OK, so case studies are, are fun and interesting, and they help us learn about what we can do in terms of trying to solve further cases. So let's look at this one. This is Peppa, who is a Frenchie.

Poor little Frenchies, they have so many health problems, and skin, is, they are genetically predisposed to have skin problems. So you will find that they do turn up in your dermatology clinics quite frequently. So, Peppa's skin problem manifested at less than 3 years of age.

So that's making me think, well, it might be an allergy because that's usually when allergies show up. Peppa lives with 5 other dogs, horses, and a lot of people, and none of them have lesions. None of them are scratching or uncomfortable.

It's only poor little Peppa, who is very, very itchy. She's very pruritic. She's in a, she's in a suffering state.

Her problem was progressive, so when they first got her, it was very mild and it's gotten worse and worse and worse. The main affected areas are the face. Feet, the axilla, so the armpits, the ventrum, her tummy, and her skin folds.

Skin folds are, are just wonderful places for growing bacteria and yeast cause they're warm and dark and moist, and the bacteria and yeast go, yes, perfect environment for me. So you always have to look out for dogs with skin folds. There's no GI involvement.

She hasn't had any diarrhoea, so That doesn't rule out a food adverse reaction, but it makes it maybe a little bit less likely. There are definite seasonal flares. She starts getting really bad in the spring and gets progressively worse through the summer.

So, I'm getting a lot of hints here that are pointing me towards allergy. So, that's gonna be at the top of my differential list. Again, we are not diagnosing the vet is.

But we can kind of point the investigations in a certain area if we have got the information from the history that are strong clues to go in that area. So I took the time to do a really thorough history. You know, I found out about the other 5 dogs and horses, etc.

And I got a really thorough history, and these clues kind of pointed me down the trail of adipe. So I checked, is her parasite treatment good? Yeah, it's totally up to date.

This dog's on one of those pet club schemes and gets her treatment every single month. I did, just to rule out skin scrapes and plugs, it is possible you can have skin allergies and mites at the same time, so it's always a good idea to check, but this was negative for mites, all kinds. We did coat brushings, for dermatophytosis, and these were also negative, and we did tape strips and impression smears, and it was positive for bacteria and malahesia.

This is very, very common in allergic skin disease. You will get secondary infection because the dog has been scratching and chewing. If you don't treat this, you will never get to the bottom of the problem.

So you have to identify the secondary infections. Or the scratching will never stop because bacteria and malices are very itchy. I don't know if anyone's ever had a spot on their face, but it is very itchy when you get them because bacteria makes you itchy.

So, we need to, to identify these and apply the correct treatment to eliminate them so that we don't have to deal with the secondary infection as well as the initial underlying cause. We did a food trial just in case, but there was no significant improvement, so we came off the trial and then we did blood testing for serology and get a positive for trees and grass pollens, storage and dust mites. Now storage and dust mites, you get really, really, really commonly.

That's a really common allergy, but so the, the main one that was, we were worried about with this dog was the tree and the grass pollens because we were seeing the seasonal flares. Ideally, we do an intradermal skin test because that's the gold standard for identifying. Allergens.

However, it's generally not available in general practise, and as long as you're using your serology judiciously, you can get sometimes some false positives, like, say this dog had never been exposed to a cat and the serology came up as positive to cat dander. Well, you don't need to include cat dander in the In the allergy shop because the dog doesn't interact with cats. But because the dog goes running around in the fields, it does need treatment for treating gas breasts problems.

So just looking at her, you can see the ventrum there's no hair death there at all. There's severe alopecia. Papules are little red dots which you can see in the smaller photograph.

Commodons are blackheads, which you can see in both photographs. Hyperpigmentation is the darkening of the skin which we will see in the main photograph. And lichenification is thickening leathery skin, which you can definitely see in this photo of the ventrum.

So this has been ongoing. There, it's, there are chronic skin changes now. It, it's not a new disease.

So our treatment plan. We are pretty much sure it's an allergic skin disease cause we've eliminated everything else. We've eliminated the food, we've eliminated the parasites, we've eliminated dermatophytosis, and we've done serology, so we're gonna treat for allergic skin disease.

We've asked that the dog be bathed twice weekly. With a shampoo that's gonna have treatment against bacteria and fungal. So you've got to look at your shampoo bottles and make sure you're choosing the correct one.

There are a lot of them on the market. Generally speaking, if it's got chlorohexidine in it, it's gonna do the job. You've got to make sure the owner can bathe the dog.

This owner was like a Did trials and horses and stuff and was very fit and healthy. She had no problem bathing her Frenchy. So we're gonna do that twice a week with the appropriate contact time.

Every other day we're doing wipes in the skin folds. We're using Loyvet man. Essential fatty acids to help, get the skin a lot stronger and healthier and to, reduce inflammation.

We're doing the immunotherapy, so we're doing the allergy shots definitely for the pollens. We've put her on a supportive skin diet, not hydrolyzed diet. She doesn't need that, but it's a supportive skin diet that has some additional essential fatty acids in it and, and things that will help her a little bit.

We've asked the owner to wipe down the dog after walks. So just with a sponge, a moist sponge, wipe her down and get off any topical things like the pollens that are aggravating her, and avoidance. So what this owner has done in terms of avoidance was, she ripped up all the turf in her garden and put down concrete slabs because the grass was making her dog go crazy.

So this is a really, really dedicated owner. But avoidance is one of the things. So maybe not walking her in grassy areas, but then quality of life, the dog wants to have a run around in the fields off leads, so got to balance that out, but at least the dog is not getting exposed to grass in her, her home environment.

And stay on top of the parasite treatment. So, your your job as a nurse would be to teach how to bathe and use the wipes. Keep on, you got to do monthly checkups.

This is a quite severe case. You got to keep checking up on maybe just over the phone, but this owner needs support because this is gonna go on for this dog's whole life and prepare for flares. So maybe contact the owner in March going flare season's coming up.

Do you want to, you know, up the treatment? Maybe let's get the bass 3 times a week and use the wipes every. Day, stuff like that, and be ready to alter the treatment plan as needed.

Allergy is a progressive disease. It might get worse, it probably will get worse. So just support the owner as you alter and, and just keep on top of it.

OK, so we have Buster here. Buster has had a recurrent ear infections, that started in middle age, so he was about 8 or 9 years old. .

He is one of those breeds that is predisposed to skin conditions, and he's also got pendulous ears. Pendulous ears are predisposed in ear conditions because they're holding the moisture and the heat inside the ear, making the environment much more pleasant for the bacteria and the yeast. It wasn't that itchy at first, but it got worse.

No one else seemed to be getting ear problems. It wasn't seasonal. No GI involvement, but Buster was starting to gain weight and slow down, and the owner thought it was just middle age.

There had been previous treatment for the ear infections. They did clear up, but they just kept coming back and Buster was up to date with his parasite treatment. So if you look at this area here, it's, it's awful.

It's got erythema. It's got terrible swelling. This, if you look, you can see there is no ear canal.

This ear canal has swelling shot. It has significant stenosis. So how you can even clean that ear, and then you can see loads of discharge around the ear.

So this is a problem. I suspected hypothyroidism because the dog's problems started in middle age and because he was getting a little bit overweight and run down. It could have just been middle age, but you know, not necessarily.

So we just made sure there the flea and worm treatment was being applied correctly and being used regularly. We did ear cytology and it was positive for everything. It was awful.

So we did also a swab because we wanted correct identification of the bacteria for the appropriate treatment. Did some scrapes and plucks, lots and lots of teenage and hairs, lots. So this dog was not growing new hair.

And that kind of points us towards maybe hyperthyroidism. Mentioned a food trial that owner flatly refused. You'll find this happens quite often.

Luckily, adverse food reactions are not that common, but you know, that, that can be a problem. We did a blood test and the general profile showed raised cholesterol, which can sometimes indicate a hypothyroid problem. So we did T4, TSH.

The T4 was low, the TSH was high, diagnosed by the vet for hypothyroidism. Now, here's a photo of another dog which you can see has horrific skin, . Does it have much hair left at all.

It's got like henification, hyperpigmentation, commodones, erythema, alopecia. It's got about every skin condition you can name. This dog had Cushing's.

And once on treatment, his hair grew back and it was fine. So the treatment plan for Buster, we had to give it some Preds, because we couldn't even get in the ear canal. We couldn't even find the ear canal.

So we had to give it Preds, so the inflammation resolved and the swelling resolved and then Just for a few days, and then we gave it a general anaesthetic to flush out the ear. Now it is a bit risky giving pread to an animal that has depressed immune system with hyperthyroidism. So it, it, it needs to be a discussion with the owner.

But in this case, there was just no way of getting in the ear, otherwise it had to be done. So big thorough ear flush and then we set up daily ear cleaning, making sure the owner knew how to do it properly. Appropriate treatment was given according to culture and sensitivity results.

In the slide there you see neutrophils and lots and lots of rods, so you've got gram-negative bacteria there, which always indicates a culture and sensitivity and thyroid supplement, and Buster didn't get any more ear infections. OK, we, we have Neville here, darling Neville, . His lesions were limited to the facial region.

And he showed up in the practise as a rescue cat, so he had no prior history. We had no idea what was going on, and because he looked so sad, of course, he was adopted by someone on the staff because that's what we do, don't we? The new owner had no other pets in the house, but she did start to notice some lesions on herself.

Neither she nor the cat were pyretic, but they became so eventually. The lesions were not seasonal, but they were progressive. And also with this breed, we think Neville was a Persian, but again, we have no history.

There is a predisposition to dermatophytosis. Parasite treatment was up to date. We did do a food trial because Adverse food reactions can manifest on the face.

We did some plucks, which were negative for mites, some tape strips. We didn't get any harvest mite, but we did get a lot of bacteria. Didn't really need to do a culture and sensitivity, but the honoured was a veterinary personnel, and so they did do a culture and sensitivity, which is fine, and a staph infection was identified.

We use the word slab because we're thinking it might be spermatophytosis, . The wood slab is a great tool. It doesn't identify every type of fungus.

It identifies some of them, but not all of them. So you should, if you've got a negative on your woods lamp, you also need to do coat brushing. So we used a sterile toothbrush and brushed it.

We didn't do in-house dermato flight testing. We sent it off to the lab and it came back positive for dermatophytosis for a ringworm, which explained why the owner also had lesions. So, Treatment, clip away any remaining hair so that we could treat the area topically.

We advisediona to treat herself so she didn't give it back to the cat and the hum. Unfortunately, spores, can live in the environment, ringworm spores can live in the environment for 18 months. So you've got to really, really dust and hoover and clean up to get rid of those guys.

It's a bit of a pain. So different options here to treat this. You can shampoo twice weekly with the chlorhexidine and myconazole mixture, making sure you don't have to shampoo the whole cat, just the affected areas, making sure that, there was the appropriate contact time, you know, 3 minutes or 10 minutes, depending on which shampoo you're using.

You must be very careful because you're working around the eyes. You can use antifungal and antibacterial mousse or wipes daily. Or you could put an e-coer on and use an antibacterial plus anti-fungal cream.

So you've got three options here. You also have the option of using an oral anti-fungal medication. You do need to be aware.

That antifungal medications are not safe for women of childbearing years to handle. They must wear gloves. This owner was in the process of trying to get pregnant, so we just, no, absolutely, we're not going that way.

The cat didn't like wearing a collar, didn't like baths, so we went with the wipes. And that seemed to do the job. Right, this is pumpkin, .

This was a Labradoodle, 18 months old, female spayed, that's her signal mint. Lived with another Labradoodle, her litter mate, who also had lesions, but they were not nearly as bad as this. There was a gradual onset until they got to this point and the owner decided to go to a vet.

And there was some pruritus with their dog rubbing its face, sometimes on the concrete in their garden. So what you're seeing here are papules and some pustules on the muzzle. So, you know, but these are big ones.

These are really big papules, . And I immediately went, this is an autoimmune disease, this is something really weird like panhagus or erythema multiforme. It's just really weird.

I've never seen something like this. So I immediately went for the exotic disease. Although I had no idea actually what it was.

This is another picture. Once the papules erupted, you can see there's erosions there in the skin. This is nasty, really nasty.

Checked the parasite treatment. It was being done, but not every single month, so we said you really need to do it every single month. Did a tape strip and impression smears around the muzzle, you know, nasal area, got positive for bacteria.

Did plaques negative for mites, hair sample was negative for dermatophytosis. I mean, it could be a fungal infection because some of them do have manifest in very interesting lesions. So it was definitely worth taking some samples for.

Phytosis. We weren't sure what type of bacteria, so we definitely sent a swab off for culture and sensitivity, and we also did a biopsy in case of autoimmune disease or a, a deep dermatophytosis or a deep yoderma. And we asked the owner about doing a food trial and she burst into tears.

It turned out that her son was allergic to almost everything in the world, and the thought of having to also put her dog on a food trial just which she couldn't. It was just not within the realm of possibility. So you have to work with the owner and the patient.

You can't just say this, this is the protocol, and this is the way it goes. And if you're not going to follow the protocol too bad, you have to, you know, be a team. We want compliance here, so you have to work with the owner.

So, it turned out that it was a just a really, really nasty bacterial infection and because it was a deep infection, it did warrant systemic antibiotic treatment, the correct treatment being chosen through culture and sensitivity, plus topical treatment and treatment was also given to the other dog. On a follow-up appointment, the owner mentioned that the dogs like to chase lizards in the garden. This is in California, by the way, not England.

We don't have a lot of lizards in England running around the gardens, and that she was wondering if they had picked up the bacterial infection from the lizards. And it's quite possible, so we advised training to stop chasing lizards. Don't know how she got on with that.

Hopefully, hopefully they're not gonna get any more of these hideous lesions because they were really hideous. OK, so we've got Beau here, poor little Beau, you can see she's got hives all over her face. She just looks absolutely miserable.

This was a sudden onset, and she's in her middle life. She's not a youngster. The parasite treatment is up to date.

The other dog didn't have any problems. It was itchy. This, this particular dog has a complicated medical history.

It's had meningitis, it's had eye surgery, it's had problems with its, trachea. It, it's got. It's been and out in and out of the vets a lot, and noted in the history was a recent change of diet.

So, it looked because of the sudden onset, like a contact allergy or maybe a bite, a sting, or insect bite, or it could be an adverse food reaction. So we did a tape strip. Nothing came up.

No yeast, no bacteria. Discussed contact possibilities with the owner. Has she got, did she spray the upholstery or put carpet, new carpet down or carpet cleaner?

She said nothing has changed. I asked her about insects, said she didn't notice any stings, and she was a really, really invested owner. She would have definitely noticed if her dog had been stung.

. Asked if she'd go for a food trial, absolutely went on it immediately. Problem resolved within days. We challenged the food trial.

So the challenge is when, after you finished your trial of 8 to 12 weeks, you challenge with specific proteins like chicken, OK? The dog didn't itch on chicken, beef, dog didn't itch on chicken or beef, great, it's not allergic to beef or chicken. Let's try it with cheese.

Oh, the dog's itching again. OK, it's allergic to dairy products. So that's how you find out what the dog's allergic to, and then you just choose a food that doesn't have that in it.

You don't need to keep the dog for life on hypoallergenic diet. Nobody could afford that. It's ridiculous.

. With this owner, there, we challenged, we couldn't find anything. There was no reactions to the various proteins we challenged, including wheat. And We said, OK, go back on the food that you were feeding.

Maybe it was a sting, who knows? Immediately dog went back into hives. So we said, change the brand of food.

And the dog was fine. So it was something in the food. It wasn't one of the novel proteins.

It could have been, some foods have dyes in them, it could have been a preservative. We don't know, it doesn't matter. The problem was solved, just don't feed that brand of food.

A little note on food reactions, they are fairly rare. The statistics show that it's not 0.05% of dogs, react to, have adverse food reactions.

The most common are beef and dairy. And not grain, as every single client will tell you that their dog is allergic to grain. It is an allergen.

Dogs do get allergic to it, but it's not in the top two. Food allergies can only be diagnosed by food trial of 8 to 12 weeks. Sorry, that's a real pain.

It would be great if we could diagnose them via saliva or sergy. Unfortunately, those tests give Numerous false positives and are just not accurate. The only way to diagnose an adverse food reaction is with a food truck, and that's where the nurse has to come in supporting the owner because they are so hard to stay on.

Food reactions often manifest on the face or with the ears, and you must challenge with single proteins afterwards to identify the culprit, so that the, the owner can just buy a nice affordable food that just doesn't happen to have dairy products or beef in it. And avoidance is secure. It's really easy, really, really easy.

It's a nice, it's a nice disease to have. It's just a hard one to diagnose. And that is it.