Hello everyone, and thank you for joining us for our four-part series covering the, the role of the vet nurse in, in dermatology. And it gives me great pleasure to introduce Francis Giano, who's very kindly taken the time out to create these talks. I'm really excited about listening to them.
Frances, for those of you who don't know her qualified in 1998 while and while practising at the RSPCA Hospital in North London. She's worked at the Royal Veterinary College in clinical research, as well as outpatient diagnostics for ophthalmology and dermatology. In 2002, Frances received her diploma in dermatology for veterinary nurses, achieving the highest marks overall, I might add, and since then Francis has also published a manual, called Veterinary Dermatology, a Handbook for nurses and technicians.
So, Francis, thank you so much for doing this for us. I'm going to mute my microphone and and hand over to you for the, for the first session. Thank you for that lovely introduction.
So, my first session is gonna be about why be a dermatology nurse. There's loads of reasons, so I'm gonna start right at the beginning. 30% of all cases in general practise are skin problems.
That's a big number of our patients walking in the door that are itchy and uncomfortable, and we really need to pay more attention to them. They're not the exciting cases. It's not the emergency and critical care we're going to rush it around the back and put it on oxygen, but these animals have long term chronic problems that are really, really affecting their quality of life, and nurses can make a huge difference there.
The other reason that we need to look at it as nurses is that vets actually have very limited time to deal with dermatology cases. Most veterinary appointments are 15 minutes in general practise, and that is not even a beginning for dermatology. In referral for dermatology, we're looking at 90 minute appointments cause we have to do really thorough clinical history, medical and dermatological history.
And then we have to take samples, we have to look at them. We have to find underlying causes. These take a really, really long time, and vets in general practise just don't have that kind of time.
I know all of us nurses are very, very busy, and maybe we think we don't have the time, but we can set it up within our nurse clinic, slots and, and really get in there and do some of the detective work. The great thing about dermatology is that nurses can do 90% of it. So you have some real autonomy there where you can work on your own and and be proud of what you've done on your own, .
The history can be done by the nurses, the sampling, examining it under the microscope, we can advise about. Which topical treatments, the over the counter ones, which are tremendous amount of what's available and how to apply treatments. Basically, all the vet needs to do is do the formal diagnosis and prescribe the POMs.
So, I mean, dermatology is your field as a nurse. Another thing to look at is the way that nurses can communicate with clients. We are able to translate into English, into simple language, to maybe relate our own experiences and try to come across as somewhat less intimidating.
A lot of clients are afraid of vets. They see them as authority figures. And I mean, I'll have them come in.
To me and say, well, I was afraid to tell the vet, or I didn't want to bother the vet. And without client compliance, this just forget dermatology can't be done because most of the treatment is done at home. So as a nurse, you're in a prime position to teach the client, to support the client, and work as a team with the client.
So, ideally, it's a nurse that should be driving the dermatology cases. Oops, I'm going in the wrong direction. There we are.
So the other thing that we need to think about with skin is that all skin problems have an underlying cause. So you can't just go, oh yeah, your dog's itchy, here's some red by. Why is it itchy?
What happened? So some of the underlying causes that we can look at are parasites. It's amazing how many simple cases are just fleas.
Even with, although we have these wonderful flea products now. I mean, we didn't used to, when I first started nursing, we had the horrible spray stuff and it Only worked for about a week and the dogs and cats were afraid of it. Now we've got really good, effective, safe products, but a lot of people don't use them on a regular basis or they don't use them properly or they don't use them consistently.
So the underlying cause can be something as simple as parasites. Allergies are a big issue with canines, but also with beelines now we're finding, and you can't just Keep throwing pre at them. You need to find out what's the animal allergic to, how can you treat that?
Is there a way to avoid it, that sort of thing. Another area that we aren't always thinking about is endocrinological problems. Dogs with hyperthyroidism have reduced immune systems and are likely to get skin infections.
And unless we identify the fact that the dog is hypothyroid, then we're gonna just keep treating the same infection over and over. It's not gonna go away and the clients won't be too happy with that. Some cancers can manifest as skin problems.
Infectious diseases can manifest as skin problems, and then we have our autoimmune diseases that are, are rare but they do occur and they can be major causes of skin problems. So, why do I keep going backwards? OK.
The other thing we need to think about is skin workups take time. So, What we need is a full medical history. Again, if there's an endocrinology problem, if there's an infectious skin problem, if there's a parasite problem, all of these would be underlying problems.
Sometimes a dog might be having diarrhoea, and that could be an indicator that it has an adverse food reaction and that can also manifest as a skin problem. So we need to get a very full medical history. Travel history is very important nowadays.
A lot of people do travel with their pets, even post Brexit, and we need to be aware that there are some exotic diseases out there that can manifest to skin problems. I'm thinking particularly of largemaniasis. This is quite a serious disease and you need to know if the dog has travelled from in that country.
Or originated in that country is a rescue maybe from that country, because this is a disease that needs to be addressed. And again, if you have a skin problem that's underlying with an exotic disease, you're not going to solve the problem until you do the diagnosis of the disease. We need to know if there are other in contact animals.
We often find that people are treating their dogs for fleas, but not their cats, and then they wonder why their dog has fleas. Well, obviously they go from the cat to the dog. People don't think about this sometimes.
Are other in contact animals picking up lesions in that case? Oh, well, maybe it's something infectious if it's spreading around, maybe the owner has it. Then you might be thinking about something like dermatophytosis or caliella, or even scabies.
It's a little bit embarrassing to ask the owner if they have lesions. Sometimes they'll show you, which you don't really want to see, but please don't ever give advice to an owner if they need to go and see their doctor. We need to know about the environments.
Where does the dog exercise? Is the cat an indoor or an outdoor cat? What sort of environment indoors?
Is it a big house? Is it a flat? Does the dog go in the car?
Maybe the car is infested with fleas. It could happen. We need their history of parasite control.
Do they do it? Every month or only in the summer, or only when they see fleas, what kind of products do they use? There are still some people using products from supermarkets and pet stores that might not be as effective, and then we need to educate them why that veterinary products are more useful.
And then we have to look at the history of the skin problem. My favourite phrase is with an itch that led to a rash, or a rash that led to an itch. If it started out as just a lesion and then the dog scratched at it and made it much worse, that's gonna indicate, maybe an allergy, whereas if it, if the dog was initially itchy, then that might be a parasite.
And any treatment previously received for skin problem. And again, this being a nurse is gonna be helpful there because you can maybe try to step back and not be too judgmental. So if they want to mention their homoeopathic treatment and stuff like that.
Maybe these have worked. We can't, we can't know because I haven't been in clinical trials, but we need to know anything the person has done, including a lot of people think putting their dog on a grain-free diet will cure skin problems. So we need to know if they've made that choice because it can be all part of our detective work.
And when you're digging in there and getting your full history, this is when you're going to get that information. See if I went in the right direction this time. OK, if you don't take the time, what's gonna happen is the problem is gonna persist.
It's gonna be quite annoying to the owner because they're going to keep coming back over and over and it's going to get really expensive for them. They are going to get very dissatisfied. Quite often they will leave the practise and go somewhere else because they think, well, you guys don't know what you're doing.
But primarily the animal is going to suffer because it's going to have a chronic skin skin tradition, and some of these are progressive, like allergies are progressive. And it will just get worse and worse and worse because you haven't found the underlying cause and I mean, that's why we're here to take care of the animals, so we're not taking the time to find out what's really wrong and solving that problem, we're not addressing animal welfare. Another thing to think about is behavioural problems that can develop due to skin problems.
This is a real big issue now with behaviours are starting to talk a lot about a lot of behaviour problems are actually pain related, and there, or, you know, some sort of chronic skin or arthritis problem can lead to behaviour problems. Particularly I would think about ears, cleaning ears over and over and sore ears can make a dog or cat ear shy. This poor kitty you can see here doesn't have any ears, probably due to skin cancer.
But it can get harder and harder to treat a pet that's had sore ears over and over, and we do underestimate the pain that ear infections cause. If any of you have had children with ear infections and listened to that screaming that goes on all night long, you'll understand ear infections are very, very painful, and we need to address this issue. We need to treat the animal for pain and we need to find the underlying cause.
I'd like to give a few examples of dogs that I've seen that the underlying cause was not looked at. So, we had a dog walk in to a practise that was absolutely beet red, complete alopecia on the legs and undercarriage, so it was bald and it was bright red. It had obviously been suffering with this condition for quite a long time, and it turned out to have demodex.
That can be found in general practise. You can do skin scrapes, you can do plucks. You need to do several cause Demodex can be quite hard to find sometimes.
So you would do a minimum of 5 sites. And then if you're still suspecting Demodex, you can do a biopsy, or you can do a clinical trial of off-license extra treatment of your antiparasitic, like using it every 2 weeks. All of those things could help you solve it.
All of that can be done in general practise. You don't need to wait till the dog is half bald and then send it to referral. I did get quite in quite a lot of trouble in, in that case cause the dog walked in and I went, Oh, what a bad dermodex case.
And the client turned to the referral vet and said, How did this nurse diagnose it just by looking at my dog when this dog's been under care of a general practise vet for a year and it wasn't diagnosed. I was told to keep my mouth shut after that. Anyway, Yeah, you need to, you need to do your homework.
Another reason that we need, another example is Pred. A lot of people say itchy dogs and they go, oh, it's scratching. Pred is great for itchiness.
Pred is really good for itchiness. It is a drug that has got some bad rap, but it really does help in a lot of skin cases. If you lose those low dose, doses and give it every other day, it can be really, really helpful.
However, you need to make sure that you're giving it to a dog that is suffering from pruritus and not a dog that's suffering from parasites. Because if you give pred to a dog or a cat that has mites, that will lower the immunity even more, and the mites would just go bananas, they'll have a party. They'll have a rave and the dog will get or the cat will get worse and worse and worse.
So you need to do your lab tests before you prescribe your drugs. Another one I saw was a little bit of Border terrier that had been given an antibiotics for skin problem for 6 months, and it wasn't getting any better. The owners were really unhappy and had come to our practise.
We did a tape strip and identified a yeast infection. The dog did not have a bacterial infection. It had a yeast infection.
So obviously, antibiotics weren't doing any good whatsoever. So we solved the problem in about 10 minutes instead of 6 months, and it was just a simple tape test and you need to do that with skin. You can't look at skin and diagnose it.
You need to look under the microscope. Let's see, what else did we have? Oh, I had a dog that come that went to the vet college.
It had fleas. It went to a referral dermatology service because it had fleas. Probably no one had sat down with the owner and said, look, Your dog has fleas, you need to treat it for fleas every single month.
You need to treat all the incontact animals, including the cats. You need need to treat your house with a premise spray. It needs to be enough of a premise spray to cover your whole to treat the whole house, and if your dog goes on car trips, you need to treat the car.
And you need to accept the fact that it's gonna be about 3 months before the flea cycle is broken. A nurse can do that. A nurse can have a 15 minute appointment, explain the whole treatment protocol, and what to expect and sort that out.
There's no reason to send a dog for a dermatology referral with fleas. That's kind of crazy in my opinion. One more that I want to mention it's, it's quite upsetting actually was a dog that had an ear infection and the vet was treating it for pain quite nicely, and just cleaning, but hadn't done any ear cytology, and didn't feel any ear cytology needed to be done.
In this case, it did. Sometimes you can solve the problem just with cleaning, but it's always worth doing some cytology to make sure. Especially if there might be a gramme negative infection going on, then you would need to do culture and sensitivity and make sure you were treating with the correct antibacterial.
But in this case, the dog was just treated for pain. And with a little bit of air cleaning, the ear infection got so bad by the time it came to us, the dog was banging its head against the kennel wall, and blood was spurting out. We had nurses just sitting there crying watching this dog.
It was in so much agony. It was horrific. And at that point, the only thing we could do was put the dog to sleep.
Because someone couldn't be asked to do cytology at the beginning of the treatment. Another thing to think about with ears is if you can get to the bottom of the problem quickly, you can save the ear. If it goes on and on and on, you're gonna end up having to do surgical intervention like a tikka, and the dog will very likely lose its hearing.
So it's really, really worthwhile to, to do your groundwork at the very beginning. OK, I'm gonna move on because that was kind of depressing. All of this takes an awful lot of time, and you find that vets really don't have this time, as I said before, they've only got the 15 minute appointments.
You can set, if you've got a nurse clinic slot, you can set an hour aside, and you can sit down, do your full medical, do your dermatological history, have a chat with the owner, take some samples, look at them in the lab, and set up a treatment programme that works for. That client, you do need to be very aware that some clients are not going to be able to bathe animals. Some clients might need help with air cleaning, that sort of thing.
So you have to work with the individual dog and cat and the individual owner. There are animals that are refractory to treatment. Then maybe we need to do something slightly different, like give them a GA, do a really, really thorough ear clean, and then give one of the long acting ear treatments.
So you have the time, if you've got an hour slot and you can work with the patient and the owner to individualise their programme. You can also set up follow-up meetings. I've got a slide here of a progress report that I used to do.
With just making sure everything's ticking along, keeping the owner motivated, keeping them going. If it's a chronic condition, owners are gonna need a lot of encouragement to keep going. They get overwhelmed.
They feel like, oh, this is never gonna end. It isn't ever gonna end if it's an allergy, and you have to learn to live with it, and you have to learn how to cope with it on a daily basis. And A lot of people need support to do that.
You, you don't want them to give up on their pet. I was doing a retrospective study at one point and ringing up people with atopic dogs, and it was horrific how many had been euthanized, and I think it was just people couldn't cope. And it it just they felt like things weren't getting better, and most atopic dogs and cats are treatable, but people do need help.
It isn't easy. You need to charge for these clinics if you can spend an hour with a person, you're certainly not doing it for free. You are a qualified registered nurse.
You need to charge £50 for an hour clinic. I don't see anything problem with that. Depends on where you live and the demographics of the area.
Certainly in certain areas you can charge more and others you might charge a little bit less, but you're also going to charge for your sampling. Any products you need to sell, follow up appointments, any special foods, so this can be a way of not only really helping animals, really supporting clients, tying them to your practise, that's always good, and also bringing some money to the, to the practise. I mean, most people aren't gonna support starting up dermatology clinics unless you can do some kind of proof that it's gonna bring in revenue.
Right. As a student nurse, you have already learned all these sampling techniques. I'm sure you had ran around trying to get them and going, Please, please call me when there's a dermatology case.
I need to do my skin scrapes for my CSL or my progress report or whatever. So you have learned how to do these. You may not have done them in a while, and you need to refresh a bit, but they're not hard.
You can do it. Coat brushing, anybody can do that. That's my dog.
She looks really miserable, doesn't she? I'm sorry. She likes to pull a face.
This was not hurting her. Skin scrapes, a little bit more complicated, but they can be done. They're not difficult.
You know how to do it, just keep asking vets to practise. You can actually do them with the client in your clinics. The animal may be a lot more amenable to that with their own owner holding them.
It depends on the patient. Some patients are better away from their mom and dad. Some patients are worse, so you can find out.
And also, now that you're qualified, you can go and grab your student nurses and go, look, I've got a skin case for you, and they will love you for that. Client compliance, I mentioned this before, and I'm gonna keep mentioning it. You've got to get the client on board because so much of skincare is done at home.
You as a nurse, you're gonna be a whole lot less intimidating to the client. If you spend an hour with them, you're gonna end up being best friends with this client. I mean, I see people in town that stop and have chats with me and ask about my kids and everything.
In fact, I think I need to move because I know too many clients in my area now. But simple things like applying the spot on, you'd be surprised how many people can't do that. They don't know how to separate the hair and get down to the skin, so show them how to do it.
Maybe the animal needs to come in once a month and have it done for them. Maybe you have a district nursing, programme set up in your practise, and you can go out, to the little old lady's house and put their flea treatment on. Months, district nursing really, really lends itself to dermatology care.
So if your practise hasn't thought about that, really do think about it. Mobile nurse clinics are fantastic for, assisting with client compliance and for caring for any chronic cases. Really, really think about getting those going.
Another thing that can be really useful in your appointment or in your district nurse appointment is you show the client and then they show it back to you. So especially with ears, what I'll do is I'll clean one ear. I usually try to do the really bad ear, and then I have them show me how to clean the other ear.
Clients do not know how to clean ears. In fact, there's a lot of vets that don't know how to clean ears, and they might put in a few drops of the cleaner and think that's it. You got to flood that ear.
There's got to be air cleaner going everywhere. And then you have to massage for a really, really long time, remembering that the ear canal is a. YouTube and you want to get all the way around that YouTube and break up the wax.
So you need to show people how to do this. You're not gonna just know without. And you also need to send them home with some printed instructions, because a lot of people forget or they're nervous and, and they're not listening very well, or they hand the job over to someone else to make sure that you've always, always got written instruction for basic things like baths and, cleaning ears.
Follow up and encouragement, skin conditions are chronic, and the constant treatment can get really tedious and overwhelming to owners, especially something like bathing. Bathing is hard. Especially if you've got a bigger dog.
If you're doing it twice a week, that's a really big job. So again, let's personalise it. Is the main problem the feet?
Well, maybe the dog just needs to have its feet bathed twice a week, and you don't need to do the whole body. But if you do need to do the whole body, make sure your client knows how to do a proper bath. This one isn't proper because there's not a towel in there.
There should be a rubber mat or a towel in the base of the bath so the dog doesn't slip and get scared. If you've got contact time with your shampoo, most of the new shampoos are only 3 or 4 minutes, so that's pretty easy. But if you're using one of the other shampoos, 10 minute contact time.
How are you gonna keep that pet in the bath? So I talked with the owner about, well, maybe you want to feed the dog in the bath, maybe you wanna give it treats, maybe you want to practise tricks when they're sitting there with their contact time. Maybe you want to shampoo up the dog and take it for a walk, and bring it back and rinse it off.
I, I used to sit and read to my dog. I, I don't know why, but it seemed to really, he liked it. I think it was just the fact that I sat with him and I was talking to him, but the contact time is something people need help with.
Another one that people really need help with is, food trials. Food trials need to last 8 to 12 weeks. They are the only way of diagnosing a food adverse reaction.
Sorry, there isn't any other way, and it's so, so hard to keep animals on these food trials because they might raid the bin, they might pick something up in the on walks, they might steal the cat food or the other dog's food, . Cats on food trials have to be kept indoors so they don't go shopping around the neighbourhood. So unless you're supporting the client, I can guarantee you you will not stay on a food trial.
I think you need to ring them every 3 or 4 days saying, how is it going? Oh, you had a slip. Yeah, that happens.
It's OK, just get right back on the programme. You know, you're doing the right thing. Think how wonderful it would be if we find out exactly what's going on.
And if it is a food allergy, that's great because then we just never feed the dog chicken or beef or whatever, and you never have to worry about this again, so they need that support. Seasonal flares also, this is a nurse can step in and go, yup, yup, you knew your dog or your cat was gonna get worse in the summer. Happens every summer.
They're allergic to the, you know, the pollens that come out. So, you know, let's up the treatment a little bit. We're not failing here.
We're not regressing. It's just a seasonal flare. We can do it.
We've done it before. So, that's where you're stepping in. Or even ringing the owner, you know, maybe you can have a little system that you set up where certain owners you ring in April and go, yeah, it's coming up to that time of year.
Do you wanna, you know, increase the bass a little bit or do you want to make sure you've got enough wipes and, you know, it's gonna happen, so let's get ready for it, and, and maybe preempt the flare, which would be even better. Job satisfaction, I think dermatology nursing is incredibly satisfying, a lot because you're doing it. I mean, if you're assisting with orthopaedics, great, but you're not actually doing the fracture repair.
You're helping and you won't be doing the physio afterwards, but as a derm nurse, you're pretty much doing everything. And you can look at it and say, hey, I did that. I really improved that dog's life.
I made the owner happy. I made the owner stay at my practise. I earned some money from my practise.
I'm really doing good stuff here. So it is very satisfying. It's also a whole lot more interesting.
You get to use your brain, you get to be a detective. You get to do samples. You get to go in the lab.
And I don't know about your practise, but my practise at the lab is wonderful because it's upstairs and it's away from everything. So things are going crazy, crazy downstairs, and I'm just sitting there with my microscope, being all calm and looking at my samples, and I'm in my own little world and I'm, I'm improving animal welfare, and I'm not caught up in the rat race. So it's great in the lab.
As I said, you can see real improvement in quality of life. This is a picture of my niece's dog, and that's the dog in recovery. It had horrific papules and pusils all over its face with ruptured and they had erosions, and it was one of the most disgusting things I've ever seen, and it was just wonderful to see it get better.
Another thing is owners are gonna be really grateful and bring you chocolate and wine. And all your friends and relatives will ask you for advice. I live in the UK now, and I get loads and loads of email pictures of dogs from the states where I used to live going, look what my dog has, what should I do?
I always say go to the vet, but it's nice to know that people think you know something and that they appreciate your knowledge. So get started now. You don't have to wait for any big turn of events.
You can just start looking at skin and practise. Look at normal versus abnormal. Note, this is red, OK, so that's erythema.
This has a lot of scratches, so that's excoriations. You know, there's some thickening of skin here. This dog's had chronic allergies.
It's got like henified skin. I see blackheads, there's some common downs. So just looking at normal versus abnormal and getting familiar with that.
Get a book. I'm obviously advertising my own book here, but there is another one I've found on Amazon that is a, a technician's manual, so it's geared towards American animal technicians, but I'm sure it's just fine for UK nurses. That book was written more recently, so it's probably a little bit more up to date, but mine has great pictures and.
So get a book, start, get a book aimed at nurses. The ones aimed at vets are gonna get very theoretical and you'll get bogged down. They're interesting, go ahead and get one if you're interested, but start out with one aimed at nurses.
Make sure you get a book with a lot of pictures, so again, you can see normal versus abnormal. Lots of training courses out there. Some of them are free, some of them are online, some of them are in person, just type in nurse, veterinary nursing, dermatology, and you'll see loads of things coming up.
Create a box of supplies that you need to take your samples. You will need to be ready if you're gonna do dermatology clinics and you'll look very unprofessional if you're running around going, oh, I forgot I need some tape or I haven't got enough slides in here. So get yourself a little toolbox and put all your supplies in it.
And then just let the vets know. I'm really interested. Can I help you?
Can I take these samples? I know you've got an ear coming in. Can I just do a quick swab and look at it, under the microscope while you're talking to the owner?
The vets are only gonna be grateful. Eventually they'll want to start charging for the cytology do, but you do. But at the beginning, just do it as an exercise and and see how it goes, and the more you do it, the more you learn, the better you get and the faster you'll get, which is important.
The bottom line about being a dermatology nurse is animals are suffering from skin disease. A lot of animals are suffering from skin disease. Some have been suffering for years.
And you can make a difference. And that's what we want to do, right? We want to take care of animals.
It's a picture of a puppy that had scabies, really treatable condition, very treatable condition. We've got loads of, of online of spot-ons that totally sort this out. We can do math, we can do baths.
You can diagnose it with a skin scrape. This puppy was never diagnosed. The skin condition became so bad, you can see it lost all its fur.
It was covered in infection. It had literally torn itself to pieces because scabies is the most itchy thing could possibly happen. And you can think about it, the mites are eating the dog's skin.
Think about how awful and painful that is. This poor dog had to be put to sleep. It died from a completely treatable condition because no one took the time to do skin scrape.
You can do that, you can save lives.
