The First Visit: Allergic Skin Disease
An itchy dog presents an incredible opportunity for veterinary practices to make a lasting impression.
Year after year, veterinary clinics have a pretty clear-cut leader at the top of the rankings. Skin conditions are the No. 1 reason that dog owners take their pet to the veterinarian, said Andrew Hillier, BVSc, Dipl. ACVD, director of dermatology medical strategy, Zoetis. “Specifically, it’s allergic dermatitis. It’s been that way for a number of years and it’s not going away anytime soon.”
Indeed, allergic dermatitis is a huge issue for dogs, in part because of the popularity of certain breeds. Golden retrievers, Labrador retrievers, French and English bulldogs, “all of these breeds are highly predisposed to allergies,” said Dr. Hillier.
Treating allergic skin disease
In the field of veterinary dermatology, about 80% of the cases seen are allergic skin diseases, said Amelia White, DVM, MS, DACVD, assistant clinical professor of dermatology at Auburn University’s College of Veterinary Medicine. “The remainder of the cases we see are autoimmune dermatoses, neoplasia (cancer), and infectious diseases.” Most veterinary dermatologists see primarily dogs and cats, and some will also see horses, farm animals, and exotic animal species.
In general practice, studies have estimated that skin diseases rank in the top three most common reasons people take their pet to the vet, White said. “As the awareness of the specialty field of dermatology grows, clients are increasingly self-referring or asking for a referral to a veterinary dermatologist. Additionally, public advertisements for new allergy medications on television and the internet is contributing to clients’ awareness of allergies.”
There are so many options for treating allergic skin disease in pets. Some of the options have been around for decades, while others are newer to the pharmaceutical market.
In general, the approach to allergies in pets takes on two major avenues, said White: 1) treating the allergy directly, and 2) treating the clinical signs of the allergy (sometimes referred to as symptomatic or supportive care).
Direct allergy treatment involves first making the correct diagnosis for the allergy itself since there is more than one type of allergy in pets, White said. “Most commonly, pets are allergic to insect bites and environmental allergens (referred to as atopic dermatitis). Less commonly, pets may be allergic to an ingredient in their diet (referred to as adverse food reaction, or simply food allergy).”
White said that food allergies are a simple fix as long as owners can identify the offending food allergens and avoid them. “This is most commonly achieved by feeding a veterinary prescription diet that is restricted in ingredients.”
However, insect bite allergies and atopic dermatitis
are much more challenging to treat since it can be more difficult to eliminate and/or prevent exposure to the offending allergens. Insect bite allergies are controlled through the use of strict ectoparasite prevention programs for the pet and the household environment, White said. “By preventing the insect from biting the pet, the clinical signs of itchiness and dermatitis are avoided.”
Atopic dermatitis treatment is centered around reducing the over-abundant inflammatory reaction to environmental allergens through the use of allergen-specific immunotherapy. “Serology (serum allergy testing from a blood sample) or intradermal allergy testing are two diagnostics used to identify the offending allergens for the pet, and then these same allergens are injected under the skin or administered orally to the pet to desensitize the immune system,” White said. “This therapy is one of the safest allergy therapies to consider since treatment for atopic dermatitis is life-long. Allergen-specific immunotherapy is not appropriate in every case depending on the client and pet factors, and these should be considered prior to making the decision to perform serology or intradermal testing.”
Symptomatic therapies to treat the clinical signs of the allergy including itchiness and inflammation of the skin are much more diverse in options. “The trick about these therapies is that they vary in efficacy, safety, and duration of activity,” White said. For all of these therapies, the clinical signs of the allergy usually return shortly after stopping the therapies, which requires that these therapies are used consistently and long-term for maximum benefits. If the therapies are discontinued, the clinical signs of the allergy will return nearly immediately. Some of these therapies have higher safety profiles and are safer for long-term use, while others could pose a significant health risk to the pet if used for the duration of the pet’s life especially at high dosages and increased frequencies.
Traditional therapies such as oral omega fatty acid supplementation, antihistamines, glucocorticoids, cyclosporine, specialized diets, and routine topical therapy continue to be used frequently and with success in allergy cases, White said.
The two newest drugs to the market are APOQUEL (oclacitinib) and CYTOPOINT (interleukin-31 antibody therapy). These medications work differently but have the effect of reducing itch in the dog. These drugs are approved for use in dogs only, so newer allergy therapies for cats are lacking, White said. Both of these drugs carry a high safety profile for short-term and long-term use in dogs.
Too many remedies?
There is an enormous number of choices when it comes to products available claiming to help treat allergic dermatitis, from over-the-counter products to prescription products. “It’s confusing for pet owners and also veterinarians,” said Hillier.
Treatment almost always starts before a visit to the veterinarian. Hillier points to market research that shows almost 9 out of 10 people tried at least one OTC product before they ever go see a veterinarian with an itchy dog. “In fact, some people have tried up to 15 over-the-counter products,” said Hillier. “That’s unfortunate. While you may get short-term, temporary relief from some over-the-counter products, they don’t really provide a satisfactory and effective solution.”
Hillier said many veterinarians may not recognize the vast majority of dog owners who are bringing their dog in with allergic itch have already tried over-the-counter products. In addition, in the beginning, the itch is usually not too severe. Thus, it’s tempting to try things like antihistamines, shampoos, sprays, and lotions. The mindset is “because the dog doesn’t have a severe disease yet, it’s not the end of the world if we don’t succeed, because it’s not a train wreck.”
However, “that first visit is an incredible opportunity”, said Hillier. “We fail to recognize the urgency of itch. It’s not an emergency of course – the dog is not going to die in the next 24 hours if we don’t provide relief. But, consider that the owner has been watching this progress and feels strongly enough about it to take time out of their day to come into the veterinary clinic. They are looking for relief for their pet. They want life to get back to normal. They don’t want that to happen in a few weeks or a few months after the spray or lotion or antihistamine failed to work. They’ve already tried most of those remedies.”
The veterinarian has an opportunity at the very first visit to wow the owner. “Provide that pet with the relief they deserve,” Hillier said. “Get life back to normal. Help the owner get away from the emotional roller coaster of concern, worry, and confusion about why their dog is itching.” If it’s 24 hours after the visit to the veterinarian and the dog has slept all night and is comfortable, then you are giving them a positive experience because you provided a solution. “You’ve now got an owner who is so grateful, who trusts you, who will be loyal to you, and who will accept the recommendations you have for the health and well-being of their pet,” he said.
Cost concerns are always an important piece of the puzzle when developing treatment plans for pets. Financial limitations are more prevalent in certain geographic
regions and demographics as compared to others.
White practices in a rural area, so she frequently encounters this as compared to some of her colleagues living in urban areas “where clients don’t even seem to read an estimate before handing over the credit card,” she said. “It is important to have a good understanding of your common clientele challenges, but also it is important not to make assumptions.”
The cost of services will not always align with the perceived client value. “I have found some of the most seemingly unlikely clients are the ones most willing to provide care for the pets no matter the cost,” she said. “I think it is absolutely necessary that we discuss the costs of services with every client, and let them be the deciding factor about the perceived value of those costs. If you have taken the time to build a foundation of trust with the client, then the client will tell you honestly if the perceived value is too low to justify spending the money for that service. Let them decide if they can afford it.”
Dermatological conditions usually are lifelong, so veterinarians should discuss realistic short-term and long-term expectations of care, White said. There are so many options for managing allergies in pets that you can almost always develop a care plan that works for that pet and that client.
Hillier said he believes the cost issue is more in veterinarians’ minds than it is in many pet owners’ minds. “I’m not forgetting that for some people there may be financial limitations,” he said. “But there is research showing that 8 out of 10 owners would accept the recommendation for a test or a treatment if the value of the test or treatment was made clear to them. Not the actual dollar cost, but why it’s the best thing to do and what it will mean for them and their pet.”
There is no point in holding back treatments like APOQUEL and CYTOPOINT until things have worsened or as a last resort, Hillier said. “We should provide the best medicine that provides rapid, effective, safe relief from allergic itch from the beginning,” he said. “That’s what the owners want, and I think we need to recognize that.”
How people feel about their pets has changed, even over the last five years, said Hillier. “Pets are part of our lives. They sit with us while we watch TV. They sleep with us. They go on vacation with us. We talk about ‘pet parents.’ If we’d used that term 10 years ago people might have thought we were a little crazy. But that’s the truth now. Pets are valued members of the family.”
Hillier said he believes pet owners are not looking for second- or third-rate treatment, or just something that is cheap: “They want what’s best for their pet’s health. They are committed and expect to be offered the best.”
It is important to recognize how communication with clients has changed. In the past, it was expected that the veterinarian knew best and would tell owners what had to be done. “Now it’s really a partnership,” said Hillier. “There’s a relationship that we have. How we communicate is incredibly important. They want to hear the options and what value each option brings to them and their pet. Once we come to a decision, we make a firm recommendation with validation, like ‘That is a wonderful choice. Here is how we are going to start that treatment.’”
When veterinarians say their clients have money issues and won’t accept recommendations in terms of best medicine or diagnostics and services, it may be “because we haven’t framed the recommendation correctly and told the owner ‘why’ this is the best treatment for their dog. It’s really important – we don’t always get taught this at veterinary school so it’s not intuitive.”
As scientists, veterinarians tend to be a little black and white. So they may say something like ‘Your dog has allergic dermatitis, I can give an injection of CYTOPOINT that will cost $95 and it lasts for 4-8 weeks,’” Hillier said.
While that statement is true, veterinarians need to translate the benefits to the owner. “It would be far better to say ‘An injection of CYTOPOINT that I can administer in the clinic now, will start working within a day and will keep your dog comfortable for the next 4-8 weeks. Apart from not having to worry about the itch, you are also not going to have to worry about administering medications, and remembering to do it every day.’”
Hillier said framing the recommendation that way creates value for the owner. “You’ve told them very clearly that their dog is going to be comfortable, and quickly, and neither the itch nor the treatment is going to disrupt their lives.”
Achieving the solutions and outcomes that we all want is about advocating for best medicine and communicating in a relationship based on a partnership between veterinarians and pet owners, he said. “That’s when we all win – the pet, the owner, and the veterinary practice.”
White said she does not think there are a lot of extremely successful home remedies for animals with moderate to severe allergies. But, pets with milder forms of allergy do have the potential to improve with minimal intervention.
“At-home remedies that most of my clients have attempted prior to bringing their pet to the vet include oral omega fatty acid supplementation (fish oils), supplements, dietary modifications, antihistamine therapy, and topical therapies (primarily oatmeal shampoos),” she said. “Other clients remove upholstery from the house when they can, such as drapery, carpets, and replace pet bedding. Some clients install HEPA filters in their homes, and I even once had a client replace all living grass in the yard with astroturf!”
For the most part, clients tell White that these environmental changes provide the pets with some relief, but not enough. “Or, occasionally a client will tell me that these modifications seemed to make a significant difference initially, but then stopped helping over time. This is not unusual, especially since allergies tend to become more severe with time and continual exposure to the allergens.”
When Dr. Google falls short
“While it can be very off-putting when a client tells us they did internet research and they know XYZ to be true since they found it online, I think it is important for us as vets to take a step back and consider the bigger picture in these moments,” said White. “Clients turn to the internet because there is a plethora of information there at their fingertips that is quickly accessible. Some of that information is reliable, and much of it is not. But what we need to think about is the client’s goals in the process of seeking information.”
It all boils down to they are worried about their pets and trying to take care of them, White said. “Ultimately, the client came in to see you, so there is some degree of expertise you as the vet have to offer that the internet could not. Be curious to understand what problems the pet is having and what information the owner is seeking. Explore the options with pet owners and offer them reputable online resources to turn to in the future. By showing curiosity, empathy, and concern for their pet, you will build trust with clients and assist them in improving their pet’s condition.”
Sometimes the advice pet owners get online not only fails to help alleviate the problem but can actually do harm. Some of the worst online advice White has seen that results in harm to the pet includes using garlic to prevent fleas (garlic is toxic to pets), instill hydrogen peroxide or rubbing alcohol into the ear to treat ear infections, and putting old automobile oil on pets to treat for presumptive mange. “Usually these practices can worsen the dermatology problem and increase the discomfort of the pet.”
Photo credits: istockphoto.com/cmannphoto, istockphoto.com/KruPichai; istockphoto.com/mladenbalinovac, istockphoto.com/MachineHeadz