The complex relationship between canine skin disease and behavioral change

For veterinary professionals, the connection between a dog’s skin and behavior can often be witnessed in practice daily.

Some of the  obviously related behaviors would include a dog incessantly licking its paws or keeping their guardians up all night scratching. Other behaviors reported may not immediately suggest skin problems, such as irritability, increased anxiety, or even aggression—but it’s possible for any of these behaviors to be traced to inflammatory skin disease.

The question often raised is: Are these dogs predisposed to both dermatologic and behavioral issues, or does the relentless discomfort of conditions like canine atopic dermatitis (CAD) actively create behavioral change?

Recognizing when behavioral change may be caused by an undiagnosed skin condition is key. It determines whether to prioritize dermatologic investigation, seek behavioral support, or bring both disciplines together in a collaborative approach from the very beginning.

The link between pruritus and problem behaviors

Studies have established a clear association between chronic skin disease, specifically chronic pruritus, and negative behavioral changes in dogs.

A 2022 study published in the Journal of the American Animal Hospital Association, co-authored by veterinary dermatologist Lindsay McAuliffe, DVM, behaviorist Colleen Koch, DVM, DACVB, and researcher James Serpell, Professor Emeritus of Animal Ethics and Welfare at the University of Pennsylvania, found that chronically pruritic dogs experience fear and anxiety and are more likely to display aggression. The data pinpointed increases in stranger-directed aggression, dog-directed fear, non-social fear, and touch sensitivity.

This aligns with other findings. A 2024 review, published in Veterinary Medicine: Research and Reports, examined existing work showing that fear, anxiety, aggression, and decreased trainability are commonly reported behavioral changes in dogs with canine atopic dermatitis.

Even more concerning is how a pet’s quality of life is affected by changes in activities such as playing, walking, and sleeping. Sleep disruption, a known consequence of pruritus, is particularly important as chronic sleep disturbance is linked to irritability and reduced learning.

McAuliffe explains that these serious symptoms are often underrecognized by pet caregivers. “It dramatically affects their quality of life. And I think because animals can’t talk and people generally don’t know how to read body language or interpret behaviors, they just don’t see it. So, I think the urgency is not there.”

She notes that these behaviors may appear over time and become more serious, eventually becoming the reason a dog is presented at the clinic. The owner may have never connected the behavior changes with illness or other physical changes.

Because these behavioral changes may have existed for a long period of time, it may not be until the dog has been treated for their pruritus and begins to recover that the extent of the distress becomes clear. “The clients don’t even necessarily realize how dramatic the behavior changes are until the dog feels better,” she said.  “And then, you know, [they’re] acting like a puppy again. [They’re] playing with toys that [they haven’t] played with in three years.”

The itch-stress behavior cycle

Persistent pruritus is extremely uncomfortable, leaving the dog in constant physical irritation, causing disrupted sleep and fatigue, which gradually reduces their ability to cope and behave normally.

“These conditions obviously make many of these animals quite miserable. It must be just like hell on earth to have these chronic skin conditions that make them uncomfortable all the time,” says Serpell.

Koch agrees and goes on to explain how discomfort can escalate. “When your largest organ of your body is miserable, you’re going to be more irritable. So, you’re going to be more aggressive. Your fuse is going to be shorter. You’re just not going to have the tolerance for things that you did before.”

The discomfort from itching can easily escalate to pain, says McAuliffe. “The [neuronal] signaling is really, really close together and it’s super hard to tease them apart. There are definitely some receptors that are pain-specific and some that are itch-specific, but there’s so much overlap between the two.”

The neuroimmune pathway helps explain this biologically, with cytokines acting directly on sensory neurons to produce the sensation of itch. The ensuing scratch cycle causes more inflammation and more itch, creating a self-reinforcing loop of physical discomfort and neuronal signaling.

A distressed patient

When this sensory distress is ongoing, it does not remain a purely physical experience—it can also affect the dog’s emotional state. This state of neuroinflammation and chronic sensory distress is a recognized contributor to stress-related behavioral changes. Clinical animal behaviorist Helena Woodfield, ABTC-CAB, APBC, describes it as a “causal loop”: “It’s like cyclical looping, self-reinforcing, but not reinforcing in the same way as a compulsive [behavior].”

The whole view of a dog in this context must move away from a “problem dog” to a “distressed patient.” Addressing the pain and discomfort must be a priority if the dog is going to be treated successfully. If the dog already has a history of fear and anxiety related to the caregiver, to being touched, and potentially to the intensive treatment that is likely to be necessary, both the dog and caregiver will need support.

Woodfield emphasizes that when stereotypic/repetitive behavior is present, the inclusion of behavioral medication should almost always be considered, as the aim is to modify patterns that have become deeply learned and reinforced. Simply preventing the dog from performing the behavior is neither realistic nor humane, as it represents a well-established coping mechanism. Instead, treatment should focus on expanding the dog’s behavioral repertoire, enabling greater cognitive flexibility and providing access to alternative, more adaptive responses.

Behavior as a clinical sign

Given the strong link between pruritus and behavioral change, the question for practitioners is often one of origin. Is the behavior a clinical sign of skin disease, or does a predisposition to anxiety manifest as dermatologic illness?

This distinction may be further obscured when reported by caregivers. They often assume that licking and chewing are the result of boredom or anxiety rather than recognize them as potential signs of pruritus.

Available evidence indicates that behavioral change usually follows skin disease, while recognizing that underlying anxiety can complicate some cases.

A 2019 study from the School of Veterinary Medicine and Science at the University of Nottingham examined dogs diagnosed with atopic dermatitis and found that as itch severity increased, so did the frequency of behaviors such as hyperactivity, excessive grooming, attention-seeking, and reduced trainability compared with healthy controls. These associations remained even after accounting for age, sex, breed, and other health factors. The authors suggested that these behaviors were better understood as responses to chronic discomfort and stress, rather than evidence of a primary behavioral disorder.

In practice, this is consistent with the behavioral improvement often seen once pruritus is brought under control, supporting the view that behavior functions as a clinical sign of the disease itself.

There are always nuances. Dogs with a predisposition to anxiety or compulsive behaviors may experience a more severe behavioral deterioration from pruritus.

Furthermore, a 2015 study at Tufts University showed there are genetic predispositions in some breeds such as German shepherds, bull terriers, and Dobermans, which would make it more likely that stress may be directed onto their own bodies. This is where Abnormal Repetitive Behaviors (ARBs) like excessive licking, chewing, or flank sucking can complicate diagnosis and therapeutic decisions.

In such cases, treating the skin alone may reduce the trigger, but additional behavioral support is often needed to fully resolve the cyclical pattern.

Woodfield illustrates this process with one of her cases in which a dog with a predisposition to itch-related behavior developed a pattern of foot chewing as a response to discomfort and stress. Although dermatologic treatment resolved visible skin inflammation, the dog continued to focus intensely on chewing one foot, particularly during periods of increased stress or behavioral arousal.

Tracking revealed a consistent association between emotional challenge and chewing behavior, suggesting that an initially pruritic response had become a learned coping strategy. In such cases, Woodfield notes, it can be difficult to distinguish persistent subclinical pruritus from a behavior that now functions primarily to regulate emotional distress.

Woodfield emphasizes the need for ongoing behavioral monitoring. “We can see that there’s a correlation between him experiencing stress, being more vocal, or being more behaviorally challenging, and him doing the chewing. It’s really hard in that scenario for us to actually pinpoint whether that’s either a learned coping strategy to chew his foot, or whether there is any residual itchiness there.”

This diagnostic uncertainty highlights the importance of continued dermatologic involvement alongside behavioral intervention. Where pruritic and stress-related drivers cannot be clearly disentangled, ongoing dermatologic support is necessary to address potential residual inflammation while behavioral strategies are implemented.

The case for early clinical intervention

McAuliffe finds that many clients come in and say their primary veterinarian never mentioned seeing a dermatology specialist. “Early referral is what we harp on all the time. Just offer it to your client, document it. They don’t come, they don’t come, but at least you told them.”

Regardless of the origin, the behavioral impact is a serious welfare and clinical concern. Clients consistently report that behavioral and mood changes are the most affected quality-of-life issues for their dogs. While behavioral problems are a leading cause of euthanasia generally, the 2024 review cited previously suggests CAD-associated behaviors are often perceived as manageable, suggesting that dog caregivers want to find solutions. This perspective is reflected not only in welfare reporting, but also in how clients are willing to invest in treatment.

The economic data underscores this: 2025 research indicates that clients prioritize care for discomfort and support for behavior problems associated with CAD; nearly half were willing to pay extra specifically to improve pruritus-related scratching.

Koch believes that to address behavior, pain and inflammation must be considered a priority. “I treat the pain because the pain is the big thing for all of these guys. The pain is from inflammation. So, we need to treat the inflammation first and foremost. If we can get that to stop or be minimized, then we can work on some other things.” This gives caregivers the opportunity to help prepare the dog emotionally for treatments that may create conflict, such as bathing.

The dog may already be sensitive to touch and even aggressive, and those behaviors are often misunderstood prior to diagnosis. She recommends “going slow” and reframing the situation from a dog being “stubborn” or “difficult” to recognizing that “this animal is really hurting and they’re afraid.”

She notes that well-intended handling can cause further distress and suggests that anxiolytics are sometimes useful alongside addressing inflammation and proceeding gradually. As she points out, most owners are not prepared to become de facto trainers or groomers, highlighting why professional behavior and training support are so important.

Integrated care is the ideal

It is clear that dermatology and behavior are both involved in chronic pruritic disease. Success is more likely with an integrated strategy from the first consultation.

Serpell explains what this can look like. “I really think every veterinary practice should have some kind of close relationship with behaviorists in their area. It may not be necessarily a board certified veterinary behaviorist but there are good trainers out there who understand these basic principles of classical conditioning,” he said. These professionals can help with “setting up positive reinforcement for the kind of behaviors that you want the animal to show and to develop tolerance in the animal to these sorts of aversive treatments.”

McAuliffe adds getting the inflammation and pain under control before a referral appointment can make a huge difference, especially when ears are involved, because it can be impossible to examine the dog otherwise. “These dogs are so painful. We’ll get the referrals and we’ll reach out to say, ‘Please put this dog on prednisone prior to the appointment so that the inflammation and the swelling is under control, so they’re actually amenable to us examining them.’ And even then, nine times out of 10, they’re still too painful and we’ll usually start gabapentin for chronic nerve pain.”

Creating a clinical framework for helping dogs’ behavioral problems related to CAD does not have to be complicated:

1. A comprehensive dermatologic workup is nonnegotiable for any dog presenting with new or exacerbated self-directed behaviors or negative behavioral changes. Assume the skin is the cause until proven otherwise.
2. Make simple questions about sleep, reactivity, anxiety, and tolerance for handling a standard part of every dermatology history. Use tools such as the Pruritus Visual Analog Scale (PVAS) which captures behaviors like licking and rubbing.
3. The treatment plan must target both the neuroinflammatory itch pathway and the resulting behavioral distress. This often means medical and behavioral support.
4. Prepare the caregiver so that they understand that treatment itself (bathing, ear cleaning, topical application) can be aversive. Proactively provide clients with access to guidance regarding structured, reward-based protocols to build tolerance. This prevents treatment from becoming a fight and, instead, helps it to become a predictable, cooperative process.

Predictability in practice

That predictability is vital to reduce anxiety during the treatment period, and it is so important to reduce any fear the dog has of the people who are providing that treatment.

Woodfield shares some good advice to give clients: “If you’re in a position where your dog needs to suddenly have a lot of baths, we need to make that a really predictable process and introduce something good alongside it. So obviously it’s going to be a not nice thing for them, but what we want is that it’s a super clear thing. So, it’s never a surprise. It’s never something that we’re just dropping on them. We’ve got our protocol, we go through the protocol, and then they get to opt out of it at the end.”

In practice, this might mean that each bath follows the same sequence, every time. For example: the dog is brought to the bathing area in the same way, given a predictable cue that the bath is about to start, and paired with a consistent positive experience throughout. Koch suggests placing a non-slip mat in the tub, as slipping can be a significant source of anxiety, and recommends using peanut butter or another easily spreadable food along the edge of the bath. She also advises using only a small amount of water with shampoo mixed at the bottom of the tub, and for dogs that find the shower spray aversive, using pitchers of water instead.

Once the final step is completed, handling stops and the dog is given a cue allowing them to disengage and leave. Over repeated sessions, the dog learns not only what will happen, but that the procedure will reliably end, reducing anticipatory stress and the need for defensive behavior.

The “chicken or egg” question about whether behavioral predispositions result in CAD or the other way around leans very much towards behavior being a symptom of skin disease. Whether or not there is a genetic predisposition that connects both is still uncertain but there is no doubt that, with more DNA research being done, we will have information that will help not only treat but prevent these common but serious problems for dogs and their keepers in the future.

Photo credit: chris-mueller via iStock/Getty Images Plus

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