex
-Dermatophyte
-Yeast dermatitis
-Pododermatitis
-Otitis
Primary Disease
-Allergies: atopy feet, food rears + ears, scabies PP reflex, flea/insects back/hotspots
-Endocrine: hypothyroid big dogs, Hyperthyroid small dogs.
Lecture 2
Folliculitis (bacterial pyoderma, demodicosis, dermatphytosis)
What are the 3 most common causes of folliculitis in the dog and cat?
Folliculitis: infection of the hair follicle
Furunculosis (when severe enough to cause cellulitis, pus oozing out of the skin)
-Lesions: They all look alike
- Staphylococcus
- Demodex
- Dermatophyte
Furunculosis
-Min 21-30 days treatment, likely 6-12 weeks
-Deeper infection
Bacterial infections are always secondary to an underlying disorder, why?
What are common organisms that cause superficial vs. deep infections and cellulitis (fungal, bacterial, and parasitic)?
Superficial Pyoderma
Cause underlying allergy or endocrine disease
C/S
-Infection of hair follicle that spreads outward under stratum corneum
-Single follicle = papular rash > papule > pustule > crust > epidermal collarette
-Alopecia, papules, crusts
Staphylococcus schleiferi
-Staphylococcus aureus
-Potential zoonosis
-Papular dermatatis coalescing lesions, erythematous plaque.
-Early epidermal collarettes
Superficial Pyodermas
Pyotraumatic dermatitis - Hotspot
-Thick-coated dogs
-Alopecia, erythema, exudation, ulceration
-Pruritic and painful
90% triggered by insect bites
Tx
-Clip and clean
-Atringents
-Antipruritics topical or sytemic
-Topical antibacterials, usually do not need systemic antibiotics
Correct predisposing cause = insects
Skin fold dermatitis
-Anatomic defect!
-Erythema, exudation within folds
-Must differentiate from folliculitis/furunculosis, malassezia dermatitis.
Tx
-Like diaper rash
Treatment - Pyoderma
-Topical shampoos
-Chlorhexidine
-Colloidal silver
-Antibiotics: minimum 21 days
-Cefpodoxime, Ceohalexin, Clavamox, Clindamycin, TMS or PRIMOR.
Deep Pyoderma
- Pus, Cellulitis, Swiss cheese, draining tracts
-Organisms: Nocardia, Actinomyces, Blasto/Crypto
What is the best way to determine the cause of deep infections and cellulitis?
General Dx
-Cytology
-Skin Impression smear
-Culture
-Tape preps
Best
-Biopsy
-Culture bacteria + fungal
-DNA PCR testing
Staph, demodex, dermatophyte, nocardia, actinomyces, balsto/crypto
How and why is Malassezia such a common secondary infection and what are the unique clinical lesions?
Unique lesions: interdigital bullae, lesions, rash, abscess.
Malassezia Dermatitis = Linchenification = Elephant skin
-Malassezia pachydermatis: Hypersensitivity reaction, IgE serology test, allergy skin testing
-Takes 6-12 weeks to tone down and normalize, up to several months
-Football-shape yeast, purple diff-quick solution
Tx
-First try: Vinegar + water (1:1) TID
-Degreasing shampoos: bezoyl peroxide, selenium sulfide.
-Systemic fungals
-Ketoconazole, Terbinafine, Fluconazole, Itraconazole. 30 days
Pododermatitis - Interdigial Bullae
Secondary infection
-Bacteria or Malassezia
Primary disease
-Allergies or endocrine
-Environment: moist and dirt, plant awns.
-Traumatic folliculitis: ingrown hairs, micro-abscess
Antibiotic Resistance
Staphylococcus Resistant
-Penicillin
-Ampicillin
-Amoxicillin
-Tetracycline
-Doxycycline
Methicillin Resistance - Use
-mecA gene: inducible, transferable
-Oxacillin
-Cephalexin
-Clavamox
Three ways we get into trouble
1. Steroids
2. Apoquel
3. MARSA continuous use of fluoroquinolones
Culture & min 21-30 d Tx
Good systemic skin drugs - Staphy mecA
-Cephalexin
-Clavulanic acid - amoxicillin
-clindamycin
-Cefpodoxime
-Trimethoprim sulfa
-Ormetoprim sulfa (Primor)
Dermatophytosis - Microsporum canis = Cats
Microsporum gypseum = dogs
-Cutaneous fungal infection
-Invades keratinized structures
-Self-limiting disease
-May take months to resolve
-Depends on host immune status
Zoonosis
-Immune compromised humans
-Folliculitis
-Common cats from shelters
Dx
-Fungal culture 8-% accurate but slow
-Skin scrape
Tx
-Topical therapy &
-Systemic therapy
Ringworm - Dermatophytosis - Fungal
Tx
-Topical: Terbinafine - Lamisil
-Systemic: Terbinafine, ketoconazole, itraconazole/fluconazole
Demodex - Folliculitis, furunculosis
-Demodex mites should be easy to find except in cats
Tx
-Bravecto, simparica, Credelio monthly preventatives
Do not use high dose avermectins
-Collies, Australian sheperds, Old english sheepdogs, shelties.
“White feet do not treat” Genetic test
Lecture 3 Otitis
The healthy External Ear Canal
-Microflora: low numbers of yeast (Malassezia) and Gram (+)
What are the very few causes of primary otitis?
What causes secondary otitis?
How should recurrent secondary otitis be treated and controlled?
Otitis Externa
-Inflammation of the ear canal
-Rise in temperature, humidity, pH
-The three Ps
-Predisposing causes
-Primary causes
-Perpetuating causes: secondary
Predisposing factors
1. Conformation
-Pendulous pinnae
-Increased ceruminous glands: Cockers
-Stenotic ear canals: Shar Pei, Chow
-Hair: Poodles
- Excessive moisture
-Swimming
-Overzealous cleaning - Systemic disease
-Immune suppression
Primary Causes
1. Parasites
-Otobius megnini (spinous ear tick)
-Demodex mites
-Chiggers
-Sarcoptes scabiei
-Poultry mites
- Hypersensitivity disorders - allergies
-Atopy (pollen/grass)
-60% have otitis
-3-5% only clinical sign
-Food allergies Ears and rears 80% otitis, 25% only clinical signs - Foreign bodies
-Grass, awns, seeds
-Dirt, sand, dead insects
-Concentrations of medications - Neoplasm
- Endocrinopathy -Hypothyroidism, hyperthryroidism
- Auto immune diseases
Secondary Infections
-Yeast: Malassezia pachydermatis
-Bacteria - cocci Staph
Stage 1 or 2: Wax 99% of otitis (sterile?), Staph and Malassezia.
Stage 3: Pus - pain - ulcers 1% of otitis: pseudomonas + mixed rods. Corynebacterium, E. coli.
C/S
Acute
-Head shaking
-Inflammation
-Abnormal ear carriage
-Pain/pruritus
-Wet - pus or Wax
-No infection does not mean normal Sterile allergy vs. infectious
Dx
-Cytology should be done every time
-Technique: swab junction of horizontal and vertical canal. Roll swab on slide = L + R
-Stain with Diff Quick for cytology, mineral oil for mites
-Examine at 100x (oil) 4-10x for mites
Severe Otitis Externa
-Culture and sensitivity
-Radiographs/CT scan: bullae osteomyelitis suspicion, many weeks of treatment
-CBC/Chem TT4/TSH
-Bacterial cultures are based on oral dosing. Pseudomonas are always predictable
Otitis Media
-Inflammation of the middle ear
-Temporomandibular, bulla, auditory tube, and ossicles
-Eustachian tube, facial nerves affected
-Parasympathetic and sympathetic nerve pass through middle ear = Horner’s syndrome
C/S
-Chronic otitis externa
+/- pain when opening the mouth
+/- ruptured tympanic membrane
+/- facial paralysis
+/- Horner’s syndrome
+/- Head tilt
Sedation required for examination
Tx
-Control primary disease
-Resolve secondary infection
Otitis Steps
Pick only one product for each spot
- Cleaning Stage 1
-EpiOtic advanced 4oz
-No acids no alcohols, herbals
-Fill ear canal - let shake dry - repeat until clean
-Alchohol flush for swimmers - Otitis Stage 2
-EasOtic short acting 1ml pump
-Claro (florfenicol, terbinafine, mometasone furoate) long acting. Need dry ear cannal
-Oti-pak long acting
-Allergy or endocrine disorder as the trigger
-Mild non infected will become infected
-Multimodal ointment: Antibacterial, anti-yeast with steroid
-Long acting vs. short acting: do not stop long acting bc resistance develops, so 1-4 weeks - Severe purulent ulcerated and painful Stage 3
-Usually mixed bacteria, pseudomonas
-TrisEDTA 4 oz with 1200 mg enrofloxacin and 40 mg Dexmethasone
Pseudomonas
-Tris EDTA chalates ions, perforates cell wall/coat, allows antibiotic to penetrate
-Lowers mic levels
-Clean ear canal SID 10-14 days treatment
Prevention
-Use whichever ear product at longer intervals
-Multimodal: use every 3-7 days
-Long-term Ear pack use every 2-3-4 weeks
Ear Miticides
-Simparica
-Bravecto
-Credelio
Lecture 4 - Allergies
What are the unique patterns associated with each type of allergy? Food, Atopy, Insects
Food, Atopy & Insects = Pruritus
Itchy dog
-Face, feet, axilla, flanks
-Excoriated mosquito bite
Atopy = feet
Food = ears and rears
Scabies = PP reflex
Flea/insects = back/hotspots
Describe the immune response that causes allergies
Type 1
-Immediate hypersensitivity
-Late phase IgE
-Injured keratinocytes - Leukotrines - IL4 - PG - Substance P - Mast cell - IgE - from Th2 B-lymphocyte and Langerhan’s cells.
Type IV
-Cell mediated
Basophilic reactions
When treating Atopy, rank the treatment options from safest to most dangerous
Safest
1. Cytopoint
2. Allergy skin test and vaccine
3. Atopica
Emergency-Rescue - Most side effects
Only 3 treatments stop severe ITCH
1. Steroids
2. Apoquel
3. Sedation
Itch scale 1-10
1-4: probably no infections
5-10: has an infection
Safest - Topical therapy
-Genesis topical spray
-Antibacterial shampoo: mild products, no need for 10 minutes contact, prophylactic for pyoderma
-Head and shoulders shampoo: zinc
-Otmeal shampoo/rinse/conditioner
-Pramoxine shampoo/rinse/conditioner
Antihistamines
-Variable response
-7d treatment trial
-2-3 antihistamines
-Tachyphylaxis
Cats: chlorpheniramine 70% response
-Amitriptyline
Essential Fatty Acids
-25%-30% response
>60 days
-Combined with other therapies
-OmegaDerm, EFA-Caps, 3V caps, EFAVITE
What 5 feline disorders need to be ruled out on PE before Dx feline allergy syndrome?
What are the 5 common clinical syndromes/lesions caused by feline allergy syndrome ?
What is the best treatment for insect/mite allergy?
Allergy prevention therapy
Prevent insects
Monthly Simparica, Credelio
-Block histamine
-Promote skin and gland health
What is integrated pest management?
Parasite Control
-It is about IgE levels
-Any parasite
-Year round
-Fleas, mosquitos, chiggers, flies, ticks, whips
Mites
-Demodex
-Sarcoptiform mites: round bodies, pedicles with suckers, 21 day life cycle, live on host, infect several species, Stimulate an allergic reaction
Zoonotic Mites
Acariasis
-Skin scrapes test
-Prevention Simparica
Killing Scabies
-Historical Ivermectin, Selamectin
-Better Tx, safer and more effective: NexGard, Bravecto, Simparica, Credelio
Fleas
-Hard to get rid of
-Stay dormant 12 months
-2 weeks life cycle
Zoonotic rickettsia
-Frontline, Spinosid, Isoxazolines, effective and safe.
What common allergy treatments can suppress the immune system cause demodicosis?
Apoquel
-Development of bacterial pneumonia and generalized demodex
Side effects
-Malignant neoplasia
-B-cell lymphoma
-Apocrine gland adenocarcinoma (dermal, anal)
What are the most common food allergens in dogs?
-Beef
-Chicken
-Dairy products
-Turkey
-Bison
-Buffalo
How does Cytopoint (Atopica) work?
New concept
CADI: Canine Atopic Dermatologic Immunotherapeutic
T-cells: inhibit cytokines
Langerhans cells: decreased IgE receptor, decreased tissue migration, decreased antigen processing
Mast cells: Decreased histamine release
Keratinocytes: decreased IL-8 receptors
-98% effective within 48 hours
-Lasts 4-8-12-26 weeks
IL-31 allergy monoclonal antibody
1. Allergy skin testing
2. Allergy vaccine shot
3. Atopica cyclosporine
Cyclosporine/Tacrolimus
Cyclosporine
-5 mg/kg/day on empty stomach
-Ketoconazole
-Taper to qod after 8 weeks to lower cost
Protopic - Tacrolimus ointment
-Apply BID - qd
-Taper to qod - q3 d after resolution
When should dogs be allergy skin tested and placed on desensitization?
Best, cheapest, safest, especially dogs >30lbs
Cyclosporine expensive for bigger dogs
Who should be tested?
-Atopic clinical sigs present
-Older than 1 yo
-Severe clinical signs > 3months
-Not responsive to symptomatic therapy
-Owner and patient willing
Procedure
-Discontinue antihistamines (at least 2 days) and steroids (at least 1 week)
-Sedate the patient
-Clip and mark
-Intradermal injection of antigens
-Positives according to size, color, texture
Hyposensitization Response
-Based on IDAT (skin) 86%
-Based on Serum testing 65%
**The goal is to come up with a recipe for allergy vaccine/shots to stimulate the Th1 cells
-Most respond within 3 months of treatment
-70% cured after 2 years of shots, good investment
Follow-up
-Control pyoderma, otitis, yeast dermatitis
-Adjust vaccine schedule
-Modify symptomatic therapy
Lumbar Dermatitis
Positive pennal-pedal reflex
Insect allergies, Scabies
-Flea Allergy: lumbar dermatitis
-Scabies: Positive pennal-pedal reflex
-Chiggers: Legs, ventral abdomen
-Cheyletiella: cats
Tx
-Monthly Bravecto, Credelio, or Simparica
Lecture 5 Allergy 2
Allergy Treatment Levels
Level 1
-Allergy avoidance: reduce all and any IgE allergy antibody
-Frequent baths every 3-7 days, shampoo + oatmeal conditioner
-Itch control: Generic antihistamines every 12 hours (Benadryl at bedtime). Topical Genesis or leave on lotion every 12-24 hours. Omega 3 Fatty acids and CBD oil every day
Level 2
-Cytopoint every 1-3-6 months to control and prevent infections
-Food allergy: avoid beef, dairy, cheese, chicken, egg, and turkey
-More aggressive strict yeast and bacteria control and prevention
-More aggressive strict mite/insect prevention high dose + repellent
Level 3
-Allergy skin testing and allergy desensitizing vaccine therapy
-Low dose Dexmethasone on weekends
-More aggressive strict diet, home cooked diet
-Cyclosporine/Atopica/Cyclavance daily treatment
-Consider endocrine disease
Level 4
-Steroids q3 d or qd
-Apoquel
Environmental Atopy
Breeds
-Terriers, Goldens, Labs, Cockers
Age
-1-3 yo
Season
-Spring/summer
C/S
-Foot licking
-Feet brown from dog saliva
-Yeast infection develops and causes discoloration interdigital and nail base
Only environmental allergies affect the foot plantar/palmar aspect
-They can be concurrent with food allergies
-They can be concurrent with secondary infections
Only Cyclosporine or allergy desensitization immunotherapy vaccine can cure it
Tx
-Th1 = IgM - Vax
-Th2 = IgE - Cyclosporine
-Goal is to stimulate Th1with Vax or suppress Th2 with Cyclosporine
-Do not want to suppress both Th1 and Th2
Erythema Multiforme
-Tx: cyclosporine
Food Allergy
-Cokers, GSD
<1 yo
>5 yo
-Year round pruritus
-Variable signs “Ears and Rears”
-Poor response to Cytopoint
C/S
-Perianal dermitis
-Ear dermatitis
-Not all allergies itch
>30% GI symptoms: poop/gas
-Poop >3x per day
Dietary Trail
-Limited ingredients
-No other antigen source
-Chew toys, chewable medication eliminated
-10 weeks trial period
-Challenge with original food
Commercial Prescription Diets
-1.5-2% still contamination
-Monthly preventative medications also contamination, except Simparica
-Exposure is like a quick switch on reaction
When < 1 yo
-Rule out scabies
-Insect allergies
-Food trial
Lecture 6 - Allergy Cats
Hives
Urticaria - Hives
Ddx: Lupus, andioderma, vasculitis, vaccine reaction, insects, food
-Acute allergic reaction
-Vessels start leaking
-Transient: lesions shift within hours
Urticaria
-Insects - stings - bites
-Drug reaction - vaccines
-Food allergy
-Atopic antigens
-UV light
-Heat or cold
Tx
-Antihistamines
-Steroids: oran anti-inflammatory dose. Short acting injectable
-Identify and resolve cause
Angioderma
-More severe form
-Deep tissue edema
Contact Dermatitis
Causes
-Flea collars
-Collars too tight
-Preventative meds pour on reaction
-Ultrasound gel reactions
-Scrotal dermatitis contact with concrete and bleach when cleaned, kennels floor
Acral Dermatitis
Causes
-Non-stop licking
Locations
-Joints
-Front legs mostly
-50% efficacy of treatment multimodal
-Secondary infections
Lick Granuloma
-Characteristic lesion
-Always secondary to allergy, neuropathy, habitual
-Always infected
Ddx: Blastomycosis
Dx
-Scrape
-Cytology
-Culture
-Biopsy
-Find primary disease: allergy/endocrine/neuropathy/Psychogenic
Tx
-Antibiotics (DSMO + enrofloxacin)
-Modulate endorphins, behavior component
-Modulate serotonin
-Topicals: barrier, steroids-synodic, bitters
Cats - Military Dermatitis
-Head
-Neck
-Papular, crusting, rashes
-No details about triggers
Evaluating Feline Pruritus
Insect Hypersensitivity
-Mosquitoes
-Moth, cockroach
-Flies, fleas
Mites
-Demodex gatoi 10% atopic dermatitis cases
-Otodectes
-Cheyletiella
-Notoedres
Food allergy
Atopy
Contact dermatitis
Pyoderma
Malassezia
Drug reaction
Paraneoplastic
Pemphigus
Mycosis Fungoides
Psychogenic
Herpes virus
FeLV/FIV
Papilloma virus
Tx
BAD treatment = DepoMedrol/Vetlog = Cardiomyopathy diabetes (<20% experience side effects)
5 Classic Clinical Diseases
- Kittens Dermatophyte
-Ringworm
-Fungal - Bloody face Herpes virus
-Shingles dermatitis - Nipple dermatitis Autoimmune
-Sores around mammary gland
-Autoimmune Lupus, pemphigus - Swiss cheese skin Deep infections
-Draining sores
-Deep bacterial infection/Fungal - Old onset >10 yo Paraneoplastic
-Bowen’s Disease (papulosis)
Feline Atopic Allergy Syndrome
10% Demodex Gatoi
- Military Dermatitis
-Focal crust on the body
-Head and neck sores dermatitis - Allergic Alopecia
-Bald-belly
-Bald legs or back - Mural folliculitis
-Hair-loss and crusts on the arms - Indolent Rodent Ulcers
-Ulcers in the upper lip - Fat chin Syndrome
-Swollen chin - Stomatitis
-Mouth or Gum sores - Eosinophilic Plaques or Granulomas
-Mouth
-Body - Plasma Cell Pododermatitis
-Eosinophils
-Mast cells
-Lymphocytes
-Weird manifestation of allergies
Dx
-Biopsy
Treatments
Step 1
(60% effective, safe, inexpensive)
-Prevention of insects
-Apply revolution Plus every 30 days
-Genesis liquid every 12-24 hours if tolerated
Step 2
(70% effective, safe, inexpensive)
-Chlorpheniramine 4mg tablets
Step 3
(90% effective, safe, moderately expensive)
-Atopica/Cyclavance/Cyclosporine every 24 hours to control symptoms
Step 4
(95% effective, adverse effects, inexpensive)
-Oral Dexmethasone every 3-5 days
-Injectable if severe symptoms
Step 5
(65% effective, safe, moderately expensive)
-Regional allergy vaccine
-Weekly injections
Step 6-11
(wait on these)
-Amitryptyline
-Apoquel
-Allergy skin testing and desensitization
-Home-cooked diets
-Skin biopsies
-Metabolic blood work
-Abdominal ultrasound for para neoplastic dermatitis
Lecture 7 - Autoimmune
Rare compared to allergies and Endocrine
What are the unique clinical patterns associated with auto immune disease?
Recognize the pattern 90% of cases
- Planum
- Pinnae
- Pads
Pemphigus = Acantholytic
-Foliaceus: most common
-Vulgaris = bloody
-Erythematous
-Paraneoplastic
Bullous Pemphigoid = bloody
Lupus
-Discoid lupus erythematous
-Systemic lupus erythematous = bloody
Bloody = stratum basale affected
How should autoimmune skin diseases be diagnosed?
Dermatohistopathologist
Biopsies sent to dermatopathologist
InnovativeVetPath.com
~1-2% of dermatology cases
Primary
-Spontaneous
Secondary
-Induced (humans)
Cytology
-Acantholytic cells = pemphigus “Big fried eggs stained purple”
CBC & Chemistry
-Inflammatory
-SLE = bone marrow/renal
ANA (Anti-nuclear-Antibody)
-SLE & PE
List 10 treatment for autoimmune disease from safest to most dangerous
Prognosis
-PE, PF, DLE = good to fair
-SLE, Bullous pemphigoid, PV = Poor
80% life long treatment
10% cure
10% Complications, euthanasia
Tx
-Control secondary infections
-Antibiotics, corticosteroids
-Suppress immune response: Focal therapy for DLE, Systemic therapy
-Avoid UV light: PE, SLE, DLE
Start with
-Antibiotics: topical and oral
-Topical: steroids or Protopic (0.1% tacrolimus)
-Essential fatty acids
Start - most benign therapy
-Tetracyclines/docycycline (used as anti inflammatory) 70% effective in mild cases
-NIacinamide = Vitamin B3 + Vitamin A
-Cyclosporine: slow to work, takes 3x the allergy dose
Next - lastly
-Apoquel
-Glucocorticoid steroids: immunosuppressive dose. Taper dose every 3 weeks. 80% response
-Chemotherapeutics
-Gold salts
Pemphigus Foliaceus
Lesions
-Pustules - Crusts
-Wax and wane
Location
-Nose, ears, foot pads, trunk
-Crust tips of ears Ddx: scabies
Rarely
-Mucocutaneous junction
Cats
-Lesions on the top of the feet
-Head and neck dermatitis
Dx
-Diff-quick stain
-Acantholytic cells
Discoid Lupus Erythematosus
2nd most common AI skin disease
Thickened layer at biopsy
Breeds
-Collies, GSD, Shelties, Siberian Huskies, Brittany Spanieks, German short hair pointers
Good prognosis
UV aggravated
Systemic Lupus Erythematosus
1 arthritis
Clinical Signs
#2 skin lesions
Renal disease
Bone marrow disease
“The great Imitator”
-From normal to terrible in 7 1/2 weeks or less
-Red feet, loss of foot pads, grease looking, exudative, erosive ulcers mouth, gingiva, hard palate
Antinuclear Antibody (ANA)
Not great in VetMed
90% positive in SLE
-Many false positives
-Drugs, infection, pyoderma, technique
Lecture 8 - Alopecia/Keratin/Tumors
What are the clinical symptoms caused by most common endocrine diseases?
Non Pruritic Alopecia
-Can be pruritic too
-Sertoli cell tumor increases estrogen = alopecia
Add Total T4 to bloodwork
Dx
-Rule out folliculitis
-Hypothyroidism: 30% of cases
-Free T4 by EQLD
-TSH
-Hyperadrenocorticism: 50% of cases
-LDDST or ACTH stim
Hypothyroidism
-Medium to large dogs
-Iatrogenic more common
Calcinosis cutis
-Middle age 6 yo
-Thyroid hormones influences all tissues
-Dull hair coat, tragic facial expression, lethargy, obesity, cold intolerance “heat seekers”
-Atrophy of the skin
Comedones
Hyperadrenocorticism
-Middle to older dogs
-Small breeds
-50% classic or “atypical”
-ACTH or LDDST
-Muscle becoming weak
-C/S: PU/PD/Polyphagia, urinary tract infections, pendulous abdomen, weakness, muscle atrophy, panting
Tx: Melatonin vs. aggressive (can lead to Addison crisis)
Color-dilution Alopecia
-Fragile and break
-Clumps of hair break off
Tx
-Melatonin and Vitamin A
-Topical conditioners
How are follicular dysplasia’s diagnosed?
Alopecia X
-Sex hormone alopecia
-Castration responsive alopecia
Recurrent flank alopecia
-Pattern baldness, color alopecias, anadeen/telogen defluxion, bald thigh syndrome
-Injection reactions
Dx
-ALP, Platelets, LDDST, ACTH stim
-No infection
-Intact
Rule out
-Folliculitis
-Hypothyroidism
-Hyperthyroidism
-Neuter
-Biopsy: color dilution, recurrent flank
Tx
-Melatonin
-Vitamin A and B3
Seasonal Recurrent Flank Alopecia
C/S
-Bilaterally symmetric bald spots
-Gets better 2-3 years
Dx
-Rule other things out
Tx
-Melatonin
-Vitamin A
-Vitamin B3
Non-pruritic Alopecia - Endocrine
See previous
Keratinization Defects
Secondary Keratinization defect
Seborrhea - Excessive production of Sebum
- Seborrhea sacca: dry
-Dry flaky scaling - Seborrhea oleosa: greasy
-Grease rancid stinky - Seborrhea dermatitis
-Seb. Oleosa + Inflammation
Primary Keratinization Defects
- Follicular Casts
-Entire body affected - Idiopathic - Vitamin A responsive dermatitis
-Cocker Spaniel
-21-28 days to respond
-Tx: Antiseborrheic topicals, Zinc shampoo, Vitamin A - Sebaceous adenitis
-Akita dogs
-Lumbar, ears, body
-Follicular casts - Ichthyosis
-Golden Retriever blood lines
-Cosmetic disorder
-No redness, no dermatitis
Looks like paper thin skin
-Weirdly flaky
-Keratinocytes do not mature properly - Epidermal dysplasia
- Schnauzer comedo syndrome
-Focal lesions
-Rule out bacterial folliculitis
-Comedones cosmetic disorder
-Vit A helps - Nasal hyperkeratosis of OLD dogs
-Bulldogs
-Common with age - Ear Margin Dermatosis
-Most likely Mild vasculitis
-Vitamin B (Niacnamide)
-Omega 3
-Topical ointments and steroids
Weirdopathies
- Blepharitis
-Around the eyes
-Inflammation of the eyelids
-Allergy workup - Aural hematoma
-Let heal on their own
-Treat otitis - Perianal fistula
- Symmetrical Lupoid Onychodystrophy (SLO)
-Not fully understood
-Vascular Lupus syndrome?
Lumps, Bumps, Draining Tracts
Infectious
Neoplastic
Immune mediated
What are the 5 most common skin tumors?
- Nodular dermatitis
-Infection: fungal, bacterial, parasitic
-Sterile
-Neoplasia
Dx
-FNA
-Cytology: FNA, Impression
-Biopsy: dermatohistopathologist
-Culture
-PCR
- Sebaceous Gland Tumor
- Follicular Cysts
-Nocardia
-Actinomyces
-Atypical Mycobacterium - Squamous cell carcinoma
- Mast Cell tumor
What are the 5 differentials for round cell tumors?
-Lipoma
-Cutaneous Histiocytoma
-Cutaneous melanoma
-Cutaneous melanocytoma
-Basal cell tumor
