Dermatologic problems often cannot be cured and instead must be managed for a significant time, perhaps over a pet’s lifetime. “If I have a nail in my head, I don’t just take ibuprofen,” said David Senter, DVM, DACVD, a spokesperson for the American College of Veterinary Dermatology. “I would strive to get to the root of the problem and remove the nail.”
Dealing with dermatologic issues sometimes requires the care of the primary veterinarian and a specialist. But that doesn’t mean the general practitioner loses all the revenue.
EDITOR’S NOTE
This article is the third in a three-part series on veterinary dermatology and the practice team’s role.
“The American College of Veterinary Dermatology wants to have collaborative relationships with general practitioners,” said Dr. Senter, who works at Veterinary Allergy and Dermatology Clinic in Overland Park, Kansas. “We want to be an extension of their practice.”
Prioritize Health Management
General practice veterinarians don’t have to hand off patients to the local dermatologist automatically. Rather, teamwork should be the goal.
“The best way for [general practice] veterinary teams to deliver profitable dermatology services is to appreciate that most skin cases won’t be cured with a single visit and to consider how many of these cases can be optimally managed over a lifetime of pet-specific care,” said consultant and author Lowell Ackerman, DVM, DACVD, MBA, MPA, CVA, MRCVS. He is also Galaxy Vets’ head of global veterinary strategy.
“The profitability of dermatology cases is not measured by metrics like average transaction charge but rather by lifetime value,” Dr. Ackerman said. “When dermatology cases are handled appropriately, hospitals work closely with clients around health management rather than disease management.”
Dermatology cases are profitable, Dr. Ackerman said, because when handled correctly, the team manages the patient’s quality of life very closely, and the client, in turn, is often quite loyal.
“Effective communication means clients have realistic expectations, and they understand the long-term plan that has been created for them,” he said.
On the other hand, when cases are mismanaged, clients can become frustrated and seek services elsewhere.
“Managing the process is what makes dermatology profitable, not markups or gimmicks,” he said.
The $925 Tipping Point
A primary veterinarian’s failure to refer to a specialist can hurt clinic revenue.
Dr. Senter said that while many clients worry about the expense of veterinary care, they potentially save money if the right tests are performed and the right treatments are administered fairly early on. For example, an ACVD survey found that clients would save 25% on their veterinary bills if a referral were made by the pet owners’ tipping point. The survey involved 288 clients who visited a board-certified dermatologist after seeing their primary care DVM.
“It found that clients reached the tipping point of frustration with their primary care veterinarian after their third visit or a total of $925 spent on the problem,” Dr. Senter said. “Seventy-three percent had already reached the tipping point before seeing the dermatologist, and by then only 62% would return to their primary care vet for more than basic care.”
The survey also found that 58% of clients felt better about their primary DVM for recommending a board-certified dermatologist.
The goal of most primary care veterinary teams isn’t necessarily to diagnose and treat all the exotic skin problems that pets get but to competently manage the cases seen regularly, Dr. Ackerman said.
“As far as profitability, the most important thing is to manage chronic skin cases properly over the pet’s lifetime rather than treating recurrent problems as though they were a sequence of one-time occurrences,” he said. “Cases should be referred to dermatologists when they are unusual and don’t behave as anticipated based on a preliminary diagnosis, and to get input on the best way to manage conditions long term.”
Dr. Ackerman said the continued use of antibiotics each time a dermatologic problem recurs invites the development of antimicrobial resistance, public health concerns, and the use of stronger and more expensive antibiotics.
“Clients quickly infer when veterinary teams do not seem to know what they are doing,” he said.
“Referral should be a proactive process to create a logical management plan that everyone can live with rather than a measure of last resort. Involving early dermatology referrals allows pet owners to see that their primary veterinary team works cooperatively with experts and that everyone is committed to their pets’ proper management.”
Dr. Senter recommends that primary DVMs refer if a problem is chronic —the clinic has seen the animal three or more times for the same problem — or if the patient’s response has been inadequate.
“Unusual lesions, rapid skin changes and ulcers on skin can be a sign of deep infection,” he said. “Autoimmune issues might respond to treatment if diagnosed quickly.”
Specialists Own More Tools
Another important reason to refer to specialists is their range of diagnostic and treatment equipment.
“Video otoscopes, carbon dioxide laser, cryosurgery and hyperbaric oxygen chambers plus a fully trained staff are beyond what most general practitioners can offer,” Dr. Senter said.
“Typically, dogs with allergies and related skin disease are a huge deal in general practice,” he said. “How do you make working up those cases more profitable? Most itchy dogs have an allergy, and allergic dogs often develop infections. A lot of practices don’t do skin cytology but could. Get a good-quality microscope and practice cytology skills, and charge owners for the service.
“Another suggestion: In a busy practice, there’s often pressure to move on to the next appointment. Be sure to set aside enough time for dermatology appointments. Not doing so can contribute to the client’s tipping point of frustration.”
Could adding a staff dermatologist, even part time, be a good idea in a general practice?
“It’s not a possibility,” Dr. Ackerman said. “Even major referral hospitals and veterinary schools often have difficulty finding board-certified dermatologists to hire. It is not possible for most primary care veterinary hospitals to hire a dermatologist, but the good news is that it doesn’t take a dermatologist to competently handle the most common skin problems that pets get.
“When cases prove difficult to diagnose or manage, referral to a dermatologist early in the process is the best way to align everyone — the pet owner, primary care veterinary team, veterinary dermatologist — around the best options for care.”
BEHIND THE ITCH
Board-certified veterinary dermatologist Dr. David Senter said the most common reasons for pets’ itchiness are, in order:
- Fleas
- Flea allergy
- Atopy
- Food allergy
Other parasites, including scabies and mites, can cause intense itching.
Secondary infections can add to the problem, he said, and include an overgrowth of surface yeast, bacteria and fungi. Autoimmune issues and skin cancers are other possible causes.
Dr. Senter said other household pets and wildlife could be the source of fleas. Opossums, for example, carry the same flea that infests dogs.
WHAT TO TELL CLIENTS
Dr. David Senter shared the discharge paperwork his practice gives to pet owners in cases involving atopic disease and allergies. A section titled “Client Discussions” reads:
“Environmental allergy to substances such as pollens, molds and dust mites is formally called atopic dermatitis, or atopy for short. Flea allergy dermatitis is the only allergy that is more common than atopy. Pets having a genetic predisposition towards atopic disease develop an abnormal immune response against normally harmless substances. Such pets can be affected by either breathing in these allergens or by absorbing them straight into the skin, especially where there is no hair coat. While many humans suffer from allergic rhinitis and conjunctivitis (itchy, runny nose and eyes), animals are more likely to have itchy skin. The allergic inflammatory reaction to the allergen becomes apparent when the pet exhibits biting, licking and/or scratching.
“An animal is suspect for atopy if it bites, licks or scratches the following area(s): paws, face, ears, underarms, groin and front legs. This often results in hair loss, redness and excoriations of the skin. Coughing, sneezing and asthma-type symptoms may also occur in atopic animals but are less common.
“In most cases, atopy can be controlled but not cured. Cortisone (steroid) type drugs are the most commonly used nonspecific, anti-inflammatory, anti-itch medications prescribed for atopy in both oral and topical formulations. However, there are side effects associated with the use of steroids that should be discussed with your veterinarian. Other nonsteroidal medications, including cyclosporine (Atopica) and Apoquel, may be used to help control your pet’s allergic symptoms as well. These medications, while not steroids, also have different side effects that must be discussed and carefully monitored for. Fatty acid supplements and antihistamines have fewer side effects and are effective in approximately 20-30% of animals with allergies.
“Hyposensitization is another alternative to steroids and is successful approximately 80% of the time. This requires the initiation of a treatment known as immunotherapy and is the only treatment that can address your pet’s underlying allergy specifically and help achieve remission of symptoms. Fortunately, immunotherapy is very safe for your pet and has no long-term side effects.
“Hyposensitization requires an intradermal allergy test (skin testing) in order to identify the specific allergens to which your pet is sensitive. Intradermal allergy testing is a technique where small amounts of allergens are injected intradermally into the skin. A positive reaction at the site of injection indicates the pet is allergic to that allergen. This is the ‘gold standard’ test in both veterinary and human medicine.
“Hyposensitization involves injecting your pet with small amounts of specific allergens to which your pet tested positive. Pet owners can easily be taught to give these injections (about every two weeks) at home. Alternatively, with sublingual immunotherapy, a few small drops are administered daily under the tongue. Over time, the immunotherapy stimulates the pet’s own immune system to eliminate or decrease the allergic reactions.
“Hyposensitization may take up to one year to be effective, though pets often show improvement within the first four months. Once a response is obtained, the pet will require maintenance injections for the rest of their life in most cases, although as many as 20% of cases can go into remission after discontinuing therapy. Your dermatologist will work with you to determine the correct dosage and frequency that your pet needs to maintain the best control of his or her symptoms possible.
“Animals with atopic disease are prone to secondary infections and may require additional medications. Infections and flea bites will aggravate the atopic condition and cause itching to become worse. Allergy flare-ups may also occur in otherwise ‘controlled’ cases. For these reasons, maintenance therapies may be recommended.”