Nothing\u2019s easy in veterinary dermatology. \u201cEvery itch complaint looks the same,\u201d said Jennie Tait, AHT, RVT, a charter member of the Academy of Dermatology Veterinary Technicians. \u201cThere are no magic bullets. Because everything looks the same, it will take multiple appointments to work the itchy animal up. What you\u2019re seeing is most likely just the tip of the iceberg.\u201d<\/p>\n
Dermatology is not one and done, she emphasized. \u201cIt\u2019s a matter of lifelong management versus cure unless the cause is something like mange<\/a>,\u201d Tait said. \u201cWe can fix that and move on.\u201d<\/p>\n This article is the first in a three-part series on veterinary dermatology and the practice team\u2019s role.<\/em><\/p>\n Rusty Muse, DVM, DACVD, said the most common cause of itching in pets is an allergic skin disease. This includes allergies related to the environment, fleas<\/a> and food. Dr. Muse is the medical director at Animal Dermatology Group, which comprises dermatology specialty practices throughout the United States, Australia and New Zealand.<\/p>\n Good flea control is always important, even for pets that do little itching or scratching, he said. If a dog has a true flea allergy, an arsenal of things can be helpful, but flea control is paramount. Most veterinary dermatologists prescribe oral flea control, he said.<\/p>\n Chronic allergies have two contributing parts. \u201cOne is an abnormal immune response, which triggers itching that a normal dog wouldn\u2019t react to, like pollen and house dust mites,\u201d Dr. Muse said. \u201cThey can cause a cascade of symptoms.<\/p>\n \u201cThe second is an abnormal skin barrier that contributes to secondary infections. We have to manage both aspects to control the itch and control secondary infections. This [second step] is often overlooked.\u201d<\/p>\n Therapies for managing the itch alone won\u2019t stop the chronic problem, Dr. Muse said. Steroids might control the itch at first, but the animal remains prone to secondary infections. In such a case, the itching will return.<\/p>\n \u201cWe have to control the infective organisms while sorting out the problem,\u201d Dr. Muse said. \u201cRoutine bathing becomes critical. It\u2019s a myth that you shouldn\u2019t bathe a dog too often.<\/p>\n \u201cAllergies are a chronic disease,\u00a0and general practitioners have to be interested in chronic management,\u201d he said. \u201cWhen we schedule a new appointment, we schedule an hour. It takes time to go through a patient\u2019s history, and a good dermatology workup needs a good history.<\/p>\n \u201cSometimes, this is a problem in general practice because of time constraints. The time commitment is always a challenge. We have to educate the client. If people understand what needs to be done, they are willing to commit to the lengthy process. They want to know why.\u201d<\/p>\n Dr. Muse asks his clients to provide a thorough patient history before the visit. The next step \u2014 whether by a general practitioner or specialist \u2014 is a complete physical exam.<\/p>\n \u201cThe clues are there on the dog\u2019s skin,\u201d Dr. Muse said. \u201cTake the time to look at it and understand what\u2019s going on. Is there redness? Crusting? Are there scales? Papules? Lesions on the pads? All are important in putting the picture together. Then perform diagnostics to confirm what you suspect.<\/p>\n \u201cLots of different disorders cause itching and scratching. They can be primary or secondary. Itchy skin disease management is multimodal. Sometimes it\u2019s easy, as in the case of mites. But most are chronic, though still manageable and treatable.\u201d<\/p>\n The American College of Veterinary Dermatology advises that to distinguish between different diseases, proper interpretation of the history and clinical signs, together with cytology and possibly cultures, can be necessary for achieving the correct diagnosis and treatment.<\/p>\n Follow-up is essential, Dr. Muse noted. \u201cVeterinarians and dermatologists need to see if the pet has completely responded,\u201d he said, \u201cso checking clinical signs is critically important. We usually see a pet six to seven times a year.\u201d<\/p>\n Treating chronic skin conditions is a team sport, said Tait, of the Academy of Dermatology Veterinary Technicians. Therefore, every practice team member should be attuned to recognizing that an itchy pet should see a veterinarian.<\/p>\n That training should start on each team member\u2019s first day in the clinic, Tait said. \u201cEverybody should know what the plan is for dealing with dermatology issues. Customer service representatives and reception staff are the front line, the first people your clients contact. Make it a good experience for them. With dermatology, you want to set up realistic expectations for owners.<\/p>\n \u201cDermatology cases are always complicated,\u201d she said, \u201cand there are often years of history by the time a pet gets to the specialist.\u201d<\/p>\n Tait also serves on the executive committee of the Canadian Academy for Veterinary Dermatology, whose \u201cEmpathy for Itch\u201d campaign is designed to educate the practice staff and pet owners on what itchiness looks like. For example, licking indicates itchiness. So, if a pet\u2019s evening routine is to lick its paws, the veterinarian needs to know. Also, pink skin isn\u2019t normal, she said; it should be white.<\/p>\n Tait advises against offering dermatology care suggestions over the phone. \u201cIf the client is concerned, we should be concerned, and the pet should see the veterinarian,\u201d she said.<\/p>\n Sometimes, the primary reason for a visit isn\u2019t the itching. But a random comment from the owner that the pet has been chewing, biting, rubbing or scratching should trigger questions.<\/p>\n The veterinary technician can be the liaison to the client and is often the first to do the dermatology exam and take the patient history if empowered to do so, Tait said. The technician\u2019s main role, however, is client education.<\/p>\n All team members should know that infestation, infection and allergies are the three main causes of itching, Tait said.<\/p>\n \u201cAlmost every case needs to have cytology done. A secondary infection might look like yeast, but antifungals won\u2019t work on bacterial infections, and you don\u2019t know the difference until you look under a microscope,\u201d she said. \u201cThis allows for accurate diagnosis.\u201d<\/p>\n Technicians at Veterinary Allergy Dermatology & Ear Referral (VADER) in Ontario, Canada, where Tait works, do the initial dermatological exam. They go over a history form with the client, do skin scrapings and examine the samples under a microscope. The clinician then sees the patient.<\/p>\n VADER technicians also handle patient summaries, sedation, anesthesia, skin biopsies and discharge. Besides freeing the dermatologist for more involved medical issues, \u201cThis allows clients to bond with the technicians,\u201d Tait said. \u201cIt spreads the wealth and strengthens a client\u2019s bond with the clinic. It shows the client that technicians are valued members of the veterinary care team.\u201d<\/p>\n The veterinarian summarizes the findings and tailors a diagnostic plan, understanding that client education is a component.<\/p>\n At VADER, clients receive a written summary. \u201cIt\u2019s worth its weight in gold,\u201d Tait said. \u201cIt gives both the client and team something to look back at. And we attach any appropriate client handouts to the summary. Putting things in writing allows the pet parent to go home and study what\u2019s going on.\u201d<\/p>\n The summary covers a possible diagnosis, the tests being done and prescribed medications. \u201cIt helps the client understand why we seem to be doing 5 million things,\u201d Tait said.<\/p>\n Clients are frequently frustrated by the time they get to the dermatologist. \u201cThey often aren\u2019t receiving the information that I\u2019m sure the family vets are trying to get them,\u201d Tait said. \u201cIt results from trying to educate clients in a 20-minute appointment. Lots of information in a small window of time is difficult to absorb.\u201d<\/p>\n She suggests booking double appointments as a way for general practitioners to get started with a dermatology case. \u201cThere\u2019s no justice in a 20-minute appointment,\u201d she said.<\/p>\n Clinic staff should listen for client remarks that might indicate itchiness, said Andrea Crabtree, CVPM, SPHR, CCFP, of FurPaws Consulting. \u201cSometimes a client brings in a pet for something else but says something like, \u2018Oh, he\u2019s always had that red spot\u2019 or \u2018He\u2019s been scratchy this month.\u2019\u201d<\/p>\n The team member should mention such comments to the veterinarian. \u201cTrain staff to listen for clues that clients are giving us,\u201d Crabtree said. \u201cSometimes we have to extrapolate information that they don\u2019t always know they have.\u201d<\/p>\n When a client calls to make an appointment, the receptionist should ask questions. By inquiring about any itchiness, vomiting, diarrhea, hair loss, head shaking or appetite changes, the staff might learn that what was to be as an annual exam is now a medical case.<\/p>\n \u201cThe timing allowed for the appointment could change between a sick pet and well-pet exam,\u201d Crabtree said. \u201cIt can feel like pulling teeth to get the relevant information.\u201d<\/p>\n The advent of curbside care has allowed some streamlining of care. \u201cIt used to be that the front office or technician took a history, then presented the case to the doctor, who went into the exam room and went over the same information,\u201d Crabtree said. \u201cIt\u2019s different now with curbside.<\/p>\n \u201cNow, technicians often have pre-appointment history questionnaires filled out before the client comes in. This saves time and is more efficient.\u201d<\/p>\n Crabtree recommends training the entire team to be more inquisitive. When the front office team knows the right questions, time is saved in deciding whether the patient should be seen immediately.<\/p>\n She has found that clients\u2019 most common questions on itchiness involve the one thing pet owners have control over: Can it be the animal\u2019s diet<\/a>?<\/p>\n \u201cThey often think it\u2019s something they\u2019re doing wrong,\u201d she said. \u201cUsually, though, it\u2019s not their fault. This is where education comes in.\u201d<\/p>\n According to the American College of Veterinary Dermatology, clients should be asked these questions to help determine whether a treatable dermatologic condition is present.<\/p>\n
\nEDITOR\u2019S NOTE<\/span><\/h3>\n
\nDon\u2019t Rush Things<\/h3>\n
Check for Visual Signs<\/h3>\n
Teamwork Pays Off<\/h3>\n
The Client\u2019s Role<\/h3>\n
Do It in Writing<\/h3>\n
Listen Up<\/h3>\n
\nWHAT TO ASK<\/span><\/h3>\n