Whenever a dog with dermatosis drops by the clinic, I always hint that their utmost patience will be appreciated, while giving them a benign precaution that the dermatologic workup is time-consuming, laborious, and costly. If I’m put in a negative light by my inability to cure an animal’s dermatosis instantaneously is of no consequence to me, as long as my approach is methodical and consistent with current therapies in Veterinary Dermatology.
If a client wants to start treatment immediately, I provide these three things, but only with thorough explanation and a precaution that these should be done only with prior consult.
1. Treatment that provides relief, if not cure, for suspected skin infections. I remind clients to strictly follow the prescribed duration and interval.
2. Treatment for suspected parasites that burrow under the skin or are present externally. Of course, I also insist on testing for what may not be readily visible.
3. Antihistamine therapy for serious itching, contact allergies, or post-vaccine reactions. This treatment is given under strict supervision.
Practice makes perfect
European dermatology veterinarians say that dermatology has changed and must no longer be based on pattern recognition alone. It’s often said in clinical symposia and veterinary conferences that dermatology leaves no room for intuition but must be based on a step-by-step approach and practiced with patience, method, and time, according to a 2011 compilation on itching in dogs published in Veterinary Focus.
I must beg to differ, but not necessarily disagree. There is neither enough time nor resources for people caring for sick dogs to be patient, and most don’t come back if there’s no strong palliative (defined as something intended to make a bad situation seem better but doesn’t really improve the situation, according to Merriam and Webster).
Palliative care is focused on providing relief from the symptoms of a serious illness, and the goal is to improve the quality of life of both canines and their humans. But in their eyes, especially in the context of a developing country, a series of trips to the clinic as a vet tries to systematically rule out different conditions using a step-by-step approach is profiteering. A pressured veterinarian is then left with approximately ten minutes to cram the whole diagnostic process.
It is an undeniable fact that health professionals sometimes struggle with diagnosing patients based on pattern recognition. A bad working diagnosis may lead to catastrophe, which was what happened to me. I was initially diagnosed with primary idiopathic epilepsy, but after a CT scan upon being rushed to the ER of a government hospital, I was thought to have a tumor. Another scan, this time with contrast, led to a new diagnosis: arteriovenous malformation in the brain.
While brain disease is nowhere near dermatosis, diagnosing both can be rather challenging. Vets, just like doctors, want what’s best for a patient. It’s a good thing that while neurologic diseases are potentially fatal, dermatologic diseases are usually not.
Going back to dogs whom I treat for the first time, I would suspect them to have mange, based on the history and regardless of their breed, as long as they have been in contact with animals that have familiar, suspicious-looking lesions in locations where mange has a predilection to occur; exhibit an itch-scratch cycle; show a stereotypical motor response induced by cursory palpation in the absence of sophisticated equipment; and show typical results in equally important tests, such as microscopy. After all, microscopy is the most basic of all tests, encompassing parasitic, bacterial, fungal, and yeast dermatoses.
I may not necessarily disagree, but I differ from authorities in their approach, even as they use peer-reviewed journals and textbooks. Whenever I use the empirical approach in treating what I deeply suspect as sarcoptic or demodectic mange, there are good results.
Furthermore, if a client is unwilling to go along with an opinion that entails more expenses, I usually end up relying on intuition, which many may frown upon. This allowed me to successfully treat one patient originally diagnosed with an endocrine system condition called Cushing’s disease; as it turned out, it was simple sarcoptic mange. Too bad there was already so much weight gain by the time I saw them, because of previous steroid therapy.
There was a good response to a macrocyclic lactone given orally for a month, resulting in complete healing.
Coming to a diagnosis
VisitSome may say that many skin conditions look the same as there is little opportunity for the skin to respond, but if the skin has had time to recover after treatment, then even chronic skin infections or intermittent reinfestation should not look the same. If an animal stops scratching for some time, the lesions heal and will not look the same.
There is usually a secondary infection, perhaps bacterial or fungal in nature, with the latter resulting in a “smelly sock” odor.
A thorough history should include details pertaining to diet, such as protein sources, dog food brands, amount of food, and table scraps given. Skin scrapings can be done routinely and taken from multiple sites to ensure adequate sampling that includes both healed and raw lesions. Preliminary tape cytology and Wood’s lamp test may be followed by more cytology workup and more definitive colorimetric dipstick tests for fungal infections. Lastly, skin biopsies and intradermal skin testing should be done last, as they may be expensive and require expertise for accurate results.
Pattern recognition may be flawed as an approach as the skin condition may relapse in the future, which can spell disaster for the veterinarian-client-patient relationship. Simply put, a client’s confidence in their vet may dip, potentially undoing already-established rapport.
If the problem is not serious, no treatment is necessary. If, however, the skin lesions are severe, they necessitate intervention; otherwise, further skin injury and even loss of hair is possible.
Word of caution
The use of crankcase oil as a skin treatment is too anecdotal — its safety and efficacy are still unproven. I once had a weeping client who dragged me to their house to resuscitate a dying dog due to apparent toxicity to crankcase oil after it was absorbed through the skin, especially with the presence of open lesions.
Unfortunately, it was too late to save the canine. To prevent such a mishap, I advise others to ask, “Is this safe?” Then, “Is this effective?” Treating without vet advice comes with risks, so please ge to a board-certified veterinarian for competent care, especially with skin concerns.
This appeared in Animal Scene magazine’s March 2019 issue.