SAD Ch 18 Miscellaneous Skin Disease Flashcards
1
Q
What leads to the development of cicatricial alopecia?
A
Cicatricial alopecia results from insults to the skin that cause fibrous tissue deposition that replaces follicular units and adnexal structures.
2
Q
What are the most common causes of cicatricial alopecia?
A
Localized injection reactions, ischemic dermatopathy, vasculitis, dermatomyositis, sterile nodular panniculitis, posttraumatic scarring, erythema ab igne, and thermal burns.
3
Q
True or false: alopecia seen in cicatricial alopecia is permanent
A
True
4
Q
What are the histopathologic features of cicatricial alopecia?
A
Fibrosing dermatitis with lack of hair follicles or adnexal glands that connect to the overlying epidermis. The overlying epidermis is often acanthotic but may be ulcerated or unremarkable
5
Q
What is the treatment for cicatricial alopecia?
A
Surgical removal of the affected area, otherwise the area will remain alopecic.
6
Q
What is the cause and pathogenesis of granulomatous sebaceous adenitis?
A
Idiopathic It is believed that sebaceous gland destruction is due to a cell mediated immunologic reaction directed against a component of the sebaceous gland
7
Q
What breeds are predisposed to sebaceous adenitis
A
Standard poodles, viszlas, akita’s, German Shepherd dogs, and samoyeds. Also Springer spaniel’s and Lhasa apsos
8
Q
What variation and clinical presentation is commonly seen with Akitas and Springer spaniel’s with sebaceous adenitis?
A
More pyoderma and severe disease
9
Q
What are follicular casts?
A
When a hair or group of hairs develop a sheath of keratin debris that remains attached to the hair above the follicular ostia
10
Q
True or false: pruritus is not typically present with sebaceous adenitis unless a secondary infection is present
A
False. Pruritus varies from not present to intense and as such is not a helpful diagnostic finding
11
Q
True or false: dogs and cats rarely undergo spontaneous remission of sebaceous adenitis
A
True
12
Q
What is the only treatment to date shown to result in an increase in sebaceous glands along with clinical improvement in sebaceous adenitis?
A
Cyclosporine
13
Q
What condition has been characterized by chronic idiopathic hypereosinophilia associated with a diffuse infiltration of various organs by mature eosinophils?
A
Hypereosinophilic syndrome
14
Q
It has been recommended that peripheral blood eosinophil counts exceeding _____ be considered hypereosinophilia in dogs and cats.
A
5x10^9/L
15
Q
What signalment of cat is more likely to be affected by hypereosinophilic syndrome?
A
Middle-aged females
16
Q
Which organs are typically involved in hypereosinophilic syndrome?
A
Bone marrow, lymph nodes, liver, spleen, GI tract. Rarely cardiac.
17
Q
What dermatologic signs are seen in cats with hypereosinophilic syndrome?
A
Generalized maculopapular erythema, severe pruritus, marked excoriation, and possibly wheals and soft-tissue swellings of the limbs.
18
Q
How is hypereosinophilic syndrome diagnosed?
A
Combination of unexplained prolonged eosinophilia and evidence of multi organ involvement.
19
Q
What is the prognosis for hypereosinophilic syndrome?
A
Poor. Survival times are short and patients do not respond to treatment.
20
Q
What condition is characterized by progressively enlarging skin folds, especially over the neck and trunk?
A
Idiopathic diffuse lipomatosis
21
Q
What are the histopathologic findings in idiopathic diffuse lipomatosis?
A
Diffuse thickening of the panniculus. Proliferating fat may resemble mature adipose tissues with mucinosis only of interlobular septae and with small numbers of primitive mesenchymal cells and lipoblasts around blood vessels. In other cases, the normal anatomy of the panniculus is lost in a proliferative mixture of normal appearing and dysplastic lipocytes.
22
Q
What is the treatment for idiopathic diffuse lipomatosis?
A
No effective therapy.
23
Q
At what age are animals with idiopathic greasy skin and haircoat with sebaceous gland hyperplasia diagnosed?
A
Usually within the first year of life
24
Q
What are the histopathologic findings of idiopathic greasy skin and haircoat with sebaceous gland hyperplasia?
A
Remarkable sebaceous gland hyperplasia. Otherwise, the skin appeared normal.
25
What's wrong with this dog?
Lichenoid dermatitis
26
What is the cause of lichenoid dermatosis?
Unclear, but immune-mediate pathomechanism is suggested.
27
Describe the lesions present in lichenoid dermatoses.
Asymptomatic symmetric onset of grouped, angular, flat-topped papules, which develop a scaly to markedly hyperkeratotic surface.
28
What are the differentials for lichenoid dermatoses?
Psoriasiform lichenoid dermatosis of English Springer spaniels, actinic keratosis, some papilloma viral lesions, and cyclosporine induced lichenoid plaques.
29
What are the histopathologic findings in lichenoid dermatoses?
Hyperkeratotic and hyperplastic lichenoid and hydropic interface dermatitis
Usually lymphoplasmacytic inflammatory infiltrate
30
In lichenoid dermatoses, what histopathologic findings might influence your treatment plan?
If intraepidermal pustular dermatitis, suppurative folliculitis or both are present, suspect a lichenoid tissue reaction in response to staphylococcal infection. Should respond to antibiotics.
If eosinophilic microabscesses are present, suspect a lichenoid tissue reaction in response to an ectoparasite (especially scabies or cheyletiellosis) or Malassezia
31
What is the prognosis for idiopathic lichenoid dermatoses?
Good. All cases have undergone spontaneous remission after a course of six months to two years.
32
What form of therapy has consistently been shown to be beneficial in the treatment of idiopathic lichenoid dermatoses?
Sorry, trick question. No form of therapy has consistently been shown to be beneficial.
33
What are some ideologic factors involved in the genesis of panniculitis in dogs and cats?
(hint, there's a lot)
34
Which two species of bacteria appear to target the panniculus?
*Mycobacterium* and *Nocardia*
35
Panniculitis has been associated with disease of which internal organ?
Pancreas
36
Which hereditary disease predisposes humans to sterile panniculitis?
Hereditary deficiency of α1-antitrypsin
37
True or false: association with anti-trypsin levels has been detected in dogs with sterile nodular panniculitis.
False. It has not been detected
38
Which breed has been reported to be predisposed to sterile nodular panniculitis?
Dachshunds (51% in one study)
Possibly also miniature poodles and collies.
39
What other clinical signs can be seen with panniculitis, especially in dogs with multiple lesions?
Pyrexia, poor appetite, depression, lethargy, arthralgia, abdominal pain, vomiting, hepatosplenomegaly.
Fat necrosis in other organs including bone, spinal canal, and abdomen have also been reported.
40
Do dogs with sterile nodular panniculitis more commonly present with a solitary lesion or multiple lesions?
What about cats?
Dogs-debatable, one study showed more often it was single one study showed more often it was multiple.
Cats-solitary lesion in the majority(95%). Most commonly over the ventral abdomen and ventrolateral thorax
41
What might you see on an aspirate from a nodule in sterile nodular panniculitis?
May be suppurative, pyogranulomatous, or granulomatous with lipid or fat cells present.
Macrophages may be particularly foamy, but no microorganisms are seen
Occasionally the presence of spindle cells leads to an erroneous cytologic diagnosis of neoplasia.
42
Describe the histopathologic findings of panniculitis.
Usually lobular or diffuse but in some cases maybe septal.
The infiltrate maybe granulomatous, pyogranulomatous, suppurative, eosinophilic, necrotizing, or fibrosing.
The presence of saponification and necrotic fat is associated with pancreatic disease-induced sterile nodular panniculitis and also vitamin E pansteatitis in cats.
43
What is considered the minimum database to search for concurrent disease before a definitive diagnosis of sterile nodular panniculitis can be reached?
Abdominal ultrasound in chemistry screens with amylase and lipase (E. G., pancreatic lipase immunoreactivity)
CBC may show mild to moderate leukocytosis and neutrophilia, and a mild non-regenerative anemia in animals with multiple lesions And systemic illness.
44
What is the treatment for sterile nodular panniculitis?
In one case, when pancreatitis was resolved, the panniculitis also resolved.
Careful surgical excision of solitary lesions maybe curative.
Multiple lesions usually respond well to systemic glucocorticoids. (2 mg/kg once daily in dogs, 4mg/kg once daily in cats). If no cause is found or the underlying disease is effectively treated, attempts to stop therapy after remission are warranted. Recurrent cases can be treated with alternate day steroid therapy.
Azathioprine or cyclosporine can also be used.
Oral vitamin E 400IU q12 has shown good results. Tetracycline and niacinamide have been reported effective.
45
What is split paw pad disease?
Unknown etiology. Thought to be associated with a congenital defect in cornification of the foot pads. The defect weakens the epithelium and results in separation of the superficial layers from the deeper layers of the epidermis when friction is applied to the pad.
Wet feet are at greater risk
46
What are the characteristic histopathologic findings for split paw pad disease?
Brightly eosinophilic, coagulated appearance that extends into the superficial dermis and resembles the severe coagulation no necrosis of a burn.
47
What is the treatment for split paw pad disease?
Supportive care. Protective bandaging during healing. Pain medications as needed. Use of hunting boots that breathe may limit the frequency and severity of relapses.
48
Which breeds may be predisposed to sterile granuloma/pyogranuloma syndrome?
Collies, dachshunds, Doberman pinschers, English bulldog, Weimeraners, great Danes, boxers, and golden retrievers.
49
Describe the lesions seen in sterile granuloma/pyogranuloma syndrome
Lesions are firm, painless, nonpruritic dermal papules, plaques, and nodules.
May develop in circular donut shaped lesions and become alopecic, ulcerated, and secondarily infected.
Usually multiple and typically affects the head (especially bridge of the nose, muzzle, and periocular region), pinnae, and paws
50
What are the differentials for sterile granulomatous/pyogranulomatous syndrome?
Other granulomatous and pyogranulomatous (bacterial, mycotic, foreign body) and neoplastic disorders.
51
What is history of pathologic findings of sterile granuloma/ pyogranuloma syndrome?
Nodular to diffuse, granulomatous to pyogranulomatous dermatitis. Generally the center is more neutrophilic, the outer peripheral infiltrate has more macrophages.
52
Which microorganism should be tested for using PCR before making a definitive diagnosis of sterile granuloma/pyogranuloma syndrome?
Leishmania
53
What are some treatment options for sterile granuloma/pyogranuloma syndrome?
Tetracycline and niacinamide
Surgical excision of solitary lesions maybe necessary if pharmicotherapy is ineffective.
Glucocorticoids for multiple lesions. About 60% of dogs and require prolonged alternate morning glucocorticoids therapy.
Cyclosporine or azathioprine maybe used in dogs
Chlorambucil in cats.
54
Which syndrome in dogs has been compared to Wells syndrome in humans?
Eosinophilic dermatitis and edema
55
Which breed has been overrepresented with eosinophilic dermatitis and edema?
Labrador retrievers
56
How does eosinophilic dermatitis and edema present?
Acute onset of erythematous macules that progressed and coalesced into arciform and serpiginous plaques or wheals, especially on the ventral abdomen, pinnae, and thorax.
57
What are some possible underlying causes of eosinophilic dermatitis and edema?
Drugs, gastrointestinal disease, new diets, arthropods, and concurrent allergic or immune mediated diseases.
58
What are the histopathologic findings in eosinophilic dermatitis and edema?
Superficial and deep perivascular to interstitial dermatitis with marked dermal edema and vascular dilation. Numerous eosinophils. Flame figures seen about 50% of the time.
59
What is the treatment for eosinophilic dermatitis and edema?
Drug withdrawal where appropriate, systemic glucocorticoids, and antihistamines.
60
True or false: eosinophilic dermatitis and edema requires meticulous Long term care.
False. Most cases are resolved within weeks, with no further episodes.
Occasionally there may be recurrences or a waxing and waning course.
61
What has been suggested as the underlying cause for canine eosinophilic granulomas?
Insect bite reactions.
Possible hypersensitivity reactions to pollens, molds.
62
What 2 breeds have been overrepresented with canine eosinophilic granulomas?
Cavalier King Charles spaniels and Siberian Huskies
63
What is the typical appearance of eosinophilic granulomas in dogs?
Most commonly seen in the oral cavity as ulcerated palatine plaques and vegetative lingual masses.
Less commonly, they occur as multiple cutaneous papules, nodules, and plaques over the ventral abdomen, prepuce, flanks, and cheek.
64
True or false: cutaneous lesions in K9 eosinophilic granuloma are usually nonpururitic and painless.
True!
65
What are the characteristic histopathologic findings in canine eosinophilic granuloma?
Variably sized foci of flame figure formation, eosinophilic and histiocytic cellular infiltration, and palisading granulomas.
66
How are canine eosinophilic granulomas treated?
Very glucocorticoid responsive.
Lesions regressed in 10 to 20 days, and no further therapy was needed.
Some lesions undergo spontaneous remission, and some lesions are seasonally or chronically recurrent.
67
Hereditary cutaneous hyaluronosis is an inherited disorder of which breed of dog?
Chinese Shar-Pei
68
What are the clinical signs of hereditary cutaneous hyaluronosis?
Generalized, thickened, puffy, non-pitting skin.
Most prominent over the face, neck, and limbs.
Multiloculated vesicles or bullae may occur with the thickened skin or as the only lesions. When ruptured, these lesions yield an acellular, clear, viscid, sticky, stringy fluid.
69
How is hereditary cutaneous hyaluronosis diagnosed?
Diagnosis is supported by puncturing the skin with a hypodermic needle. Stringy, sticky, clear fluid loses from the puncture site.
Confirmation is by biopsy, which revealed marked diffuse dermal mucinosis and mild perivascular accumulations of mast cells and eosinophils.
70
In which conditions may Chinese Shar-Peis also experience localized and generalized mucinosis?
Hypersensitivities (atopy, food hypersensitivity, flea bite hypersensitivity), and hypothyroidism.
71
How is hereditary cutaneous hyaluronosis treated?
May spontaneously resolved or deflate as the dog ages.
Glucocorticoids (triamcinolone may work better than prednisone)
Pentoxifylline 10mg/kg q8h
72
At what age are puppies typically affected by juvenile cellulitis?
Between three weeks and four months.
A few reports of dogs with older age onset and typical lesions and findings have been reported.
73
Which dog breeds are predisposed to juvenile cellulitis?
Golden retrievers, dachshunds, and Gordon setters.
English cocker spaniel, Labrador retriever, and Lhasa apso may be predisposed
74
What are the most common clinical signs in juvenile cellulitis?
Acutely swollen face, especially eyelids, lips, and muzzle.
Submandibular lymphadenopathy
Papules and pustules within 24 to 48 hours. Progress to fistulate, drain, and crust.
This externa is common, pinnae are frequently thickened and edematous.
Concurrent sterile pyogranulomatous panniculitis with firm to fluctuant subcutaneous nodules on the trunk may be seen.
75
What are the differentials for juvenile cellulitis?
Staphylococcal dermatitis, demodicosis, and adverse cutaneous drug reaction.
76
Describe the histopathologic findings in juvenile cellulitis.
Multiple discrete or confluent granulomas or pyogranulomas consisting of clusters of large epithelioid macrophages with variably sized cores of neutrophils
Sebaceous glands and epitrichial sweat glands maybe obliterated
In later severe lesions, suppurative changes in the superficial dermis in and around ruptured hair follicles and in the subjacent panniculus are predominant
77
What is the treatment for juvenile cellulitis?
Early and aggressive therapy with large doses of glucocorticoids to prevent scarring (2mg/kg once daily) for 14-28 days (until disease is inactive)
Antibiotics if concurrent bacterial infection is present
Can use cyclosporine with prednisone
78
Describe the cause and pathogenesis of sterile eosinophilic pustulosis
The cause and pathogenesis are unknown. Intradermal skin testing, hypoallergenic diet, and immunopathologic studies have not been helpful in elucidating the etiopathogenesis.
79
What are the differentials for sterile eosinophilic pustulosis?
Staphylococcal folliculitis, pemphigus foliaceus, drug reaction, and subcorneal pustular dermatosis.
80
True or false: most dogs with sterile eosinophilic pustulosis have a peripheral eosinophilia.
True.
81
What are the histopathologic findings in sterile eosinophilic pustulosis?
Combination of subcorneal, intra-epidural, or follicular eosinophilic pustules.
Eosinophilic folliculitis and furunculosis may occur.
Flame figures are occasionally visible in the surrounding dermis.
Direct and indirect immunofluorescence results are negative.
82
How is sterile eosinophilic pustulosis treated?
Glucocorticoids. 2.2 to 4.4 mg/kg once daily. Rapid response in 5 to 10 days.
Cure is unlikely, so long term alternate morning therapy is indicated.
Can also use antihistamine(Diphenhydramine) and an omega six and omega three fatty acid supplement.
83
Which disease has been compared to sweet syndrome in humans?
Sterile neutrophilic dermatosis
84
What are the causes of sweet syndrome in humans?
Four forms described
1. Classic form - middle-aged women after an upper respiratory infection, inflammatory bowel disease, pregnancy, or idiopathic
2. Associated with malignancy
3. Drug induced
4. Associated with lesions developing following trauma, such as following injections, surgical incisions, animal bites, burns, or sunburn.
85
What is pathergy?
The test used to help diagnose some sterile neutrophilic diseases such as Behςet syndrome, but also sweet syndrome and pyoderma gangrenosum.
It involves pricking the skin with a needle point and the subsequent development of induration, with a sterile neutrophilic pustule developing at the site.
86
Which drug has been associated with sterile neutrophilic dermatosis in dogs?
Carprofen
87
What is the suspected pathogenesis of sterile neutrophilic dermatoses?
Speculated that there is an antigen-induced T cell-mediated immune reaction.
Drug administration and paraneoplastic syndromes may be the source of an antigenic stimulus.
88
What are the three requirements for diagnosis of acute febrile neutrophilic dermatosis in humans?
1. Clinical findings of acute onset of tender or painful erythematous or violaceous plaques or nodules
2. Histopathology of lesions demonstrating predominately neutrophilic infiltration in the dermis, without leukocytoclastic vasculitis
3. The patient must also have two of the following minor criteria:
* Preceding fever or infection
* Accompanying fever, arthralgia, conjunctivitis, or underlying malignant lesion
* Leukocytosis
* Good response to systemically administered corticosteroids but not to antibiotics
* Increased erythrocyte sedimentation rate
89
What are the histopathologic findings in dogs with sterile neutrophilic dermatoses?
Moderate to severe neutrophil-rich dermal infiltrate that may be superficial to deep and perivascular to diffuse
Edema is generally prominent, and leukocytoclasia is uncommon, and if present mild.
90
What is the treatment for sterile neutrophilic dermatoses?
Stopping any possible inducing drug and treatment with systemic glucocorticoids should be effective
91
92
Which rare disease in cats is related to abnormal collagenesis during wound healing?
Acquired reactive perforating collagenosis
93
What are the clinical signs of acquired reactive perforating collagenosis?
Multiple firm, conical, hyperkeratotic, yellowish brown lesions, 2 to 7 mm in diameter, are present over various areas of the body. The lesions tend to cluster and form linear configurations.
The lesions cannot easily be scraped or pulled off, and when they are, hemorrhage is likely.
Lesions often occur in areas where the cat is pruritic or where there has been trauma.
94
What are the histopathologic findings for acquired reactive perforating collagenosis?
Superficial interstitial dermatitis Rich in eosinophils and mast cells underlying a conical exophytic projection from the skin surface.
The exophytic mass consists of necrotic cellular debris, strands of keratin, and numerous collagen fibers in varying degrees of degeneration
95
Which stain can be helpful in the diagnosis of acquired reactive perforating collagenosis?
Masson trichrome.
Normally, collagen fibers stain homogenously blue.
In perforating dermatitis, collagen fibers show segmental red bands. Presumably indicating some kind of abnormality in collegen metabolism (Synthesis, packing, degradation)
96
What treatments have been reported for acquired reactive perforating collagenosis?
Oral vitamin C (100 mg every 12 hours)
Depo-Medrol
Control of con current allergic skin disease
Topical betamethasone, which inhibits collagen I and III production, as well as topical hallofuginone, a specific collagen I inhibitor.
97
How is acquired skin fragility characterized?
Markedly thin and fragile skin in the absence of hyperextensibility
98
What are some of the causes associated with acquired skin fragility?
Spontaneous or iatrogenic Cushing's syndrome
Diabetes mellitus
Excessive use of progestational compounds
Isolated cases have been reported in association with liver disease (lipidosis, cholangiohepatitis, Or cholangiocarcinoma), phenytoin administration, feline dysautonomia, nephrosis, and feline infectious peritonitis
99
What are the histopathologic findings of skin fragility syndrome?
Severely atrophic dermis. Dermal collagen fibers are very thin and disorganized.
Panniculus is usually not present in biopsy specimens. The epidermis and hair follicles may be atrophied.
Masson trichrome stained sections may show the segmental staining abnormality of collagen seen in cutaneous asthenia, but milder
100
What is the prognosis for acquired skin fragility syndrome?
Grave. Affected cats are very difficult to handle without skinning them. Early cases in association with spontaneous or iatrogenic Cushing's syndrome have resolved when the inciting cause was eliminated.
101
What three lesions have traditionally been recognized in feline eosinophilic granuloma complex?
1. Indolent ulcer
2. Eosinophilic plaque
3. Eosinophilic granuloma
102
Which form of feline eosinophilic granuloma complex is most variable in its presentation and more likely to be determined to be idiopathic?
Feline eosinophilic granuloma(linear granuloma)
103
Where do most feline eosinophilic granulomas occur?
Caudal thighs, face, and in the oral cavity (especially the tongue and palate)
104
True or false: feline eosinophilic granulomas are often pruritic.
False. They are often nonpruritic.
105
Describe the histopathologic findings of feline eosinophilic granuloma
Nodular to diffuse granulomatous dermatitis with multifocal areas of collagen surrounded by cytolytic eosinophils and extruded granular material, which are referred to as flame figures.
Multinucleated histiocytic giant cells are common
Mucinosis of the epidermis and hair follicle outer root sheath, focal infiltrative to necrotizing mural eosinophilic folliculitis or furunculosis and focal eosinophilic panniculitis may be present
Eosinophils are less prominent in chronic lesions
106
True or false: feline eosinophilic plaque is often pruritic.
True. It is likely that licking contributes to the formation of many of these lesions.
107
Where are most eosinophilic plaques on the body?
Abdomen and medial thigh. Occasionally mucocutaneous junctions
108
What are the main differential diagnosis for eosinophilic plaque?
Cutaneous neoplasia, particularly squamous cell carcinoma, lymphoma, mast cell tumor, and metastatic mammary adenocarcinoma.
109
What might you see on biopsy of an eosinophilic plaque?
Hyperplastic superficial and deep perivascular dermatitis with eosinophilia, to interstitial or diffuse eosinophilic dermatitis.
Diffuse spongiosis that involves the outer root sheaths of hair follicles and eosinophilic microvesicles and micro abscesses may be visible.
Some lesions have remarkable mucinosis of the epidermis and hair follicle outer root sheath
110
What are the differential diagnosis for indolent ulcers?
Infectious ulcers(Bacterial, fungal, viral), trauma, and neoplasia(squamous cell carcinoma, mast cell tumor, lymphoma)
111
Describe the therapy for feline eosinophilic granuloma complex
Antibiotics (clavamox, convenia, clindamycin, and marbofloxacin)
Glucocorticoids (prednisolone, methylprednisolone, or triamcinolone)
Cyclosporine
112
Where are feline idiopathic ulcerative dermatitis lesions typically seen?
Dorsal neck and shoulder. Usually solitary
113
How is feline idiopathic ulcerative dermatitis treated?
Either surgical excision or aggressive glucocorticoid therapy is usually curative once secondary infections are controlled.
114
Describe the clinical appearance of plasma cell pododermatitis
Soft swelling of usually multiple footpads, rarely a single footpad is involved.
The surface of affected pads is cross patched with white scaly striae.
With chronicity, depigmentation and even loss of pad architecture may be seen.
Ulceration present in 20 to 35% of cases
115
What are the differentials for plasma cell pododermatitis?
Eosinophilic granuloma of the footpad - typically will not involve multiple pads of multiple paws and may have concurrent skin lesions.
If only one pad is involved, neoplasia and foreign body
116
How is plasma cell pododermatitis diagnosed?
A tentative diagnosis maybe based on history, physical exam, and aspiration cytologic study wherein plasma cells are numerous.
Biopsy shows diffuse dermal and even adjacent adipose tissue infiltration with numerous plasma cells. May only see superficial and deep perivascular plasma cell dermatitis.
Russell bodies (Mott cells) are typically seen.
Fibrosis may be seen in chronic lesions
117
How would you treat plasma cell pododermatitis?
Doxycycline (10mg/kg q24) - inexpensive, safe, and effective in resolving about one third of cases and improving over 80%.
Make sure you chase it with water. Continue treatment until pads are normal, this may take 10 weeks.
Glucocorticoids are indicated if there is poor response to doxycycline and the cat has significant symptoms associated with the disease.
Can use cyclosporine.
Surgical excision has been described as beneficial in cases not responding to medical therapy
