Ricky : Face. Ricky : History. Ricky s hind legs. Ricky : Problem list POLLY A PRURITIC LABRADOR RICKY A PRURITIC MIXED BREED DOG

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1 Ricky 7 year old, male neutered, mix breed POLLY A PRURITIC LABRADOR RICKY A PRURITIC MIXED BREED DOG Claudia S. Ne0-Me0ler Dr. med. vet., DACVD & DECVD vetderm.ch Dermatologie und Allergologie für Tiere c/o ENNETSeeKlinik für KleinIere AG Rothusstrasse 2 CH-6331 Hünenberg Ricky : History Ricky : Face Non-seasonal pruritus 9/10 for one year Intermi0ent vomiing Previous work-up by referring veterinarian High levels of IgE for house dust & storage mites Previous therapies Improvement on steroids No-response to EliminaIon diet trial over 4 weeks Immunotherapy for HDM and StM allergy Ricky s hind legs Ricky : Problem list Severe spontaneous pruritus LichenificaIon, crusts, excoriaions, erosions Face, paws Erythema, alopecia, lichenificaion Paws, pinnae, tarsi, elbows, axillary, inguinal region Generalised lymphadenopathy Intermi0ent diarrhoea and vomiing Italian origin 1

2 Ricky : DifferenIal diagnoses InfecIous SarcopIc mange Bacterial overgrowth Malassezia dermaiis Demodicosis Dermatophytosis Allergic dermaiis Atopic dermaiis FIAD Contact allergy Contact dermaiis Metabolic disease Zinc deficiency Superficial necrolyic dermaiis Ricky : Minimal data basis & results Skin scrapings negaive Cytology +++ cocci Sarcoptes AB posiive Fungal culture negaive Haematology normal Blood chemistry normal FNA lymph nodes reacive Ricky : Diagnoses SarcopIc mange Secondary bacterial overgrowth Possibly allergic dermaiis? Atopic dermaiis Food induced allergic dermaiis Flea bite allergy Ricky : Therapy SelamecIn 6mg/kg q 14 days topically Prednisolon 0.5mg/kg SID for 3-5 days Cephalexin 25mg/kg BID for 30 days Shampoo therapy Chlorhexidine/Miconazole once weekly Ricky : 1 st Follow-up at Day 30 IniIally quick improvement Pruritus 4/10 Skin lesions improved by 90% Face with mild bilateral periorbital erythema and hypotrichosis Erythematous pododermaiis Ricky : PresumpIve diagnoses SarcopIc mange (in remission) Bacterial overgrowth (in remission) PresumpIve allergic dermaiis Food induced allergic dermaiis Concurrent GI-symptoms Age of onset >7years Atopic dermaiis Serology posiive for house dust & storage mites à likely cross-reacion with sarcoptes mites (Flea allergic dermaiis) But should have improved under selamecin 2

3 Polly 11month, f, Labrador Polly : Clinical presentaion History Sudden on-set pruritus 7-8/10 mainly face, ears, elbows, hocks for the last 3 weeks Bred in England, lives in Switzerland Diet history Commercial OTC dry food for growing dogs Rawhide bones, various dog treats Lives with a family in a house with garden close to the forest Current on vaccinaions and deworming Regular flea control with fipronil Polly : Clinical presentaion Physical examinaion Within normal limits Dermatological exam Severe erythema Chin, pinnae, elbows, hocks Self-induced alopecia Pinnae, elbows, hocks Mild erythema Axillae and ear canal osium ExcoriaIons Face, chin, ear osia Polly : DifferenIal diagnoses SarcopIc mange Allergic dermaiis (Demodicosis) Bacterial infecion Polly : Minimal data basis Pinnal pedal reflex: posiive SensiIvity: 82% Specificity: 94% Deep and superficial skin scraping: negaive Skin surface cytology ++ neutrophils, + cocci Working diagnoses SarcopIc mange 2 nd bacterial folliculiis Polly : IniIal therapy SelamecIn topically 2x every other week Cephalexin 25mg/kg q12h for 3 weeks Prednisolone 0.5 mg/kg q24h for 3-5 days Chlorhexidine Shampoo 1-2x/week 3

4 Polly : 1 st follow-up at 3 weeks Exam Pruritus improved 5/10 Erythema: Face, elbows, hocks, pinnae DifferenIal diagnoses SarcopIc mange non-responsive to selamecin Bathing, incorrect applicaion Allergic dermaiis Treatment 2 nd diagnosic trial IvermecIn 0.4mg/kg q 7 days orally Topical therapy with Chlorhexidine shampoo HC-aceponat spray once daily Polly : 2 nd follow-up at 6 weeks Exam Pruritus 4-6/10 Erythema Face, chin, elbows, hocks, pinnae MulIple facial excoriaions Pruritus improved with HC-aceponate spray DifferenIal diagnoses Food induced atopic dermaiis Atopic dermaiis sensu strictu Leading symptoms of FIAD Clinical presentaion idenical to non-seasonal CAD Age at onset Picco et al, Vet Dermatol 2008 Less than 1 year : 48% (16% in CAD) Less than 3 years: 83% FIAD more common in dogs > 3 years old Breed predilecions WHW Terrier Boxer Golden & Labrador Retriever German Shepherd Rhodesian Ridgeback Pug GastrointesInal symptoms and FIAD 10-15% FIAD paients have concurrent GIsymptoms Picco et al, 2008: > 30% with GI-symptoms Clinical symptoms - Chronic diarrhoea - Intermi0ent vomiing - Borborygma - Loose stools - Increased defecaion - Flatulence h0p:// Diagnosing FIAD - Gold Standard EliminaIon-provocaIon test To observe improvement or resoluion of clinical signs while fed an eliminaion diet To see recurrence of pruritus when the paient is challenged with previous food items Food allergens Complex water-soluble glycoproteins Dalton (Dog: > 20 kda) - Allergens oren glycosylated with oligosaccharides Resistant against heat, acids and proteases The offending food is one that is commonly fed Substances within the main diet Substances within a regularly fed treat Any food item can be the source of the allergen! 4

5 Frequent food allergens Beef Chicken Wheat Dairy products Lamb Cross-reacIons 1 - Beef lamb dairy products 78% allergic to Beef, chicken, dairy products, wheat 2 Soy Porc Egg Corn Fish Rice Horse Potatoe Choosing an appropriate diet 1. No single diet suitable for every suspected FIAD case 2. Detailed diet history is mandatory Treats Table scraps Flavored medicaions Food supplements 3. EliminaIon diet with one novel protein and one carbohydrate source 1 MarIn et al, Vet Derm, Vol 15, Dec Roudebush, Vet Derm Vol 24, Apr 2013 Cyno-DIAL canine test To choose an appropriate trial diet Can test up to 8 food items Immunoblotng Proteins extracted and separated on a gel/ membrane Incubate blot with paient serum Detects specific IgE for proteins in the tested foods PosiIve results = bands on blot membrane Allergen limited diets Home-cooked or commercial diet Advantages of commercial diets Balanced Saves time Increases compliance Cheaper than home cooked Cadiergues, Vet Derm, 2015 Advantages of home-cooked diets No foreign proteins No conservatives No additives Home-cooked diets Ingredients well controlled, but oren not balanced Sources for novel protein and carbohydrate Horse, venison, kangaroo, rabbit Green pies, potatoes, sweet potatoes, pumpkin, parsnip B.A.R.F diets possible Commercial eliminaion diets Increasing range of products ExoIc protein sources Rabbit, duck, venison, kangaroo, ostrich, quail, horse, reindeer, boar, buffalo Carbohydrate sources Potatoes, parsnip, green pies, spelt, oats, wild emmer, corn starch OTC diets also offer exoic protein sources Ingredients < 5% do not need to be declared 5

6 Hydrolysed diets (prior to 2011) DegradaIon of a common protein source into pepides and amino acids by proteolysis, Should prevent adverse reacion even in dogs allergic to parent protein source Advantages Increased digesibility Decreased allergenic potenial Disadvantages Decreased palatability OpImal degree of hydrolyzaion unknown Up to 50% of food allergic dogs showed reacions to hydrolysate Olivry, Vet Derm 2010 à Best used in dogs not sensiive to the mother proteins of the hydrolysate New generaion hydrolysed diet New protein source < 1000 Dalton No allergenic potenial Low molecular hydrolysed feather protein Purified corn starch 95% of ingredients < 1 kd 5% of ingredients < 6 kd 100% of protein content < 1kD 88% free amino acids 12% low molecular oligo-pepides High palatability and acceptance Anallergenic Clinical results 49 dogs suspected or proved FIAD CADESI > 50 (mean 52) All dogs improved in CADESI & Pruritus 80% within 4 weeks All dogs relapsed arer provocaion Arer 8 weeks on diet à 37.5% without clinical symptoms Hydrolysed foods contain high molecular weight proteins Roitel et al, Vet Derm 2015 All 3 tested hydrolysed foods showed Presence of several high molecular-weight (HMW)proteins (15 kda to 60 kda) IgE immunoblotng revealed that HMW proteins were targeted by circulaing dog IgE Mass spectrometry idenified starch protein from maize à Even highly hydrolysed hypoallergenic foods may sill contain immune reacive HMW proteins Appropriate length of a diet trial No exact data 4-10 weeks Arer 3 weeks on a diet trial Improvement in 26-95% Maximal improvement arer weeks? RecommendaIon 6-8 weeks stringent eliminaion diet trial Recheck 4 weeks into diet Ricky s Diet history Various commercial foods based on Beef, porc, soy, lamb, corn, rice Bred Rawhides (beef) Dried fish Ricky s trial diet: Rabbit/potato/spelt 6

7 Polly s : Diet history Food history Puppy and junior dog food Chicken, rice, corn Treats Rawhide bones from beef and pork Table scraps: Pasta, rice, bred Dog treats: chicken, beef, pork Scavenges food and faeces when outside Choice of the eliminaion diet Horse & potato dry food Ways to a successful eliminaion diet trial Set a Ime frame it s not a life long trial Give the owner control over the pruritus Use a diary Plan follow-up s on a regular basis Treat concurrent infecions at all Imes Sources for diet indiscreions DisconInue Treats, rawhide bones Table scraps GelaIne capsules Flavoured medicaions Deny access to Food bowls of other animals Cat loo Dishwasher Crumbs under the dining table Small kids, grandparents.. Ricky : Follow-up at 6 weeks Stringent diet with rabbit/potato/spelt Improvement by 90% Pruritus 1/10 No apparent skin lesions No GI-symptoms Tag 30 Polly : 3 rd follow up at 10 weeks Stringent diet with horse meat & potato But... Scavenges for food and faeces outside Small kids in the household Pruritus sill 6/10 Exam New excoriaions in the face Erythema face and ears 7

8 Successful diet trials in Retrievers Polly : 4 th follow-up at 14 weeks History and exam 100% stringent diet! Pruritus 2/10 Could cease all medicaions Mild erythema: Pinnae and chin PresumpIve diagnosis Food induced atopic dermaiis End of the diet trial provocaion If improvement or remission Prove FIAD by provoking with previous foods ProvocaIon Ime varies from 1 to 14 days Once individual relapse Ime is known Test single food items If no relapse, consider Perennial CAD Incomplete provocaion Ricky : Final diagnoses Food induced atopic dermaiis PosiIve provocaion test arer 48 hours PosiIve reacions to Beef, soy, pork SarcopIc mange 2 nd bacterial overgrowth Polly Final diagnosis Food induced atopic dermaiis PosiIve provocaion test arer 12 hours ReacIons to Beef, pork, wheat FIAD can mimic sarcopic mange à Pseudoscabies 8

9 Take home message FIAD is a common and someimes difficult to diagnose disease Gold standard eliminaion/provocaion Other diseases mimic FIAD Oren complicated by secondary infecions and concomitant allergies QuesIons? 9