Welcome everyone. My name is Doctor Kirsten Rundgren, and I'm the consulting veterinarian at Many Pets Pet Insurance. And this is the first of our official series of sponsored CPD lectures for 2026, so I'm very excited.
Number one, because I'm a nerd and I love to learn, and I love to gather my, my fellow people who like to get CPD, but I'm also a big fan of dermatology, which I feel like is not necessarily a popular, trait among general practitioners, so. Excited to finally have a derm webinar and as Amelia was just starting to mention a couple housekeeping things quickly, if you do have questions, please put them in the Q&A box you'll find at the bottom of your Zoom screen, and we will come back to those at the end, and David and I will kind of have a few, a few questions in terms of back and forth if I see things pop up that kind of go along with what he's. Talking about, we'll hit a case or two, but again, if you do have questions, pop them in the Q&A box for us.
So, I would like to start before I get too excited by introducing our speaker. Doctor Davide Emiliano is a very well accredited smart man who will be teaching us about canine atopic dermatitis in 2026, a little bit of review, but also kind of diving into some of the new tools and some really, really great. Slides I'm excited for you guys to see that are very practical tips because I find that when I go to a CPD I'm always looking for what are the little pearls that I can take away and take back to the clinic with me, right?
We want those useful, applicable pieces of the trade that we can take back and and use with our cases. And so there's some really good slides coming up for you guys. So I will get that introduction taken care of and then I'll give it away for this, for the lecture.
So we have, like I said, Doctor. Emediato, who is currently working at Davies's Veterinary Specialists, with my very good friend Johnny Hughes. So thank you, Johnny for the recommendation, and he graduated from University of Bari in Italy in 2013 and started his PhD.
So not only has this man got a DVM behind his, his name, but he also has a PhD, and he worked in medical mycology and parasitology and was also responsible for teaching in the diagnosis of veterinary mycosis for several degrees. He is. Also the author and co-author of several publications, abstracts, posters, and a regular speaker.
So very well versed in the speaking circuit. Also won several awards as well, Young Researcher Award in 2016. So after he did his PhD, he moved to the UK where he worked for four years in first opinion practises in Oxfordshire, South Wales, so he's been around the UK and in 2018, he started his certificate in veterinary dermatology, and then got his GP cert in derm.
In 2019, he also did internship at South Fields and then completed in the same year, a dermatology internship at North Carolina excuse me, externship at North Carolina. So he has also spent time in the US with my, my nice people over there. So, joined Davies in 2021 as a clinician and from October 2023 started residency in dermatology.
So like I said, the man is very well versed. I'm very much looking forward to learning from him tonight. So I'll give it to you, Dana, take it away.
Thank you so much 1st 1st Kirsten for the present for the introduction first of all, and as she mentioned, we're going to discuss about allergies in dogs today. We're going to have an overview about allergies, but most importantly, we're going to talk about different treatment options, approach to allergic disease in dogs, and what will be the best way to approach those complicated cases in most of the time, most of the time. So let's start beginning with a quick introduction on what atopic dermatitis is.
We know that it is a genetically predisposition, predisposed disease. It's progressive, it's chronically relapsing, causes inflammation, pruritus, and has got different clinical features which are associated with IGE antibodies directed towards environmental allergens, most commonly. The pathogenesis is quite complex, and there are different interactions between epidermal barrier dysfunction, immune dysregulation, dysbiosis of cutaneous microbiome which cause this disease quite difficult to manage.
Let's have a quick look on what are the pathway processes that leads to allergies in dogs. First of all, we have the allergens that are uptaken by the Langard cells and Bring to the lymph nodes and at the level of the lymph nodes, the T cells cause a differentiation to TH2 T helper 2 cells, and the TH2 cells produce different kinds of interleukin, including the 31, which then cause the sensation of itchiness, but also interleukin 4 and 13 and 5. The fine goes to call eosinophils and neutrophils from.
From the vessels, whereas interleukin 4 and 13 they promote the differentiation of B cells and plasma cells. We can see that the B cells then produce mast cells and basophils where we have the presence of the IGE which then binds the different allergens, releasing all the mediators of the inflammation and therefore we have the cause of the inflammation of the skin that we commonly see in patients. As we know, the clinical signs of allergies are quite pleomorphic.
We may have different types of clinical presentation going from only pleuritis to erythema, macular lesions, papular eruptions, self-inflicted alopecia, excoriation, hyperpigmentation, lechification, and secondary infection. Commonly, patients can develop clinical signs starting from 4 months of age up to 3 years of age, even if this can be also present. Later in life and could be either perennial or seasonal, the most important thing to remember is that there are not diagnostic tests or patternormonic clinical signs to diagnose an allergy, so we should rely on response to treatments, clinical signs, and type of seasonality, age of onset.
In these slides, I'm going just to touch base on the fact that it's important remembering that the aspect of lesions can mimic other types of clinical disease, for example, flu allergic dermatitis, sarcotis infestation, demoticcosis. And not only allergies, so I suggest having a look at this article which can give you some information on how the different diseases might manifest, and this might help to discriminate between an allergic patient and a patient with a different type of condition. And it's important also to mention that dogs have specific areas of the bodies that can be most commonly affected by allergies.
For example, we can see our German shepherds commonly have the ventral abdomen, the front paws most commonly affected, whereas French bulldogs might have the axillary area and the paws most commonly affected. And it's important also to mention how the same breed coming from different locations, for example, in this case we have dogs coming from Europe and in this study dogs coming from Korea, despite being the same breed, they may have different body parts affected by allergy, and I think this is important given the current globalisation and the fact that we have patients coming from different parts of the world. But let's see how we should approach an allergic patient.
I love for diagrams because I think it will give us a very clear overview on what we should do step by step. So first of all, we should take a very good clinical and dermatological history. What we should focus is the type of distribution of the lesion.
If the prrius was present from the beginning of the lesion onset. How the apparatus is now, if there has been any changes, if the apparatus is seasonal or not, the age of onset, the previous treatment that were used, and the response to the previous treatments, if other pets or humans in the in the household are affected, and there are if there are other types of systemic signs, and I think it's very, very important to explain to clients what we meant for products for itchiness, because, Sometimes we think that the dog is itchy only because scratch, but also biting, chewing, licking, gnawing, rubbing and rolling, rolling are signs of pruritus. A lot of time we have clients that say, oh my dog loves rolling on the grass, but is that actually pruritus, or the dog is rolling because it likes doing that?
So it's very important to explain what are all the different signs of pruritus to try to get the most from the client's history. It's also important having a good dermatological examination and not only a general examination, because we need to see what type of lesion we have, the distribution of the lesion. Othoscopy is always important for every single dog that presents with a skin disease, even if the ear issues is not the primarily issue that the dog presents.
And then this is very important, performing minimal collection of sampling, cytology from skin and ears, coat brushing, skin scrape, and dermatophyte culture if we believe this could be important. I know that everyone works in a very busy practise. We have only a few minutes for a consultation.
And sometimes taking cytology is not easy, but what I was doing when I was in first opinion was taking sample, send the dog and the clients home, saying I will call later just to tell you what I found, and then make a plan based on the findings that we have. What we should do next obviously is start treating the itchiness, the pus, and if, if needed, also treat secondary infection and parasites, ottais externa, all the signs and the lesions that we have. It's important to evaluate the response to treatments after a couple of weeks, and then if we have dogs that don't have any flares when the medications are discontinued, we can say that maybe the dog had a fungal infection, parasitic infestation, bacterial infection that now has.
Or maybe the dog has a seasonal atrophy. Therefore, we can continue with the regular free and one treatment. We can obviously evaluate if the history is consistent with a seasonal autotropy, discuss management option, or see if the dog might have some endocrinopathies and therefore secondary bacterial infection.
So we need to evaluate the patient and decide how we want to move forward, but in case the level of itchiness flares at the dose reduction or discontinuation of the treatments, then we can think that either we have a recurrence of the infection, so we might need to review the, the treatment for bacterial, fungal infection, or maybe the dog is allergic, and therefore we have a res a response to the treatment, but then a relapse when the medications are discontinued. Now I want to focus, and the most, the majority of this presentation will focus on the different allergy management options. First of all, I want to introduce the concept of preatus threshold, which I believe is very, very important to understand before we move forward.
As you can see, we have a table now here where we have. Four different patients. One dog has got atopy, one has got atopy, but also flea allergy and pyoderma.
The third one has got atopy, flea allergy, pyoderma and malacia dermatitis, and the 4th 1 has got allergy and malaysia dermatitis. Now, when we have a dog with the with itchiness caused by multiple factors, like for example, in the dog 32, or 4. If we use an anti-itching medication, we might be able to control the level of proraus caused by the atopic dermatitis.
Therefore, the dog will reduce the level of itchiness, but the clients will report that the dog is still its, itchy. This is because we have other factors on top of the allergy that can cause pruritus. Therefore, if we don't treat and manage all the different aspects of the puss, the dog will still itch, and we can think that maybe the medication that we use is not working.
But actually it's not because the drug doesn't work, but because maybe we haven't covered all the different aspects of the apparatus. So if in the dog tree, we have a good flea borne treatment, we control the bacterial infection, we control the yeast infection, and we control the allergy, the level of puratus will go beyond, below the level of threshold, and therefore the dog will be H3 or have a very low level of puratus. Let's start to talk now about the different medications that we have to control itchiness in dogs.
First of all, let's start with the steroids. Everyone knows what the steroids are. They are very good to control itchiness.
They decrease the level of T cells and eosinophils by increasing apoptosing and contributing to the suppression of chronic allergic inflammation. It's the onset of action is quite rapid, between 1 to 2 hours, and everyone knows the dose that we use for of steroids, prednisolone 0 05 1 milligramme per cake once a day, taperating the dose to the lowest effective dose. And the methylprednisolone 0.2, 0.5 milligramme kg daily tapering the dose.
It's important to pay attention to giant breeds because those are more predisposed to steroid side effects. Therefore, be always cautious when you use steroids in large dogs. Side effects.
Everyone is aware of the polyuria, polydipsia, polyphagia, lethargy, exercise intolerance, muscle wastage, punting, secondary infection, calcinosis cutis, and the calcinosis, it's more common in French, in all the brachycephalic dogs, Frenchy, pugs, bulldogs, but also Labrador. So always remember when you have those dogs to try avoiding long course of steroids and also urinary tract infection. The use of steroids is indicated for acute flares but also for chronic management, even if we discourage the use of steroids long term.
Even if in some cases we have to use, but we try to avoid as much as possible, and then we should consider monitoring patient every 6 to 6 months with the blood haematology, biochemistry, urinalysis, and also we should be care combining the Apoquel and cyclosporine with steroids. We do it mainly with Apoquel, but we should be careful because we can create a quite severe immunosuppression. Then we have the Apoquel olicitinib.
This is a JACK1 dependent cytokine that inhibits the JJACK1 and causes a reduction of the interleukin 31 and therefore the protus. It works in about 4 hours even if we have full control of the itchiness after 24 hours. We know the dose that is commonly given.
Twice daily for the 1st 2 weeks and then once a day and remember about the rebound effect. What does it mean? It means that when we go from the twice daily dose to the once daily dose, the dog may start developing some level of itchiness.
Therefore, we may need to use a bit of steroids throughout that period of time just to try to minimise this rebound effect. Side effects are quite a lot. We may have pyoderma, presence of wart-like lesions appearing, vomiting, diarrhoea, lethargy, anorexia, polydipsia, polyphagia, UTI and cystitis, otitis, a lot of different types of side effects.
It's important to remember about the demodecosis. And aggression, I've seen dogs developing aggression while on on Apoquel, but demodecosis is very important, mainly in West Island White Terrier. Remember, all the time that you have a dog on Apoquel and noctur on Apoquel, you should make sure that they have a very good flea and worm treatment to try to minimise the onset of demodicosis.
Apoquel can be used for acute flares, but also chronic management. Ideally, we, we suggest monitoring the patient every 3 to 6 months with bloods, biochemistry, rheumatology, and urinalysis. And as everyone knows, we should avoid using this medication in dogs less than 12 months of age or less than 3 kg, and don't use in dogs with.
Evidence of immunosuppression or if there is a presence or reported presence of malignancies, and we need to be careful when combined with steroids and mainly cyclosporine. Cytopoloyvetmb is a monoclonal antibody. A few times I had questions about using cytopoint in cats.
Cytopoint in cats doesn't work, so it's a monoclonal antibody is a caninized monoclonal antibody, therefore is not going to be effective on cats. It's used to treat itchiness in dogs and is select selectively binding the interleukin 31. Now it's important to mention that when we use cytopoints, given that cytopoint has only an anti-itchy action, if we have a dog with inflammation of the skin, cytopoint is not going to be effective because it's not going to control the inflammation.
Therefore, we should select the cytopoints only in dogs with no inflammatory skin disease that only present pratis itchiness as the most common or the most obvious clinical sign. It's quite rapid onset of action between 8 hours and 3 days. Everyone knows the dose of 1 milligramme mL subcutaneously every 4 weeks.
And also cyto points, despite being safer compared to other options, can carry vomiting, diarrhoea, lethargy. Urinary incontinence, pain and injection sites, but also hypersensitivity reaction and neurological signs. I only had one dog so far developing sort of ataxia and weird behaviour while on cytopo.
Cytopoin can be used for acute flares and chronic management. There is no need of monitoring and also in this case not used in dogs less than 3 kg of body weight and in dogs over 8 weeks of age. A small percentage of dogs might also develop antibody towards the cyto point, therefore, we might not see any more efficacy after 2 or more applications, and in some cases, dogs might need up to 2 injections before starting showing signs of improvement.
And there is no major knowledge about drug interaction. We use in some cases along with steroids or Apoquel. And there are no reports of adverse events using the two together.
Now let's talk about the Zelrea ilunocytinib, which is the new drug that has been launched in the UK. Now Zarrella is also this one is a JAK inhibitor and contrary to the APquel that is selective for JAK 1, in this case we have action on JAK1, JAK2, and tyrosin kinase 2. Therefore we have a bit wider action compared to Apoquel, and this means that this medication might have a higher anti-inflammatory action compared to Apoquel.
Similar to Apoquel, the onset of action is between 4 hours and full efficacy after 24. It is given at a higher dose compared to Apoquel, but is given once a day, and this in some cases might be a benefit instead of giving a tablet twice daily to start with. In this table we can see a comparison between the most common side effects between Zarrella and Apoquel.
As you can see, they both can cause a GI disorder, and Apoquel might have a slightly higher percentage compared to Zaria can have a slightly higher percentage compared to Apoquel. They can cause parrato, seborrhea, isotoma formation, eczema, and masses, and Zarrea has got a higher percentage compared to Apoquel. Systemic disorder, it's higher on Apoquel compared to Zarrella, ear issues is higher on Zarrella compared to Apoquel, and a normal blood results are similar, even if this is not always true, and we're going to see in a few minutes what does it mean.
They can be used for acute flares and chronic management. We suggest monitoring for infection, decrease in hematocrit, haemoglobin, red blood cell count, and evidence of neuroplastic condition. And then not is not licenced for use in dogs less than 12 months of age or in dogs with serious infection and that are on treatment with immunosuppressive medication, given that we don't have knowledge about it.
Now I put this part here in red when Zarrella was launched in the US. They suggested to avoid giving vaccination on dogs on Zarrea and to stop the Zarrella 2 weeks, 21 months before and after the vaccination because it was observed that dogs on Zarelia that were vaccinated had a fatal disease, so they died. Now, nowadays, I had a chat with the manufacturing company, they stated that this is not anymore true.
There are no risks vaccinating a dog while on Zarrella, and obviously we should make aware that every dog might have a reaction to vaccine which is not likely to be associated with the Zerea administration. So also in the US they are going to change the reflect and this will not be any more reported, but if there is something like that nowadays we don't believe this is more true. In this little table we can also see the comparison between the efficacy on reducing pruritus in dogs between Apoquel, which is the grey line, and Zarrella, and we can see that dogs on Zarrella might have a good outcome in controlling pruritus compared to dogs on Apoquel.
But what's happened in real life when Zarrella was launched, there was a discussion on a forum between all the dermatologists from different parts of the world, and the American people, which were the first ones using the product. Shared some observation about their views, which I encountered in on a daily basis life. First of all is that the success rate is higher compared to dogs not responding to other antipruritic medication, and this was true for dogs not responding to Apoquel, but also for dogs not responding to Apoquel and cyclosporine together.
A quite a high percentage of dogs develop anaemia and neutropenia, and this now has also been included in the reflex where we expect that dogs might develop neutropenia and anaemia to the lower referral range, and commonly this starts to go back to normal levels after a few weeks of treatment. And in the US they noticed that this anaemia and neutropenia resolved when the dose was reduced, and the dose reduction didn't coincide with a worsening of the productus. They also report that side effects are commonly reported within a month of treatments, and for side effects we include anaemia and neutropenia.
Dose reduction doesn't coincide with a flare, and in one case there was an increase of ALT which resolved when the medication was stopped. In one case, a dog developed acute diarrhoea and hematochezia, and this happened also to one of my cases after a month of treatment. One dog developed leukopenia which improved but no resolved when the medication was reduced or stopped, and then they always suggest to perform blood monitoring.
Before starting the medication and 4 to 6 weeks during the treatment to make sure that there are no major alteration in the red and white blood cell count. However, this article also showed a comparison between Apoquel and Zarrella has been published in 2024, as soon the medication was going to be launched. Another medication that exists but is like everyone is scared to use is the cyclosporine.
Now cyclosporine is an immunosuppressive medication that works on the T cell population. And is quite effective to control allergies in dogs and cats. The downside of this medication is that it has got a slow onset of action, between 6 to 8 weeks, and this makes this drug not suitable for acute management, but only for chronic management.
Therefore, we can use Apoquel, cytopo steroids, Zarrella to start with, and then we can transition towards cyclosporine throughout the weeks. Side effects are vomiting and diarrhoea. This is in about 20% of patients, but also lethargy, hyperactivity, anorexia, jangival hyperplasia, wart-like lesions appearing.
Hypertrichosis, and this is very important because a lot of time I have clients say, oh my dog has got an increased shedding or they have long hair compared to before, this is normal because because cyclosporine acts on the pathway of hair cycle, causing an increase of the allergen phase and therefore of overgrowth of hair. We may also have muscle weakness or cramp, salivation. We can have onset of diabetes, and this is most commonly observed in human and in West Island white cider, so be careful when you use cyclosporine on Westy and always check, urine to make sure that there is no evidence of glycosuria.
They can cause, Urinary tract infection, but also a rare condition called psoriasiform lekenoid dermatitis which is similar to the one present in this picture. In this case was an idiopathic form which is typical of spaniel, but in the case of cyclosporine. Periform leukenoid like dermatosis, dog may have lesions similar to those, so crusts around the eyes, alopecia, but also on the ventral abdomen and trunk.
Biopsies will confirm the diagnosis, as we say, it's used for chronic management. Commonly we suggest performing blood tests every 6 months with haematology, biochemistry, and urinalysis, and we should not use in dogs less than 6 months of age or less than 2 kgs body weight, and we should not use in case of previous or present malignant disorder just because it's an immunosuppressive drug. And it is also very important to not vaccinate dogs with live vaccine while they are on cyclosporine.
We suggest withdrawing the medication two weeks before and after the vaccination time just to make sure that the immune system is able to process the vaccination, and we need to be very careful with drug interaction. Cyclosporine works on the cytochrome P450. This means that we should avoid or be very careful when this drug is used with antiepileptic medication or for example, antifungal Adzole, given that they both.
Work on the liver and the cytochrome P450. Therefore, serum monitoring of the level of phenobarbital, for example, is important. Or if we have to use the cyclosporine along antifungals, we should reduce by half the dose of the cyclosporine.
Let's check now topical products. We have the Cortavans. It's a very good steroid because it works locally and doesn't have any systemic absorption, and this made this product suitable for long-term treatment.
Works quite quickly between a few hours. Commonly we use one pump on the affected area daily for 2 weeks and then long term 2 to 3 times per week. Be careful on using on the ventral abdomen or area where the skin is very thin because we can have even more thinning of the skin and fragility of the skin.
Side effects we may have transient local reactions like erythema or pruritus that can occur very rarely and then skin thinning on long-term daily base usage. This can be used for acute flare, but also for chronic management for localised pruritis. There is no need of monitoring, but we need to be careful on using this product in areas where we have ulceration or in case of hypersensitivity to the hydrocortisone acephonate, and careful when you use this medication in dogs with Cushing's disease, as we still are using a steroids, so we need to consider risk benefit of this drug for these dogs.
Antihistamines. This is a big question mark because everyone uses antihistamines, but we know that as we saw before, that histamine is not one of the most common and present mediators of allergies in dogs. Therefore, the use of antihistamine is quite controversial.
There are no strong evidence of its efficacy in controlling atopic dermatitis. And the other important thing is the onset of action, that is 2 weeks. Therefore, if we have to control allergies in a dog that has got an acute acute flare, there's not much need for using antihistamines.
The place of antihistamines could be when we have dogs with a seasonal allergy. We want to start antihistamines a month or two prior to the season of the allergy, and this might help to reduce to a certain extent the development of the clinical signs throughout the allergy season. But using it when the dog has got an acute flare is not maybe going to be effective.
If we want to use an antihistamine. I would prefer maybe using more hydroxyzine or cetirizine over pyritone chlorphenammine, because the two appear to be more effective compared to chlorphenamine. Now let's talk about supplements.
Everyone might be a bit, let's say, sceptical about the use of supplements, but actually they can find a place in controlling the allergies. Let's start with this PEA. I will never be able to pronounce the name, so I'm not going to pronounce it, but the PEA is endogenous arrachinoid acid derivated fat, fatty acid that has got cannabinoid-like effect.
Everyone knows, and there are studies showing that the endocannabinoid receptor works in dogs and humans to control pain, but also inflammation and signs of mild pleuritus. Therefore, the use of a medication containing PEA should be. Helpful in controlling signs of skin inflammation and mild pruritus in dogs.
Maybe they will not be enough on their own, but they can be associated with other conventional medications. And as we are going to see in the next slides with the essential fatty acid, the use of this drug might help reducing the needs of other drugs to control allergies in dogs. Commonly.
Might take up to 2 months to work 12 weeks, is indicated for chronic management. Commonly it is 1 capsule every 10 kg body weight. There are no side effects reported and there is no evidence of a need of monitoring.
And as mentioned, PEA were using study in dogs with non-seasonal, mild to moderate atopic dermatitis and mild to severe pus, and was found to be to significantly reduce the level of preatus in dogs. We have two formulations. One is the palmidol.
And the other is the Redanil Ultra. The main difference is that Redanil Ultra contains not only PEA but also biotin and essential fatty acid. So we have a bit wider range of action compared to the Palmidol, which is a pure PEA medication.
They are both can be bought online with no prescription, so easy to take from the client. And essential fatty acid, as I was mentioning, also the omega 3 and 6 are important in controlling the inflammation pathway in allergic patients, and they act on the Cox and Locks enzyme via the arachinoic acid pathway. Therefore, also in this case, we might have an onset of action of 12 weeks indicated for the chronic management.
We can give 1 pump per capsule every 3 kg of body weight, and as I was mentioning, the use of essential fatty acid might help to reduce the need of other medications to control the allergic signs in dogs. Maybe they are not going to be effective on their own, but definitely we can use, along with other drugs to control the allergy. Now let's move forward after that we've seen all the different drugs that we can use.
Let's move quickly forward towards the control of superficial skin infection. Now the most common bacteria that we may found is Staphylococcus pseudontermedius, which is, which is a skin resident, can cause papules, pustules, epidermal cholerates, and the management, it's commonly done using topical products. What we should do is do cytology, check what do we have on the skin, and then we can start topical products we're going to see in the next slides on a regular basis and only if indicated by culture and sensitivity or if there is no response to topical treatment after performing a culture and sensitivity, we should should start systemic antibiotics.
This is a table that, That is extrapolated from this article that I encourage you to read because there are very good guidelines about management of surface, superficial, and deep pyoderma in dogs caused by Staphylococcus seummedius, which will give you all the information that you need to know on how to recognise this disease, how to manage, when and how to use antibiotics and all this sort of stuff. But let's also see the mass infection and then I'm going to tell you what's uncommon in doing to control topically this condition. Malassetia is another inhabitant, resident of the skin of dogs, and can be commonly cause of infection in dogs with allergy.
Commonly we have pruritis, erythema, alopecia, greasiness of the skin, hyperpigmentation, and lack inification. Commonly we can manage the problem topically and rarely we need to use systemic anti-fungal medication. Commonly we tend to use hydroconazole at 5 milligramme per kg.
Textbook says once a day, but I prefer using it every other day for 3 weeks. We can also use terbinafine, which is given at a different dosage, but I don't see why we should use terbinafine unless we have liver disease for which azoles are not indicated, so we can consider using terbinafin at 30 to 40 milligramme kg once a day. When we have dogs with anyway infectious skin disease, could be either bacterial or fungal, we should, as we mentioned, use topical products.
Now I'll put here some of the most common products that we have. Malaceb is a combination of chloraxidine and meconazole. It is indicated for fungal infection, but also for bacterial infection, given that we have a synergistic effect between meconazole and loraxidin.
Instead, loraxidine shampoo is indicated when we have a pure bacterial infection. What we commonly do is using the shampoo 2 times per week and then associate a foam in between shampoos, so every day except the day of the shampoo, which could be either the Crexium foam, which is a 4% solution that is going to be more effective for yeast infestation infection. The Duoxo is a 3% Cloroxin foam that doesn't work much on yeast, as is the 4%.
Zzincocebo spray is the only one that contains, along with salicylic acid, which is good to remove the scales, contains also a low percentage of chlorimbazole and chloraxidine, so it can be used when we have a fungal and bacterial infection. Remember, only the spray, the shampoo and the foam, they don't contain Clotrimazole, therefore they're not going to be effective if you have a fungal infection. Pepttit shampoo or foam is a peptide that has got actions against malasetia, so you can use that one to control malasitia.
And then we have Cortex, which is a pure claraxin-based shampoo. I don't use it much, it's not one of my favourite products. Therefore, I, I, I don't have a lot of experience, but if we have to choose a shampoo, I definitely prefer using Malaceb or Cloroxiderm over Cortex, and then we need to associate one of the other foaming agents.
I commonly do twice weekly shampoo, everyday foam for 3 weeks, and then I'm going to reduce the frequency of application based on the response that the patient has. Use of wipes could also be considered when we have issues localised on specific body areas that cannot be reached with a shampoo, like for example, the face, facial folds, tail folds, or when we have lesions only on the poles. Bio skin contains only chloraxidine and wipes contain antifungal and chloraxidin, so it may be a bit more suitable for dogs with fungal and bacterial infections.
Then let's see quickly prevention of ectoparasites, as we say, ectoparasites are a very frequent flare factor for pruritus in dogs with allergies, so we should always treat dogs with anti-parasitic products all the time that we have an allergic patient to try to minimise the chance of having secondary parasitic infestation that can worsen the primary allergic problem. I always suggest using hyoxyzalin, therefore, Breveto injectable spot on or tablet. We don't know yet if the injectable is going to be effective for Demodex and sarcoptes.
NextGard Spectra or normal Nextguard, Simpatica or Simpatica Trio, but also strong gold salamactin is a quite good product to control Demodex, even if it's not licenced. There is a study that shows that it's quite effective to control Demodex, so that could be another potential option. Now prevention of the ear infection.
Now this is another big chapter. Obviously we cannot spend all the time talking about the ear infection, but I want to touch base very quickly on the fact that ear infections are a common manifestation of flare-ups in dogs with allergic skin disease. Always perform cytology because if we Don't know what we are going to treat.
We cannot choose the right product. If we have a dog with pseudomonas and we use a long lasting medication like Ozornia or Nectra, the florphenicol is not going to be effective against pseudomonas in about 90% of cases. Therefore, it will be a waste of money and time for everyone.
Instead, choose a product that is suitable to control pseudomonas or rods infestation. We have a list here of the most common products. The indication, the formulation, the dosage, and the species for which they are licenced.
As you can see, there is a new product that I believe you are familiar, it's called Mometamax Ultra. This contains gentamicin, and this is a very good product to be, to use if you have pseudomonas infection in the ear of dogs, and this is a long-lasting product. Obviously, all those products are only licenced, and also this one licenced if you have an intact tympanic membrane.
Use of these products with a ruptured tympanic membrane might lead to autotoxicity and also to neurogenic dry eye and serumacteria. So be always cautious when you applying a product. Making sure that you can see the tympanic membrane and if you cannot see the tympanic membrane, you can use products that have low low or non-autoxicity potential when applied in the middle ear.
Those are the recipes that we use. Every dermatologist has got a different recipe. Those are the most common ones, using Betril, using marbosil, the marbosil is the 1% marbosil, Batril is the 2.5 injectable one, the gentamicin is the injectable 1, 40 milligramme ill.
Cheftazidim and piperacillin trosobactam should be used only if culture suggests that those medications need to be used and therefore you have resistance to the other antibiotics, even if we have to remember that when we talk about ear infection, that we found on paper that rely on bloodstream diffusion of the antibiotic. Application of an antibiotic in an ear canal of dogs and cats is able to reach a so high concentration that can overcome the resistance that we have on paper. Therefore, we have to keep this in mind when we choose also the antibiotics for otitis external.
We can use also the Flamazin that is compounded all in a syringe with saline and then the canasta solution where we have only yeast infection. So in terms of those products. We tend to use between 0.5 1 mil daily, and the dose depends on the size of the ear of the dog.
Small dogs, 0.5 mil is fine. Large dogs, 1 mil should be used.
We commonly do it for three weeks and then we recheck and we see where we are. For the Pyraintrosobactam, the Flamazine, and the Canasan, as you can see, there is not any steroids, topical steroids in this formulation. Therefore, what we do is preparing a different solution containing B4X or Trizoral 100 mL, plus 10 mL of injectable dexamethasone, and we apply 0.5 to 1 mL.
Once a day or 3 times per week in the affected ear, 12 hours apart from the other medication. I know that maybe there is a lot and you may have a lot of questions about this. I have had a presentation about ear infection.
I don't think that now is the time to discuss in depth all this because we're going to spend 2 or 3 hours if we want to discuss everything in quite in deep details. This is a list of all the different cleaners, I'm not going to mention all of those because we're going to spend also in this case, hours. I want to point attention on two important things.
Auto-proof. Never ever use auto-proof as a cleaner to give clients to bring home. Auto-proof is a very strong serummiolithic product.
This must be used only if and when you do a flush under GA flush, always under GA, no sedation. Just to dissolve the wax, the cerumen that is present in the ear and then must be flushed out straight after and never use if you have a ruptured tympanic membrane. Autoact, Odyne, Trisak, Borex, Trizoral are licenced to be used if you have a ruptured tympanic membrane.
And if you have yeast overgrowth, the use of malasitic oral or chloraxin auto are the most indicated product. I believe everything is written in these slights with a few information about the cleaners, but again, in the presentation of otitis, this is discussed in much more in-depth details, and that is the right presentation where to discuss all this. What to do when we have cleared the infection.
Now it's important to identifying the underlying factors. Therefore, if we have a dog with allergy, we should address the allergic issue if we want to try to control the recurrence of the ear infection. However, this is not always possible.
Therefore, we have to consider either pro proactive maintenance. Or surgical management with Zika. In terms of proactive maintenance treatment, we have a few options.
First of all, we have the use of Cortavans or corrotic. Cortavans is off label. We commonly apply 05 mils in each ear 2 to 3 times per week, depending on the case, and this is used lifelong, always if the eardrum is intact.
Cortotic. It is licenced to be used for up to 2 weeks. Also in this case only if the tympanic membrane is intact, but we can use off-license 2 to 3 times per week based on the case.
One pump delivers 0.22 mLs of product. Therefore, if you have a large dog, you might need to use two pumps to deliver the 0.5, 0.44 mLs, which is equivalent to the 0.5 mL of the cortas.
Raciort, I don't use much of this product because the type of steroids is quite strong, can cause severe side effects in long-term use and systemic absorption. You should use it for up to 14 days, but it can be used long term in case we have a recurrence of the infection, and also in this case only if the tympanic membrane is intact. But if the ear tympanic membrane is ruptured, we can use the B4x resoral autodine compounded with the steroids, applying 0.5 0.51 mLs in each ear, 2 to 3 times per week, and also this one is off label.
Let's move now on restoring the epidermal barrier integrity and function as we saw initially. Allergy obviously is a disease where there is an alteration of the epidermal barrier and the skin surface microbioma. Therefore, restoring the barrier is an important step to try to improve the overall situation, and obviously we need to consider using those products along with all the other systemic and topical drugs that we have discussed so far.
We have different types of spots on formulation or shampoo that can be used to restore the epidermal barrier, and this could be an adjuvant treatment along with what we say the previous medication that we discussed. And finally, we're going to discuss about the diet trial and the immunotherapy, diet trial now. It's important to mention that there is no test, diagnostic test that is reliable to diagnose an allergic food allergic reaction in dogs.
I know that there are blood tests that can be done, but those are not reliable, so I don't think that we should use this blood test. Because it will not give us the results that we need. The food trial is the only way that we have to understand if a dog is allergic or not.
Trials should be done for at least 8 to 12 weeks, ideally with a food rechallenge afterwards, and this will confirm if there is or not a food trial. It's very important to remember that we should use antipyretic medication before, at the same time when we start the trial. This is because when we have a dog with food allergy, the food might take up to 4 weeks to kick in the body and start to give the effect that we want.
If we don't control the level of itchiness for the first few weeks, the dog will start scratching, create a secondary infection which therefore will persist and cause pruritus. And therefore the food might be able to control the allergy but not the pruritus caused by the infection. So it's the same concept of the purus threshold applies also for a food trial, so.
You can start with the steroids for 4 weeks, doubling the dose, or Apoquel or cyto points or Zarrella, whatever you like. After the 4 weeks. You stop the medication and you just continue with the diet, and then you see if the food is able to control the problem or not.
If it does, it means that the food is the dog is allergic to food, and then you can, your food rich food rechallenge, you can start introducing new new proteins and all this sort of stuff. If the dog instead is. Responding to the trial means that the dog is not food allergic and therefore we can focus on environmental allergens.
It's very important to mention that we have to use a very highly hydrolysed diet. Over the counter diets are not going to be effective, and as you can see, I listed here the most important food for me. In this is not included the Hills Zi.
Why? Because LCD is a high hydrolysed diet, but it is not a highly hydrolysed diet. Therefore, it is still able to cause a reaction, and the same thing applies for the royal canine hypoallergenic.
So if you have to do a food trial, use one of those drugs, those foods, and if you have to use a single protein. Diet, try to choose a real single protein diet. For example, trot, horse, or rabbit, for example, wheat only are quite good products.
The dry of the trut contain poultry proteins. Therefore, I don't suggest using the dry version of the trut for a food trial, but you can use the wet. A butternut box does the pork this way, which is a good product because it's a single protein diet that contains other vegetables which are not a problem and doesn't contain apple.
And this is important because in human medicine apple can cross react with birch. Therefore, if we have a dog with allergy to birch, we might cause a reaction just because we have a cross reactivity between apple and birch. And then there are other foods that are single protein diet.
So all the time choose the right food and be clear with the clients on what the dog should eat. Another important pitfall is the presence of other pets in the house. If other dogs or cats are present in the household, all the dogs should be fed with the same food, because even sharing the same water bowl, same toys, might create a cross contamination of the water bowl or the toys and therefore causing an allergic reaction.
And then we should avoid giving any. Pill giver, any type of extra food. Anything that is not this food that we choose for a trial.
We can use carrots, we can use bananas, which are fine, but that's it. So it's very, very important that this is explained to the client because if a client cannot do the trial properly, there's no point in doing the trial. It's just a waste of time and money for everyone.
In this table is explained obviously all the process in a bit more details. Finally, let's focus on the allergen-specific immunotherapy. Now, Allergen specific immunotherapy is done by injection, but to understand what type of allergens are involved in the allergic process, we should perform either a blood test or an intradermal test, ideally both.
Remember that. Blood test is not a diagnostic test to diagnose allergy. If we do a blood test to healthy dogs, they will have a positive reaction, so we need first to diagnose the allergy via response to treatment, and then we do the intradermal blood test or intradermal test to know what are the allergens that are involved in the process to then formulate the immunotherapy.
Now, I put here two different tests, this is just because I want to show you, this is an old test, this is a new test. In this old test, you had all these different classes, class 0123, and 4. A lot of time I had colleagues saying, writing in notes, oh, the dog has got a class 1 allergy, I'm not going to.
Because it's not allergic, this is false. Class 0 means that there is no evidence of IE in the blood. Class 123, and 4 means that there is a reaction.
There is evidence of IGE. Now it doesn't matter how high is the class, this doesn't coincide. The severity of the clinical sign.
I can have a dog on class 1 having the worst skin ever and a dog on class 4 having just a mild itchiness. So never rely on the class. That is just a lab indication for them more than for us, and this is the reason why I believe they have changed, just putting positive or negative just to rule out any kind of issues.
Another important thing to remember is that we have a percentage of dogs that the spine being allergic, and this goes between 10 and 30%, might have a negative reaction to the blood test and to the intradermal test, and those are called atopic-like patients. A negative blood test or intradermal test doesn't mean that the drug is not allergic, just means that the immune system doesn't want to show us the allergens and therefore we cannot formulate an immunotherapy. Now, the immunotherapy is the most effective, proactive way to manage the allergy.
It's a mix of mix of allergens that is given progressively, increasing the dose and the frequency of application until we reach the normal dose that is 1 meal every 4 weeks, as you can see in this table here. There are different types of protocols. The one that we commonly use is the subcutaneous injection.
The sublingual has been discontinued, and I also agree with this because everyone thinks oh the sublingual is easy, but actually I would see how many of you would be able to apply a pump underneath the tongue of a dog twice daily for the rest of their life. It's quite unpracticable, therefore, the injection maybe is a bit easier given that it's just once a month when we reach the maintenance maintenance phase. It's important to mention that the immunotherapy might take up to 1 year to work.
Therefore, we should not expect an improvement after 2 months, 3 months, but may take up to 1 year, and it works in about 65% of patients. This is very important because client expectation and informing the clients about what they are doing is very important. You should not say the immunotherapy will fix the problem because it's not true.
It works in 65% of patients and it's reasonable if a client says, I don't want to do the immunotherapy because it's not going to be fully effective. It's better focusing the money and the attention on other types of treatment. And be realistic with the clients about what they do they should expect from every single treatment.
Now, if effective, the treatment should be for life. This is not always true. Ideally, we should stop the immunotherapy after 2 to 3 years because the immune system should have been taught how to respond to the different allergens, but this is not always true, and sometimes we have to continue for life.
And it's also true that in some cases we might have dogs that might develop new forms of allergies throughout their life. Therefore, a vaccination that was effective might become not effective at some point because the dog has developed new allergies, so we have to repeat everything from scratch, repeating blood tests, make sure that we don't have parasite infestation and all that sort of stuff, and then investigating again the allergens. Side effects are uncommon, but we may have injection site reaction, transient pruritus, but also more rare systemic side effects like vomiting, diarrhoea, and anaphylaxis.
It's always important that a patient is observed for at least 20 to 30. Minutes after the induction phase of the immunotherapy to make sure he is not developing any anaphylactic reaction because that is an emergency that requires steroids and requires all the adrenaline and the normal medication that we commonly use, so make sure that the clients are monitored after the injection. And in case a dog develops pruritus throughout the immunotherapy induction phase, first, this could be a good prognostic factor because it means that the dog might have a good response to the immunotherapy, and what we commonly do is give him some pyriton, and this way in this case it's justified because we have a type 1 hypersensitivity, so we have release of histamine the day before, the day of, and the day after the injection, and this should help to control the itchiness.
But let's quickly see how the immunotherapy works. If you remember, we had in the, in the first slides, we saw how the allergens are taken by the lung lung cell and then our. Are brought into the lymph nodes, we have a conversion of the T0 helper to TH1 and then we have all the mediator of the itchiness, but when we have immunotherapy, what happens is that we have also formation of the TRG and BRG cell, and in particular the BRG cell.
Are able via the plasma cell to produce not only IgE but also IgG and IgA that act as a blocker. Therefore, the allergens are taken from the I IgA and IgG, and they are able to block the binding towards the I IgE and therefore block all the pathway of inflammation that we commonly have. Now we're going to touch base very quickly on a case just to see how we should approach a patient with allergy.
Unfortunately I don't have a picture of this case. I'm sorry, but it's a quite nice and I would say something that we might see on a daily basis. This is a 4 year old male neutered Labrador called Charlie with a 2 year history.
Of pre skin disease. The skin disease resolved with the on and off administration of steroids and oral antibiotics on two different occasions, but there was all the time a flare, a discontinuation. It was done at serology, which was negative, was done at a trial with LZD but was not beneficial.
Now I say that LZDD is not one of my favourite foods. It's fine, in this case it was done. Sometimes we have to accept that client doesn't want to go again to the root of the foot trial, so I haven't done a foot trial in this patient, but this looked more a seasonal issue.
Therefore, I wasn't very worried about the food. The dog had widespread skin disease with crust, erythema on pin neck, axilla, groyne, abdomen, chest, and perineum, alopecia with scaling on the periocular area, muzzle and chin, had crust and epidermal colours on the dorsal trunk, and the paritus was 10 out of 10. What we do first is create a list of possible differential diagnosis.
We have allergy, superficial parderma, malaysia dermatitis, demodecosis, sarcoptic mange because we have a very high level of pleuratus. We have lesions on the ears, and sarcopter commonly cause lesions on the ear edges. The first thing, we may have dermatophytosis because we have rounded lesions that were expanding with crust.
I also put pemphigus. This is because pemphigus can create thick crust and scales, so it's always worth to include potential immuno-mediated disease when we talk about crust and scales, and then malassetia hypersensitivity as a potential differential. What we did, what was never done in the previous year, so taking samples to see exactly what do we have on the skin.
So despite the dog didn't show any signs of otitis externa, we took a neurocytology and we had presence of Malaysia. We, we did tape strips from different body areas which show moderate number of malassetia, neutrophils, and fucoccoid bacteria. We did a skin scrape, which was negative for Demodex.
We did hair plug, which was negative for Demodex, and there were no fungal elements. The hair plug may also help us to see if we have air intelligent allergen, if we have fractured tips that might suggest possible. Self-inflicted alopecia, we can check if we have other disorder of the melanin pigmentation in case of diluted coat colour and all this sort of stuff.
And then we did an intradermal test where we had a strong reaction to histamine and the malasitia, and this is interesting because the IGE serology was negative, but we had a positive intradermal test. So diagnosis came down to superficial poderma, malaysia dermatitis, bilateral malasitia otitis second to atopic dermatitis, and concurrent malasitia hypersensitivity. So what we did next?
We need to control the puritus, and in this case, the use of steroids is justified because we have a very intense and acute pruritus, so we have to control that pruritus. We did a tapering dose of steroids between 0.51 milligramme per cake.
Then, in this case, given the fact that the dog had a malasetza hypersensitivity, the use of oral hydroconazole was justified. So we started with the three weeks' course of 5 milligramme kilo of hydroconazole every other day. We started with some exotic inbo tears.
Disotic, we commonly use 1 pump 5 days on, 2 days off. This is because the gentamicin has a residual effect and therefore we always prefer giving 5 days on, 2 days off, and then repeat until the full bottle is finished. Then we did a Malaceb wash twice weekly for 3 weeks and Clarxium foam in between shampoo for 3 weeks.
Why we use Clarraxin foam? Because it's a 4% chloroxidin, so it's going to be effective also towards malassetia, contrary to a 3% chloroxidine which is present in the duoxo. Recheck.
We did a recheck after 2 weeks and the level of pruriuss reduced from 10 to 3/4 out of 10. This is because either the steroids, even if it was a tapering dose, but mainly because we controlled the malassetia. Malassetia produce lipase and other enzymes that cause pruritis.
Therefore, controlling the malasetia was the key point to control and reduce the level of prolitis below the threshold. And then we also had a resolution of the otitis externa and the skin lesions. We repeated the cytology, what we should do all the time to see the progress of the disease.
Are now the yeast infection, is now the yeast infection resolved? Yes or no. Without cytology, you will never be able to know this, and what we did in the long term.
We switched from the steroids to the Apaquel, we started immunotherapy. We continued with the mace, reducing to wash every 7 to 10 days. We also continued with the foam to the entire bodies 3 times per week, and we started the Cortavans as a long lasting, longer term proactive maintenance treatment, 3 times per week.
The dog was then rechecked after 5 or 6 months roughly. At that stage, the dog was already on quite long term on the immunotherapy, was on the maintenance phase, and what we started doing was start reducing the other medication, just keep the dog on the immunotherapy. And this is what allowed us to see is the immunotherapy actually controlling the allergy, controlling the molass overgrowth, yes or no?
If the answer was yes, then we're going to gradually stop all the medication and just keep on the immunotherapy. If the dog instead starts flaring, we can consider maybe continuing with the medication for a bit longer until we reach the full year of the immunotherapy and then start again with a dose reduction to see if the immunotherapy actually works. If after one year, the Level of pruritus and infection cannot be controlled only with immunotherapy, then we can assume that the dog falls in the 35% of patients that doesn't respond to immunotherapy and therefore we can focus our attention on topical treatment, on antipruritic medication, and on the systemic, on the systemic medical management of the allergy.
Now, before finishing, I want to just mention some key points that for me are very important, that diagnosing an allergy is a long process, it's a frustrating process and a confusing process for the clients. Therefore, you must be clear all the time in every step that you take. You have to inform the clients on what you are doing.
I know that it is time consuming. I strongly recommend and suggest to request at least. 20 minutes if not 30 minutes consultation for skin disease because they are long.
They will take more money in the long term because dogs need to recheck on a regular basis, but you need time to deal with the client and with the patient in the right way. Allergy is a lifelong disease, requires chronic multimodal management. That need to be tailored on each individual.
You cannot use the same treatment for every single dog. It's not going to work. Every dog is different.
Every dog has different needs, different infection, different requirements, different level of pruritus, different types of ear infection. Different types of anatomy, so you have to tailor your choice on the patient and the client that you have. Every client is different.
Every client wants a different approach. You need to be able to know all the different ways of approaching the patient and offer the best treatment for that client and that patient. It is important that clients know that flares are a common thing.
This will help us to be realistic about the expectation, increase the owner complaints, and also decrease the frustration and the complaint towards you. So it's very, very, very important to be clear with all these little aspects. Be clear about cost.
Allergy is for life. Cost could be quite high, so be clear on the cost, and referral at an early stage might also help to minimise the cost in the long term. Provide timelines to clients, be clear about the stage of diagnosis, treatment, and what needs to happen.
You need to be empathetic with clients. You need to try to create a sort of bond with clients to try to create trustness, and in this way, the clients will accept potential failure because they understand that this condition is difficult to manage and failures are expected to happen if you don't create this kind of bond. The clients will not trust you and then we leave, we'll complain, and everyone knows what's going to happen.
You need to recognise the client's. That they might suffer from overload of information, so try to be clear, try to give to to to handle some, reflect to them that explain what allergy is. Try to go step by step without throwing a lot of information at the same time because they will get lost.
You can give just brief information about everything at the beginning, but then you have to say. OK, now we need to focus on controlling the infection and the products. Next time, based on the outcome, we can start discussing about the food.
If the food fails, we can discuss about environmental allergens. If that is negative, we can discuss about other possible long-term medications. You need to have a step by step approach that needs to change based on the evolution of the disease.
It's also important to try to prize the clients, even if there are very small improvements. It's important to show them that they are doing a good job. They are taking care of the pets.
They are doing all the effort that they have to try to improve the situation, so try to. Be quite comprehensive towards clients because it's not easy washing a dog twice weekly, using foam every day, giving tablets, ear drops. It's quite frustrating.
It's quite difficult, so you need to understand also the client's perspective and try to empathise with them. And then be sure to talk to clients about the ongoing monitoring, blood works, depending on the drug that you use, the possibilities of repeating certain tests and all this sort of stuff. Now, I have finished my presentation.
I want just to inform you about a project. That we're doing between us at Davis and the Specialist Scotland dermatology centre in in Glasgow with Real canine about the use of food to try to control allergic signs in dogs with non-food allergy. If you are interested in this type of trial, you can contact either me or my colleagues in Scotland.
You can see all the details written here. What we do, the baseline of this project is to see if a dog has got a non-food allergy, are we able using a food containing natural products to control the inflammation and afford the need for the dog to require a certain type of medication. What we offer is.
After the first consultation, which will be charged as normal, we offer 6 months of free food, support from our study coordinator, 3 free of charge follow-up with sampling, and obviously we're going to share the data when everything is available. So if you want to have more information, if you're closer to Davis or Scotland, and if you want to have more information, feel free to contact either myself on this email address or my colleagues at this one. And they can give you more info about the inclusion criteria and what we need to, to, to, to know before enrolling a patient.
So I want to thank you so much, Mants for inviting me for this presentation. I know that I've been just beyond the time, but allergy is quite a complex disease that requires time to be discussed. I'm more than happy.
Answer any question if I'm not able to answer today, I will make sure that I will reply and just send everything to Kirsten so she will be able to to send a reply to the specific person that has brought to me. Thank you so much.
