Issuu

Editor: Norma White-Weithers, MS, DVM, DACVD Veterinary Allergy & Dematology Consultant Baldwin, NY 11510 Work: 646-329-4719 Fax: 631-694-3401 E-mail: nweithers@yahoo.com

FROM THE PRESIDENT

Derm Dialogue Assistant Editor: Tim Strauss, DVM Frederick,CO 80516 E-mail: drtim@comcast.net

Dear Colleagues, It was great to see so many of you in Disney World! It was a very successful meeting with a busy and varied scientific program and memorable social events. Certainly, a highlight of the social program was the Yeastie Boys concert at the House of Blues. We are definitely a group with many skills and talent! We had record attendance and the meeting would not have been such a success without the efforts of the NAVDF organizing and program committees. It takes a lot of time and effort to plan a national meeting, and it would not be possible without the commitment and volunteered time of many individuals within the AAVD and ACVD. Members of those committees depend greatly on the expertise and Dr. Outerbridge dedication of the NAVDF Meeting Manager Jill Senior and all who work with her, including our new AAVD Executive Secretary Libby Dietrich. Welcome aboard Libby! Also, indispensable to the success of the NAVDF is the ACVD Executive Secretary Alexis Borich. At the next meeting please take a moment to thank these remarkable individuals for all of the hard work that they do. I am honored to serve as president of the Academy and follow in the footsteps of so many incredible individuals who have championed the interests of the AAVD. I am fortunate to have working with me very capable and talented individuals: Dr. Rod Rosychuk (Past President), Dr. Leonard Jonas (Vice President), Dr. Klaus Loft (Treasurer) and Dr. Rose Miller (Member-at-Large) and we are all committed to the success of the AAVD. I extend a warm welcome to Dr. Andrew Mills as our newest member-atlarge. I thank each of them for their efforts on behalf of the AAVD.

The AAVD is the oldest organization devoted to promoting and advancing veterinary dermatology. It began in 1964 and was organized by Drs. Conroy, Kral, Muller and Schwartzman in Philadelphia. continued on page 20

FALL 2017

At the executive meeting, we shared ideas about how to grow the AAVD including development of a new website. We are continuing the AAVD Senior Veterinary Student Awards in Dermatology, increasing the financial support of the ACVD research foundation and are exploring ways to fund preceptorships in dermatology for general practitioners who practice in areas that are underserved in access to veterinary dermatologists. I encourage the membership to reach out to me, or any member of the executive board, with your ideas for the Academy.

FROM THE IMMEDIATE PAST PRESIDENT

Reflections of 40 Years in Veterinary Dermatology by Dr. Phil Roudebush I have been involved with AAVD in one way or another almost 40 years, so it seems appropriate to reflect on some aspects of veterinary dermatology that have emerged during my career and involvement with the Academy. I hope this will stimulate others to share their historical perspectives of our veterinary specialty and organizations. My exposure to dermatology actually began in utero. My mother worked as a microbiologist for a human dermatology practice in Indianapolis, Indiana before I was born and during her pregnancy. She performed bacterial and fungal cultures for the multi-person dermatology practice and was also involved in clinical trials of patients with tinea capitis (scalp ringworm). Effective systemic antifungal medications were not available at the time so treatment was limited to topical agents such as potent coal tar derivatives, which were usually not very helpful unless they elicited an intense inflammatory response. One effective treatment for ringworm was irradiation of the scalp, which resulted in complete loss of hair for several months but did usually eliminate the fungal organisms. As a child, I heard my mother recount many stories of her experiences working at the clinic and knew about human dermatophytosis, sporotrichosis, impetigo and tertiary syphilis at a very young age. Most veterinary schools in the early 1970s did not have clinical faculty members with an interest in dermatology. I was fortunate to be taught by Cliff Blakemore at Purdue who had a strong interest and passion for veterinary dermatology. Cliff was one of the first members of AAVD and a founding member of the veterinary dermatology college when it was organized under the umbrella of ACVIM. Many of the early veterinary dermatologists were small animal internists with an interest in skin disease and I was able to work with many of them over the years ― they had a unique perspective of approaching the patient with skin disease from a whole-animal viewpoint. As an internist myself, I wonder if we are missing a contemporary opportunity for dermatologists and internists to work more closely together on issues of common concern. At the recent World Congress in Bordeaux, Ed Breitschwerdt addressed this issue under the concept of “One Health” as it related to infectious diseases ― I encourage AAVD members to read his review paper from the Congress in the February 2017 issue of Veterinary Dermatology. As a new graduate, I began practice in the flea scarce location of Denver, Colorado. Another new graduate who started in the practice at the same time was from eastern Colorado and graduated from CSU. He exited the exam room one day in an extreme state of excitement ― “Phil, I think this dog has fleas.” Dave had never seen live fleas before and I confirmed that the dog (who had just moved from southern California) did indeed have a moderate flea infestation. He was extremely proud of his diagnosis! Later that year, a prominent dermatologist from the northeast gave a CE seminar and said that most cases of canine pyotraumatic dermatitis were associated with flea infestation. We saw many dogs with ‘hot spots’ in the summer months in Denver and none of them were associated with fleas ― this reinforced to me the strong regional nature of the dermatologic conditions we diagnose and manage. My residency at the University of Missouri covered all aspects of small animal medicine. There were no specialty services in the teaching hospital so patients with skin disease were seen along with those with other medical issues. John MacDonald had just joined the faculty and brought his enthusiasm for dermatology from Cornell to our medicine group. Craig Griffin was an intern that first year and Jim Noxon followed as medicine resident the next year so we had a core group of folks interested in the skin. John MacDonald’s enthusiastic approach to skin disease was infectious and it was no accident that many Missouri students from that era would become board certified dermatologists in the years ahead. At Mississippi State in the early 1980s, the only board-certified dermatologist was Jim Conroy. Jim was a founding member of AAVD and helped organize the first formal dermatopathology courses in the 1970s. Clinical patients with skin disease were seen by one of us in the small animal medicine service and Jim provided dermatopathology support. Robert McDonald and Ellen Codner were other internists on the faculty at MSU with an interest in dermatology so we continued on page 3 2

FROM THE IMMEDIATE PAST PRESIDENT

continued from page 3

covered classroom and clinical teaching in the discipline reasonably well. My academic career was followed by clinical research, product development and technical training for over 20 years in the animal health industry. It was rewarding to know that animals and pet owners benefited each day from products that you helped develop and bring to market. I attended my first AAVD/ACVD meeting in Los Angeles in 1980. There were 45 of us who gathered in a single room for the scientific program and everyone introduced themselves at the beginning of the session. I had registered for the meeting very late and arrived in Los Angeles without a hotel room reservation. Marv Samuelson took pity on a young veterinarian and allowed me to use the spare bed in his room. The small size of the group in those days enhanced the ability to interact and get to know each other. The continuing education session for general practitioners was held in conjunction with the AAHA annual meeting. This format continued until 1991 when we left the umbrella of the AAHA meeting and conducted our first stand-alone scientific and continuing education meeting in Scottsdale, Arizona. The growth of the veterinary dermatology discipline during my career has been tremendous â€• from 45 North Americans in one room in 1980 to 1,750 delegates from 72 countries at the most recent World Congress in Bordeaux, France. The Academy continues to provide a home for dermatologists, internists, pathologists, immunologists, residents, general practitioners and veterinary technicians who will actively move the discipline forward over the next 40 years. I hope you will become or remain involved in these exciting endeavors.

NAVDF Program Committee Dr. Andrea Lam, Chair

Dr. Rose Miller

Dr. Sandra Koch

Dr. MarcyÂ Murphy

Dr. Alberto Martin

Dr. Mitchell Song

AAVD Executive Board President Dr. Catherine Outerbridge Davis, CA

Members-at-large Dr. Rose Miller Salt Lake City, UT

Immediate Past-President Dr. Rod A. Rosychuk Ft. Collins, CO

Dr. Andrew Mills Shoreview, MN

Vice President Dr. Leonard Jones Wheat Ridge, CO

Graduate Student-Postdoctoral Fellowship Program Dr. Robert A. Kennis Auburn, AL

Treasurer Dr. Klaus Loft Weymouth, MA

Editor, Derm Dialogue Dr. Norma White-Weithers Westbury, NY 3

Executive Secretary Ms. Libby Dietrich 1.877.SKINVET (754-6838) ldietrich@pamedsoc.org info@aavd.org

WAVD UPDATE

WAVD Update Prepared by Dr. Phil Roudebush

9th World Congress of Veterinary Dermatology

It has been my privilege and honor to serve as the AAVD Representative to the WAVD Administrative Committee during the past 16 years. During that time, WAVD has transformed itself from an organization that focused primarily on the planning of the World Congress of Veterinary Dermatology to one with additional new programs and initiatives to address the global needs of veterinary dermatology better. I am proud to have represented our Academy in those efforts. I am also pleased that Dr. Jeanne Budgin will replace me as the AAVD representative. She attended the most recent WAVD-AC meeting and has already begun working on several WAVD committees or projects. Her active involvement in private practice and past leadership positions in AAVD will allow her to represent you well in the years ahead. Please give Jeanne your full support and forward any inquiries about WAVD activities to her.

The Executive Organizing Committee of WCVD9 has been approved and has already met twice to begin planning the next congress in Sydney, Australia in October 2020. Mandy Burrows (AUS) – President Rusty Muse (USA) – Secretary Rosario Cerundulo (IT) – Treasurer Peter Hill (AUS) – Program Beth McDonald (AUS) – Local Organizing Carmel Taylor (HK) – Publicity David Lloyd (UK), Wayne Rosenkrantz (USA) and Mike Shipstone (AUS) – Sponsorship Karen Campbell (USA) and Phil Roudebush (USA) – Publications Craig Harrison (UK) – Exhibition Stephen White (USA) – WAVD Representative Koji Nishifuji (JPN) – Asia Representative

8th World Congress of Veterinary Dermatology WCVD8 in Bordeaux, France was a huge success with a total of 2,150 participants and 1,750 delegates from 72 countries. The congress was also a financial success and surplus money will be distributed to the constituent organizations later this year including AAVD. Abstracts from 230 research papers and posters were published in the Veterinary Dermatology Supplement in May 2016 and are available in the Wiley online library. Eleven review papers and research manuscripts from the congress were published in the February 2017 Veterinary Dermatology issue. Proceedings from the continuing education portion of the congress are available online at WAVD website. Finally, Volume 8 of Advances in Veterinary Dermatology will be published as an electronic book in the summer of 2017 and will also be available in the Wiley online library. Advances will include all the original manuscripts plus summaries of the eleven workshops presented in Bordeaux.

10th World Congress of Veterinary Dermatology The 10th congress will be back in North America in 2024; the bid process will begin next year.

Peter Ihrke Scholarships WAVD established a scholarship to honor Dr. Peter Ihrke. The scholarships will allow individuals from areas of the world that are under-served with respect to veterinary dermatology to complete an externship with the veterinary dermatology group at the University of California, Davis. The first two recipients were chosen recently ― Dr. Sabrina Costa (Brazil) and Dr. Veronica Pereja (Ecuador).

Clinical Consensus Guidelines WAVD has established a process to have expert committees develop and publish clinical consensus guidelines. The first two guidelines will be published soon on the topics of dermatophytosis and methicillin-resistant staphylococcal infections. Future topics will include demodecosis, Malassezia infections, immune-mediated therapy and equine hypersensitivity. Thanks to Dr. Wayne Rosenkrantz who has coordinated the guideline efforts on behalf of WAVD and all the committee members for their efforts.

Two deceased members of AAVD were honored in Bordeaux. The continuing education stream of practical dermatology was named in honor of Dr. Peter Ihrke and special recognition was given to Dr. Didier Carlotti, WCVD8 President, during the opening ceremony.

AAVD BUSINESS MEETING MINUTES

2017 AAVD Business Meeting Agenda Meeting: AAVD Business Meeting Recording: Libby Dietrich Presiding: Rod Rosychuk, AAVD President

Date: April 29, 2017 Time: 12:30-2:00pm Location: Orlando RECOMMENDATIONS FOLLOW-UP / ACTIONS REQUIRED

TOPIC/AGENDA ITEM

DISCUSSION

Opening Comments

A. Dr. Rod Rosychuk None KRAL Awards were bestowed to: 2016 Winner – Dr. Wayne Rosenkrantz Presented this meeting due to no NAVDF in 2016 because of WAVD. Accepted and spoke a few words

2017 Winner – Dr. Philip Roudebush Awarded the 2017 Kral award. Accepted and spoke a few words.

Introduction – Libby Dietrich

2016 Business Meeting Minutes Motion. Seconded. Minutes approved.

2016 Minutes

The minutes from the 2016 Annual Business Meeting were approved as presented.

Treasurer’s Report

B. Dr. Lenny Jonas None Dr. Jonas reviewed the financial activity of AAVD for the year 2016 as outlined in the Treasurer’s Report in the agenda. AAVD had a good year that ended in the black by $29,572.76. 2016 was the first full year of investments and $27,044.64 was earned after fees. The Treasurer’s Report was approved as presented.

Derm Dialogue

C. Dr. Norma White-Weithers None There was no Derm Dialogue in 2016 because of the WAVD. Dr. Tim Strauss has joined as Assistant Editor of the Derm Dialogue. All moderators should include as much information as possible in the write up of the roundtable sessions. The Derm Dialogue Report was approved as presented.

WAVD update

E. Dr. Phil Roudebush Dr. Roudebush’s term representing AAVD expires at the end of 2017. Dr. Budgin will replace Dr. Roudebush once the year ends.

2016 was a successful World Congress in Bordeaux with 2,150 participants; 1,750 delegates from 72 countries. WAVD provided scholarships for 30 individuals from under-served regions. A monetary surplus was achieved; funds will be shared with AAVD. CE Proceedings are available online at WAVD website. Volume 8 of Advances in Veterinary Dermatology will be published as an Ebook this summer; it will be available in the Wiley online library.

The 9th WCVD will be held in Sydney Australia. Organizing Committee has formally been approved including Dr. Mandy Burrows as President and Dr. Rusty Muse as Secretary. The bidding process for 10th WCVD will beginning next year in North America.

2 Peter Ihrke scholarship winners were chosen for externships at UC Davis.

Clinical Consensus Guidelines will soon be published. First two will be dermatophytosis and methicillin-resistant staphylococcal infections. Topics for 2018-2019 will include demodecosis and Malassezia infections and topics for 2020-2021 will include immune-mediated therapy and equine hypersensitivity.

NAVDF Program Committee Report

F. Dr. Mitch Song None 2018 NAVDF will be in Maui, Hawaii from May 2 to 5. 2019 NAVDF will be in Austin, Texas from April 10 to 13. There will be no NAVDF in 2020.

None

continued on page 6 5

AAVD BUSINESS MEETING MINUTES

2017 AAVD Business Meeting Agenda Meeting: AAVD Business Meeting Recording: Libby Dietrich Presiding: Rod Rosychuk, AAVD President

Date: April 29, 2017 Time: 12:30-2:00pm Location: Orlando RECOMMENDATIONS FOLLOW-UP / ACTIONS REQUIRED

TOPIC/AGENDA ITEM

DISCUSSION

Old Business:

G. Dr. Rod Rosychuk In Memorium – Candice Benuck 2016 A moment of silence was held in honor of Dr. Benuck. She was an avid runner. Interested parties can join in a memorial run/walk at 6:00pm on Saturday, April 29th.

None

New Business H. Dr. Rod Rosychuk 1. Student Awards 2017 = $3000.00 and in process. AAVD has 8 recipients as of April 2017. 2. Review the 2018 dues rate. Dues will remain the same for 2018. Journal rates for 2018 will be: $188 (print and online) $160 (online only) The AAVD board of directors voted to increase the ACVD Research and Fund donation to $15,000 from $10,000. AAVD will award a complimentary conference registration to a vet technician. The winner is number 19 – Kathryn Del Re Southeast Veterinary Dermatology and Ear Clinic.

Notify vet tech award winner.

3. Election An email will be sent to AAVD membership to nominate individuals for the position of member of large on the executive council. Nominations will be due May 19th. Electronic vote will be held for the final election of the Member at Large position.

Member at Large Election will be held. Nominations to

Membership voted to accept the executive council’s suggestion of Dr. Loft moving into the

ldietrich@pamedsoc.org

by May 19th.

Treasurer position. Motion. Seconded and Approved.

Recognition of Dr. Rosychuk’s two years of president and tenure on the executive council. Adjournment

2:00pm

ROUNDTABLE SUMMARIES

Demodicosis Missy Streicher, AAS, CVT, VTS (Dermatology), Auburn University

Diagnosis and therapeutic monitoring: The traditional deep skin scraping with a dulled scalpel blade or a skin spatula remains the mainstay of diagnosis and evaluation. The second most common technique was hair plucks, especially when sampling around delicate structures such and the eye. As samples are commonly collected in the presence of the pet owner, participants noted the hair pluck technique was more acceptable to owners. None of the participants reported using skin squeezing and acetate tape preparations for regular sampling. There was some debate as to the number of sites that should be sampled, but 1-5 seemed to be the consensus. Some practices charge a flat fee for the service, others charge by the site. All agreed that deep scraping should be collected in the same direction of the grain of the hair. Participants agreed that either a new blade or a sanitized spatula should be used to prevent fomite transmission of disease agents. There was discussion about the clinical importance of counting mites and categorizing life stages, many in private practice have abandoned this tedious process.

Demodex species, incidence and treatments discussed: Mite species (host)

Incidence

Treatments (dosing frequency)

D. gatoi (feline)

Rare

Lyme sulfur dips (weekly)

Advantage multi (biweekly)

Bravecto topical

D. cornei (canine)

Very rare?

D. injai (canine â€“ seborrheic terriers)

Uncommon

Same as D. canis

D. canis (canine)

Common

Nexgard (3 weeks)1

Bravecto (8-10 weeks)2

Simparica (3 weeks)

1. Nexgard is labled for puppies 8 weeks and older 2. Bravecto is labeled for pregnant and lactating bitches. It was noted that all practitioners are moving away from the use of daily oral ivermectin and amitraz was not even discussed. Also of interest, was that PCR studies seem to confirm that isoxazolines do not completely eliminate demodex mites from patients (they remain as commensal organisms).

Length of treatment and appropriate follow up: Most practices are evaluating demodex patients monthly. Typical, two negative skin scrapings at monthly intervals were used to determine the length of treatment. Patients are treated 1 month beyond the second negative skin scraping. Because Bravecto has a three month duration and most patients have two negative skin scrapings by that time, one dose might seem adequate. However, most participants are recommending 1 year of therapy (every 3 months) with the Bravecto. There was discussion on improving client compliance with recheck examinations; including pre-paid appointments and setting the recheck appointments at the first visit. There was recognition that immunomodulatory therapies like apoquel contribute to the development of generalized demodicosis.

ROUNDTABLE SUMMARIES

Equine Sarcoids T. Prange, Dr. med. vet. MS, DACVS

Awareness Challenges: There is evidence that equine dermatologic diseases are not taken seriously and are often neglected or are managed without professional help by owners leading to progression of disease until the problem is very advanced. Increasing client awareness of sacroids and discouraging owner monitoring equine tumors without professional consultation are important steps to better treatment outcomes.

Diagnostic Challenges: Because of the highly variable appearance of equine sarcoids a clinical diagnosis may not be accurate and the group encouraged biopsy and histopathology of suspected lesions. Differential diagnoses that need to be considered include granulation tissue, traumatic lesions, alopecia areata, (fungal) granulomas, papillomas, fibromas/fibrosarcomas, cutaneous lymphomas, habronemiasis, pythiosis, squamous cell carcinomas, peripheral nerve sheath tumors, melanomas, basal cell and mast cell tumors. Because trauma can lead to more aggressive tumor behavior, excisional biopsies were recommended, or if only a portion of the lesion is removed for diagnostic purposes, then immediate therapy should be instituted pending the results. Using an experienced equine pathologist is important to avoid nondiagnostic results.

Treatment Challenges: Equine sarcoids can present with multiple lesions or cover large areas. Even with â€˜cleanâ€™ surgical margins these tumors can re-occur. Adding to the challenge, recurrent lesions become harder to treat.

Treatment options discussed: Imoquomid

High success reported

Best for occult or verrucous types

Acyclovir

High success reported

Best for occult or verrucous types

Surgical excision

12mm clean margins recommended

Difficult for large lesions

Local chemotherapy Cisplatin or carboplatin

Post surgical adjunct treatment for incompletely removed tumor

Intralesional chemotherapy Cisplatin or carboplatin

Single treatment for periocular nodular lesions

Electrochemotherapy Cisplatin or carboplatin

Further increases success rates for nodular lesions

Benign neglect 48% regression of occult lesions

Must have close professional oversight and vigilant owners

ROUNDTABLE SUMMARIES

Flea and Tick Roundtable Dr. Frane Banovic, DVM, PhD, DiplECVD

Isoxazoline drugs availability, use and efficacy: Almost all participants indicated they have access to these new drugs (fluralaner â€“ bravecto, afoxolaner - nexgard and sarolaner â€“ Simparica) and are using them. Many participants preferred to use multiple flea protection products (topical products that use a different mode of action) alternative with an isoxazoline drug dose to increase coverage and prevent a drop of in efficacy. Some participants are using the isoxazoline medications more frequently than labeled. One participant noted frequent vomiting from fluralaner and was concerned about the potential for seizures. The rest of the group had not seen these side effects. Five participants are using topical fluralaner for cats as anti-flea medication with no side effects observed. There was discussion of using flavored preventatives during diet trials. Some participants recommended switching to spot on products (Advantage Multi) during a diet trial, other felt it was unnecessary.

Approaches to flea allergic patients: The group agreed that the speed of kill of isoxazoline drugs was adequate to control canine flea allergic patients. For feline patients, a number of approaches to diagnosing flea allergic dermatitis were discussed; using nitenpyram (Capstar or generic) for several weeks, salamectin (Revolution) every 2 weeks, or topical fluralaner (Bravecto).

Discussion of induction of flea resistance to medications: The group felt that the use of preventative flea and tick medications should be treated like antimicrobials to prevent the induction of resistance. It was hoped that the parasitology group would develop guidelines for regular rotation of these medications.

THANK YOU! The AAVD Executive board would like to thank Dr. Joy Barbet for her dedication to the Derm Dialogue as the Assistant Editor since 2011. Dr. Barbet gave up this position due to family commitments in 2016. As the Editor, I want to thank her for her dedication and her contribution to the dialogue. She was always enthused and welcomed the challenge of editing with calm and grace. I wish her and her family much success in their endeavors. The Derm Dialogue

ROUNDTABLE SUMMARIES

MRS infection Control J. Scott Weese, DVM, DVSc, DACVIM

Introduction While methicillin-resistant staphylococci (MRS) are no longer â€˜emergingâ€™ problems, it is clear that they represent an ongoing challenge as endemic, widespread and frustrating pathogens. They are almost universally identified by veterinary dermatologists and in some practices, account for the majority of skin and soft tissue structure infections.

Virulence of methicillin-resistant staphylococci While high profile and clinical challenges, MRS are no more inherently virulent than other staphylococci. This applies to both MRSA and MRSP, and is an important consideration when dealing with cases, counseling owners and considering screening. The presence of an MR Staphylococcus on an animal does not necessarily have greater relevance to that patient than finding a susceptible Staphylococcus, as long as it is recognized and an appropriate treatment is provided. Further, finding MRS on a patient does not necessarily indicate a need to treat. Some, such as coagulase negative staphylococci, are common contaminants and typically of limited virulence. Even important pathogens such as MRSP can be found as colonizers or contaminants, so consideration of the patient and the disease that is present are critical to determine if treatment of an MR Staphylococcus is needed.

Prevalence of MRS in dermatology patients The prevalence of methicillin-resistance amongst staphylococci from dermatology patients is high and variable. Most participants indicated moderate to high rates of resistance (e.g. 25 - >50%) in SP isolated in their practices. However, this is regionally variable and understanding the epidemiology of MRS in a given practice area is critical. The prevalence of MR Staphylococcus carriage in animals presented to veterinary dermatology practices is less well understood. The overall population prevalence in many regions is probably in the range of 1-3%; however, it can be much higher in the dermatology population, because of underlying disease, repeated antimicrobial exposure and veterinary hospital exposure.

Zoonotic risks There are only few case reports of MRSP infections in humans. The zoonotic risk is very low; however, it is still there. How to address this with staff and owners is a challenge. Putting the risks into perspective is important. This general thought process is important to remember: -

Most dogs shed SP.

MRSP is no more virulent and no more likely to cause a zoonotic infection than susceptible SP.

Millions of people have close contact with dogs every day. This includes millions with compromised immune systems and other factors that increase their risk of zoonotic infection.

SP infections (susceptible or resistant) in humans are very rarely reported. They occur but appear to be very sporadic and with an exceptionally low incidence overall.

Therefore, while MRSP (and SP, in general) poses some zoonotic risk, it is assumed to be limited. Any MRSP carrier presumably harbours many other opportunistic pathogens that pose a greater risk to the owner than MRSP. Counseling owners about the low but potential risk and basic infection control and hygiene practices is appropriate, but care should be taken not to over-react. continued on page 11

ROUNDTABLE SUMMARIES

continued from page 10

How to handle previously infected animals? A contentious issue in some veterinary practices is management of animals previously diagnosed with MRSP. This is of particular concern in some surgical facilities, where aggressive approaches to previously infected animals may be used. Currently, evidence about duration of shedding and the risk posed by a colonized animal to other hospitalized patients are lacking. Some infected animals will become longterm carriers. Some will shed for short periods of time and eliminate MRSP. Some are likely largely refractory to colonization and eliminate MRSP quickly. In the absence of an active screening program (something that is a challenge because of logistics, cost and questions about how to properly sample, test and interpret results), management of this situation can be a challenge.

The potential risk posed by patients is probably in descending order: -

Patients with active MRSP infections of external body sites that cannot be adequately covered

Patients with active MRSP infections of external body sites that can be covered

Patients with active MRSP infections of internal body sites

Patients with recent MRSP infection

Patients with more distant MRSP infections

Use of enhanced infection control practices (e.g. isolation, cohorting, barrier nursing) for the first 3 categories is easy to justify. Measures to address potentially colonization animals are harder to interpret. A key aspect to remember is that the goal is not necessarily to identify dermatology patients that are potentially infectious. While this is ideal in the grand scheme, the emphasis really should be on identification of patients that pose a greater risk than the general patient population, to justify use of enhanced precautions compared to other patients and services. The population prevalence in different populations, risk tolerance, ability to effectively cohort services and patients and similar measures influence the steps that need to be taken. Ultimately, implementation of an encompassing and effective general infection control program is probably the most critical approach.

Boarding and grooming Ethical dilemmas arise with grooming and boarding. There are some facilities that will require carrier cultures prior to seeing the patient. However, whether this is needed or effective is unclear. Optimal sampling and testing approaches have also not been defined. It is reasonable to exclude animals with active infections, unless there is an ability to properly isolate the animal. However, as discussed above, the question for animals with previous MRSP infections is whether they constitute a greater risk than the general dog population, not whether they are known to be MRSP-free.

Treatment Management of MRS is no different than management of other pathogens, apart from drug selection. Topical therapy is a mainstay of treatment of superficial infections. Chlorhexidine resistance has been documented in vitro but clinical relevance of this in staphylococci is unclear. It is of greatest concern with pathogens such as Pseudomonas, where high level resistance is clinically relevant. This is anecdotally most common in facilities that (inappropriately) use chlorhexidine as an environmental disinfectant. Awareness for detection of treatment failures is the most important aspect pertaining to resistance issues in staphylococci. If clinical treatment failure is identified, particularly in cases where response would be expected and underlying disease is being control, investigation for chlorhexidine resistance is warranted.

Underlying causes It is essentially universally accepted that staphylococcal skin disease is secondary in nature. Identification and treatment of underlying causes, whenever possible, is critical. This is an important consideration with multidrug continued on page 12 11

ROUNDTABLE SUMMARIES

continued from page 11

resistant infections. There are ethical concerns about using critically important antimicrobials in patients with uncontrolled underlying disease, because of the likelihood of recurrence. It is hard to justify use of a drug like linezolid when it is almost certain that the patient will be back in the same clinical state shortly after treatment, as this creates unnecessary risk of resistance with little ultimate patient benefit. More broadly, there is a need for consideration of whether it is ethical to prescribe any systemic antimicrobial in cases where owners refuse to (as opposed to are unable to) properly address underlying problems.

Antimicrobial options While topical therapy is a key component of MRS treatment, systemic therapy is needed in some cases. As MRSP continues to become more resistant, options are limited and often undesirable. Rifampin is used by some clinicians, with varying impressions, ranging from ‘safe and effective’ to ‘high risk of causing adverse effects and often resulting in resistance emergence’. One important aspect for toxicity might be the use of lower (5mg/kg q24h) doses, although this is hypothetical. In some regions, doxycycline susceptibility is still present, although it is important that clinicians know whether current (revised) breakpoints are being used by their lab. Otherwise, some isolates may not truly be susceptible. Minocycline is an option in some doxycycline resistant infections, but testing is required to confirm that. Fluoroquinolones are not often used for MRS. Most often, isolates are resistant. Further, evidence and recommendations from human medicine and observations in veterinary medicine indicate unpredictable (and often poor) clinical response. However, there has been recent emergence of a fluoroquinolone susceptible strain of MRSP, perhaps most widely in the northeastern US. Anecdotally, infections often respond to fluoroquinolones. While data are lacking, this might be taken to indicate that fluoroquinolones should not be dismissed as options for this strain, particularly when other options are undesirable.

Carrier cultures While sometimes performed, cultures for carriage of MRS can be confusing, in large part because of questions about the relevance of the results. Carriage is not an indication to decolonize, since we have no evidence it is potentially effective. Carrier cultures also require proper sampling and testing, and optimized approaches are lacking. There are some situations where carrier cultures might be useful, such as in a dog with previous MRSP infection that is to undergo TPLO, since it has been shown that MRSP carriage in that population increases the risk of MRSP TPLO infection (and a corresponding change in peri-operative antimicrobial prophylaxis could be implemented). Otherwise, it is critical to consider the response to positive and negative results any time screening is discussed.

Disinfection and Environmental Controls Reducing broad environmental exposure will reduce the need for disinfection, but is difficult to avoid. Identification and cohorting of high risk (or different risk) groups can be effective and practical, both for awareness and to reduce broader environmental contamination. Application will be very hospital-specific but the concept can be universally applied. Balancing optimal patient care with infection control is a challenge and is another area that needs to be tailored to the individual facility’s needs and risks. Efforts are probably best focused on the highest risk groups that are discussed above, with animals with active skin lesions posing the greatest risk of environmental contamination. Dermatology practices have some potential high risk equipment and common contact surfaces. One particular area of concern is clippers. Disinfection of clippers and clipper blades is higher variable, with some clinics reporting use of sterile blades for each patient, some reporting sterilization of blades after high risk patients and others reporting targeted or periodic spraying or wiping clippers and blades with disinfectant. Cohorting clippers by service (e.g. surgery vs dermatology) or even within service (e.g. clippers for suspected infectious cases vs others) can potentially help reduce cross-contamination and can be a practical approach in many facilities. Gas sterilization of clippers is a good option in facilities where gas sterilization is available. continued on page 13 12

ROUNDTABLE SUMMARIES

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Personal protective equipment Routine use of personal protective equipment is an area than can often be improved upon. Practices vary greatly between clinics. Routine use of lab coats can be useful to facilitate easy and prompt changing of outerwear (something that is less likely to occur if scrubs or street clothes have to be changed). There seems to be more common in-clinic laundry of lab coats and other items, something that is ideal to help reduce the risk of transmission of pathogens from the clinic to households. Gloves are variably used and there is a lack of consensus about optimal approaches. Gloves can be an effective additional barrier, but they are often misused (e.g. not changed enough, used to touch common areas and items, failure to perform hand hygiene after gloves removal).

Dog shows and other events Various other potential high risk situations were discussed. There is a concern regarding judges and how they examine the dogs. It does not seem like there is concern for passage of organisms from each pet, despite the repeated contact with mucous membranes and skin, usually in the absence of any hand hygiene steps. This topic has recently been addressed in a white paper published in JAVMA (Stull et al, J Am Vet Med Assoc 2016;249:612-627)

Other multidrug resistant concerns While MRS are the most common and problematic antimicrobial resistant pathogens in veterinary dermatology, they are not the only issue. Multidrug resistant Pseudomonas in otitis, and the emergence of extended spectrum betalactamase (ESBL) producing Enterobacteriaceae are also important and increasing problems. Fortunately, many of the same issues and approaches to MRS also apply to other multidrug resistant bacteria. However, attention must be paid to these, and other, emerging multidrug resistant pathogens, through both targeted activities and use of good general infection control and antimicrobial stewardship practices.

NAVDF Organizing Committee Chair – Dr. Christina Restrepo

OC Member (AAVD) – Dr. Lenny Jonas

Co-Chair – Dr. Jeanne Budgin

OC Member (ACVD) – Dr. Emily Rothstein

Treasurer – Dr. Marcia Schwassmann

OC Member (ACVD) – Dr. Adam Patterson

OC Member & Social/Sponsorship Liaison Chair –

2017 Program Committee Chair: Dr. Sandra Diaz

Dr. Rod Rosychuk

ACVD NAVDF Executive Secretary: Alexis Borich

Past Chair and Social/Sponsorship Liaison Assistant –

AAVD NAVDF Executive Secretary: Libby Dietrich

Dr. Bob Kennis

NAVDF Meeting Planner: Jill Senior

OC Member (AAVD) – Dr. Catherine Outerbridge 13

SENIOR VETERINARY STUDENT AWARDS

Senior Veterinary Student Awards Congratulations to the 2017 winners of the AAVD Dermatology Senior Veterinary Student Award: Name of school Winner Tuskegee University

Regina Adkins Ringer

University of Florida

Christopher Alling

University of Georgia

Samee Berger

University de Montreal

Camylle Bergeron

Cornell University

Scott Gerald Bertoldo

Western University of Health Sciences

Lauren Bradhurst

Ohio State University

Katelyn Cobb

Washington State University

Ashley Ann Day

University of Calgary Faculty of Veterinary Medicine

Katrina Frost

Oklahoma State University

Ian Frye

University of Illinois

Morgan Hill

University of Tennessee

Sarrah Elizabeth Hoppers

University of Wisconsin-Madison

Anna Jenstead

UC Davis School of Veterinary Medicine

Marguerite Kissel

Oregon State University

Kelsey Lawrence

Iowa State University

Taylor Morrison

Tufts University

Mei Lun Mui

Purdue University

Kristina Naef

Louisiana State University

Elena Pavlova

Michigan State University

Lisa Reznik

University of Pennsylvania

Marvin Schuldenfrei

Kansas State University

Amber Smith

Texas A & M Victoria Thiers Mississippi State University

Erica Unz

Colorado State University

Karyn Wesley

VA-MD College of Veterinary Medicine

Austin Wigley

ROUNDTABLE SUMMARIES

Controversies in Immunotherapy Chair: Douglas J. DeBoer DVM, DACVD, University of Wisconsin-Madison Secretary: Rusty Muse, DVM, DACVD, Animal Dermatology Clinics

General Concepts There was a general agreement among the participants that allergen specific immunotherapy (ASIT) for atopic dermatitis (AD) should be based on allergy testing of some form as opposed to ‘blind’ or regionally-based allergy vaccine cocktails. There is abundant evidence that the most of effects of ASIT are allergen-specific, though some are not. In cases when clients have severe financial restrictions and allergy testing is beyond the financial capability of the client, blind or regional-mix ASIT without testing could be considered as a viable option instead of a lifetime of corticosteroids. However, in clients with severe financial restrictions, immunotherapy may not be the best option as other options for allergy control do exist and may be a better use of restricted finances long term. This is more of an issue for clients being managed by the primary care veterinarian. Another undesirable feature of using allergy vaccines not based on allergy testing methodologies is that if the therapy fails, and clients do get referred or consult a dermatologist, it may be more difficult to convince them to reinitiate ASIT. It may be perceived as an ineffective option that has already been tried.

At What Age Should Immunotherapy Start? There were a variety of responses regarding age guidelines for beginning ASIT. Some participants felt that waiting until a patient has experienced a variety of seasons is important, and they try to wait until the patient is at least a year of age. Other participants will allergy test young patients once they have determined that the patients do not respond to food trials, infection management and parasitic therapy. Allergy testing patients as early as 4-6 months has been done by multiple participants routinely, with strong positive results in many cases. There was some discussion that age of onset of AD may vary geographically, with some participants seeing very young patients presenting with atopic dermatitis including participants from Australia, Southern California, Arizona and Memphis. Other areas that are more temperate in climate appear to see patients that present in the more standard time frame of a year or older. Some participants suggested that monitoring patients for early signs of allergic skin disease such as recurrent folliculitis from poor barrier function may be missed as early “atopic signs”. Many participants also see a waxing and waning level of pruritus as opposed to persistent nonseasonal pruritus initially. There were no concerns about the use of ASIT in older dogs. Many participants routinely use allergen specific immunotherapy in dogs over 10 years of age. There was some question about patients with autoimmune diseases such as AIHA – would ASIT cause any problem? On this question, no issues have been noted by any of the participants.

Opinions on Formulation Opinions on the number of allergens allowed to be put into one vial varied considerably, with approximately half of the participants using 10-12 allergens as a standard, and using a second vial if needed. The other half put as many allergens into one vial as is suggested based on results of allergy testing methods, without limitation. This would obviously result in less of each allergen in the entire mix. Because a dose effect (i.e. a minimum effective dose) has been clearly observed for humans, mixing a very large number of allergens in one vial may not be ideal, as the dose of each allergen will be smaller. Unfortunately, the minimum effective doses have NOT been established for animal species, so we have no evidence-based guidelines for this issue. Limiting the number of allergens in the mix by choosing one representative allergen from each cross-reactive botanical group may help with reducing the number of allergens in a single vial. continued on page 16 15

ROUNDTABLE SUMMARIES

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Most participants do choose allergens based on exposure, clinical history, and botanical groupings. One older retrospective, unpublished study by Drs. Angarano and MacDonald, presented long ago as an NAVDF abstract, suggested that there was no difference in efficacy based on the number of allergens per vial. It is known for people that variations in frequency of dosing and in and allergen concentration may affect efficacy, but such variability has not been studied in veterinary species.

Does Microbial Hypersensitivity Exist? Most respondents believed that yeast and bacterial hypersensitivity are clinical entities for some patients. This is most often documented by IDT with either Malassezia or Staphylococcus extract, though some serology laboratories now provide microbial allergen-specific IgE results. To test for staphylococcal hypersensitivity, Dr. DeBoer recommended IDT with a 1:10 dilution of S. aureus extract (Staphage Lysate - SPL, Delmont Laboratories). Additional testing products based on S. pseudintermedius may be coming in the future. Malassezia yeast hypersensitivity is tested for by most on IDT, though it was recognized that some serology companies offer yeast-specific IgE on their panels. The use of SPL as an ingredient in ASIT formulations is a common practice by some clinicians. This may be of value in patients that exhibit classic signs of “bacterial hypersensitivity” - IE, a severely pruritic dermatitis with evidence of staphylococcal infection, and antibiotics completely resolve the bacterial pyoderma and itch, but then infection recurs within the next month or two. Some participants add SPL directly into the same allergen vial, while others use it as a separate injection. When used separately, most participants will use SPL for 4-6 months before efficacy can be evaluated; most use the 1.0 ml weekly or .5 ml 2 x weekly.

Mold Extract Concerns Most participants report mold reactors as common in their practice. Some of the drier areas have less of an issue with mold reactors including Southern California, Arizona and Wisconsin. It was very clear that mold reactions have strong variation by region. It was noted that in people, published guidelines in both the USA and Europe recommend against mixing mold extracts with others, because the mold proteases may degrade the other allergens. The recommendation is to administer molds as a separate injection. Nevertheless, many veterinary dermatologists continue to mix molds and pollens in the same vial.

Can You Stop Immunotherapy? The question of whether immunotherapy can be discontinued in patients that respond favorably to it was explored. The group was evenly split between those that recommend stopping after a few years of good success to gauge for clinical remission or cure, vs. those who continue long-term. A previous study by Dell et al. showed that between 5-7% of patients can be put into long term remission. Once the allergens are discontinued, some clinicians report a high rate of eventual relapse.

How long do you use immunotherapy before deciding it is not successful? There was general agreement that it the initial treatment trial period should be at least 12-18 months, but in some cases of human ASIT, it may take years for optimum response. In some patients, the benefit from ASIT may be “medication sparing”, IE allowing lessening of other drug therapies that are required for optimal control. The consensus was to continue to use ASIT longterm if clients are willing to continue to use it if there are no obvious adverse issues. continued on page 17

ROUNDTABLE SUMMARIES

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Subcutaneous versus sublingual therapy â€“ what to recommend?

Welcome New AAVD Members!

The majority of participants were using subcutaneous therapy more routinely, reserving sublingual for patients that have problems with injections. Sublingual therapy is also more difficult for those that have travel schedules that are not amenable to twice daily therapy.

ACVD Members Jeanmarie Short, DVM

One participant discussed the concurrent use of both SC and sublingual therapy which may be associated with a more rapid improvement by exposing the immunological responses to the allergen by two different routes. Dr. DeBoer related the results of a Korean study that suggested that there were better responses with this approach in people, but the effects remain unstudied in animals.

Student Award Members Camylle Bergeron, DVM Lauren Bradhurst, DVM Katelyn Cobb, DVM Morgan Hill, DVM Sarrah Hoppers, DVM Mei Lun Mui, DVM

Some participants had seen better response when switching from shots to drops, or drops to shots, although this was not seen universally. Most the time, cases that were switched were done so because of undesirable side effects associated with one or the other approach.

Kristina Naef, DVM Elena Pavlova, DVM Lisa Reznik, DVM Erica Unz, DVM

Do dogs on ASIT develop new sensitivities over time?

Victoria Bole Thiers, DVM Karyn Wesley, DVM

The development of new sensitivities was felt to be relatively uncommon phenomenon, though it is widely discussed. It was noted that in people, some studies indicate ASIT has a protective effect at preventing new sensitizations.

Austin Wigley, DVM

Veterinarian Members Lydia Cook McAnulty, DVM

Are there breed predispositions to response to immunotherapy?

Affiliate Members

Breed variation in success of immunotherapy appears to be well noted, though anecdotally. Golden Retrievers were perceived to be good responders in general. French Bulldogs, Labrador Retrievers, and Bichon Frise dogs may be on the lower response scale. Could genetic sequencing be helpful in the future to know if individuals will respond to immunotherapy?

Debbie Corll Alexandra Rand Annette Royce Mary Wilhelm

Are there other manifestations of allergy that may benefit from immunotherapy? Some participants have been involved and working with ophthalmologists in cases that have qualitative defects of tear production which have been clinically improved with the addition of ASIT.

ROUNDTABLE SUMMARIES

Therapeutic products for otitis externa assessment and comparison Carol George, VT Flushing is an important treatment for otitis problems. These are the products being used and the number of attendees using them. Flush/Cleanser Products

Number of attendees using this product

Douxo Micellar

T8 Keto Flush

Epi Otic Advanced

Malacetic Otic

Triz Ultra plus Keto

Cerumene 3 Leave in otics such as Claro Otic Solution and Osurnia Otic Gel were being widely used by the attendees. These were usually applied in clinic after cleansing the ear and were reassessed and repeated every 1-3 weeks. Compounded products (usually with lanolin) were less popular and there was one report of vestibular disease in a pug after using and Oti-Pack preparation. Only two attendees reported compounding ear medications in house. Popular combinations they use are tobramycin/ dexamethasone/miconazole and enrofloxacin/dexamethasone/clotrimazole. They usually recheck the ears in 4 weeks and feel the liquid preparations penetrate into the ears better than ointments and that it is important to use enough volume to fill the canal. One attendee felt is better to keep topical products separate and dose them individually. For bacterial infections, attendees reported using topical amikacin, tobramycin, ceftazidime, mupirocin (mixed with warmed saline and burrows solution), pipericillin and ticarcillin. Attendees agreed that enrofloxacin should only be used based on culture and sensitivity results. For fungal infections, attendees reported using topical miconazole, clotrimazole or terbinafine for resistant infections. Less frequently used commercially available products being used included EasOtic , Mometamax, Posatex Otic Suspension, Baytril Otic, and Surolan Otic. Some attendees reported avoiding gentamycin containing products over fears of ototoxicity. The majority of attendees use anti-inflammatories as needed for inflammation. Most often they are combined with antimicrobials. There are five attendees that always use topical steroids with initial therapy. CortAstrin is used by one attendee with good success for controlling inflammation, helping to prevent recurrent infections. Zymox otic hc was also reported to help decrease wax build up and control inflammation. For more severe inflammation Synotic is sometimes used.

ROUNDTABLE SUMMARIES

â€œJournal Clubâ€? Liuis Ferrer, DVM, PhD, DECVD After the introduction of all participants at the round table, three recent scientific papers that the attendants had received previously were discussed. Fukuyama T., Gianchinoco JR, Mishra K, Olivry T et al. Janus kinase inhibitors display broad anti-itch properties: A possible link through the TRPV1 receptor. J Allergy Clin Immunol 2017 Jan 26. This paper, using different in vitro (cultures of dorsal root ganglion neurons) and in vivo strategies (mice models) shows that janus kinase inhibitors (i.e. tofacitinib and oclacitinib) in addition to blocking the signaling of some cytokines act directly inhibiting the pruritus signal in neurons. These molecules inhibit the TRPV1 (transient receptor potencial cation channel subfamily V member 1) and therefore stop the pruritus signal quickly. The authors demonstrate this additional mechanism of action of JAK inhibitors using different complementary and elegant experiments. The participants at the round table underlined that this was big step ahead in the understanding of the mechanism of action of these molecules and that this would explain the extremely fast onset of action of oclacitinib. Also, they made several comments on the diverse mechanisms of action of this new drug. Oclacitinib seems to have immunomodulatory and anti-allergic properties but also a strong and fast anti-pruritic activity that probably is not -or not only- dependent on the inhibition of the cytokine signaling. This broad and complex mechanism would explain the high success of this molecule in the treatment of allergic dermatitis. The participants also shared their clinical experiences with oclacitinib and discussed the potential reasons for failure of this treatment in some atopic dogs. Ruzicka T, Hanifin JM, Furue M, Pulka G et al. Anti-Interleukin-31 receptor A antibody for atopic dogs. N Eng J Med 2017; 376: 826-835. In this phase 2, randomized, double-blind, placebo-controlled, 12-week trial, the authors treated human pacients with moderate-to-severe atopic dermatitis with nemolizumab a humanized monoclonal antibody against IL-31 receptor A. The nemolizumab was administered at a dose of 0.1 mg, 0.5 mg, or 2.0 mg per kilogram of body weight every 4 weeks or at an exploratory dose of 2.0 mg of per kilogram every 8 weeks. The primary end point was the percentage improvement from baseline in the score on the pruritus visual-analogue scale at week 12. Secondary end points included changes in the score on the Eczema Area and Severity Index (EASI), and body-surface area of atopic dermatitis. Of 264 patients who underwent randomization, 216 (82%) completed the study. At week 12, among the patients who received nemolizumab every 4 weeks, changes on the pruritus visual-analogue scale were -43.7% in the 0.1-mg group, -59.8% in the 0.5-mg group, and -63.1% in the 2.0-mg group, versus -20.9% in the placebo group (P<0.01 for all comparisons). Changes on the EASI were -23.0%, -42.3%, and -40.9%, respectively, in the nemolizumab groups, versus -26.6% in the placebo group. Respective changes in body-surface area affected by atopic dermatitis were -7.5%, -20.0%, and -19.4% with nemolizumab, versus -15.7% with placebo. The authors concluded that, nemolizumab at all monthly doses significantly improved pruritus in patients with moderate-to-severe atopic dermatitis, which showed the efficacy of targeting interleukin-31 receptor A. The participants underlined and discussed different aspects of this very interesting paper. The most striking conclusion was the similarity of the results obtained in the clinical trial in humans with the results obtained with lokivetmab in atopic dogs. The dose (2 mg/kg/ 4 weeks), percentage of success (around 60% in pruritus; around 40% in lesions), and also the lack of host neutralizing antibodies against the therapeutic monoclonal antibody are almost identical in atopic humans and dogs treated with these monoclonal antibodies. Schwarz A, Bruhs A, Schwarz T. The Short-Chain Fatty Acid Sodium Butyrate functions as a regulator of the skin immune system. J Invest Dermatol 2017 137: 855-864. continued on page 20

ROUNDTABLE SUMMARIES

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There is evidence that gut commensal microbes affect the mucosal immune system via expansion of regulatory T cells (Tregs) in the colon. This is mediated via short-chain fatty acids, bacterial metabolites generated during fiber fermentation, which include butyrate, propionate, and acetate. In this excellent and groundbreaking paper, the authors postulate that short-chain fatty acids produced by commensal skin bacteria may also activate resident skin Tregs, the activity of which is diminished in certain inflammatory dermatoses. Sodium butyrate (SB) either injected subcutaneously or applied topically onto the ears of hapten-sensitized mice significantly reduced the contact hypersensitivity reaction. This effect was histone acetylation-dependent because suppression was abrogated by anacardic acid, a histone acetyltransferase inhibitor. The genes encoding for the Treg-specific transcription factor foxp3 and for IL-10 were up-regulated upon treatment with sodium butyrate, as determined by quantitative real-time reverse transcription-PCR. Immunofluorescence analysis showed enhanced numbers of Foxp3-positive cells in sodium butyrate-treated skin. Additionally, CD4+CD25- nonregulatory human T cells exerted suppressive features upon incubation with sodium butyrate. This indicates that Tregs can be induced by short-chain fatty acids, suggesting (i) that resident skin microbes may prevent exaggerated inflammatory responses by exerting a down-regulatory function and thereby maintaining a stable state under physiologic conditions and (ii) that short-chain fatty acids may be used therapeutically to mitigate inflammatory skin reactions. The participants commented on the importance of this paper. In addition to the importance of the paper to explain how the skin microbiota interact with the skin immune system, they were specially interested in the clinical implications of this paper, especially: (1) The mechanism of action is very similar to the mechanism reported for allergen specific immunotherapy: inducing more Tregs and the production of IL-10. (2) Topical administration of SCFA can be used in the near future to treat allergic dermatitis in dogs and cats. (3) SCFA can be added to shampoos or cosmetic to reduce the inflammatory reaction.

FROM THE PRESIDENT continued from page 1

The Frank Kral award honors one of the Academyâ€™s founding members and is awarded by the AAVD to recognize outstanding achievements and dedication to the veterinary profession and specialty of veterinary dermatology. Congratulations are in order to Drs. Wayne Rosenkrantz and Phil Roudebush who received the Frank Kral Award for 2016 and 2017, respectively. At the business meeting, Dr. Rosychuk bestowed these awards and we all had the opportunity to recognize and thank both of these individuals for all they have done for our specialty. I look forward to seeing everyone in beautiful Maui in May 2018. Check out navdf.org for more information on what promises to be another exceptional meeting. The meeting will include two half days to allow attendees some beach or pool time in the afternoon. In lieu of a lunch meeting, our AAVD business meeting will occur early Wednesday evening with a complimentary mai tai. Mahalo and Aloha,

Dr. Catherine Outerbridge AAVD President