Dermatology in general practise. What we are trying to do is give gold standard care to all of our patients. Unfortunately, with the current economic client, that's not always possible.

However, what we can do is individualise each case and give the best care we can for that individual patient and their caretakers. 30% of the cases seen in general practise are skin related, so this is an enormous part of our workload. And unfortunately, skin cases aren't something you can do in a 10 or 15 minute consult, which is where our nurses can step in and assist our vets because they can do a great deal of the skin workup.

The first thing we need to address in any skin case is how are parasites being dealt with. I'm afraid even in referral, we are seeing flea-infested patients, and it's a real shame for a client to pay for a referral fee, which is quite a bit more than a regular consult and it to turn out to be flea allergic dermatitis. So this is something that we can do quite easily in general practise.

Luckily, a lot of our Patients are on the care plans where they're getting treatment every month as they're paying for it. However, a lot of them are actually applying it, so that's something to discuss at a consult or to book in your patient with a nurse who can go over appropriate parasite control. Some people don't understand how to separate the fur coat and make sure that the product is applied directly to the skin.

I have with cats quite often clipped a little patch on the dorsum to apply the product directly to the skin because they do have such a thick plush coat. They're obvious they're not always getting the product. It's just kind of decorating their fur and obviously skin problems with cats are very often related to fleas.

So this is something we really need to look at. Some people just forget to give it, and you can give them advice like make the alarms on your phone, or make marks on your calendar, and that sort of thing. Another thing that we look at is if an animal does have a skin problem, it's being bathed a lot and some of the topical products are being washed off.

And then also ask about if the dog has a swimming hobby. I live in Cornwall and a lot of the dogs here swim on a very regular basis, so their products are being washed off. And also those products are going into the environment, which is not ideal.

We have traced them to rivers and waterways and it's not good for the local and natural wildlife. So what we really do want to point some patients to towards would be the tablet form of the treatment. So I, I start out with the premise that everybody has fleas.

This is a dog that came in to be euthanized actually because of its skin problem and it really was just infested with fleas so badly, so we rehomed it to someone that could actually give flea treatment. All pets in the household do need to be treated year-round. We find a lot of people decide not to give the treatment in the winter because they feel there isn't a flea problem then, but fleas love central heating, and they make nice little homes under our sofas and under our beds, and they're perfectly happy populating in our homes.

So it does need to be year-round treatment. Often, the dog will come in with skin problems and we're treating that. We find out the owner also has a cat and that's just not reckoned in.

Sometimes the cat hasn't been to the vet in 1012 years, so of course, it's not on proper flea treatment. So then that has to be factored in. Another problem we can come across is people having many pets in a household, and then it gets really expensive to treat them all regularly, but if you have a fully allergic animal, it, everybody in the house has to be treated.

Maybe not the humans. I won't go that far. And the house needs to be treated.

So ways that we can make this more affordable is offering to sell products one tablet at a time. I, we do that with a lot of our clients where they just come in and buy one tablet and the next month they come and buy the next tablet. Obviously, if there's several animals then they still need to buy.

Quite a bit at the same time. We do need to discuss the fact that veterinary products are gonna be effective, whereas the things that they get from pet stores, or supermarkets may not be and it's also a waste of, of their limited resources. This needs to be done diplomatically.

There isn't any scientific proof yet that fipronil doesn't work, but there is a lot of anecdotal proof that perhaps fleas have developed a sort of immunity to fipronil, which is of course available over the counter. So if you've got a flea allergic animal, maybe they do need to step up to have the, the, more modern flea products, and that has to be discussed. Premise sprays, you need to tell people how to use them.

They might just spray one room instead of the whole house. You need to let them know the how the car needs to be sprayed. If the dog's taking trips in the car, their garage needs to be sprayed, and one tin of spray might not be enough for their whole house.

So that needs to be explained. We usually give a handout of how to use the premise spray, . And I think that really is helpful to people as well.

If they are in council housing, they can ask the council to spray the home. And another assistance they can get with flea products is contacting their local charities. Sometimes charities will assist owners with payment for flea products on an individual case.

Certainly, if they have a note from the vet saying this animal has flea. Allergic dermatitis and needs this treatment, the owner can't currently afford it, then a charity, I, I have known some charities to assist with the cost of fleet treatment. So that's certainly something worth going, look looking at.

What can the client do to help with flea control? Keep your dog out of the bed. It's a good idea.

That's my dog, sorry. Hoover every day if they can possibly do that, and if they are doing that, they need to empty the hoover bag because the fleas can live inside the hoover bag, as can the eggs. Wash bedding on a high temperature weekly, particularly the dog's bedding.

Get rid of soft toys or wash them on a high temperature on a regular basis. Removing carpeting can also help. All of these steps can also help with dogs that have dust mite allergies.

So these are things that aren't gonna cost the owner additional funds. But they can do this to help in the battle against fleas, and I think we need to really think of it as a battle, and we are supporting owners in this battle, and they need to understand that it's not something that's going to go away overnight, but it's gonna take at least 3 months to eradicate because sometimes they'll stop using the products they say, oh, it didn't work. But if you explain the flea life cycle, not too Much detail because they're usually not interested.

But if you can explain the flea life cycle and say, it might take a while to get all the different aspects of the fleas flea life cycle eliminated from your home, but please hang in there. And sometimes they need some kind of telephone support or advice. And if they are coming back each month to buy the flu product, this is where you can step in and say, how is it going?

Have you been able to, you know, wash all the bedding, that sort of thing, and, and just give them a lot of support because it is a war on fleas, I'm afraid. The next thing that we need to look at in terms of parasite control would be our, our mites. We routinely used to do skin scrapes for mites, and if the animal is not on a regular veterinary parasite product, then yes, skin scrapes are, are certainly a step in your diagnostic toolbox.

However, if they are on the product, do we need to scrape and then charge the client for that? It's also not the most pleasant procedure for the animal. I think it is a little bit painful.

I think owners get a bit upset when they notice the scrape spots because of we've had to scrape till we get capillary ooze. And if you're going to put them on a flea product or parasite product anyway, is it actually necessary to skin scrape? You can consider your application of the product to be your clinical trial and see is the animal improving, OK, then that might have been the problem.

It really depends on the owner's finances, and if you're really limited, I would, I know it's not gold standard, but I would eliminate the step and just proceed to applying the product. If you're dealing with different types of mites that are surface mites like Calitella, then go ahead and tape strip. That's not an invasive procedure.

It's a real quick glance under the microscope. That would be something your practise would need to decide whether you want to actually charge for that or not. It's not something I charge for because it is such a simple and straightforward procedure, but that would be something you would need to discuss with your practise.

And then again with Kayla Tella, the, they respond better to surface products, even sprays in some cases. So that would help you choose the product. So if that is something you're suspecting, if you're seeing a lot of scurf and it looks like I might have walking down drift, then proceed to a tight strip.

Another common problem that we're seeing a lot in general practise with skin cases is ears, and this is something where owners get really discouraged because you're getting continuously people coming back. The, the ear infection just recurs and recurs and recurs, and they, they just feel like it's not getting any better. And this is where you get the phone calls saying, Oh, it's the exact same thing again.

Can I just have the drops you gave me last time? And you have to explain, no, you need to come in. We need to see the ear.

We need to make sure the eardrums intact. We can't just give out drops willy-nilly, especially if it's been 6 months since we've last seen your animal. And this is when owners get really cranky with us because It's, it is the exact same thing and they know you're probably gonna give probably the same treatment.

So they're just don't understand why they have to pay for another consult. So this is where we really need to think about why is this animal getting ear infections and why do they keep coming back. Once in a while, it's just a straightforward infection.

Maybe it went swimming, got a lot of water in its ear and started scratching, and it's a straightforward infection, or it had a foreign body, you've removed it and it's fine. But generally speaking, there's an underlying reason for ear infection, and it's something we have to look at. So it's kind of being just treating the ear as it is, is really being penny wise, pound foolish because if the animal is going to keep coming back, it's gonna end up costing the owner a lot of money in the long run, even going to the point of them needing ear surgery.

So getting to the bottom of the problem early on is gonna save the owner money. It's To save the animal a lot of pain. Ear infections are incredibly painful, and we, we don't really take that into account.

But if any of you've ever had a child with an ear infection and they do that high pitched whale all night long, you will know how painful ear infections are, and it can affect the behaviour of the animal as well. So it's really, really worthwhile looking at it the first time. And if you don't have the time in your 15-minute consult.

And say, OK, I'm gonna clean up the air or I'm gonna refer you to a nurse clinic to get the air cleaned. I'm gonna give you these drops and then you need to keep coming back and seeing a nurse to check the ear and to make sure that all the treatment is being given appropriately. So, ears, looking at them, does it just need a good clean?

Quite often you will get just a really waxy dirty ear, especially if you've got A lot of the poodle coats, cockapoo type coats, they, the ears get a lot of wax buildup because the hair is, is clogging the, the drainage more or less. And in those cases, teaching the owner how to clean the ear is a really, really useful thing to do, and setting up a norm a normal cleaning pattern like I think this ear needs to be cleaned once a week or usually I will say clean twice a week, come back in a couple of weeks. OK, maybe we can drop down to once a week and then maybe eventually it only needs a good clean once a month.

Over cleaning can be just as dangerous as under cleaning, so you kind of have to monitor that at first. But a lot of this can be done in the nurse clinic, saving the vet time and saving the owner time because obviously we don't charge as much for nurse clinics as we do for veterinary clinics. If it doesn't just need a good clean, then we have to think, is it allergy or infection, or is there an endocrine element?

And when should we do cytology and when not. There is a school of thought that we should be doing cytology on every year. That would be wonderful in the best of all possible worlds, but unfortunately, we don't live there.

So in some cases, I have worked with a client where it's, I either charge for the cytology and they can't afford the treatment or We have to Guess, a very educated guess, and give the treatment. This is not ideal, but again, we have to do what is in the best interests of that animal in that individual case. However, there are a lot of indicators that can point us towards what kind of treatment to give.

Even without psychology. The first thing you do wanna do is teach the client to clean the ears properly, and what we usually do is have them go to a nurse clinic. The nurse demonstrates on one ear.

And then the owner has to go on the 2nd ear, really useful. The dogs have two ears and cats. Sometimes with cats, they won't let you get around to the 2nd ear, but at least have a very good demonstration.

I think the first problem that we have with ear cleaner is people will put a few drops in and that's just not effective. You need to flood the ear. There needs to be so much cleaner that it's almost coming out.

So, Often people feel that the cleaner is the same as the your medication and you're only putting in 2 or 3 drops or just a squirt. It really needs to be emphasised that this is your, your flush. It's your washout.

I, I'd say like you're jet cleaning your car, that's what you're looking at. Now, in the first picture here, I have the nozzle in the ear canal that's wrong. That was my own dog and I apologise to him and give him a treat afterwards.

But that's to demonstrate that a lot of people do tend to stick the nozzle in the ear canal and that is painful and it's also, if you've got one type of infection. On one ear and a slightly different infection on the other ear than you're, you're causing cross infection. So you shouldn't be doing that.

You should be dribbling the cleaner in along the into the canal. Obviously, massage underneath. I explained to people, it's like a U bend.

You've got to get around the corner. That's where a lot of the junk is sitting. Let's break it up.

Most dogs really like the massage, and, and the owner really laughs and He goes, Oh, look, he's really enjoying that. So that's a good thing to demonstrate to them. And then emphasising to wipe out with cotton wool, not with cotton buds.

A lot of owners are still using cotton buds, and we have seen, video images of that actually, damaging the ear canal. They're, it's, they're just a little bit too harsh. So cotton wool, and also they can't stick down too far if they're using cotton wool.

Cleaning will emphasise to them, they often don't realise how dirty the air is so that you can show them. I know it sounds a bit disgusting, but I do show them the we go, look, look, look how much wax is coming out, and that really emphasise them to them the need that you do need to clean, and you need to put a little time and effort into it. And obviously doing this very gently and carefully so the animal doesn't come, become ear shy.

If they're not on a special diet, definitely give your treats, lots of praise, encouragement, try to make it as pleasant an experience as possible. Again, this is only possible if the ear is not too painful. If the ear is so painful, you can't get near the dog.

You're not cleaning it. You're giving it something to alleviate the pain and waiting a few days until the inflammation goes down and then approaching the ear. In some cases, you might, if the ear is that bad, you might need to actually give a general anaesthetic and flush out the ear.

Again, that's really expensive for the owner, but it's saving money in the long run because if an ear is so bad that you can't even get near the dog, you're not gonna get it clean enough just Manually, you need to get in there and really, really flesh it out. And get to the debris down at the bottom of the air because your medication is not going to be effective if there's a lot of debris in the way. And I have seen occasions where drops have been prescribed to animals without any air cleaner and it's Waste of time and money.

It's just not gonna work if there's debris in the way. Examining the estate can give you some idea of what is going on in the ear. So if you're looking at a really red ear and it's itchy, but there's not really any discharge coming out, that would probably indicate that there's an allergic component to this problem.

And that can be confusing cause sometimes an allergic dog will have scratched the ear so much that that caused an infection. But if you get it in the early stage of this and my dog's really scratching its ear and it's, it's just red, you're like, that's like an allergy to me. Allergies don't need antibiotics.

The allergies do not respond to antibiotics. If you're giving antibiotics for secondary infection. So if it's just red, then you're looking at something where you need to alleviate the inflammation.

There are topical Steroids that you can give There is a brand where you can just dribble it in on the pinna and it goes in and it's not absorbed systemically and that is quite good if you're only doing it. You can start out doing it every day and then drop down to twice a week as needed. And if it's used carefully, it shouldn't cause any systemic effects.

So those are things that you can look at. If it's dark brown, it's usually just a waxy buildup. Like I said, with the poodle type ears, you'll sometimes get that.

And I've seen this a lot in Labradors as well. I think a lot because they swim, and it just really needs a good clean. When, whenever my dogs go swimming, I clean their ears right afterwards because that will have a bit of a drying effect.

And going back to cleaning, there are people who think that you can clean the ears with water, so please let them know you do not put water down a dog's ear. You wouldn't clean your own ears with water. Although some people have probably tried, so please let them know that that just makes a really moist, pleasant environment for bacteria and yeast to multiply.

A cleaners are what you need to use for cleaning airs because they have a drying aspect and they have ingredients that will break up wax, that water cannot do that. If you're getting a pal brown discharge, that is probably malaashesia. Ideally, you would do a swab and just look at it in-house.

You don't need to send off. Malaceia is really, really easy to identify in-house. You can just roll your cotton bud on a on a slide.

Dip it in the blue stain and look at it under the microscope. The entire process shouldn't take you more than 5 minutes and you can identify malahesia really easily. I'm not a pathologist and I have had no trouble identifying malaesthesia.

And then you would choose the appropriate treatment that would have an anti-yeast effect. If you've got pale brown to yellow discharge, you can have mixed yeast and ground positive. Obviously, you would clean and treat that.

If the owner can't afford cytology, and I'm, I'm just talking about in-house cytology because again cockey are really easy to identify under the microscope. Go ahead and choose a treatment, but I would start at the lower end of your, your treatment protocol. You don't want to go to the strongest drugs immediately.

You don't want to be using Marbifoxin immediately because then you're gonna cause a res antibiotic resistance and that's not gonna help the dog and it's not gonna help us in our fight against antibiotic resistance. So start with the, the Weaker isn't the appropriate word, but they don't take out your big guns first. Start with something that is a little bit less stringent, and then you can move up if necessary.

If you've got a yellow-green discharge, then you've probably got gramme positive and brown negative mixed and again, you can identify this in-house. I will show you some slides later, but it will be quite clear to you that you've got rama negative bacteria on your slide. This needs a real, real thorough clean.

This is when you might think about doing a general anaesthetic and flushing all the way down to get all the debris out. This is when you might think about sending off a culture and sensitivity if that's within the owner's remit. If they cannot afford culture and sensitivity, you can still treat this ear.

If it's pale green with a mucopurulent discharge, then that is probably pseudomonas. And, and that's when you've really got to do everything because it's not gonna go away unless you're doing a really, really thorough flush, possibly cultural and sensitivity, cytology, and house and your treatment, and you're gonna need to follow up on this case. And if you are not Really fighting this one with a lot of effort, it's not gonna go away and you're looking at ear surgery, which is prohibitively expensive for many of our clients.

So this is when you, you've really, really got to put a lot of effort in and you've got to get the owners on board to put a lot of effort in. And also this is a case where It might be so painful at first that you can't touch the ear and you might not need to have a few days of Praddicinolone just to get the inflammation down so you can actually exam examine the ear. You will find with Pseudomonas, if you've got an experienced receptionist, they'll tell you.

That they, you've got a pseudomonas ear case in reception because it's such a strong smell. So if you're really worried about finances and you don't feel that you can push to culture and sensitivity, you will, you will know your pseudomonas cases. They will have that.

Horrible smell, a horrible mucopurulent discharge. So you can proceed, before your culture and sensitivity results or proceed without them. Again, that is not gold standard.

I don't recommend it, but sometimes we have to do what we have to do. This is, ears go bad. You can see the exam on, the example on the left, the canal is so narrow.

There's no way you can get no scope down there. You can't see what's going on. You don't know if there's an eardrum left.

You would have to give steroids to examine that ear, to open it up to even get the treatment's not going down there. It won't, it just won't, where will it go? It'll just spill out the air.

Why give medication that's not gonna be effective. So that one you would, you would have to treat it with steroids first. This is the same dog on the other side, obviously, it's had surgery.

So looking at, look at the big picture, think about Why is this ear so bad? What can I do to find out why this animal is suffering so much? If it's gotten to this case, you know, there's an underlying reason.

It isn't just, you know, the animal got something in the air, got a little bit itchy. You can see looking at this dog, it's got severe alopecia. It's got a very, very bad case of uncontrolled atopic disease.

So look at your big picture. Is there an underlying allergic cause, be it sorry, environmental or food, because food allergies can affect the ears in both dogs and cats, or is there an endocrine cause? I've seen a lot of older dogs come, start to have ear infections and keep coming back and keep coming back, and the owner is getting really frustrated and no one saw.

To do a T4 TSH to see if it's hyperthyroid, because if it's hyperthyroid, it's gonna be very prone to ear infections. Cushing's can also affect the ears. So you need to take that into consideration.

If the animal is middle-aged, could there be an endocrine cause? Maybe I'll need to explore that as well. Yes, that's an additional cost to the client, but In the long run, is it gonna end up saving them money?

Yes, because if they keep coming back with ear infections over a period of time, it's gonna end up costing them a lot of money. So looking at the underlying problem of a lot of our skin cases is allergic skin disease. This is an example here of a ventum with epidermal colorettes, and you can see how red and angry it is.

That is an animal that is very uncomfortable and it is in a suffering state. It does need to be treated. So, this is another example, a very bad case of atopic dermatitis.

This is chronic skin changes. This animal has been scratching, chewing, licking, rubbing for a very, very long time. Its skin is now like tenified.

It is, this is what we call armadillo skin. It's never gonna go back to normal when it gets this bad, but we can at least alleviate the suffering. And it is, it is a case of animal welfare.

Think about being itchy all the time, night and day, just constantly wanting to scratch. It would drive you crazy, and it would definitely affect the behaviour. You do hear of skin cases becoming Aggressive, but that's not really the appropriate word.

I would just say very irritable from being uncomfortable all the time, never getting any proper rest cause you're constantly scratching, chewing, licking, and this is a real, real case of severe animal welfare distress. The thing that needs to be clear to the owner is there is no cure for allergy. This is a disease that is managed.

That needs to be explained from the get-go because people want a cure and they're gonna get very angry if there is no cure. So you need to explain. It's like asthma.

It doesn't go away. There is no magic pill. I can't surgically excise it.

This is your animal's life. You're gonna manage it. I'm gonna help you manage it.

It's gonna take a little bit of effort. I do think these people need some reassurance. I think they need some support.

Again, this is where the nurse can step in and say, you know, do follow-up phone calls, follow-up checkups, things like that. People will give up. They will let things slide.

Things will happen in their family. You need to be there to say, OK, let's get back on the bandwagon. Let's get back with the, the band.

The treatments don't give up because the animals suffer, and in some cases, people do euthanize for atopic skin disease because it is a lot of hard work. And I think without the support from the practise, it is more likely that people will give up and they will let a dog get in into this condition, which is inexcusable. It's, it's just not OK.

The other thing that needs to be made clear to the owner is that this is a diagnosis by exclusion. We cannot take a blood test and say, yup, your dog's got atopic skin disease. And I think there are still some vets that are doing this thinking that they can take a blood test for a serology test and say, yup, it's got allergies, that's a problem.

That is not how we diagnose atopic skin disease, and that will not get to the bottom of the problem and, and solve the animal's suffering state. It is a diagnostic workup and I'm afraid the food trial, the dreaded food trial is part of the diagnostic workup. And we also need to address the secondary infection.

In the case of this dog, you can all imagine that it's got a really bad malashesia, infection in all those folds in there. So just doing some tape strips, I could find loads and loads of yeast. There were cockey as well, and all of that needs to be treated cause it's, we need to treat the itch, we need to treat the secondary infection, and that's a vicious cycle because If they're scratching, they create a secondary infection.

The secondary infection makes them more itchy, they scratch some more, so we can't leave that out of the equation. That does need to be addressed. So one of the criteria, the one of the ways of Of deciding that you're going down the allergy workup is looking at Favreau's criteria.

So onset at less than 3 years of age. You're gonna have to sit down and ask the owner some questions, or you're gonna have to give them a questionnaire that they go home and bring back, or your nurse is gonna have to sit down and ask them some questions. So, did it start early on?

Some people don't know. It's a rescue animal. Some people can't remember, but You can, it's an important question to ask, and if you go back into the animal's history, usually you can find some evidence that, yeah, it was itchy or there was a hot spot or it got an ear infection, something like that.

The pet lives mostly indoors, that's generally considered about 80% indoors. If it's a kennel dog that lives outside in the concrete. It's less likely to suffer from some of our allergens, but it could still get environmental allergens from pollens, but it usually doesn't fit into our criteria.

The itch before the rash. So the animal didn't have any lesions until it started scratching. That's what you need to look for.

Responsive to steroids. So probably somewhere if you're not getting this animal from day one, probably somewhere it had steroids and it got better. And the owner probably wants those again, so you're gonna have to work on that issue.

Or even I'm gonna give this animal steroids and see for a week and see, have it come back and the owner's gonna tell me how it did. The front feet and the ear pinna, so the inside of the ear would be affected. So you, you'll get chewing on the front feet and you'll see saliva staining.

I think the classic example is the Westie with the red feet, but you would see it on a lot of, on any atopic dog it's gonna be a front foot chewer, and the inside of the ear is gonna be red. Not the pinna, that's the ear pinna margins is when we're looking for sarcotes. And the dorsal lumbar area is not affected.

Dorsal lumbar area is flea allergic to dermatitis. If you remember the slide back where I showed you the dog that had really bad FAD, that was the dorsal lumbar area, and then you're looking at a, a different issue. Recurrent secondary infection is not part of the criteria, but you will see it in the history or the owner will expect, yeah, it does keep getting ear infections or it does keep getting these little pustules on its ventrum, that sort of thing.

Your allergy workup usually, well, it needs to start out with a questionnaire either on the first visit or before the first visit. There's just so much information that you need. When in, when I'm working on a referral, the first appointment can be 60 to 90 minutes just going over the information from the questionnaire.

You can't do that in general practise. So the owner needs to take this home and do it, maybe email it back to you. Or post it back if they want to do that, and you can go over that, or you can have the nurse go over that and put the information into the animal's file.

But it actually has to be done. I've listed here some places you can get, you can just download the questionnaires. You don't have to make them up yourself.

Nextimmune has a, a very decent dermatology questionnaire and the VNDG, the Veterinary nursing dermatology Group, as an Excellent questionnaire that people can fill out. You will need to talk to them about it a little bit afterwards. You need to set time aside to do that or set time aside in a nurse clinic to do that so that if people didn't understand all of the questions.

A vast score is really important. So that's your visual analogue score explaining, you know, 0 is not itchy, 10 is the dog's chew its front feet off sort of thing. That's really, really important.

And going along down the line, getting people really used to doing a vascore and maybe even doing a daily itch diary really helps you tailor their treatment so that you're not overtreating. Because that is not necessary, it's wasteful and it's not really good for the animal. And a little map of the dog where they can, you know, circle the places where there are lesions like, you know, the feet, the ventrum, the ears, that sort of thing.

So vast scarring is a really, really important part of your, of your assessment. So 0 is the normal animal with just occasionally itch, just like we will occasionally itch. So it's within normal limits.

2 is it's itchy, . A little bit more than normal. And you do need to explain to people that chewing and licking and is part of the whole itchy process cause some people say, oh, he never scratches, but then you find out the dog chews all the time.

Well, that is being itchy. So for itching and scratching a lot, but we'll you know, it won't stop, it's walk, it won't stop playing or eating to scratch. The one at night, I think this is the one that we get all the time is people going, it's chewing its feet all night long and it's driving me crazy.

I can't listen to the sound. I think a lot of people, that's when they decide, OK, there's a skin problem because this dog is keeping me awake. .

8 is, is quite severe. We'll stop doing everything to exercise, you know, exercise, eating, scratching, etc. I did have a 10.

I had a cat come in that as soon as we took the buster collar off, it started attacking itself. It started ripping its fur out. This cat was so, so ridic.

It was, it was horrific to watch. And so vast scores of 10 do exist and those animals are really suffering. This picture here is a cat scratching itself on a cactus, so it must have been somewhat pruritic.

Diagnostics that you're gonna do in your workup, your tape strip, I've talked about that, that's really easy. You're just getting some sellotape and putting it around lesions, on lesions, areas where you've noticed the animal licking, so quite often we're doing it between the pads on the feet, perianal region, axilla, ventrum, . The ear, I'm usually doing the ears swab there, so you just obviously don't put your cotton bud down too far, but a little bit there, just roll it on a slide.

Again, really use quick, just quick stains, and you can look at it under the microscope. You can do it during your consult, but again, you've got limited time. So quite often people will save their slides, look at them later, then make up the treatment and have the owner come and collect it, or you can ask the nurse to, to examine these slides.

I, I generally do the staining and look at the slides for the vets that I work with, and then I write up my my results. You have to have a, a, The communication about how you want the the results recorded in terms of I usually write how many yeast identified for high power field using the times 100. On the, on the microscope and then we're all on the same page so we know what heavy infestation is versus a mild.

Using the wood lamp is also part of your, diagnostic workup. We, it's not gonna identify every type of dermatophytosis, but it's useful for Plucking hairs that tend to fluoresce, you can look at it under a microscope and see does that hair itself have hyphae or do I wanna send these off to a laboratory or do in-house dermatified testing with the plates. It It's especially useful, I think, with cats because dermatophytosis can have any kind of appearance on a cat.

It, it, it doesn't always have those lovely nice little rings. And certainly I've found with little terriers that like to go and play with hedgehogs, and stick their nose where it doesn't belong, you can get incidences of dermatophytosis on the face, and that can be very much confused with allergic reactions. So things that you're gonna find under the microscope, so on the left hand side, you've got your malashesia.

Some people say they look like snowmen, some people say they look like footprints, but they are quite distinctive. They, they stay in a really dark purple. This I would consider a very heavy infestation.

One or two high-powered field is not anything to worry about, but you've got that, that many malahesia, you've got a, a real good yeast infection going there and that would definitely need some treatment. The middle slide, you've got some neutrophils there and some cocci. I believe that was from an ear, and, the slide on the other side, that is a pseudomonas case, so you've got your gramme negative, your rods there, and that would need very Very strong treatment there.

So, you're gonna treat your secondary infection. You can't ignore it. It's all part of your workup.

You're not gonna get a clear picture of what's going on in terms of your allergy unless you're, you, you're treating your secondary infection. I'm not promoting any of these brands. I'm just showing you there's a lot of different treatments out there to choose from.

People working in corporates are obviously pointed towards using one product or another, but try to choose the product that's appropriate for the animal. Be aware that. Some skin cases have very dry skin.

Some need more moisturising. Some of these shampoos are very effective, but they might be too drying for this particular animal's coat, and I know it, it's gets really, really confusing trying to choose which, which shampoo to use, but think about, If, if it's an active infection, if you have found coucci or malacesia, then you're gonna need to use something that has chlorhexidine in it. There are price ranges on these.

Some of these products are available over the counter and certainly with clients on a limited budget, I will show them a picture or I would ask them to take a picture of the product and say this is what you want. Get it online cause it's gonna be cheaper from the veterinary than ordering it from the veterinary practise. I know that's not good for our revenue, but if you need the animal treated and the animal suffering and the owner can't afford to buy the product from veterinary practise, there are online pharmacies that are a lot less expensive, and some of these products are available on, .

Amazon, I hate to say it, but, or in pet stores, and if that's what the owner can afford, then, then that's what you need to do for the welfare of the animal. Make sure that the owner knows how to bathe properly, that they're not getting the ears wet, that they're not getting shampoo in the eyes. The coat has to be completely rinsed.

Then building up a ladder, make sure they understand the contact time. Some of these shampoos have contact times of 5 to 10 minutes. They're not going to be fully effective, and they're expensive shampoos, so you want them to be fully effective.

So make sure they know about the contact time. I always give a handout with bathing, and there's also a YouTube video of Ralph Mueller teaching people how to bath their dog, which is really worthwhile. I'm sure there's a lot of you.

To videos on how to, to bathe the dog and, you know, people are into the internet. So say, go ahead and look at that first. This isn't one we can really demonstrate like air cleaning, but make sure they do know how to do the bathing properly because this is an important part of the treatment protocol.

If you leave this out with allergic dogs, a lot of them aren't gonna get better and if it's not being done properly, it's gonna really, the owner's gonna feel like it's not working. And it isn't working unless it's done properly. So, so educate them.

And again, this is something where maybe a nurse needs to sit down with them and explain how to bath a dog. That sounds a bit condescending, but A lot of people do need that assistance. Some people choose to send their dog to a groomer.

That's your choice, and, that's certainly a good choice, but a lot of people can't afford to do that. Bathing is gonna remove the allergens from the coat, so it is the ideal method. However, we need to be aware that some people are quite limited physically, and bathing might be very difficult for them.

In that case, you might just say bathe once a week or bathe when it goes to the groomer, and then And use the other products like the wipes or the foams, or maybe just bathe the affected areas, like that maybe it's just the feet, and they can get a bar with bathing the feet twice a week, and that makes a really big difference. Certainly with a big dog, if you can say bathe the affected areas, that's gonna save them a lot of money, because a big dog can go through the shampoo really, really quickly. And it might just need the ventrum in the feet.

So, fine, just do that. The trial. I need to say right at the beginning, serology testing for food trials for food allergy doesn't work.

There have been numerous studies proving that it doesn't work, so neither the blood nor the saliva tests will work on identifying foods that a dog or a cat will be allergic to. The studies they've done that have shown that Healthy dogs will show as many positive reactions as affected dogs. And that 60 to 100% of non-allergic dogs will still test positive for food allergy.

So it's a pointless test. You're wasting the client's money and there's certainly a lot of research to back that up. Unfortunately, if you're working up the allergy component of food, 30% of allergic dogs will have a food component.

To their allergy process. And cats do, I haven't got the statistics on cats, but, so it's believed to be about 5 to 13% of a food component. Those numbers keep changing slightly, but that's On the slide, there are 9 to 50% of allergic dogs, 5 to 13% of allergic cats that's the 2016 study.

So, those numbers are gonna change. As our environment changes basically and what's in our food sources. So with the food trial, you're gonna look at the fact that early onset, feet, face, and ears have been affected.

There may have been a GI component, so that should be in your dermatology questionnaire. How many stools a day have you noted? Are any of them loose, are any of them mucousy?

Any incidence of diarrhoea go through the animal's history, look for that. The most common allergens in dogs are beef, dairy, chicken, and wheat is the last one. The wheat is least likely to cause an allergen in dogs.

So putting a dog on a grain-free diet is not really gonna help its skin. It needs to go on a food trial to find out what it is actually allergic to. Cats, one of the allergens is fish, which is obviously in an enormous amount of cat food.

So again, you're gonna have to look at an an allergenic diet. Ideally, the food trial should last 8 to 12 weeks. It needs to be a hydrolyzed diet.

People will try homemade diets really difficult to get those balanced, and with a large breed dog, we have proven that a homemade diet ends up being more expensive than actually buying the food. So it is easier to go ahead and get the an allergenic. Again, you can give the option of helping the owner financially by saying acquire the food online.

Make sure that they have a picture of the food, so they're choosing the right one cause there's an awful lot out there. I will say that we recommend this particular one, the Royal Canon and allergenic, because it seems to be the safest option in terms of not having any reactions. The owner has to record any cheating and any reaction that occurs, you know, if the dog got in the bin or the cat got out and Ate a mouse or something that has to be recorded and you know, say did, was there any itching or chewing in the next 24 hours.

It can reactions can take up to 2 weeks though, so that should be noted. Some diets are not licenced for dogs less than a year old, so please be aware of that and choose the appropriate diet as needed. Again, these food allergies can manifest in very young dogs, so we might be doing a food trial when they're quite young.

Once you're at the end of your trial, then you challenge with the original diet to see if there's reaction. And this is when people need to be recording reactions. We used to say challenge with each individual thing like challenge it with each protein, challenge it with chicken, challenge it with beef, challenge it with fish.

You can go down that route, but probably the, the quicker way of challenging is put it on the back on the original diet and see if there's a reaction. And make sure that is all recorded in the owner's food diary. And then I would certainly recommend that the, the animal goes on a skin support diet for maintenance.

If it's got a skin problem, it's gonna be better off on the skin support diet. These diets have fixed formulas, they're not gonna keep changing the proteins, and they will be supplemented with essential fatty acids which have been proven to assist with skin disease. The link on the bottom there, is From Leave it's a factor, but it gives you information on how to diet trial dogs.

Most people need it explained to them quite carefully and they need it in writing as well because it is a little bit complicated. A lot of people don't understand that, . You can't give treats, you can't give dental cleaners.

You have to look at flavoured toothpastes, flavoured flew worm treatments. You might need to change those. So it is a really, really strict diet.

There are options. There has been a study where dogs have been placed on a food trial for 2 weeks while it's on Praddicololone. The Praddicolone has been tapered off.

The dog has continued on the trial for an additional 2 weeks. And if it got really itchy after the Pradicolone stopped, but while the animal was still on the Food trial, then it was assumed that it wasn't food allergic. That isn't gonna catch all of your food allergic cases.

It will only catch about 80% of them, but it can bring your trial down a little bit shorter in lengths to maybe 4 to 6 weeks if there's a real issue with finances in terms of affording this food. Treating the itch. So prodicolone owners need to be aware of the side effects.

If this is the only treatment they can afford, fine, it's better than letting the animal suffer, but please make sure it's informed consent. They need to understand that it's gonna cause thinning of Skin and atrophy of the muscles over a long period of time, as well as PUPD, it can lead to endocrine imbalances. So over a period of time, it is gonna have effects.

Do be aware of prescribing it to animals with heart disease because the heart is a muscle, and, proddicinone will affect that. And we have also seen behaviour changes with proddicinolone. We had a case of a dog that became a little bit more aggressive on it.

That's not desirable. So the owners need to be informed of the side effects if this is the choice they're making, not to make them feel guilty, but just So they know that it's a choice that they have to make. Cyclosporin, 8 weeks for it actually to kick in and it is an expensive treatment.

It's, what is licenced for treatment in cats, so it is something we do need to look at.lcinib, which I've probably mispronounced, kicks in really quickly. It's fastest acting.

It is more affordable than the cyclosporins. It can be tailored, so they might need it. Every day during peak pollen season, and then you can tailor down to maybe every 3rd day during the winter.

So this is something that you can work with the owner on, helping them to individualise their plan. If they're doing a, a vast score, you can individualise the plan and help the owner work out what is gonna be the best treatment protocol for their pet. And Lokimab is the monthly injection.

It's Really rapid onset. It's, it works very well because you can ensure owner compliance because the animals coming into you each month and so you know that it's getting the treatment a little bit more difficult to tailor for the individual patient because you can't. Be that specific in terms of days, but maybe it might not need the injections during the winter depending on other things that you're doing to control the allergens like really good fleet control, treating secondary infections, etc.

Etc. And, here is I'm showing you, this is the cat that I was telling you about that was, you can see it's ripping its hair out. It was in so much pain and it was really, really, really suffering.

And the second you took the, buster collar off, it started doing that. And that particular had to be controlled with proddicolone. It, it had to have it regardless of the side effects.

It, it couldn't go on living like that. Immunotherapy? I'm just saying serology is not a diagnostic test.

I'm repeating that because quite often it is used as a diagnostic test. It is. AdiP can only be diagnosed by exclusion.

You have to do the diagnostics. Yes, that takes time, but use your nurses. Serology is useful if you're gonna use avoidance as a one of your treatments.

So, If you, if it's got a dust mite allergy, the dog's not gonna be let upstairs where there's carpeting and bedding, etc. And it's gonna stay downstairs where there isn't that much in terms of soft furnishings and carpets and stuff like that. Or I'm not gonna walk it in grassy fields if it's allergic to grass pollens, or when I walk it, I'm gonna wipe it down right afterwards and remove the, the pollens, the cutaneous pollens that might have attached.

That sort of thing. If you're doing serology testing, you need to do it during the peak season for environmental allergens, which would be late spring, summer. The antigens won't be present if you do your serology testing in the winter, unless it's only allergic to dust mites.

And quite often they're allergic to a number of things, so it's not fair on the owner's pocketbook if you do your serology testing at the wrong time of year. Control the itch, treat the secondary infections. Then do your serology testing during the peak flare season and you can identify what the allergens are so the owner can avoid them or if you're gonna go down the avenue of immunotherapy.

IDST, so that's intradermal skin testing can be done year round, but that's generally done in referral centres. So there is the cost of referring the animal and having them sent there. They do have to have a big clip patch done, and if it's a show animal, the owner's not gonna let you do that.

. In dermal skin testing has been done with cats, . And has proven to be more accurate than serology with cats. We're still working on cats.

There's a long way we have to go with them. Sorry, kitties. It is believed to be most helpful in younger pets before you're doing chronic skin changes if you're choosing to go down the immunotherapy route, it's, it's a big investment initially because you've got to do the blood tests and order the vaccines, etc.

And That is maybe gonna be a lot more worthwhile if you're Looking down the line, if you're doing for it for younger pets and an animal that is 10 or 11 years old, but that doesn't make it impossible for older animals and be aware that you'll need a special import certificate for your immunotherapy. So, again, these, there's some paperwork that needs to be done. Nurses can do it, receptionist can do it.

It doesn't need to be done by the vet. Immunotherapy can be effective in about 60% of the cases. It does take a while to kick in, so you're gonna have to have other anti-itch treatment in the meantime.

And It is a component that can be looked at. If it's used throughout the animal's life, it probably saves the owner money cause they're not having to spend as much on other forms of anti-itch treatment, and it is possible that you can tailor it to the animal where they might not need to be treated as often, or maybe not be treated during certain seasons. It, it's something that you can work with to, the individual and, and help save the owner some money that way.

Weird stuff. This is really difficult in many cases, people will choose to refer. We're looking at diseases like panaggus, discoid lupus, caratinitization disorders, vitamin deficiencies.

We had this dog come in, it was a receptionist dog with ears like that, and we're like, oh, what do we do now? It, it, it's very confusing these sorts of cases. And what I've said here is use free resources.

There are a lot of dermatology groups online, and the people are so lovely and so helpful. And I have very often put up pictures and went, I don't know what to do. What do you think?

And it's the hive mind. Loads of people have, information that they share, they'll put up studies, they'll put up protocols. People are so helpful.

So please do look for those resources. There's the. That erm community, there's the VNDG website.

These people are lovely and they really will help you and they some of them also do informative webinars that are, are worth looking at. So use your resources online. Get books out, look at pictures.

Most of these sorts of cases, a lot of these cases will require a biopsy, and then you're gonna have the lab helping you as well, ring them up and say, any ideas? What do you think it is? Can you help me?

So these are a couple of weird cases that I had, the one, With, that's a, a muzzle on a dog with the little weird papules. I thought it was lupus. This was my niece's dog, and I was like, oh, your dog's got an autoimmune disease and everything.

We weren't sure. We had to do diagnostics cause we, we didn't know what we're dealing with. It turned out to be a bacterial infection with a very rare type of bacteria that the dog caught from playing with the lizard.

I will say that my niece lives in Southern California, so that's why it was playing with the lizard. There's no way I could have figured that out, so I needed the lab's help with that. The middle one, these are, are really nasty lesions.

I went to the Vanderm community online with these photos. It was suggested it might be vasculitis and to biopsy. Unfortunately, the dog was put to sleep before we proceeded towards that, but these were dorsal lesions.

They weren't caudal dorsal lesions, so we knew it wasn't flea allergy. Regular atopic disease doesn't appear usually on the dorsum, so it, it just didn't fit with a lot of pictures and so we were thinking, you know, maybe it could be vasculitis, and there were other comorbidities, so it, I would go with that diagnosis. And then the lips here, that's panhagus vulgaris and that was diagnosed again by biopsy, quite difficult because they like the intact lesions, the, the blisters before they rupture.

Hm Sorry. If you've got unusual stuff, go back to your questionnaire and look at where is the lesion located. Is it, what kind of disease is it consistent with?

What did the lesion look like when it started? If the owner's taking pictures, that's fantastic. How old is the animal?

So the dog, that looks like it's dead, it's not, it's under anaesthesia, the Westie there, I thought, oh, it's got really bad adipe. It actually had Cushing's. Possibly the Cushing's had been caused by long-term use of predicinone.

We didn't have the history because it was a rescue. But, you know, we could have gone down the wrong channel if we hadn't taken some blood tests, but it was an older animal and we did take some blood tests and, and that kind of pointed us towards taking some thyroid testing and some ACTH stems and we found out that it had Cushing's and that had to be treated. Along with whatever other skin problems besties tend to have.

Ask if it itched before it had lesions. Yeah a drug history. You can get drug reactions in the skin.

Travel history, very important these days with Lashmaniasis and other diseases coming into the country, and any changes in diets, that could have had sudden allergic reactions. The little doggy on the bottom, . It could have been a follicular disease, which we would have diagnosed with biopsy, but we did bloods first and it turned out it was hyperthyroid.

So, in some, you can't do dermatology workup in 15 minutes. It's just not possible. And you're not gonna be doing anybody any favours, least of all the pet.

If you tried to do it that quickly. Please use your nurses. A nurse can take the history, a nurse can take samples, the nurse can examine the samples.

Obviously, the vet must make the ultimate diagnosis. The nurse must teach the owner how to use the products because if they're not used proper properly, they're not gonna be effective. The nurse can order your special import certificate and order your immunotherapy.

The nurse can give your immunotherapy and your cytopoint injections if you're going down that route. And do know when to ask for help. There are online resources, you can contact, colleagues, you know, people are generally willing to, to help you if you ask for it.

Don't just keep throwing different products at the dogs. That's not going to help anybody and it is going to waste a lot of money. So if you're not sure what you're doing, please do ask for help.

Bibliography, obviously the BSABA manual. I like the cytology manual, from Siva. You can download it.

It's really helpful. There's a small annual dermatology manual available from Blackwell, and, yes, my book is still out there. You can get it on Amazon.

It is a little bit out of date in terms of products, but, the diagnostics are still in date. And references to support this talk are all available there. Thank you very much.

I hope that was helpful.