“Perhaps I Wasn’t Clear”: Mastering Dermatology Communication in Trying Times

As more pet owners are working from home, they are spending more time with their pets and are noticing their pet is itchier or more uncomfortable than previously thought. Pruritus, allergic otitis, and recurrent superficial pyoderma will consistently flare if the underlying triggers are not identified and controlled. By focusing on client education and encouragement, you can have healthy patients and happy owners.

Pruritus, allergic otitis, and recurrent superficial pyoderma will consistently flare if the underlying triggers are not identified and controlled.

by Terri Bonenberger, DVM, DACVD

Is your practice seeing even more itchy dogs lately? As more pet owners are working from home, they are spending more time with their pets and are noticing their pet is itchier or more uncomfortable than previously thought.

Canine atopic dermatitis (CAD) is one of the most common causes of chronic pruritus and a challenging condition to manage, as it typically requires lifelong management by clinicians and owners. Pruritus, allergic otitis, and recurrent superficial pyoderma will consistently flare if the underlying triggers are not identified and controlled. The recurrence of symptoms causes clients to feel they are on a rollercoaster ride of highs and lows, leading to client dissatisfaction. However, by focusing on client education and encouragement, you can have healthy patients and happy owners.

Work to Elicit an “Aha Moment”

Oprah Winfrey made the term aha moment famous (it’s now included in the Merriam-Webster dictionary). It is defined as a moment of sudden insight, recognition, or comprehension leading a person to take a look at a situation in a completely different way. As a dermatologist, I want pet owners to have an aha moment that allows them to realize that dogs with chronic skin disease can lead a happy and fulfilling life if the condition is managed in the right way. The best way to do this is by explaining allergic disease in a clear way and setting clear expectations.

I find that the most aha moments occur when I explain to pet owners that CAD and human atopic dermatitis (more commonly known as eczema) are similar conditions. Many people already understand that eczema is a chronic, pruritic skin disease with waxing and waning symptoms. In addition, people with eczema are often prone to secondary staphylococcal infections, also a common feature of CAD.

Define What Success Looks like for Pet Owners

CAD is not a curable disease but is highly manageable. Success is achieving a balance between managing a patient’s itch level (an acceptable level of itch) and maintaining good quality of life for both patients and pet owners. CAD therapy requires a multimodal treatment approach that includes both short-term strategies (giving immediate relief) and long-term strategies (to decrease the frequency and severity of flare-ups over a patient’s lifetime). There is not a one-size-fits-all treatment plan; treatment must be individualized based on client commitment, abilities, and financial concerns.

A comprehensive treatment plan (multimodal therapy) must address:

  1. Pruritus: Anti-itch medications should be used in cases where the itching is deemed moderate to severe.
  2. Epidermal barrier dysfunction: Topical therapy should be used to keep the skin healthy and to prevent skin infections from recurring.
  3. Management of flare factors: This includes preventing fleas, addressing food allergy (if present), and performing allergy testing with allergen-specific immunotherapy (ASIT) to identify the specific environmental allergens. ASIT remains an important tool, as it is the only therapy that changes the long-term outcome of CAD, resulting in allergenic tolerance and reduced drug dependency.

Focusing on only one of these elements (such as anti-itch medications) leads to a patient who may still be prone to recurrent pyoderma or recurrent otitis. Failing to identify a food allergy or pursue ASIT may lead to a lifetime of drug therapy, with increased costs and potential for negative side effects long term.

Let’s take a look at the details of each of the multimodal therapy factors.

As a dermatologist, I want pet owners to have an aha moment that allows them to realize that dogs with chronic skin disease can lead a happy and fulfilling life if the condition is managed in the right way.

Pruritis: Determine an Acceptable Level of Itch

Dermatologists recommend using the Pruritic Visual Analog Scale to rate pruritus on a scale of 0 to 10, with higher numbers corresponding to higher severity of pruritic manifestations (0 is no itching, 10 is severe itching). Have clients assess pruritus at every visit or any time a clinical update is provided (for example, via phone or email). This allows assessment of clinical severity and whether current antipruritic strategies are working. Make sure owners are aware that a lack of response to a therapy is also valuable information!

An acceptable level of itch can be different for each owner, but I often suggest this is between 2 to 4 out of 10 on the scale. Clients should be educated that even with effective therapies, their dog may still experience some itching (“comfortably itchy” but without self-traumatizing or awaking the owner at night).

Topical Therapy to Improve Epidermal Barrier Dysfunction

As is the case for humans with atopic dermatitis, dogs with CAD have alterations to the stratum corneum (the skin’s outermost layer) that compromise the skin barrier and allow easier entry of allergens and pathogens (bacteria and yeast organism) into the skin. The skin is often dry and prone to inflammation. Topical therapy can have a direct, soothing effect on the skin, physically remove surface allergens, and increases skin hydration.

In general, weekly bathing with antimicrobial products is recommended. Antimicrobial combination products (2–4% chlorhexidine with 1–2% miconazole or climbazole) are most commonly recommended in dogs with recurrent pyoderma or Malassezia dermatitis. Unfortunately, not all dogs can be bathed easily or frequently.

Have you ever tried bathing a golden retriever or husky, only to find that their thick coat of hair was impenetrable to water? Ever had a client who could only bathe their dog outside during warm-weather months or an elderly client who found it difficult to bathe their dog? As clinicians, we need to be creative!

Fortunately, there are a variety of topical products of (antimicrobial sprays, mousses, rinses, and wipes) that can be used instead of bathing or in between baths to complement shampoo therapy.

Get Creative

  • Encourage frequency through “spot bathing.” This is perfect for skin fold dermatitis (ventral neck is common) or dogs whose dermatitis primarily involves the ventral surfaces (often nonhaired). A shorter contact time (five minutes or so) can make it easier and less time consuming for owners, making this therapy more viable long term.
  • Apply sprays or mousses one to two times daily to affected areas between baths. This can help to extend the benefits of a bath and is a good technique to treat mild cases of superficial pyoderma or Malassezia dermatitis. When applied to problem areas several times weekly, it can be a good way to prevent recurrent infection. It also promotes good antibiotic stewardship. For dogs who are frightened by sprays, mousses can be a great option.
  • Medicated wipes are most effective for removal of debris that accumulates within fold areas (lip fold, facial folds, or tail folds).

Highly Effective Drugs for Remission and Management of CAD

Inducing immediate relief: “Get control”

Long-term management: “Keep control”

Oral and/or topical glucocorticoids

Oral and/or topical glucocorticoids

Oclacitinib

Oclacitinib

Lokivetmab

Lokivetmab

delete

Modified cyclosporine

delete

ASIT

Management of Flare Factors

Most dogs (even well-controlled atopics) will experience flare-ups, even when receiving proactive management. Common flare factors include flea exposure (with or without fleabite hypersensitivity), environmental allergens (increase in seasonal allergens), bacterial or yeast overgrowth, and exposure to food allergens. In most cases, oral flea preventives are preferred, as efficacy is not reduced with frequent bathing.

The Task Force on Canine Atopic Dermatitis recognizes a relationship between food allergy and CAD. Some dogs with CAD exhibit flare-ups when exposed to certain food allergens. Make sure to eliminate concurrent food allergy with a strict hypoallergenic dietary trial (followed by provocative challenge) in any dog with nonseasonal symptoms; these dogs may or may not have additional gastrointestinal signs (soft stools, vomiting, diarrhea, or increased fecal frequency).

Final Thoughts

The management of CAD is challenging because it is chronic in nature and not all therapies are equally successful. Effective communication by the veterinary team lays the groundwork to show clients that successful management generally requires several follow-up visits. However, in cases where the client is not seeing improvement, it may be time to see a veterinary dermatologist. The goal of early dermatology referral is to prevent prolonged discomfort and the irreversible pathogenic changes that accompany chronic allergic disease. Involving a specialist early can not only help diagnose and resolve the problem earlier but also potentially save the pet owner money in the long run. 

Veterinary Technicians Play a Key Role in Dermatology Communication

We know as veterinarians that effective management of allergic skin disease often requires pet owners to follow what can be a long list of treatments that include multiple oral medications, a variety of topical medications, and strict diet changes. These recommendations affect an owner’s lifestyle and interaction with their pet. If owners can clearly understand the importance of each therapy choice and be involved in the decisionmaking process (especially regarding options for flea control and performing a diet trial), then compliance is more likely.

Veterinary technicians are our liaisons with pet owners, and they play an integral role in facilitating these therapies. They are on the front lines—talking to owners in the exam room, taking clinical updates, and fielding questions from frustrated pet owners. Here are five ways that technicians can facilitate successful dermatology outcomes.

  1. Take a thorough dermatology history before all exams. These exams should focus on current itch level (0–10), review of therapies, and owner’s perception of whether a given therapy is helpful. Do not assume medications or topical therapies are being used as prescribed. If possible, use of a dermatology questionnaire is recommended for the initial dermatology exam to guide discussion. A technician’s history is important, as it can identify client concerns that may not be obvious. These include concerns that a client may be reluctant to bring up to the doctor (medication costs, lack of treatment response, pet’s quality of life, and so on).
  2. Evaluate skin scrapings, skin cytology, and ear cytology (the dermatology database). Training technicians to perform these tests increases a doctor’s efficiency and improves time management. While the technician is analyzing and recording these results, the doctor has additional time with the client to address questions and concerns.
  3. Educate clients on how to perform the perfect hypoallergenic diet trial. Diet trials are time consuming and labor intensive, and they can be an expensive part of a dermatology workup. Clients become frustrated when they find out time and money have been wasted because they did not perform a trial correctly. Technicians play an important role by informing owners that nothing should be ingested by a dog on a hypoallergenic diet trial except the food and approved treats the veterinarian has recommended.
  4. Educate clients regarding ASIT vaccines (sublingual or injectable) and the immunotherapy schedules. This is a long-term therapy that can require up to 12 months for the maximum benefit, so clients need to understand how this therapy works. This also provides another opportunity to answer questions regarding short-term and long-term goals for the treatment of CAD.
  5. Review the patient’s discharge summary at the end of an appointment and provide additional informational handouts if available. This includes a point-by-point review of recommended medications (and potential for negative side effects), topical therapies, and diet recommendations. This is a great time to review techniques for ear cleaning and application of ear drops. It is during this time that there is an additional opportunity to identify any concerns or confusion a client may have before walking out the door. Lastly, make sure the technician or client service representative works with the owner to forward-book the next appointment so you can recheck, reassess, and review!
Terri Bonenberger, DVM, DACVD consults, writes, and lectures nationally and internationally. She is a co-owner of Canine Skin Solutions, a skin-care line for dogs with allergies, and practices at Southeast Veterinary Dermatology in Charleston, South Carolina.

 

Photo credits: ©iStock.com/pomerphoto, ©iStock.com/razyph, ©iStock.com/dimarik

Advertisement

Close

Subscribe to NEWStat