Hello, it's Anthony Chadwick from the webinar vet just welcoming you to our evening webinar tonight, and we're very fortunate to have Professor Louis Ferrer from Barcelona University who's gonna be speaking to us today. All about the skin barrier, a key player in canine atopic dermatitis. This webinar is of course free to attend thanks to the kind of sponsorship of protection.

So thank you so much for protection as well. We are very, very fortunate today to have Professor Louis Ferrer on the webinar. Luis is one of the preeminent dermatologists in the world, and I've heard him speak on many occasions, and you're gonna be in for a real treat.

Luis qualified from Zaragoza University, and then he went to Hanover Vet School to do his masters and his PhD. Since 1985, he's been lecturing at the University of Barcelona, apart from a period of five years, 2012 to 2017, where he decided to go across the pond and lecture at Tufts University at the Cummings vet school over there as Professor of dermatology. He's also board certified.

From the European College of Veterinary Dermatology, and he has particular interests around canine atopic dermatitis, but also, Leishmania and of course dermatocosis as well. As I say, you're going to be in for a real treat tonight, so Louis, it's over to you and as we will say, Vamos, you can start. Thank you, thank you.

The Ramos of Rafael Nadal is veryfanos. I, I see. And in fact, Nadal, the tennis player, is from the island of Majoorca like me, so we were born in the same small village in Mallorca, so I know the family.

I'm used to the Bamos, so thank you. Thank you, Anthony, for this great presentation introduction. So, it's true that you probably don't know me.

I work at the veterinary school in Barcelona. This is a, a nice school about 20 kilometres away from downtown Barcelona. And it's in a big campus with other, with all of the schools and medicine, law, engineering, so we are pretty happy there.

It's so that I moved to the US for 56 years, but the, there is, is, is exciting and the, the, the university was also awesome, but the snow every winter was more difficult to To, to be accustomed to that, so I decided to go back to the sunny and blue skies of Barcelona. What I do at the university is pretty boring, is what most university professors do. I teach.

You see here a group of students and as you can imagine, this is Before the pandemics because we, now we teach almost everything online except the clinics. So we do a lot of online teaching, which is very boring and, and the students are not wearing the mask that now we wear the mask. I do also clinical duties.

I see patients on the, at the veterinary teaching hospital 2 or 3 times a week. And so I see basically referral cases of dermatology and here in the image that you can see, I This is a Tufts University in Boston and I'm just doing by otoscopy. And also with the remaining of time, that is not too much as you can imagine, what I do is trying to do some research in dermatology.

Now, for instance, we are working with genomics and genetics as almost everyone in medicine and we are just trying to understand using genetic tools, the pathogenesis of skin infections and we are focused, for instance, now on the pathogenesis of canine pyoderma, and you know that pyoderma in dogs and Has is causing the majority of cases by Staphylococcus in intermedius. And this is interesting, is a very interesting biological model because the, this microorganism is part of the skin microbiota, meaning it's a commensal organism in the skin, but also is the cause of the yoderva. And what makes a commensal microorganism become a pathogen.

It's fascinating and we try to approach this problem using genetic tools. So we started to do a full sequencing of the genome of Staphylococcus in intermedius. The full genome is about 2.7 mega bases to 22 million of bases.

So it's relatively big but not super big. And we started to investigate the genome just to detect genes of bacterial resistance, but now what, as you can see in this image, we, we could detect we are located the different genes causing resistance to different antimicrobials, but now what we are doing. And it's comparing the genome of my staff to intermediates isolated from pyoderma with the normal let's say flora of the skin to see what makes this this commensal organisms to become a pathogen.

So, this is my current area of research and this is my daily life, teaching, clinical duties and research if I have time. But tonight, I have to talk to you about the skin barrier. I was asked to present some of the research that we have done in the past to understand better the skin barrier in dogs.

And to, to talk about this, let me begin with just 11 clinical case, one example that I saw a couple of months ago and, and that I think it helps to understand better this role of the skin barrier. The patient that day was an English setter, 2 years old, female with a diagnosis of atopic dermatitis. I don't know in other teaching hospitals, but in Barcelona, I will say that I see between 30 and 40% of atopics that dogs every day.

So one third of my patients. Are atopic dogs. It's, it's amazing.

It's amazing if you consider that everyone knows atopic dermatitis. I spent hours, days talking to my students about atopic dermatitis. And despite this, I see patients every day with a diagnosis of atopic dermatitis, with frustrated owners or guardians.

So this is something that we could do better managing this, this condition. I think, I was talking to, to Anthony before the, the webinar and it's a problem of communication with the owners because in some cases, I, I realised that they come to the hospital and, and they expect to fix the, that we will be able to fix the condition. Or they complain because they say, well, the dog was doing well when it was on this pill or that pill, but when I stopped this, the, the, the problem came again and they say, you see what a disaster.

I say, well, this, you need to understand. That this is a chronic disease, and I don't think that if you have a diabetic patient and you stop the insulin, you go to the clinic and complain because, well, I stopped the insulin and we are back to square zero. Is doing horrible again.

So I think that there is a problem of communication and probably also a problem of, let's say planningifying organising well the long-term treatment of this condition. Anyway, that day, I had an atopic dog in my console. She was on oral isoxazolines to prevent ectoparasites.

Great, because we need to bathe these dogs frequently, it's better to use an oral treatment for parasites. She was on a limited antigen diet. She had previously a home cooked, very strict diet to rule out food allergy.

So we knew that she was not a food allergic. We knew that she was a pureopic dog, probably some environmental allergens involved. And she was visiting the local vet for the daily management of the condition.

And recently two weeks ago, she was started on, on dermal e drops and also because she was more and more itchy, it was added some prednisone by mouth, so a dose of 20 milligrammes. At the beginning, then was tapered just to stop the itching and the skin inflammation. And then because she was not doing well, even on this treatment was referred to our hospital to recheck and Evaluate if something else was needed.

So when I saw her, the general physical exam was OK, nothing else. And she was pretty pru and we used to evaluate itching in a scale from 0 to 10. And I tell the owner, 0 is my dog is never itching.

10 is my dog is itching nonstop all the time. So she was about 7, according to the guardians. And she presented clear signs of inflammation in the skin.

So the, the ectopic dermatitis was flaring and she presented erythema. She presented a lenification as you see in this image in the typical areas of the atopic dermatitis, you know, atopic dermatitis targets basically the face and then all parts of the body, and we could see this lenification, this Changes in the surface of the skin with the skin marking is very evident and with hyperpigmentation. So we perform a skin surface cytology to check if there was some kind of skin infection, no bacteria, no malaicia overgrowth.

So at that time, no secondary. Infections. So we prescribe ala in it to, let's say, continue with the, the steroids so to be able to stop the steroids and change to a lady that, you know, is safer on the long, mid long term.

We prescribed weekly bathing with a moisturising shampoo, no need to use antimicrobial shampoo because it was not skin infection. And I told the owners, you need to continue with the dermal east drops and you need to continue with the ectoparasitic treatment and that's OK we continue with the same was it, . Good, limited antigen diet was top diet.

So that was my, my prescription that day. That day, I had two students in the, in the, in the consult, and one was a, a very smart lady that I had met before in, in the classroom and she was very interested in in dermatology and in my cases. And when I finished my prescription, she asked me, so why you continue with the derma is and why you don't stop this treatment, the dog is not improving, it's, it's flaring.

And I thought, well, this is a very smart question. So in fact, hm. The answer, the quick answer is that I don't think that we have enough elements to, to assess whether dermalist has worked or not, but I can explain to you better this, .

Giving you more information if, if you want. So, what I, I did is I tried to explain her a little bit what was dermal is and say, well, dermal is basically contains two components in, in Barcelona and Spain, the name is a little bit different, but it's exactly the same product, contains on one side, Biosphere that is a fingolipids of animal origin, no plantted fingolipids of very good precursors of epidermal theramites. And then this sinolipids promote the endogenous eramide production and provides a good support for a healthy skin barrier formation and also for the hydration of the skin and also contains derm.

That is basically hyaluronic acid that supports the proliferation, the migration, and the, the life of dermal fibroblast, helping also to maintain normal skin nitration in, in the, in the dog. So I say this is the composition. What we try to do with dermal is is to repair the skin barrier.

Reducing the penetration of allergens, of microorganisms, of different agents. And also we try to reduce the trans what we call the transepidermal water loss, so keeping the skin hydrated. However, this product, thermalist has to be used in an, an adequate way.

So it has to be part of a good multifactorial treatment plan for atopic dermatitis and must be using a continuously for at least 4 weeks. If we use 2 days of product and, and they say, well, the dog is still itchy, we cannot consider that it's a fail because we are not using the product in the adequate . Manner away.

So I tell that to my student and I say, if we move specifically to our case. The inflammation, as you can see, had not been adequately controlled. We know that if the skin is inflamed, many of the cytokines that are released in the inflamed skin damage the skin barrier.

So it's nonsense that we try to repair this skin barrier if there is active inflammation on the skin. Also, the purus had not been controlled. This dog had a 7 out of 10 pruritus.

Scratching also damages the skin barrier. So, the same, no sense to use very fancy advanced molecular treatments to repair the barrier if the dog is scratching. And also, not enough time elapsed to allow a repair of the PML barrier.

So I explained to her that the medium-term goal of dermal is, is the barrier bio repair and with preparing the barrier, we will be able to reduce the use on the meat and long term of other, of other drugs. So this was my explanation. She was more or less convinced, not 100%, a little bit convinced, and she put the question that was also really smart and say, well, but atopic dermatitis is a hypersensitivity, it's an allergy.

So this dog will continue being allergic. I don't know what you do with this fancy barrier, finger lipids and all this theory. And they say, yeah, it's true, but it's a little bit more complicated.

It's, it's not only an, an allergy, probably, we need to talk more about this because it's not just an allergy, atopic dermatitis. And I tried to explain to her that it's true. When I was at the veterinary school, Antony said in Zaragoza and in the 80s of the last century.

Aid dermatitis was considered a classic example of allergy, hypersensitivity, typhus one, type one. So a classic example of acute IgE mediated allergy against environmental allergies. This was the basic theory, and this theory was accepted and alive till the beginning of this century.

And specifically, I can tell you that one paper that changed the understanding of this condition was this published in, in Europe, in, in, in Denmark, and published in Nature Genetics in 2006. And this group of people detected that children with atopic dermatitis. Skin or only or ectopic dermatitis with asthma.

In many, many cases in the high percentage, presented mutation of one protein called phylacrine. And finally, we knew that was one of the major components of the epidermal barrier, and they show that what happens in these children is that because this epidermal barrier is not normal, it's more permeable or abnormal, they tend to develop more opidermatide and they show this in a very, let's say, elegant manner comparing different populations and also doing a genetic study detecting mutations in phylacrine. So, the, this, let's say seminal or first study opened new research lines and different investigations showed that it was true all over the world, it to people in a high percentage had defects in ylagrain.

And also, inflammation itself decreased phylarene synthesis in the epidermis, and that at the end, these changes in phylarene and other components of the epidermal barrier showed that a central element in the pathogenesis of ectopic dermatitis was an impaired epidermal bar, not only an allergic reaction. So, the thylagri story led to a paradigm shift in itoppiermatitis. We stop consider considering atopic dermatitis as a hypersensitivity reaction to environmental allergens only.

And we move to a new paradigm considering HOpi dermatitis as a multifactorial disease with a central role of the skin barrier. And of course, this big change in human dermatology also was translated to veterinary medicine a little bit later, a few years later. And in dogs and cats, we started to revisit the skin barrier to understand better the atopic dermatitis, and many papers were published between 2009 and now 2020.

I just have copied two of them. On the left you have the first one by Rosanna Marcela in, in Florida, US called unravelling the Skin barrier, a new paradigm for atopic dermatitis and house dust mites. It was a one of the few papers saying, hey, the important part, or at least one important part of atopic dermatitis also in dogs is the skin barrier.

And here on your, on your right, you have another one that is also from Rosanna Marthella but also Terrio Libre, Didier Chalotti, and some others. Showing that there are many evidences, you know, the, the, the, the name of the paper is current evidence of skin barrier dysfunction in human and canine atopid dermatitis. So there are plenty of evidences now that the skin barrier plays a major role in, in HOpi dermati.

So what is this, this skin barrier? What are we talking about when we say epidermal or skin barrier? I tried to explain to my student that the the epidermis, the most external part of the skin begins in a lamina basalle or basement membrane and contains several layers of proliferating and differentiating keratinocytes.

The stratum basalle contains basically the dividing. Keratinosides and when we move up, the cells are more differentiated and and in corneocytes or scales of keratin basically. And this happened in approximately 3 weeks.

Cells moved from the southom basalle to the surface in 2021, 23, 23 days. So we call skin barrier to the barrier that blocks the movement of substances from the from the, let's say dermis, the skin to the exterior external world. And this skin barrier is composed of two different components, what we call the cornify envelope, which is an proteinic structure where phylagrine plays a major role, but also other proteins like evollucrine.

And the second part is the lipidic envelope and both together constitute the skin barrier and we know that the, the main function of this skin barrier is To limit the trans epithelial water loss, so to keep a very well hydrated skin and also, and this is very important in our case, to limit the penetration of antigens, or the molecules, or infectious agents. So this is the, the main role of this. Skin barrier.

So it's form. Separately, The cognified envelope and the lipid envelopes. So the two parts are formed in different moments by different mechanisms that we will be, will be, we'll see in a, in a moment.

And together, they form the skin barrier. A very important part of the skin barrier is the lipidic part, the lipidic envelope, and it's formed in the upper layers of the epidermis at the stratum granulosum and stratum corneum in very interesting structures called laminar bodies of the keratinocytes. In these laminar bodies, we have a mixture of enzymes and different types of phospholipids and ferramides.

They are organised in a very specific manner, creating labella. And when they are really packed and well organised, they are extruded to the external Space of the keratinocytes. And then form the lipid enriched extracellular matrix.

And this is a very important component of the Of the skin barrier. In fact, if, when we look at the epidermis under the electron microscopy, as you can see here on your, on the right part of the slide, we see that the, the corneocytes, this mature keratinocytes are separated with this lammillar, lamillar structures. The other part of the skin barrier, the proteinic part is formed inside the keratinocytes and you see here what we call the corneocyte bound protein envelope.

So these are the two big components of the epidermal barrier, the, the protein, proteinic part which is the protein envelope and outside the extracellular lipiddic envelope. So this is what we call the epidermal or skin barrier. What happens in atopic dermatitis?

Well, there is a change, we have abnormalities in the skin barrier. And these abnormalities can be seen in with, let's say, different approaches with microscopy or with chemical studies and Imply functional changes. If you look at the compositional and structural changes, there is less expression of phylarine in ectopic dermatitis, both in dogs and humans.

There is increased expression of some enzymes that degrade the phylagrine and the inflammation, let's say stimulates the production of these enzymes. There is decreased expression of terramides and other lipids. So we have less lipid component in the skin of atopic dogs and we have more expression of some enzymes that degrade the lipids.

And also we see lower number of laminar bodies and lipid bilayers. The consequence of that, of all these changes is that this skin barrier doesn't function normally. There is more allergen and penetration and there is increased transepidelian epidelial water loss.

These are the consequences of the changes in the protaic or cognify envelope and in the lipidic envelope that we have in atopic dermatite. And this has been even seen before we under understood all these things. For instance, this is a paper published in veterinary pathology in 2001.

By a French group, Thierry Lori and Huh Gatton and other, other people. And they reported that when they took samples of the skin of atopic dogs and compared with the skin with the epidermis of normal dogs, they detected that this beautiful organised lipidic structure that you can see here in number 12, and 3 that is organised between the keratinocytes was completely lost and the disorganised that there, there was a lack of this beautiful lipidic structure between the, the keratinocytes. So there, there was already some elements, but in science to change completely the paradigm, you need a new model that better explains what you see every day.

It's not enough detecting a small piece. You need to put all together and create a new model to replace the old one. And this happened really recently in the last years.

And the, the new model is that atopic dermatitis is a very complex disease and that the mechanism is not only a hypersensitivity, it's not only an immune deregulation. This is part of the disease. Of course, these dogs produce easily IGEs against penetrating allergens.

But there are other abnormalities in this skin. There is a no abnormal skin barrier. So the skin allows the penetration easily of many substances that contact with the skin, pollens, mites, and some microorganisms easily penetrate and can trigger a hypersensitivity reaction.

But also we know that there is a there is biosis in the skin microbiota, so that we know that there are abnormalities in the the composition of the skin flora and all these things together cause and create and perpetuate what we call anatopic dermatitis. It's not just an allergic reaction. So it was a long explanation and my student look at me and say, OK, sure, I see, I see this is more complex than I thought it's not just allergy.

But yeah, if I think a little bit and sorry for my daring, but that the application of a couple of mL of lipids will repair the entire epidermal barrier of a dog? You know of scientific evidence of this efficacy. It, it, it's good because now I, we are veterinary schools now trying to talk all the time about evidence-based medicine, searching for the best evidence, all these things and critical appraisal of, of questions and, OK, when you have a student that use this reasoning and say, well, I, I understand, but is there, what is the evidence behind this?

I said, well, I like the question because in fact, we have evidence both in vitro and in vivo and I have been involved in some of these investigations. So, in, in vitro, we, we did the interesting model of let's say artificial skin, what we call a skin equivalent. We developed the first one in, in 2007, and basically this is a model of canine skin in the lab in a plate.

So it's what we call a skin in a, in a plate. And, and we developed the first one in 2007 and 208. And then we use it for other purposes, but we recreated this skin skin equivalent for testing the effect of spinolipids on the skin of the dog.

So basically, this skin equivalents are very interesting because in one plate, you put fibroblast obtained from a skin biopsy basically with some collagen that you can, can buy, use this bovine collagen. And then they organise and create like a matrix that is very similar to the derby, and then you apply keratinocytes isolated also from a biopsy, separate isolated keratinocytes from a culture. And then if you leave these structures in an adequate Medium, they organise and they create an artificial skin so that it looks very similar to normal skin and skin.

You, they develop an epidermis with all the layers and from basal to stratum corneum and they develop a, a very Beautiful dermis. Of course, you don't have, for instance, nerves or blood vessels or you don't have sebaceous glands, but for understanding the epidermis is an excellent model because you have a basement membrane here, you have a dermis, you have all the components. And what you can do is that if you want, you can add different substances to the medium and see the impact on the epidermis.

So we were interested in knowing if adding a single lipids to the cultural medium. We can induce changes in these epidermis or in this skin. And it was amazing to see that increasing the, or by the addition of a single lipids to the cultural media, we could increase the amount of theramides in the epidermis, doing analysis.

We could increase the number of lipid lamellar. Structures of the stratum corneum and we could induce the formation of well structured stratum corneum. So we could modify and improve the barrier at least morphologically, at least structurally by adding this as ingulity.

So it was evidence that at least in vitro, we could do this. Of course, there is a gap between doing things in vitro and the real world. So when we have this evidence, we say, well, why don't we try with really atopic dots to see if we have this impact.

And we contacted with Rosanna Marcela in at the University of Florida. She has one of the 3 or 4 colonies of atopic dogs that they are in the world. She has a colony of Topic beagles that are hypersensitive to dermatohagoidparin.

So when you expose or apply an extract of dermatophhago desparrina to the skin, there is a flare of HOV dermatide. So it's a, it's a very good model because you can test on this model that is pretty benign because it's a superficial flare that lasts for a few weeks. You, you can try different treatments for aid dermatitis, you can monitorize, you can do investigation on the pathogenesis of the flu or whatever.

So we, we decided to use the dermal yeast spot on or drops compared with a placebo during a full flare of a dermatitis in this colony of, of allergic beagle dogs. So, and here you have the, we're, we're amazing. So this in the The red line shows the, the Care.

Carei is let's say an assessment or a quantification of the lesions on the skin cause in, in the flare of aopid dermatitis. And the green line is the group that was treated with dermal is weekly. And then, and at day 0, there was, the challenge with the dermatohagoide, so we induced the flare.

Without any treatment, the flare was pretty intense and then the first week and then maintained for a few weeks and then declined. But you see, the big difference, it was all statistically very significant that the, the dogs treated previously and during the, the flare with dermal easts had significantly less lesions and you can see the images, the difference between a control dog and a dog without previous treatment with dermal is. And also there were difference in the pruritus scores and also functionally.

So Rosanna is very good at measuring the transepidermal water loss, so she could measure that there was a difference in the water loss of these two groups of, of dogs. So it was clearly an impact and there was clearly a scientific evidence that this Treatment helps in atop canine atopid dermatitis. And therefore, we have been using that and on top of that, I told to my students this is the, the daily clinical experience, we use this and I show one case that this, this mongrel dog that is an atopic dog and, and He had basically facial pros, you will see him immediately in axillary edoema.

He, he, he's maintained basically with Loyvetma, with the monoclonal antibody and that blocks interleukin 31 and, and with shampooing once a week as a maintenant and with dermal eavesdrops. So if you control the itching and you control the, the The, let's say inflammation, the skin inflammation, you go from this situation at the beginning of the atopic dermatitis to a very well-controlled dog, and then you can use less aggressive medication and you can maintain the dog in a very good situation just with the drops, with regular bathing, so keeping a good skin AGMM. And periodically using the monoclonal antibody to stop the, the itching.

And also I told to my students, and now there is also a moose. So if you are need to act specifically in one area of the body, and you don't simply want to repair all the skin barrier, you know, you, in, in ectopic dermatitis, we have patients that specifically have one area with more damage or more inflammation and that We want repair better. So, there's a moose formulation now that we, that you have also in the UK and then we in Spain that allows a better spread of the product on the skin surface and allows you to focalize in, in one specific area.

So you can use the drops for general repair of the skin barrier, but you can also use the mousse going to To one specific area. She was pretty convinced, so I was feeling that I was winning the battle, but she still had a couple of questions, told me, well, forgive my ignorance, but wouldn't it make more sense to administer the spin lipids orally? And they say, sure, yeah, certainly, there are similar products for.

Administration and I don't know if you have this in exactly this composition in the UK but we have, for instance, one very seminar in oral presentation so with essential. Fatty acids, they called sapentanoic acid with nucleotides, aluronic acid and vitamin E and zinc, and this also helps, and there are data suggesting that also This oral administration of, of essential fatty acids increases the, the epidermal lipids and improves the epidermal behaviour. Again, when, when we use this orally, we have to use it for a long period of time.

In this case, the recommendations say that at least 8 weeks, we don't have to use it as a monotherapy. Expecting that this medication will completely cure an atopic dog. And in all the studies show that it's necessary to give the essential fatty acids by mouth at high doses to get good results.

So basically, when we treat our ectopic patients, we need to understand that the treatment is individual, so each dog needs a specific combination of drugs and that we need to combine different drugs and interventions targeting different Parts of the disease. It's not enough to go only to block the allergy or just to go to control the secondary infections. We need to do all these actions to have a good long-term control of these patients.

We need to use antimicrobials, antibiotics or antifungals. Systemic or topical in most cases is enough using topical antimicrobials and reduce the use of systemic antibiotics to control the infections. In some cases, just at the beginning, in some others, regularly bathing the patient with lorexidine shampoo.

We need to control the inflammation. We know if the skin is inflamed, there are many cytokines that cause the damage of the epidermal barrier and the damage of the, of the structure of the skin, and we can use prednisone for short periods of time or similar steroids, or we can use alacidii that is also anti-inflammatory. We need to stop the itching.

If the dog is, is scratching, there is damage to the skin and more. Penetration of allergens and we perpetuate the allergic reaction. We need to, in some way, we can also act on the hypersensitivity of reaction.

The way, the only way that we know that works on that is simply using allergens specific immunotherapy. It's a long-term therapy, but if we want to change the immune reaction, then we need to use this, this therapy. And then we need to repair the skin barrier.

And the way to do this is to use single lipids topically to repair this, this barrier. When we, when we can are able to control of these things of the acute flare in the 1st 4 weeks, then we can consider the need a long term treatment. We can consider the maintenance of these dogs.

And usually, we can reduce a lot the use of medications. We can continue. With a medicated shampoo adequate for that specific patient.

If we have to start allergen, a specific immunotherapy, we should continue and then we need to maintain the repair and the integrity of the epidermal area with a with topical yolipid. And only we will need to use a class or locky map when the dog flares because of season or short periods of time, but we will reduce a lot the number of drugs that we will use on these, on these patients. So the students say, OK, I think you have convinced me this time.

If I have more doubts, I think I will tell you and I was really pleased. I say, thank you, great, it's, it's good to convince your students. And also, to myself, I was thinking, sometimes we don't need to do exams at the university because you can detect good students because simply they make They pose very intelligent questions.

So, at the end it was a, a funny, it's a pleasant afternoon with my atopic patient and my, my, my two students. And this was my story, and I think that now we have time for some questions if you have. And we can discuss this with the colleagues of, of Webinar vet and Protein and Anthony and Gemma and all the team that I think is here with, with us.

That's great, Louise, thank you so much for that. That was splendid. As you say, I think it's good to have inquisitive students, but I I wonder was her name Thomasina, was she doubting Thomas or Thomasina?

But anyway, that's really great the way that you've presented it, and I don't know whether Pippa and Gemma want to also come on the video and I know we've got some really interesting questions coming on. Obviously Pippa and Gemma work with Protein, so if you've got any specific questions about, you know, about the product, then you can speak to, to Pippa and to Gemma. Otherwise we'll we'll march into the questions and see how we do.

And, and obviously the other thing, Louisa I would say is that I've seen some really nice comments coming through. The, the problem with webinars is you can't hear the tumultuous applause after you've finished. But I know people have been really pleased with it.

Rosalind said the story helped to make it very engaging, so, Rosalind has enjoyed it. Rosalind. No, I think it, it's always better to try to make this, history better than just giving fight and fight and.

Yeah, no, absolutely, definitely in the evening when we are all very tired. Exactly, and hopefully there's a couple of glasses of wine being drunk by people, you know, to enjoy the webinar even more then as well, but not too much, otherwise you fall asleep. We've got Zachariah saying how easy would it be and how many bottles of the drugs do we need for a 40 kilogramme shepherd dog with long hair.

Maybe that's one for Gemma. Have you got different, dosage sizes, or is it one fits all? We, we've actually been testing this on RTMs, they've been trying it out on surface area of skin at home on their animals and on a few legs apparently.

Actually, you'd be very surprised how far a 2 mil, and I think from, as Louis said, they've been using it in Spain for quite a few years now, how far 2 mil actually goes with this, because we're used to 2 mil applications being like flea spot-ons, which are obviously absorbed in the skin, whereas finger lipids are oil based. So you put them on and they do. Actually spread quite far, you can use them on quite a lot of the regional areas.

And I think Louis I'm right in saying the 2028opic dog study, they only use one pipette for each of those applications in multiple regions where the dogs were affected, Axilla and etc. In a in a in a beagle, and that was plenty. It depends because we used to very much say, we wanted to put the spot ons in one area.

I think the, the research as it's coming out more and more, and Louis will agree is, is actually there's more benefit with the topical therapies for focal application because his finger lifts are, are getting as close as possible to do the job. So with the 40 kilogramme dog, the moose will probably be your best bet if you've got very large dispersal of areas for a start, . But actually, to what we do know is whilst they're working, you know, sort of in a more concentrated manner focally, they all have an effect, as Louis said, on the entire epidermal barrier because you, you're sort of improving the whole system.

The skin is one organ, I think we forget this, don't we? So although you have different lesions, it, it does start to improve all over so. A 40 kilogramme dog, it would be hard to be say on the pipette.

It would depend on the cadacy on the lesional spread, but equally those mousse bottles would absolutely last for for quite a while even on very large dogs. I think it was something like 10 weeks, wasn't it, on, on a 25 kg 25 kg dog. If it was sort of given I think it was 10 pumps at at twice weekly would last you about 8 to 10 weeks for for that sort of size if you're covering that.

The moose looks a really interesting product actually, because it allows you, as, as Louise was saying, to go on, you know, defined areas as well, doesn't it? Yeah. The spot on as well.

So the, the spot on we tend to use now and in the initially it was used more like a spot on in one place, but to say, the research from the atopic dog study was put focally, it was put on the lesions and spread locally. And actually there was a secondary study as well, which looked at locally versus topically in one place. And they found that there was a much better response to sort of focal lesions as well.

So that's, that's what we're advising and, and moving forwards, as well. But it does have a er, an effect on the whole barrier. Somebody anonymously, Louise, is asking, can we use this in human dermatology, so we're, we're trying to put it on our spots as well.

No, yeah, in, in human dermatology, there are many, many products, aim to repair the epidermal barrier. Usually they are more creams or lotions because it's easy to apply. But, and not drops, but yeah, they have many products containing the single lipids and different types of lipids because they know the importance of repairing the barrier in atopic children so that you will find on the market several products like creams and moisturising lotions to repair the epidermal bedrid in humans.

And you can, you can, you can use this. On a human skin. A lot of them do actually contain the biosphere as well, so the biosphere is licenced across and they're used in a lot of products.

Yeah, great. We've got Kirsty here saying can we use fatty acids in the diet such as oily fish instead of drugs, or will increase the risk of hypersensitivity as the diet will change, or will this increase the risk? You can, I don't think that you will increase the risk of hypersensitivity.

You can use, oil, oil fish. The question is that you, you need, if you go by mouth, you need to go with very high doses of . The oil to get really impact on the epidermal be and usually the amount of oil that you need to give is too high, so the topical approach is faster, more direct to the epidermis, but it's of course you can do that.

Yeah. I think Danny Scott did a study, didn't he, very early on, where just, you know, they were, they were thinking it was a food allergy, but actually it wasn't, and it was just the very sort of oily fishy diets that did help the skin because of the effect on the, on the skin barrier and so on. Yeah, we've got Sue asking, how do you combine the topical application of dermales with the bathing routine, will the shampoo destroy the dermales?

Yeah, that's a very good question. Usually, what we recommend is to apply the drops or the nose. One day after bathing, so I don't know before the bath because if you apply the jobs and then you bathe with a very power, potent detergent, you can remove everything so we just bathing then the day after on a clean skin, apply the jobs or the whatever.

Zacharias, I think, is trying to help with the one of the previous questions. He's saying Xana shampoo, for example, that can be used in humans that obviously has, I think, effects. I'm, I'm presuming he's asking the question, can Xana shampoo be used in dogs too, so, you know, is it a good idea to use human shampoos on dogs?

Usually not, so we do not recommend using human shampoos because they are. There are some differences, yeah, you know, Anthony very well in the page and the composition, so we try to use a specific dog shampoos for and also you have to choose a shampoo for this specific dog if. Tends to have more malaci overgrowth.

Then you go for a shampoo with some antifungal. If this is basically a dog that shows more dry skin, you need to go with a moisturising shampoo, and there are, we are lucky now we have plenty of good shampoos for dogs. So you have a day, I'm sure in the UK everywhere we have a very good.

I've, I've done several talks on shampoos and I think one of the . One of the issues is sometimes, you know, the vets aren't aware of the range and so they use the wrong shampoo, have a bad result, and it kind of put them off using shampoos, whereas I think as you've said, people are getting better. There are a lot of shampoos out there, but it, it's so important to use the right shampoo and it, it is a little bit of a minefield for, you know, for the GP vets, isn't it?

Mhm. Yeah, I think so. I think yeah.

Let me see any more questions, . Yeah, somebody's asking the question, Costel, do you use the same protocols in cats? We love cats at the webinar vets, so we don't like to forget cats.

Cats don't always like being plunged into a bath though, do they, Louise? Oh, we, we don't bathe, yeah, they don't like bathing, but we apply some, the, the product also to cats. I, I think it's only licence for dogs, but we, we, we use this also in cats ectopic diets, cats and cats with, with allergic condition we use also this.

There is much less evidence of the damage in cats. We do not have all these studies done, but yeah, we assume that it's very similar in dogs. Yeah, crazy.

Fiona is saying, can this protect and lipid product be successfully used, in atopic dogs that already have a very damaged skin barrier. That's a very good question, and I try to, to talk a little bit about this in my presentation. You can, and usually what I do is I begin from the beginning to, to, from the start to use the, the product, but simultaneously, you need to stop the inflammation and the itching because if, if the, the skin continues to be inflamed and the dog continues scratching.

There is too much damage to the epidemal barrier to be repaired with your product. So you need to stop the itching of the dog and then help to repair the barrier. So you on the midterm will be able to reduce all the drugs.

So if the dog is still actively itching, you have to do something to stop that and only repairing the battery, you will not get that. That's great. We're getting close to 9 o'clock, so the good thing again with webinars is people can now slink out and nobody will know.

But do you mind staying on for a little bit, Luis, because I think there are a few more questions. I know it's a little bit later in Barcelona, but you're looking, you're looking good. Peter is saying.

Is it likely that the increased effect of applying dermals to the lesions is due to increased absorption, you know, in those areas? It's like. The increased effect is in locally.

I presume that's what he's meaning, saying, is it likely that the increased effect of applying dermal to the lesions? Yes. Is due to it's being absorbed directly, you know, onto those lesions?

Yeah, I think so, yeah, what do you think? Yeah, so I think definitely I think as I say, there's a comparison, there's there's one sort of very sort of new. Preemptive study, I think they were looking at looking now as it's progressing with their knowledge of of looking at whether or not it's focal to to sort of more diffuse effect and they are showing slightly more effect focally.

So definitely I think you, you're actively applying a precursor to ceramides, aren't you, to that area that the keratinocytes can utilise in that area as well. So, and also we, we, we concentrate a lot on the, the sort of the. The finger lipids, but the hyaluronic acid helps to regulate, I think, the fibroblasts in the dermis as well, which help to regulate the extracellular matrix, and they have been shown to have an effect on the filorens.

So I do think applying locally is, is, I think that's where, that's more research for you, Lewis. More research coming. Yeah, studies, no, I think it makes sense that this skin that is, damaged, inflamed, absorbs very well the product, and that you have more action also in deeper parts of the skin like in the dermis that Gemma mentioned.

Yeah, I think it makes sense. There's some cracking questions here that we've got an anonymous attendee saying which dose of fatty acids do you use, so I think the orals are. Yeah, they aren't it?

Yeah, and there are many differences in the conversation, so you have to look. A great question from Cat on a dog webinar. Should you avoid spot on flea treatments, or is there an optimal time to apply between the Dermolese treatments?

There is not a reason to avoid them, but in general in atopic dogs, if I'm going to bathe them frequently, I tend to do more, oral medication, but there's not, let's say a reason to avoid this. You can use it, but if you bathe the dog every week, then the amount of, of. Insecticide or sicide that remain in the skin.

Yeah. And I think that would fit with what we were talking about a focal application on on lesions. So you could apply the spot on the back of the neck.

And if that's not where the the lesions are axilla, or, you know, you, you can apply the delis directly to the lesions and still apply the spot onto the back of the neck. Affect each other. But I think Lewis is very, Louise is very right in that you don't want to bathe it off of God.

We're bathing these dogs so much with, with all sorts as well, aren't we? That's the, that's the issue. And I think the oxazolines have been such amazing products, haven't they?

And, you know, we get that flexibility. I know one of your other favourite subjects. Louise, I don't know whether you love or curse isoxazoles because there's not so much demodex around anymore, is there?

It's true. We don't see more any more cases of demodex because of many dogs are on this. I, I, I must admit I, I remember seeing somebody doing a study in .

Which they presented and they had lots of Demodex cases and they said that the breeders were very pleased because they could produce puppies that no longer got Demodex, and I thought that was kind of missing the point of it, you know, they needed to be spayed rather than be given iceoxazolines, but Who knows, we may get them flaring back up again, but yeah, great. Yeah, yeah. .

So, we've got another question, why are you using shampoo regularly? Wouldn't it clear up useful lipids in the skin, are we washing them off by using the shampoo and the lipid together? Now that's a, a, a, a good question.

In, in general, so. The ectopic dermatitis, each dog is different, so probably you need to make treatments for a specific patient, but in general, there are many, many evidences that bathing frequently does, even only with water helps to remove. Allergens and that penetrate the skin.

So this has been well demonstrated. Then the, the, the trick is to find an adequate shampoo for each dog and we usually do not recommend shampoos that are very strong that remove many lips on the skin. They are very mild shampoos formulations now.

Some even contain some other lipids, so we, we try to use these mild shampoos. But we know that keeping a good hygiene helps a lot in atopic dogs. I'm pleased I'm sure you know Gwilia from from Argentina is on the webinar and said thank you for a fantastic webinar.

So great to hear you on the webinar, G Gua. Right, Denica is saying, oh no, that's a similar question just on the dose of omega 3 and omega 6. I noticed the fatty acid only had omega 3 in it, but obviously I think there can be a mixture and the omega 3 seems to be the most effective one, doesn't it, if you could only pick one of them.

Yes, I agree. . Let me see, we've got Jinar who said, .

Oh yeah, it's a similar question, it depends from dog size. Just Gemma, to check, is it just one size, the product, or is, is there a few, different sizes? No, it's just one size, so contain two mals and then we have the mousse, so obviously, but to say, the big thing is is that we are recommending rather than just putting one spot on for a dog, we are recommending topical applications in the the region of lesions.

Cause, cause her question is, for example, Toy Terrier versus Saint Bernard, can I use double dose for acute difficult cases? It sounds like it's spread so well that it's, you can sometimes have a Saint Bernard that has much milder or or less, you know, more superficial lesions than a toy terrier that's absolutely covered and got no far and, you know, would take up more product probably as well. So I think, you know, it, it's so very variable and, and the hope is, you know, as Louise was saying was.

That we, we improve the skin barrier over time so much that you're not needing to apply as much as well as not, you know, use other treatments, yeah, but, but you can use double dose. I, I very, very safe, it's very safe. I use this product, in cases of, sebaceous adenitis, for instance, where the skin is very dry, and I use double dose.

If it's a middle sized dog, I give more because I want quickly to. Feel the skin lipids and I do this it's extremely safe. And Louis, is it your experience, you know, if you've got a dog well controlled, are you pulse therapying this product, or are you using it just continuously and get them into the habit of using it every week?

Yeah, it's so sometimes I do that or I, I make a treatment for a few months and then I stop in maybe some time when the dog is not flowing free nature and then we start again. So not always you need to do this for everyday life long but you can stop for periods of time if you, if you think that the dog is, as you said, was. Yeah.

No, a question probably for Gemma here and Pippa, just product availability across Europe, Beatrice is saying, can she get hold of this in Portugal? Lewis, you will, you know, I think it's very, it's very wide. So we are, currently distributing for the UK and Northern Ireland, but actually, as, as Lewis was saying, it's under a different name, so it's under a Topyvet in Europe as well.

So like in Spain, so it's and, and, will be expanding to more companies, so you know, similar product with a different name. If you can email. You, you sort of a contact detail, and I can check precisely from our guys on the export team, see where it is.

And if we don't have it as dermolys, if it's available as a copy bet in which countries for you, that's absolutely fine. We can find that out. It has, a pharmaceutical distributor as well in, in multiple countries.

They're just launching as well in other countries in Europe. And I say, Spain, I think this is its 4th year now, isn't it? So we this is why these guys are here, because Louise is the expert on this for us, so.

Yeah, because actually we've got somebody else saying, is it available in America and then Anne is a, is a vet in Norway, so obviously interested as well. So, . Yes, absolutely.

If they just want to drop us an email at either you can pass it on or if just drop us an email at technical protection.com and we'll be able to find out exactly who's distributing and where it's available in which countries for you. So.

That's great. Lily, Lily is saying if you have, the dog is licking its paws and rubbing its ears, where would you put the drops down, Louise? I would probably apply on the lesion, and, but, yeah, probably will be.

You only need to distract them, I think, for about 1520 minutes, don't you? Take them for a walk, give them a good. The, the one caveat we do have, which I think has been recommended, we haven't mentioned tonight would probably be worth it, is if they have heavily burdened with malacasia.

Malacesia can actually break down finger lipids, so it can make the product less defecacious. So I think when these dogs come in and they're under an initial very intense protocol for malacesia, I'm not sure if you do this, you would say the same, Lewis, is that you, you. You get that sorted, yeah, but you're shampooing those guys so frequently, aren't you?

It'd be hard to find the next day to get on them. It's true that it's important that you target different parts of the disease. Trying with only one medication to fix everything.

It's not possible. Yeah, if they are, you have to fix it. If there's inflammation, if you stop inflammation, and then you will.

If you do this properly for a few weeks, then the midterm is much better than you can to reduce products. I think I always used to say it was the same as, you know, a dog having an anaesthesia, and you explained it very beautifully in your presentation. You don't just give it a big dose of thiopentone and leave it at that, you know, you give it a pre-med, you have it on isofluoran.

You know, you get more control by finessing your use of drugs than just putting it on predice alone and, you know, if you do that for long enough, then you have all sorts of other problems that come up as well. Exactly. Yeah.

We have here can it be used on other animals like ferrets? It's not licenced, so it would be outside of its use, I think, wouldn't it? I think so, I think.

But you've used it in cats, haven't you, Louise? In cats. We're licenced in the UK for cats, so it, it can be used, it can be used, and I say we, we have a focus on the atopic dogs, but basically where there's any, any skin barrier dysfunction, and you've had a, you know, hotspots, anything like that, you know, to help.

And the difference obviously with the atopic dogs is the chronic use and the chronic dysfunction and the flare up. So that's why we have a focus on it as well, but. Because I think Darinka is saying there, you know, do you use it on the flared skin or or on the normal skin, but actually the whole point is you put it on the, the flaring skin, don't you?

And that's where it has its best effect. Veronica is saying she's an atopic human. Louise, an interesting one for you here, I think I know what you'll say, and I take antihistamine drugs orally, daily.

Is it recommended for use in dogs too? You think that she means the antihistamine using antihistamines in dogs. They are not very effective, so the all the this big controversy about the the efficacy of antihistamines in dogs.

If they do something, it's very tiny effect. I don't think that they, they have a role in the management of. Allergies.

In cats probably they work a little bit better, but I don't think that we have now plenty of tools to manage opid dermatitis in dogs and we, if we combine in a wise way, drugs like placitinib or Loy bedmap with skin barrier repairing products, we can, and immunotherapy, we don't need to use antihistamines that are not very effective. Yeah. Just reminding people, we have put the email in the chat box, technical at protection.com.

I think there is a survey that will come up at the end of this, and I would, you know, ask you to, you know, fill that in. It's always useful to get that feedback from, from, from you all, . Sean's asking me an interesting question, does this product have any use if there is just pruritus and no erythema yet?

Probably I, I, I do not have good evidences of the impact of these products on reducing the itch in the model that we had in Florida, there was a big difference, and, but the itch was combined with lithium. So only it is skin, I don't know if it can be managed only with these products. And we, we know that the dry skin is, is much more itchy than a well moisturised skin.

So probably reducing the dryness of the skin, you help to reduce. It's something that you have to, to assess for sure it will help. I don't know how much it will be 100% reduction or just a part.

I know, Louise there's been studies done with electronic microscopes where you take a picture of an atopic dog's lesional skin and it looks obviously in a mess. But if you take a picture of an atopic dog's normal skin, it still looks dysfunctional, doesn't it? So even though it's not lesional, there can still be problems and it could be the next piece of skin that will.

You know, become lesional down the line as well. There is one of the studies that did show that nonlesional atopic dogs did have decreased ceramides, those lamella bodies as well. So if, if they're itchy, I suppose the next thing being if they're itchy, they're gonna start tearing at that skin barrier, aren't they as well so.

Yeah, there was, there was nonlesional lateid dermatitis dogs did show a reduction in ceramide. So whilst we don't have the direct test with, with the application of the product there, it makes sense that if we can try and increase the ceramide and the filograne levels, we could potentially and as as Louisa said, it doesn't do any harm, and it's a very, very safe product. So if you're expecting a flare up, now's the time to get all our multimodal therapies ready.

Particularly with I think the moose as well, because it's got such a long sort of shelf life once it's open. It's got a 2 year shelf life, so if it is something that the owner wants to keep at home, if they do start sort of noticing their dogs starting to go and itch and go to those places where they. Quite often will start initially, they can start with the sort of the dermies and then obviously if, if it is progressing, take them into the vets, but it could be sort of like a first time thing that they are able to keep at home, and sort of start applying if they do notice that itching starting to creep in again.

Brilliant, thanks Pippa. I think this is the stage if we went on any further, Louise, we'd we'd need to at least break open a bottle of Rioca, I think, couldn't we? So maybe we've come to the end.

It's been a real treat. Thank you so much. I always love listening to you, Louis.

So it was my pleasure to be to be here with you tonight. So thank you to all of you, Anthony and all of you. Thank you.

Yeah, and thank you so much for protection for, you know, getting Louis on and and explaining to us how. You know, the disease is, is a bit more complicated than perhaps we all, we all first thought. Thank you everyone for, you know, interacting so much.

We've had some fantastic questions. If there are some that have been missed, then please do. Email us and I know Gemma and Pippa will be happy to answer any questions on the, on the product.

But just thank you once again, everybody at protects and obviously Luis as well. And everybody stay safe and hopefully we'll, we'll see you all very soon on a webinar. And maybe in Barcelona as well, Luis.

Next time I come. Take care, bye bye, thanks everyone, bye bye.