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Atopic Dermatitis - options

Published on: May 17, 2021 • By: peter · In Forum: Dogs
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peter
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May 17, 2021 at 11:37am
Thanks for the help on the Gingivitis topic, I'm satisfied his dental health is fine now, and the odour seems to have reduced as well, but that might be due to his reduced licking due to the new medication he's on, so I'm starting a new thread. During my dog's last visit to the vet, they noticed inflammation on the belly skin area, this isn't unusual for him, and they put it down to his Atopic Dermatitis. They prescribed a low dose steroid treatment of 5mg/day prednidale. The inflammation soon disappeared, but after a week, one of his ears became very red and sore. Once again this isn't unusual for him and atopic dermatitis is always suspected. With the vets permission I upped the steroid dose to 10mg/day and applied isoderm gel to the ear.  7 days later it hasn't improved much, and the side effects are are significant (high urination/ drinking/ panting sometimes) so with their permission I've dropped the dose to 5 mg/day again. I also noticed some wax in the ear today when putting the isoderm gel on. I normally try to treat his ears regularly with Otodine, but he hates this, and very little gets down the ear canal due to his resistance and shaking his head. I discussed other options with the vet this morning. One is to have him sedated and clean out his ears of wax and take a swab to see if there's any infection in the ear.  The disadvantage here is that he hates his ears being touched even when they are fine, and the last time this happened he required several doses of sedative, and it resulted in a minor injury to his eye due to him struggling. I would choose this option if it wasn't for the stress and worry. The second is to use Cytopoint injections to see if he benefits. These are expensive but it might be worth it in the long run. However I wonder if it's essential to remove the wax and test his ears for an infection first. (He previously developed an ear lump with Apoquel so that isn't an option) Another approach might be to find the source of the allergy.  An ex vetenary nurse suggested I change his food, since atopic dermatitis can just be a food allergy, although the Eden food I give him is highly rated.  My suspicion is that he might occasionally brush his ears with nettles or ivy because he's always rummaging in undergrowth.  I didn't discuss this with the vet, but perhaps it's another approach. The vet has left it to up me to decide.
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Liz Buchanan BVSc MRCVS
Keymaster
May 17, 2021 at 01:20pm
Hello!  Most ear disease is a result of skin disease, often a manifestation of an allergy.  Ears are, after all, simply skin down a hole that produces wax when the tissue is stressed (allergy stresses out the tissues).  Even the classic 'upper ear infection' is now thought to often be first caused by allergy, and any infection introduced because of the excess of wax and scratching.  Your vet will probably be as honest as they can be regarding how necessary they feel it is to spend the money on checking for infection in this particular case.  If not doing so, there is risk of an infection being missed (and also, by the sound of it, foreign bodies from undergrowth vegetation). Sometimes it is possible to ear-swab and check for signs of infection on in-house microscopes, which is often the most cost-effective.  It is my opinion if that if this is worth doing, it may also be worth giving a proper general anaesthetic.  Anaesthetic can, in some situations, be safer than a sedative because the airway is fully protected and the vet can be sure that no movement will happen while they are rootling around in the ear.  It can make for a much shorter, more comfortable experience all round so even though it sounds 'overkill,' don't rule this possibility out.  Regarding food allergy, it is also responsible for a certain percentage of ear problems, yes - sometimes when no other skin signs are present.  It isn't anything to do with the quality of the pet-food, but the actual ingredients:  if a dog has an allergy to fatty acid X and there is fatty acid X in the food, it will cause an allergy even if the fatty acid X is of excellent quality.  Finally, dogs sometimes do rub their ears in ivy or nettles when running through the undergrowth but I think you are clutching at straws here.  These tend to cause contact reactions and I would expect the worst damage to be on the pets' outer body-skin and outer ear-flaps (where the fur is) because I would expect these areas to come into contact with nettles or ivy  much more frequently than the area right down inside the dogs' ear. However, just as dogs can get ear-allergy signs from food, they can also get them from outside allergens, grass pollen etc., so Ivy etc probably shouldn't leave the list until proven 'innocent.'  Skin allergy is one of the most frustrating things for vets to deal with and specialists are also available.  It is not uncommon for vets to know what they 'should' be doing, but find it difficult to ask the client to go through the seemingly endless stages required to get to the bottom of such a problem.
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Liz Buchanan BVSc MRCVS
Keymaster
May 18, 2021 at 10:35pm
My suggestion would be to chat to your vet and ask questions such as:  'How would we go about controlling them symptoms?'  'How would we go about finding the underlying cause of the symptoms' e.g. fleas if it's a flea allergy, a particular food if it's a food allergy etc. and 'what do you recommend is  the best way forward?'  You might want to ask about treatment outcome, liklihood of a diagnosis (e.g. treating the symptoms will not give you a diagnosis), and cost (likely costs going forward) as this can turn out to be an important factor when making decisions.
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peter
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January 05, 2022 at 01:51pm
After his 3rd Cytopoint injection in late October my dogs inflammation flared immediately and badly. This was accompanied with something I hadn't seen before, reflux or vomiting. Since this started within a day of the injection this must be the cause.  The vet couldn't find anything obviously wrong with him and he remains active with a good appetite, so the Cytopoint treatment has been stopped. I'm now trying to identify the allergen and eliminate it.  I've changed from beef/chicken to a Fish and rice based diet 6 months ago and the inflammation happens all year round so I don't suspect food or pollen is the cause. I've noticed this vomiting/reflux usually happens only on the mornings after I have vacuumed the house as he wakes up, so my attention has turned to dust and mites. I vaguely remember reading that atopia can include inflammation of the oesophagus. He is treated with Nextguard Spectra which should prevent mites from living on him for any length of time. but would this prevent dust mite allergy?  I know with humans the allergy is caused by mite droppings and dead mites rather than the living mites themselves. My house is carpeted and my mattress is very old so it is a very dusty house as I discovered after moving my furniture around. I am vacuuming more regularly now, sealed his food sack, washed his toys, and moved my HEPA fan/filter downstairs near where he sleeps and replaced it with an ioniser in my bedroom where he spends some time. I think there has been an improvement in his condition since I did all this. His vomiting/reflux is accompanied with extensive lip licking beforehand. In fact he often licks his lips without vomiting on the ground. Could he be regurgitating stomach contents when he does this? Since the vet could find no tooth or gum issue, could this, in conjunction with licking himself, be the reason for his bad breath and horrible smell when I come downstairs?
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Liz Buchanan BVSc MRCVS
Keymaster
January 06, 2022 at 06:28am
Hi.  Lip-licking often implies nausea, which is generally taken as a sign of vomiting rather than regurgitation, but that's one small bit of a jigsaw.   Normal vomiting is associated with signs of nausea beforehand and a movement from the stomach, where as regurgitation doesn't involve the vomiting reflex - the food simply ascends back into the mouth as though by backward peristalsis.  The difference is subtle but it's worth spending time to figure out which this is, as the two are associated with completely different sets of causes.  Either could cause smelly breath afterwards. I don't think I have ever seen regurgitation linked to skin irritation or the drug you mention and wondered whether this could be a coincidence in this case, especially as it has only been seen once - how long does the injection remain in the body?  It is not unrealistic to see unrelated signs starting a few days after a vets visit and I wonder whether timing alone is enough to link the two things - what was your vet's opinion?  As your vet knows the patient and full history, their opinion carries far more weight than my thoughts.  If you do both feel that it could be a drug reaction, the usual thing to do would be to report it - drug companies in the UK keep track of reported reactions and will generally be honest with you if other, similar cases have been seen ie whether a link seems likely. I think this would be a good starting point.  You are right that anti-mite treatments may not protect against physical contact with dust mites. Best of luck.
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peter
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January 06, 2022 at 08:55pm
My vet wasn't keen on continuing Cytopoint, because she knows I was alarmed by the increased inflammation as well as the sickness.  The first two injections simply had no affect, so there's no point in going on anyway.  It's just over 2 months since the last injection so this is the maximum time it is supposed to work between injections. Whilst he has many of the symptoms of an allergy (snoring, inflammation of ears & underside, excessive licking, bald patches, hot spots) there's not much evidence of sneezing and coughing you might expect from a dust allergy, although I open the windows during vacuuming and for 1 hour afterwards.  My vet prescribed Oprazole for his 'vomiting' and it certainly stopped any liquid being deposited on the ground during the 7 day course, but it returned about twice a week after this.  The vomit is always a small pool of thick liquid,  sometimes saliva like, but never recognisable food. After he's finished his next 12kg sack of dry food, I will move onto wet food (probably Chappie), as storage mites can breed in dry food according to this, and he has all but one of the symptoms listed here. https://thoughtfulpets.co.uk/storage-mites-a-common-cause-of-skin-allergies-in-dogs/
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peter
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September 29, 2022 at 09:59am
First the good news; since clearing the dust from my house, his underbelly and underarm skin redness has largely disappeared and his fur has grown back in those areas. The ear pinnae have returned to a lighter shade as well, except when he scratches them. He was vomiting or regurgitating a thick foamy liquid overnight. We tried the stomach emptying drug Cisapride, but he violently vomited 3 times on the third day of taking this after his late afternoon meal which is unknown for him, so we stopped this immediately. This is the third type of medicine he has adversely reacted to, the others being Cytopoint and Apoquole.  I wondered if the empty stomach might be exacerbating the issue, so I started to feed him around a third of his food last thing at night in an attempt to keep it full. He hasn't vomited since, despite withdrawing Omprazole and antacids. My big worry though is the continuing lip licking & swallowing and the atrocious smell from the mouth which accompanies this, which suggests he is continuing to regurgitate. Both of the vets I've asked to examine him, think Megaoesophagus unlikely, because he eats well, he doesn't react to pressure on any part of his body, and is still active. However, he's dropped from a slightly overweight 40kg to 30kg over the last year, and I'm starting to feel his ribs on examination. He also continues to be bothered by his ears as indicated by vigorous head shaking, despite me (trying to) apply ear cleaner every morning. I intend to take him to the vet for another ear clean soon. The last time they were cleaned one ear was blocked by what I think was green ear wax, whilst at other times the wax was black but more scattered. I will ask the vet to take a sample to determine the fungi/bacteria balance, and note the amount of wax being produced. Is the type of fungus important (I live next to a swamp and have suffered fungal ear infection myself). I'll also ask them to check his lips for pyoderma and take blood samples for testing whilst he's sedated, these can be compared with some taken 21 months years ago when all this started, then there were mostly OK, but two borderline readings which could be explained by atopic dermatitis. Regarding the type of food, I recently tried a high protein diet: raw chicken dog food, eggs & some low starch veg to starve any potential endemic fungus. It was a disaster, all his symptoms soared. He was gurgling when sleeping, and the skin inflammation returned. So Chicken or egg is another confirmed allergen! So far I've tried insect protein, Hydrolyzed Chappie (which contains a small amount of chicken), and food with probiotics, none of which prevents the smell from his mouth and frequent ear blockages. I'm running out of options on what to try, I'm currently giving him a diet of fish without grain. I suppose insect protein + root vegetables would guarantee no food allergy? The only medicines he's taking at present are Nexguard and Droncit. In view of his reaction to all the other drugs, is it worth changing these, or even stopping them over the winter period? I may have changed to these drugs from other anti-parasitics within a year he started to have his gastric problems, but I'll have to check the date of this change.  He certainly doesn't become any worse on the days following taking these drugs on a monthly and three monthly rota. Note he had quite bad atopic dermatitis for 3 years prior to this without any smell from the mouth or gastric problems.
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Liz Buchanan BVSc MRCVS
Keymaster
September 29, 2022 at 10:58am
Hello and thankyou for the update on your lovely boy.   Sometimes it isn't a bad thing to pare down a case to essentials.  I would expect - especially as the Spring comes around - for any allergies to flare up again at some point, so it sounds as though you and the vet need a plan together, for what preventative you might want to use when the allergies begin to flare up again.  Sometimes (and don't forget - I am speaking generally because I don't know your boy) this might be good to have planned in advance, so that the skin disease doesn't perpetuate before you have chance to get him started on something.    If the allergy is to something in the environment, a good rinse down after a dog-walk can be helpful. Of course, there is no food that it is impossible to be allergic to, to my knowledge, and that includes insects. However, there is a bigger concern at the moment:  10kg weight-loss is a quarter of his body-weight - which is a lot.  I wonder what could be prompting this new regurgitation and weight-loss?  Could any dietary changes account for it or is there something more here?  This sounds to merit investigation and it may be that a new visit to his vets, so that they can especially focus on this symptom, is necessary.  Good questions might include, 'Can we account for this weight loss and regurgitation?'   'What do we need to do in order to investigate it?' I wonder whether endoscopy may be a possibility?
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Liz Buchanan BVSc MRCVS
Keymaster
September 29, 2022 at 10:58am
Hello and thankyou for the update on your lovely boy.   Sometimes it isn't a bad thing to pare down a case to essentials.  I would expect - especially as the Spring comes around - for any allergies to flare up again at some point, so it sounds as though you and the vet need a plan together, for what preventative you might want to use when the allergies begin to flare up again.  Sometimes (and don't forget - I am speaking generally because I don't know your boy) this might be good to have planned in advance, so that the skin disease doesn't perpetuate before you have chance to get him started on something.    If the allergy is to something in the environment, a good rinse down after a dog-walk can be helpful. Of course, there is no food that it is impossible to be allergic to, to my knowledge, and that includes insects. However, there is a bigger concern at the moment:  10kg weight-loss is a quarter of his body-weight - which is a lot.  I wonder what could be prompting this new regurgitation and weight-loss?  Could any dietary changes account for it or is there something more here?  This sounds to merit investigation and it may be that a new visit to his vets, so that they can especially focus on this symptom, is necessary.  Good questions might include, 'Can we account for this weight loss and regurgitation?'   'What do we need to do in order to investigate it?' I wonder whether endoscopy may be a possibility?
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Liz Buchanan BVSc MRCVS
Keymaster
September 29, 2022 at 10:59am
Again, these are questions for your vet, who ultimately knows and understands much more about your dogs case than we can possibly do online and is, after all, responsible for your dogs' health.  
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