Spring 2021 AAVD Derm Dialogue

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SPRING 2021

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

FROM THE PRESIDENT Welcome to the annual meeting Hope all have had a great meeting and enjoyed NOLA in person after two back to back virtual veterinary meetings (last year’s NAVDF and the World congress) three if you add the ECVD.

Dr. Klaus Earl Loft, DVM

Please thank the sponsors, exhibitors and the OC and PC and the new AMC, Venue West who have worked hard on getting this in person meeting off the ground.

We had 693 attendees and 40 exhibitors this year with over a 100 veterinary technicians, (AAVD members). Of the

The AAVD have been growing and trying new things, while holding on to our core traditional values, and I think most know that over the last years and there have been some growing pains particularly since the formation of the NAVDF in 2011. Where the AAVD started to drift a little until a series of brilliant boards and presidents found a path forward. My view on this is that we are now looking at a good progress and growth over the past years and the current executive board a looking strong to continue this trend. The AAVD membership have stabilized at just around 500 members after a period of significant retention issues. With the membership struggling to see “value” in their membership dollars, lost connection due to less than ideal transition to paperless registration and the past AMC Company, lead to numerous changes in executive secretary role. At this point we have our new executive secretary Julie Cushing from PAMED who have really jumped into her role with this meeting, welcome on board looking forward to working together for many more meeting.

I want to take this opportunity to personally thank the members of the AAVD board for their great work and the combination of brilliant minds creating new ideas and ways to move the AAVD forward even during a crazy time like now.

The AAVD board are looking to continue finding new ways to bring the field of veterinary dermatology for our members, with new social media on Facebook, Twitter and Instagram (TikTok likely coming soon) So please like, follow and share, retweet the AAVD posts when you see them on a device near you and if you have fun, interesting and relevant events/meetings/seminars/lectures/ congresses, stories, articles, websites or want to share a cool clinical case, dermatopathology image or important information that you think should be shared with our awesome world of veterinary dermatology. Please hashtag, tweet at, e-mail to or upload on any of our social media platforms…. And if you need help with posting or have suggestions please send an e-mail to info@AAVD.org we are always looking to find content that we can share and use to help each other. n Among new initiatives for our members have been to open up for Residents to join the AAVD for free during their program n T he AAVD website have been able to share the awesome ISVD case of the month, thanks to a cooperation between our sister/ brother group ISVD and we hope the members are finding these cool cases interesting, relevant and educational Continued on page 2

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FROM THE PRESIDENT

n W e have had some minor technical issues getting the recordings of last year’s NAVDF virtual meeting up on our website, but I hope that the members will find the archived recordings of last year’s sessions valuable and we plan to post this year’s sessions to be available after new years 2023. The goal will be to have an archive of past meetings on the password protected section of the website for AAVD members in good standing. n T he Website have a searchable membership directory that will hopefully be helpful for us all when we are looking to cooperate across the globe. A new goal to have on our website will be a platform for our members to post projects that you have started and if looking to recruit clinical cases, cooperators or find out if other members are involved in similar studies or research. n T his past year we have gotten some fantastic virtual round tables/panel discussion out to the members thanks to Candace Sousa, Jim Noxon, Rod Rosychuk and Megan Solc. The derm Dialogue have been getting out to you and the past issues can be found on the AAVD website

The student award program is growing The semi new initiative our 3rd annual AAVD organized speaker with topics on the edges of the traditional NAVDF topics and we are super happy to have Dr. Justine Lee from www.VetGirlonrun.com is this year’s AAVD organized Key note speaker closing out the NAVDF 2002, this afternoon in Napoleon room with two sessions titled “How to have a work life balance in a dog eat dog world” and followed by Top 10 Small business Hacks Dream moon shoots would be a portal protected coordination of studies to help connect multi center studies, subjects, funding, researchers etc Again I want to thank the AAVD executive board for an awesome collaboration and effort and I love how the members for letting me be a small part of this fantastic body of smart, passionate empathic and groovy people. pathology and government wherever our Academy members are.

On behalf of the AAVD executive board I am so happy to see the new and old members showing their support and we look forward to see you in April and we will have a small gift to all members in good standing at the NAVDF 2022.

Best wishes for a safe and healthy year and looking forward to see you all in 2022

Klaus Earl Loft, DVM

President AAVD Executive Board Co-chair NAVDF Program Committee Co-Chair Sponsorship and exhibitor of the NAVDF Organizing Committee

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Meeting Planner

ktravitz@pamedsoc.org

Administrative Assistant

Jill Bennish,

Overview of Staff jbennish@pamedsoc.org and Leadership AAVD Executive Board

NAVDF Program Committee

President Dr. Klaus Loft Boston, MA

Members-at-large Dr. Anna Jenstead Chicago, IL

Immediate Past-President Dr. Catherine Outerbridge Davis, CA

Dr. Brian Scott Largo, FL

Program Chair Dr. Sandra Koch

Co-Chair Dr. Klaus Loft

Dr. Petra Bizikova Dr. Alberto Cordero Dr. Gram Dunbar Dr. Brian Scott

Vice President Dr. Rose Miller Coeur d’Alene, ID

WAVD Representative Dr. Jeanne Budgin New York, NY

Treasurer Dr. Verena Affolter Davis, CA

Editor, Derm Dialogue

Dr. Natalie Theus Columbus, Ohio

Dr. Norma White-Weithers

Baldwin, NY Executive Secretary Amy Blankenhorn

WAVD Committee

Association Coordinator II Rhianna Etzweiler

AAVD Representative to the WAVD Dr. Jeanne Budgin

NAVDF-OC Committee Positions Term Name Affiliation

Email

Chair 2021-2023

Dr. Rose Miller AAVD RMillerdvm@gmail.com

Co-Chair 2021-2023

Dr. Kristin Holm ACVD Kshdvm@yahoo.com

Treasurer 2021-2023

Dr. Allison Kirby ACVD Alliekirby@yahoo.com

Social & Sponsorship Chair

2021-2023

Dr. Dana Liska

ACVD

Danaliskadermvet@gmail.com

Social & Sponsorship 2018-2023 Co-Chair

Dr. Klaus Loft

AAVD

Klausloft@gmail.com

OC Mbr AAVD

2019-2023

Dr. Norma White Weithers

AAVD

Nweithers@yahoo.com

OC Mbr AAVD

2021-2024

Dr. Anna Jenstead

AAVD A

Jenstead@gmail.com

OC Mbr ACVD

2020-2024

Dr. Lindsay McKay

ACVD

Lindsay.mckay@vca.com

OC Mbr ACVD

2021-2025

Dr. Melissa Eisenschenk

ACVD

melderm@gmail.com

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ROUNDTABLE SUMMARIES DERMATOLOGY SPECIALTY INTERNSHIP Ian Brett Spiegel VMD, MHS, DACVD Background • Specialty Internships have been around for at least 20-25 years • These have become more of a normal part of the process of becoming a resident.

Requirements for applicants.

• It is agreed that most people feel that an applicant should have completed a rotating internship.

• Exceptions would include an individual with 2-3 or more years of clinical experience in practice. General knowledge is important for a dermatology intern and ultimately resident.

• Academic performance matters, but so does experience and letters of recommendation. One participant mentioned that some programs are pass/fail, so GPA is difficult to use for those applicants.

• Most felt that those applying for residencies, should also apply for internships (as back-up). It is slowly becoming the normal means of obtaining a residency.

• One participant who has been training residents for years, sees dermatology internships as a positive as the applicant has much more knowledge and is ‘ready’ for the busy private practice setting. As a matter of fact, the applicants finally considered after interviews, all had dermatology internships.

Contracts • Some programs have written contracts and others do not.

• Non-compete clauses were discussed (difficult to defend in court).

Programs Available: 2006 • 1-2 known specialty veterinary dermatology internship positions in the USA 2021 • 15 dermatology positions in the VIRMP Match (may be more- not all are listed on VIRMP)

• 3 say Rotating but are in the dermatology section • This is double the amount of dermatology residency programs available on VIRMP • Many applicants now rank both internships and residencies.

• This is at least a 500% increase in specialty veterinary dermatology internship positions in 15 years.

• Match vs. Scramble

• Pros/cons to the match and pros/cons to selecting an Intern outside of the match.

• Appears to be the case that MANY programs seeking and Intern did not MATCH.

• Some have been successful outside the match/scramble.

• Other programs have open internship positions.

Decisions • Why do a specialty internship?

• Stepping-stone for a residency.

• Keeps the applicant in the “system”—better position to apply again • More experience focused on the area of the applicant’s interest.

• Obtain letters of recommendation from boarded dermatologist(s) • The veterinary dermatology community is small.

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• Reference means more from other dermatologists.

More experience and thus become a better veterinarian • Networking and Connections (reality) • Participants agreed that prior to offering an applicant a position, the mentor would almost always reach out the dermatologist references.

• Important to work with/rotate/extern/shadow dermatologists as the community as small and it would be advantageous to have some references who are dermatologists.

• University vs. Specialty (Motive of the program): • Cheap Labor vs. Provide Experience and get the applicant MATCHED! • Things to consider • Some corporate hospitals require that the Dermatology Intern be required to do emergency service shifts +/- work on selected holidays. While some of these programs compensate higher, it is sometimes unattractive to the applicant.

• Many applicants are attracted to programs that also offer residencies as this is seen as an advantage to potential be favored for the residency program. This is often the case, but programs with a residency option may be at an advantage over programs without the residency option when it comes to recruiting an intern.

Financial Implications • Relocation expenses.

• Most programs do not offer that for internships.

• Another year of low wages and NO GUARANTEE for a Residency.

• Student debt burden may influence the decision to do a specialty internship.

•S alary was discussed. The range is wide as it depends on location (geographic). But there are some states that require the salary to be close to that of a resident. Some programs also may pay higher with the intention that this would make a weekly emergency day not a deterrent for a good applicant.

• The ranges were likely around $30,000 to 60,000/year. Some programs have lower salaries.

Family • Geographical – willingness to relocate (several times) • Academic • Veterinary school performance (GPA) • If poor GPA, will an additional year of training make the difference? Most agree it will.

• Varies Things to consider/Goal of the Program: • #1 GOAL: Become a stronger applicant for obtaining a residency!

• Develop a more comprehensive knowledge of dermatologic conditions by helping to manage numerous patients.

• Many of the procedures should be co-performed by the intern once the level of comfort is achieved (e.g., biopsies, mass removals, skin testing, ear flushes, etc.).

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• Dermatopathology • There are opportunities to train remotely.

• One of the attendees at the round table, Dr. Karen Trainor discussed this option.

• Mentors should be able to network for find opportunities for this experience.

• Publish a review article vs. research +/- lectures. (OPTIONAL) • This may make an applicant stronger for an internship and/or residency.

• Even writing a case report to be publish would be beneficial and one participant mentioned that the student should reach out to dermatology faculty to see if there is an opportunity to do so.

• Provide foundations for a residency.

• Utilize the Intern in a way that will provide a good experience and allow for knowledge to be obtained regardless of the task.

• Consider drop-off/in house cases that the intern can be in charge of patient, but still have a dermatologist who would still oversee these patients.

• In-house examinations/emergency/same day transfers • Phone calls with clients and sometimes RDVMs.

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ROUNDTABLE SUMMARIES Otitis Externa Moderator: Dawn Logas, DVM, DACVD The discussion started with whether to culture otitis externa or not. Several of the participants no longer culture otitis externa at all and feel that they still have the same clinical success. Most others still culture. Of these some just culture to identify the organisms and ignore the sensitivity while others also still use the sensitivity patterns to decide on topical drugs. This lead to the next discussion about over coming resistance with topical antibiotics.

Multiple participants felt resistance to topical antibiotics was easy to overcome since they still see good clinical response using supposed resistant topicals. In one in vitro study of 600 isolates from otitis externa there was very low resistance to florfenicol. In another in vitro study topical antibiotic concentration in common otic products reached MBC levels for all the bacteria tested. Other participants mentioned in vitro studies that showed the development of resistance after a topical had be used repeatedly. Finally the question was asked if we really knew if we were clearing the bacteria by overcoming the resistance or by doing deep ear cleanings and more consistent flushing with antiseptics. Do we really need to use antibiotics for most otitis externa? The majority of participants did not have a comment on bacterial otitis but many feel that Malassezia otitis can be cleared with just steroids and flushing.

The question of diagnostic imaging was brought up next. If available most of the participants use CT scans although some participants said that they have cases were the CT does not pick up material in the middle ear.

Several other participants said they are asked to examine dog’s ears who have CT changes of otitis media but no clinical signs. Some of the participants who have seen this do not treat the dogs for otitis media and do not do deep ear cleanings although they have not followed these patients to see if they later have clinical otitis media.

Others do treat the otitis media by myringotomy and specific antibiotic treatment. One of the participants like using ultrasound to follow cases. The rest of participants did not find ultrasound useful. Several studies were also brought up that showed that ultrasound was not very specific or sensitive in the diagnosis of otitis media.

Otherwise most participants diagnosed and treated otitis media by deep ear cleanings under anesthesia and myringotomies if needed. Most also recommended starting both topical and systemic steroids for a short period of time (one to two weeks) before performing the deep ear cleaning. There was no consistency in how myringotomies were performed.

The next topic discussed was current biofilm diagnosis and treatments. Most participants considered biofilms to be present in many cases of otitis externa. Unfortunately most participants also felt that there is no good way to clinically appreciate the biofilms. Many participants use acetyl cysteine both topically and orally to treat possible biofilms. Clinically they feel it is helpful although in was mentioned that there are no in vivo studies confirming its effectiveness. Other participants recommend TrizEDTA with good clinical success but like Mucomyst there are no in vivo studies.

Finally it was the consensus of the group that what is needed is more research in otitis externa particularly in vivo studies to confirm what has been found in the various in vitro studies.

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ROUNDTABLE SUMMARIES Roundtable Summary: Controversies in antibiotic use for immune modulation and animal use of antibiotics important for human MRSA Moderator: Kimberly Coyner Attendees: 12 Introduction: As veterinary dermatologists, how do we ensure we are the best advocates for our patients while still maintaining responsible antibiotic stewardship for the human/animal population? If it is irresponsible to use doxycycline for DLE and mupirocin for mucocutaneous pyoderma, how do we do things better and treat our patients with safe and effective therapies but not have to immunosuppress or use systemic antibiotics for a localized disease?

What are safe AND effective alternatives to the following; are you still using these drugs? If not, what are you using instead?

1a. Doxycycline/tetracycline/minocycline for immune mediated disease; typical dose or subtherapeutic dose?

• Valerie Fadok: Feels doxycycline is appropriate for immune mediated diseases; antibiotics have other functions than microbial killing. Ophthalmologists use it as a protease inhibitor in dogs with corneal ulcers, and she has used it for plasma cell pododermatitis in cats to avoid steroids. So we are not using doxycycline randomly i.e. for pyodermas, this is a specific/calculated use, usually 5mg/kg SID (lower than dose used for treatment of tick-borne disease and coughing/respiratory infections), so she feels its appropriate stewardship when we use it carefully, and eliminating an effective treatment that has worked for years, is not a better idea.

• Kimberly Coyner: I also feel that it’s an acceptable use of doxycycline to use in perhaps the 5 cases/yr I see of discoid lupus (rather than immune suppressive drugs). I do not use doxycycline in the 7 cases/day of pyoderma that I see. I try to treat those numerous cases topically/responsibly to reduce antibiotic use in the far more common disease.

• Valerie Fadok: Would like to see in general veterinary medicine an increased understanding of the value of culture and sensitivity and avoiding “antibiotic roulette” which leads to increasing antibiotic resistance. We need to try to encourage topical antimicrobial therapies, though this can be challenging to get owners to do.

Antibiotic stewardship does not mean NOT using antibiotics but using them carefully. Since doxycycline is a multi-purpose drug, we cannot just call it an antibiotic.

• Kristin Holm: Regarding use of lower doxycycline doses: In a paper from South Korea (Kim SE, Hwang SY, Jeong M et al. Clinical and microbiological effects of a subantimicrobial dose of oral doxycycline on periodontitis in dogs. Vet J. 2016; 208:55-9) doxycycline was used with success to reduce inflammation in periodontitis at a dose of 2mg/kg PO once daily. Investigators did cultures to determine if normal oral flora became doxycycline resistant and no resistance occurred. She suggested this would be a great resident study to see if skin flora become resistant to subtherapeutic use of doxycycline. Additionally, there is a mucocutaneous pyoderma/DLE spectrum of disease and doxycycline may effectively manage both, so is it reasonable to start at antimicrobial doxycycline dose (i.e. 5mg/kg BID) then after a month reduce to 1-2 mg/ kg/day (which already occurs when we taper meds for DLE)?

• Mitzi Clark: Also likes doxycycline (if indicated based on culture as an appropriate antibiotic choice) for both antimicrobial and immune modulating effects in chronic pododermatitis cases and in horses with immune mediated diseases such as vasculitis or pemphigus as steroid sparing therapy (and it helps some patients).

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• Chiara Noli: She does not use doxycycline often; has list of antibiotics from European Federation (https:// www.ema.europa.eu/en/documents/report/infographic-categorisation-antibiotics-use-animals-prudentresponsible-use_en.pdf ) and doxycycline is on the list of antibiotics which can be used most (Categorization of Antibiotic Classes for Veterinary Use; doxycycline/tetracycline are classified in antibiotic class D: use with Prudence). Her concern is that minocycline can be used as a rescue option for severe drug resistant MRSP and she is concerned that regular use of doxycycline could induce resistance of Staph to this drug class and make minocycline not an option. She uses cyclosporine for plasma cell pododermatitis and loves it.

• Stefano Borio: When he was a resident of Chiara Noli in Italy, he would use doxycycline sometimes. He later moved to UK, and worked in academia in Liverpool and was not allowed to use doxycycline there by agreement with other dermatologists in the university. Then he moved to Switzerland and they passed a law that required veterinary reporting of every antibiotic prescribed to government officials. The reporting requirements included drug, indication for antibiotic, dose, duration, and when recheck was scheduled. This was done at the same time as antibiotic prescribed, and the fee for the declaration (10-15 dollars) which was charged to the client as part of the service. Immunomodulation was not an option to choose in the list of possible uses for the antibiotic prescription. He was not sure if human physicians in Switzerland are required to do the same antibiotic reporting as veterinarians. b. Who has used just niacinamide (without concurrent doxycycline) for DLE? Efficacy?

• Carine Laporte: Has tried niacinamide TID alone for DLE a lot in the past year but has not had great success.

• Christine McKinney Zewe: Has not used niacinamide alone, and feels the issue is that we do not have good alternatives. Human dermatology uses doxycycline all the time for non-microbial issues as immune modulatory. So if we are supposed to be good stewards and prioritize antibiotics for humans, it’s not unreasonable to use doxycycline as immune modulatory (similar to its use in human medicine) for discoid lupus and lupoid onychodystrophy (which otherwise would be treated with cyclosporine). She rarely uses tetracyclines for pyoderma, not first choice, but only based on culture and prior to more potentially problematic choices such as chloramphenicol or rifampin. She feels that we as dermatologists need to educate general practitioners better on stewardship, avoid inappropriate antibiotic dose/too short duration (such as 7-10 days), avoid fluoroquinolones, and emphasize value of cultures, etc.

• Valerie Fadok: Her mother developed bullous pemphigoid a year ago and doxycycline was the first drug tried in order to avoid steroids in elderly person.

• Christine McKinney Zewe: Just last week she was prescribed minocycline for dermatitis, and another common example is the use of tetracyclines for rosacea; so immunomodulatory use is well accepted in humans.

2. Topical therapies were then briefly discussed.

• Chiara Noli: In Italy, if you prescribe antibiotics you do not need to report every antibiotic but you can be inspected at any time, and have to show that you have done culture and sensitivity and have a documented reason for prescribing the antibiotic. She has thus rethought her antibiotic use and now uses only antibacterial shampoos/sprays for superficial infections (“Borio protocol”: Borio S, Colombo S, La Rosa G, De Lucia M, Damborg P, Guardabassi L. Effectiveness of a combined (4% chlorhexidine digluconate shampoo and solution) protocol in MRS and non-MRS canine superficial pyoderma: a randomized, blinded, antibioticcontrolled study. Vet Dermatol. 2015; 26 (5):339-44.) For deep pyoderma such as pododermatitis, callus, and German Shepherd pyoderma, she uses just steroids and they resolve. So she rarely uses antibiotics now, unlike 5 years ago.

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• Valerie Fadok: What about client compliance? Our general practitioners often state clients just will not do topicals; so it’s all about education of GPs and clients to convince them to do it.

• Chiara Noli: She tells owners that we don’t want to expose your dog to systemic antibiotics for a superficial skin infection and allows owner to perceive that antibiotic could potentially be risky/toxic to pet. If owner cannot do topicals then she chooses a first-generation cephalosporin or does culture/sensitivity to choose antibiotic.

• Carine Laporte: In her experience with topical therapies, client compliance often depends on region. In elderly owners (or her current area) owners with multiple young children and very busy schedules, compliance with weeks of daily topicals is poor. She explains dangers of antibiotic to owners, tries topicals for 2-3 weeks then gets phone or email and photo update; about 60% of time finds owners cannot do daily topicals and she has to prescribe antibiotics.

• Lynn Schmeitzel: She often uses dilute chlorhexidine solution focally in patients that cannot be bathed, and she had one elderly client use chlorhexidine solution followed by mupirocin ointment to treat recurrent collarettes in a mastiff for years and this protocol controlled the pyoderma without bathing. Since spray bottles can be difficult for elderly owners to use, she just has them dilute the concentrated chlorhexidine solution at home. For interdigital furunculosis she often uses dilute bleach spray and has found it very helpful.

3. Mupirocin for localized and mucocutaneous pyoderma, alternatives?

• Kimberly Coyner: I use Mupirocin ointment often for interdigital granulomas, acne, calluses, etc. Since Mupirocin is a drug used for MRSA in humans, this can be a concern. Are you still using Mupirocin, and if you are not using Mupirocin, what are you using that is effective?

• Lynne Schmeitzel: Sometimes will use Otomax/similar gentamicin/steroid containing ointment if very inflamed. Does not use amikacin as topical spray due to saving its use for MR infections. She likes Otomax once daily x 5 days for vulvar fold pyoderma, then switches to Vedco Microspore lotion (chlorhexidine/ ketoconazole product: same ingredients as ResiKetoChlor). She also uses Microspore on face folds and after baths/add small amount of water, massage to roots and leave on (blow or towel dry).

• Kimberly Coyner: I love this product, it seems to have better contact/does not run off like chlorhexidine sprays, and not as sticky as ointments like mupirocin.

• Kristin Holm: Used a lot of Mupirocin with great success in private dermatology practice as a way to reduce systemic antibiotic use, however now her consulting dermatology colleagues at IDEXX discourage it and recommend bacitracin or other options, would like others’ opinions.

• Christine McKinney Zewe: Uses a lot of Mupirocin especially for mucocutaneous pyodermas, lip folds, lick granulomas. She finds that the thick ointment works better than solutions in these areas. We all have interest in reducing mec A carriage and we cannot decolonize our pets, but we need to treat effectively/prevent a susceptible infection from becoming resistant and if we don’t use mupirocin then the other options are more chlorhexid1ne or aminoglycosides and she regards mupirocin as the lesser of the evils. She does believe some drugs should be off limits to veterinarians such as linezolid, carbapenems, vancomycin etc., and there should be approval/monitoring for these drugs. Even fluoroquinolones are problematic/overused. In her area GPs usually don’t use mupirocin, so the population exposure in her area to the antibiotic is small.

• Mitzi Clark: Considers depth of lesion--for focal furunculosis she does not want to use systemic antibiotics, so prefers local mupirocin for good penetration. Also considers history: if pet has not been exposed to numerous prior products, she may use topical bacitracin or chlorhexidine. If pet owners cannot afford culture she often selects mupirocin.

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• Chiara Noli: In the most recent European Categorization of Antibiotic Classes for Veterinary Use, mupirocin is in the same drug class A as linezolid, carbapenems and vancomycin as drugs to be completely avoided.

However, fusidic acid is in drug class D as easiest/best drug to choose.

• Kimberly Coyner: We unfortunately do not have fusidic acid in the US. • Kristin Holm: Recommends Canadian practitioners to use fusidic acid since its available there, unsure why it’s not available in US. • Chiara Noli: She prescribes gentamicin/betamethasone cream frequently, good for most bacteria and to reduce inflammation.

• Kimberly Coyner: In the US we have multiple gentamicin/betamethasone sprays which are often overused and cause terrible cutaneous atrophy especially on groin/axillae. I will sometimes use gentamicin/ betamethasone ointments for local inflamed pyoderma lesions if rods are present on cytology.

4. Ketoconazole/fluconazole use as pulse treatment for yeast control and as combination therapy with cyclosporine.

• Kimberly Coyner: What about using ketoconazole/fluconazole for “pulse dosing” to control Malassezia dermatitis? Or as combination treatment with cyclosporine to reduce the cyclosporine dose/price? If we can’t use doxycycline (or it’s not helpful) as immunomodulating therapy and choose cyclosporine for treatment of immune mediated disease in a big dog but the owner can’t afford it (in the US even generic cyclosporine in a large dog can be $200/month) I’ll combine it with an azole. I’ll also sometimes use ketoconazole as pulse treatment for yeasty dogs. Should we stop/does this encourage antifungal resistance?

• Carine Laporte: When we use drugs like pulse antifungals and mupirocin, we have to remember our area general practitioners pick up on this and start doing it, so we have to be careful/judicious when we use drugs including mupirocin or pulse dosing antifungals. However, if the cyclosporine/ketoconazole manages the atopic dog more effectively and reduces antibiotic use then the tradeoff is worth the potential drawback of using the combination.

• Valerie Fadok: Still uses pulse antifungal treatment especially for nailbed and lip yeast, there are not good alternatives, and yeast infections make it hard to control atopics. Immunotherapy vs. Malassezia may be helpful in some cases, but some dogs require pulse antifungal to be comfortable. There are a few papers that suggest in vitro or in vivo azole resistance in Malassezia can occur but she has not appreciated that this is a widespread issue. She spoke to a mycologist in past who told her resistance is possible but takes longer with yeast. She is hopeful for more biological control options for Malassezia in the near future.

• Lynne Schmeitzel : Great tip for greasy seborrheic Malassezia dermatitis shih tzus: She always uses Dawn dishwashing liquid as a prewash to decrease dog prior to medicated (azole containing) shampoo and leave on lotion, finds this reduces bathing frequency needed, improves lathering, reduces odor, and reduces need for oral pulse or daily azoles. Prefers this to benzoyl peroxide that can turn the dogs into “snow flakes”, but if she uses benzoyl peroxide she follows with Microspore leave on lotion.

• Mitzi Clark: Also uses and likes Selsun Blue as a prewash for degreasing and antiyeast effects.

• Kimberly Coyner: How about any European differences with oral azole use?

• Stefano Borio: Similar therapies, sometimes uses pulse itraconazole which is less expensive in Europe compared to US, ketoconazole availability in Europe variable depending on country. Rarely uses azoles in combination with cyclosporine and is generally able to talk pet owners into using cyclosporine alone.

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5. Are you using Clindamycin as a “first line” antibiotic?

• Kimberly Coyner: We previously discussed the anti-inflammatory effects of doxycycline in deep pyoderma cases. I often choose clindamycin for deep pyoderma for the same reason. Depending on the reference some dermatologists recommend clindamycin use as a first line antibiotic, but others reserve clindamycin for culture verified MRSP infections, what are you using?

• Valerie Fadok: In her geographic area she does not choose clindamycin as a first line antibiotic, as less than half of her skin cultures show susceptibility to clindamycin (even if not prescribed in past), so she only uses it if indicated based on culture.

• Lynn Schmeitzel: Uses it sometimes depending on weight of dog while waiting on culture results, but she is doing this less often as culture results are unpredictable.

• Briefly discussed regional antibiograms as ideal to enable informed choice of empiric antibiotics by general practitioners whose clientele often cannot afford costly cultures. Another desirable feature for culture reports from reference labs would be 1st, 2nd and 3rd line antibiotic recommendation based on tissue involved/ tissue penetration of different drugs. We also need to teach practitioners to better interpret cultures in view of cytology results and to be able to differentiate potential pathogens vs. less significant bacteria cultured that do not need antibiotic treatment.

6. Are you comfortable with empiric use of third generation cephalosporins (cefpodoxime/Convenia) for pyoderma?

• Points made included often better owner and pet compliance (and therefore potentially more effective infection treatment) for cefpodoxime as once daily tablets compared to cephalexin capsules 2-3 times daily.

Pharmacokinetics studies have shown that cefpodoxime lasts longer in tissue and cephalexin lasts longer in the blood. Participants stated that the concern for induction of ESBL-producing Enterobacterales with cefpodoxime/third generation cephalosporins in dogs is different than in humans, that this concern also exists for cephalexin and quinolone antibiotics, and that cefpodoxime does not have a particularly good gram-negative effect. Convenia/cefovicin remains at therapeutic levels in serum for 7 days and in tissue for at least 14 days for treatment of Staph infections in dogs.

• Chiara Noli: In Europe the third generation cephalosporins such as cefovecin are in the Class B (Restricted) drug group (in same category as quinolones). She will use Convenia in cats but not dogs, and wonders why in the US we are not using cefadroxil which is a once daily first generation cephalosporin tablet (Moderator note: in the past in the US we had veterinary approved CefaTabs and CefaDrops which were discontinued (labelled for BID in dogs and once daily for cats). There are however generic cefadroxil human products available including 500mg capsules, 1 gram tablets and 50mg/ml suspension).

7. Have you used linezolid for treatment of MRSP pyoderma? Any side effects? Are there specific protocols/controls that we should have in place to choose linezolid for our MRSP patients?

• Unfortunately not discussed fully due to time constraints. Participant points made included that this drug should not be included by reference labs on typical culture/sensitivity results, and should be reserved only for life threatening internal, bone or joint infections. For pyoderma other therapies should be prescribed such as topical antibacterial treatments. The development of non-antibiotic treatments for skin infections should be developed and pursued such as probiotic creams and bacteriophages, and of course, the underlying cause of the pyoderma must be identified and managed.

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ROUNDTABLE SUMMARIES Extra-Label Uses of Apoquel® Moderator: Tyler J.M. Jordan, DVM, DACVD The current drug monograph for Apoquel® (oclacitinib maleate) states that the drug is labelled for “control of pruritus associated with allergic dermatitis and control of atopic dermatitis in dogs at least 12 months of age,” with a dose of 0.4 to 0.6 mg/kg body weight administered by mouth twice daily for up to 14 days, and then once daily thereafter. This round table discussion took place on Friday, April 23rd, 2021 from 7:30 am – 8:45 am central time during the 21st North American Veterinary Dermatology Forum, held virtually. Fifteen attendees were present. During this round table, the experiences of its attendees with prescribing Apoquel® extra-label were discussed. Attendees’ experiences with prescribing Apoquel® to extra-label species, and for extra-label indications in dogs, were a primary focus of this round table discussion.

1) EXTRA-LABEL SPECIES Felines Feline atopic skin syndrome (FASS) • The majority of attendees reported dosing Apoquel® at 1 mg/kg PO every 12 hours to be the most effective dose for managing cats with FASS, including manifestations of the “eosinophilic granuloma complex”.

• Most attendees felt it to be uncommon to successfully manage cats with FASS with Apoquel® dosed at 1mg/ kg PO q 24 hours. However, one attendee said that they have successfully managed cats with FASS using the labelled dose for dogs, albeit uncommonly, before the PK/PD data was available for this species • On occasion, One attendee mentioned they have needed to increase the dosing frequency of Apoquel® (1 mg/kg PO) from twice to three times daily to effectively manage FASS. • Several attendees mentioned they typically only prescribe Apoquel® for cats with FASS that are refractory to other treatments or have comorbidities where corticosteroids and/or cyclosporine are contraindicated (i.e., diabetes mellitus, recurrent upper respiratory tract infections, feline immunodeficiency virus etc.)

• One attendee felt that Bengal cats may require higher doses of Apoquel®.

Feline pemphigus foliaceus (PF) • One attendee has prescribed Apoquel® as an adjunctive steroid-sparing agent in a small number of cats with refractory PF using a dose of 1 mg/kg by mouth every 12 hours. This attendee felt the response to Apoquel® in feline PF has not been particularly impressive, but has allowed for dose-reduction of methylprednisolone in one cat that was experiencing adverse effects (i.e., diabetes mellitus) from chronic administration of methylprednisolone.

Monitoring • Prior to starting Apoquel® in cats, one attendee recommends performing baseline lab work (i.e., complete blood count, serum biochemistry and a urinalysis), and repeats lab work every 6 months thereafter.

• Another attendee recommends baseline lab work (i.e., CBC, chemistry and UA) before starting Apoquel® in cats, and repeats lab work every 4 weeks for the first three months on Apoquel®, and every 3 months thereafter.

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Adverse effects • The majority of attendees expressed that they have not encountered any significant clinicopathologic abnormalities, including evidence of renal insufficiency, when prescribing Apoquel® to cats.

• One attendee mentioned they had two cats that were prescribed Apoquel® that experienced recrudescent upper respiratory tract infections (URI) at 1 mg/kg PO q 12 hours. Clinical signs of URI were reported to resolve upon decreasing the dosing frequency of Apoquel® to q 24 hours, but consistently flared when the dose was increased to q 12 hours.

• One attendee mentioned they had been managing an FIV positive cat with Apoquel® for over 1.5 years without encountering any issues or clinicopathologic abnormalities.

Equids • One attendee has prescribed Apoquel® to approximately five equids with insect bite hypersensitivity and/ or atopic dermatitis using a dose of 0.25 mg/kg administered orally every 24 hours. Two of five equids have responded favorably. One of the equids that responded favorably was a highly pruritic pony that had good response to Apoquel® and was treated for an extended period of time with this drug. Unfortunately, this pony developed gastrointestinal issues and suspected sepsis. The managing large animal internist expressed concerns over a possible association between the use of Apoquel® , and the development of GI disturbances and suspected sepsis. As such, Apoquel® was discontinued thereafter.

Other species • One attendee works with a local zoo that commonly prescribes Apoquel® to pruritic animals with presumptive environmental allergies including primates, a prairie dog and a polar bear 2) EXTRA-LABEL INDICATIONS IN DOGS In dogs, most attendees reported prescribing Apoquel® extra-label for management of autoimmune and immune-mediated skin diseases, either as a monotherapy or an adjunct. Most attendees reported variable responses in prescribing Apoquel® for management of autoimmune and immune-mediated skin diseases in dogs and typically reserve it for moderate-severe and/or treatment-refractory cases. Most attendees report dosing Apoquel® in autoimmune and immune-mediated skin disease at 0.4-0.6 mg/kg PO q 12 hours, without tapering the dose to once daily after 14 days. Most attendees evaluate the efficacy of Apoquel® in managing autoimmune and immune-mediated skin disease after approximately one month.

Canine pemphigus foliaceus • One attendee has prescribed Apoquel® to several dogs with treatment-refractory PF in combination with other immunosuppressive agents including corticosteroids, azathioprine and/or mycophenolate. This attendee does not use Apoquel® as a first-line medication for this disease but does feel it provides a steroidsparing effect.

Cutaneous lupus erythematosus • Attendee mentioned they have heard general practitioners report favorable responses to treating dogs with discoid lupus erythematosus with Apoquel®.

• One attendee reported they had a dog with generalized cutaneous lupus erythematosus that initially responded favorably to Apoquel® dosed at 0.6 mg/kg PO q 12 hours, but then flared despite no changes in dose. This dog’s skin disease could not be managed with Apoquel® exclusively.

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• One attendee reported variable responses in managing dogs with mucocutaneous lupus erythematosus with Apoquel®.

Vasculitus • One attendee reported variable response rates when attempting to manage dogs with vasculitis and ischemic dermatitis with Apoquel®, either alone in combination with corticosteroids. Nonetheless, this attendee felt that Apoquel® provided a steroid-sparing effect for managing cases of vasculitis in dogs.

• One attendee uses Apoquel® monotherapy as a first-line drug for managing cases mild vasculitis in dogs.

Erythema multiforme • One attendee reported prescribing Apoquel® (0.6 mg/kg PO q 12 hours without tapering) to a dog with hyperkeratotic erythema multiforme that was historically refractory to corticosteroids and cyclosporine.

Shortly before starting Apoquel®, this dog was suspected to have developed a doxycycline-induced hepatopathy. Dog’s dermatologic signs were noted to significantly improve within one week of starting of Apoquel®, but flared during the second week of treatment despite no changes in the dose of Apoquel® .

The attendee was suspicious the dog’s prior hepatopathy may have impacted the hepatic metabolism of Apoquel® and recently increased the dose to 1 mg/kg PO q 12 hours.

Scabies • In addition to an acaricide, one attendee reported frequently prescribing Apoquel® for short periods of time (i.e., ~2 weeks) to manage pruritus associated with sarcoptic mange. This attendee reported they will prescribe Apoquel® even in young dogs (i.e., < 12 months of age) for this purpose as it is usually only prescribed for a very short period time and may have less significant side effects compared to a course of corticosteroids in this age group.

Sebaceous adenitis • One attendee reported they had successfully managed a dog diagnosed with sebaceous adenitis that was refractory to cyclosporine and topical therapy with Apoquel®.

Proliferative arteritis of the nasal philtrum • One attendee reported recently prescribing Apoquel® for two dogs with proliferative nasal arteritis but had not yet received follow-up. None of the other attendees had experience with prescribing Apoquel® for this condition.

Sterile Nodular panniculitis • Two attendees reported favorable responses managing dogs with sterile nodular panniculitis with Apoquel®.

• One attendee reported improvements in a dog with sterile nodular panniculitis prescribed Apoquel® dosed at 0.4 mg/kg PO q 12 hours after 8 weeks of treatment. Apoquel® was prescribed for management of SNP as this dog was experiencing iatrogenic Cushing’s syndrome.

Uveodermatologic syndrome • One attendee reported prescribing Apoquel® (0.6 mg/kg PO q 12hours) to a dog with uveodermatologic syndrome that had bilateral enucleations and prostheses implanted that had experienced mild improvements in residual skin disease with 6-8 weeks of doxycycline and niacinamide. Significant improvements were noted in persistent ulceration, crusting and depigmentation affecting the nasal planum, paw pads, periocular region and lips once Apoquel® was added to a prior regimen of doxycycline/niacinamide.

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Diseases that appear non-responsive to Apoquel® • One attendee reported prescribing Apoquel® to 8-10 dogs following surgery for cholesteatoma in attempts to decrease recurrence of cholesteatoma formation. The attendee reported that Apoquel® did not prevent the recurrence cholesteatoma in the ipsilateral or contralateral bullae in these cases.

• One attendee reported prescribing Apoquel® to dogs with alopecia areata; no response was noted.

Monitoring and adverse effects • For dogs that are receiving Apoquel® dosed at 0.6 mg/kg PO q 12 hours long-term, one attendee recommends performing routine lab work (i.e., CBC, chemistry, UA) before starting Apoquel® and every three months thereafter.

• One attendee mentioned the only side effects they typically encounter with long-term use of Apoquel® is onset of demodicosis, histiocytomas and papillomavirus.

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ROUNDTABLE SUMMARIES Trying To Understand the Mind Of Cats With Dermatological Conditions Moderator: TERRY MARIE CURTIS, DVM, MS, DACVB As a behaviorist, when I have a patient who has a “dermatological condition” – such as overgrooming – I look to see what could be causing anxiety or stress in the cat’s life. Getting a complete history along with a good physical exam – it goes without saying – are both very important to get the treatment ball rolling.

Next, it is important to understand exactly what we all mean by anxiety…

ANXIETY IN CATS What IS anxiety??

Something predictably bad – fear Something unpredictable In every situation, there at least two individuals to consider: there is the CAT’s anxiety and the HUMAN’s anxiety…

Questions to ponder: • How do humans deal with anxiety?

• What causes humans to feel anxiety?

• What about cats?

How do things look from a cat’s perspective?? This is probably the most important thing to consider and to continue to think about when treating a cat where anxiety is a component of the condition you are presented with.

Example: Christmas – tree comes into the house. YEAH!! A tree! Inside!! I can mark it!! And look at all of the “toys” hanging from the branches!! That is NOT how the humans are looking at it…

Example: Guests – stressful for the humans – VERY stressful for cats. Especially children. Routine disrupted.

Noise level changes. Access to food/litter box may be altered. Did the guest bring a DOG???

Example: Human brings home a new cat…! UGH!!

The fact is that humans look at situations from THEIR point of view and cats look at things from THEIR point of view! Discussing this with your clients is very important in going forward with any treatment plan.Stressors don’t have to be so dramatic. Day-to-day things can be contributing to a cat’s stress and anxiety.

Examples include: • Litter box set up. How many boxes are there? How big are the boxes? The “ideal” box size is 1.5 times the length of the cat from the cat’s nose to the base of its tail*: BIG!!! What’s inside the boxes? Are the boxes open or covered? How clean are the boxes? Can the cat get to the box – without encountering another cat, a dog, a child or other human?? Can the cat see in the room where the litter box is? [Cats can see in dim light but not in total darkness] *A good reference for this topic is the AAFP Guidelines for Diagnosing and Solving House Soiling Behavior in Cats

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• Food. Cats normally eat about 15 small meals/day – mostly at night. Meal-feeding can cause anxiety!! Need to find a balance if weight is a concern. Type of food. How food is provided – puzzle toys, automatic feeders, etc. But we need to think twice before mandating weight loss…

• Multi-cat Households. Cat behavior can be very subtle. Don’t need full-on cat fights to show that there are “issues”. Look at the cats’ behaviors. Are they ever together? Do they hide from each other/from humans? Is one cat stalking and the other hiding? Are they not eating? Are they having house soiling “accidents”? If so, where are the “accidents”? If the urine/feces is outside the box but very close to the box – that tells you that the cat can get to where the box is but, there is something about the litter box that the cat does not like. If the “accident” is far from the litter box – WHY?? Can the cat not get there without encountering another cat? Is the box not in the core area of the cat – where the cat lives??

• Outside Cats & Other Critters. This can be a major source of stress. Again, look at things from the cat’s perspective. Cats can become VERY aroused by things going on outside. There can be displacement behaviors [over-grooming] as well as redirected aggression.

After I presented my thoughts on anxiety and went over things to think about when trying to pinpoint sources of anxiety, the roundtable participants joined in.

The #1 concern of everyone was “How to get medication into cats?”

I would agree, the goal is to medicate the cat – either with the medications that you are prescribing for the dermatological condition and/or any medications that you’re prescribing for the anxiety… AND, the goal is to do it without causing MORE anxiety!!

I always prefer the pill form. This way, if the cat “eats it” I know that the dose that I want the cat to get is getting into the cat! For that to happen, I’m looking for a substrate that the pill can be hidden in that the cat will just lick up: cream cheese, salmon-flavored cream cheese, cream cheese mixed with a number of other ingredients [catnip, chicken, tuna – whatever the cat likes], cheeze whiz, whipped cream, yogurt, pate, canned cat food, etc. Other options available: Pill Pockets or Pill Assist [new, from Royal Canin] or Pill Pastes.

I recommend that the client tries the substrate – whichever one it is – without the pill first – to make sure the cat will lick it up! When it comes time to medicate, put out a few of the “globs” or pill covers – one containing the pill – so that the cat does not feel tricked!

While it is a VERY lovely idea, none of the behavioral medications tested [fluoxetine, amitriptyline, buspirone] are effective given by the transdermal route…

We talked about amitriptyline: nice antihistamine, not so great at decreasing anxiety. It tends to make cats sedate and lethargic – qualities that most cat owners do not like. Tricyclic antidepressants [amitriptyline and clomipramine] can cause urine retention – so I never use them in male cats. Not worth the risk of blockage.

TCAs can also lower the seizure threshold… There are better medications that decrease anxiety.

At this point, the subject of cats on an elimination food trial came up – and that can be tricky… So, it’s back to looking at options that fit into the parameters above. Pumpkin? Coconut whipped cream?

The pill can also be crushed and put into food or dissolved in broth. Again, if the cat is in a food trial, these substrates need to be in line with the trial.

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Do not underestimate how far teaching a client HOW TO PILL A CAT can go! Many cats CAN be pilled very easily. Even if the cat IS pilled, it is a good idea to coat the pill first – with a little bit of pill pocket, pill paste – so that if the cat DOES taste something it is not the bitter pill.

In any case, again, we do not want the medicating to be causing MORE anxiety. So, it is important that the client interact with the cat at other times. Play with the cat. Give it treats. Don ot have the only time the owner is around when they are stalking the cat to give it medicine!

Any medication particular questions should be directed to the talk I gave on Behavioral Psychopharmacology – regarding which medication to use when, doses, etc.

While medication can be an important component in the treatment of anxiety, along with addressing the environment, there are a number of other options. In no particular order: • Zylkene – A milk-based GABA agonist that tastes like milk – what could be better? ^.^ • Pheromone Diffusers – Feliway Classic is the synthetic analogue of the cheek pheromone and Feliway MultiCat is a maternal pheromone. They can be used separately or together.

• Pheromone Spray – Feliway Classic. The spray has a very nasty and cloying odor – secondary to the alcohol vehicle. So, spray whatever surface [not the air and not the cat] and let it sit for 5-10 minutes. You want the cat to smell the pheromone, not the alcohol!

• Pheromone Collar – nurtureCAlm is my favorite. There are others, but I do not think that they work as well.

• Diets – Royal Canin Calm and Hill’s Science Diet c/d Multi-Care Stress both contain tryptophan – the precursor to serotonin and the milk-based GABA agonist. A nice option!

• Solliquin – An anti-anxiety supplement that contains L-Theanine, 2 calming plant extracts & a GABA agonist.

Not all cats like the “treats”, however – but worth a try.

• The Back Flower Essences – Such as Rescue Remedy • CBD is an up and coming topic in veterinarian medicine. I would recommend sources that are actually doing research in dogs and cats.

To summarize, anxiety can be the cause of dermatological conditions [e.g. overgrooming in a cat with separation anxiety], or an ongoing issue when treating a dermatological condition [hiding because of medicating], etc. Always attempt to look at things from the CAT’s perspective! Ask questions of the owner in an attempt to determine an inciting cause or event – remembering that cats and humans see things differently, and continue to communicate with the owner on how the cat’s anxiety level is as your treatment progresses.

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ROUNDTABLE SUMMARIES Round Table Summary: Dermatologist as Educators of General Practitioners: What are the goals?

Moderators: Dunbar Gram and Andhika Putra Attendees: 12 in the virtual platform. Mix of academics, private practitioners,house officers and consultants from around the world.

All attendees reported that part of their job included educating general practitioners regarding the diagnostic and therapeutic care options for patients with skin diseases. This process occurs during working up patients that have been referred for specialty care, in a traditional formal “didactic” setting, during telephone consultations and occasionally “wet labs.” Most but not all dermatologist typically coordinate care with a primary care veterinarian. In some countries, the relationship may not be as close and in some situations, virtual veterinary visits lead to quick referral to a dermatologist. Many attendees in clinical practice report that patients may have to wait several weeks for an appointment. This can be problematic.

Attendees commented on how important it is for dermatologists to communicate well with primary veterinarians to set appropriate client expectations for the management of chronic disease. The practice of dermatology in general practice is challenging because very few diseases are truly curable. Emerging evidence indicates that if the client does not perceive that their pet is better within 3 office visits or approximately $1,000 USD, they client is likely to seek a different veterinarian. Compared to dermatologists, many general practitioners have shorter office visits and this can be a client education challenge and barrier to optimal longterm management. Resistant bacterial skin infections, that were once responsive to antibiotics in addition to chronically pruritic patients that are no longer responsive to medications are common scenarios.

Many attendees discussed the ethical challenges of providing “off label” recommendations to general practitioners regarding a patient with a resistant pseudomonas otitis or MRSP pyoderma when the veterinarian has not recommended a work up for the underlying disease or a client has been reluctant to pursue a work up. Also discussed was the need for dermatologist to provide general practitioners with “short communication points” to be emphasized in client communications. The concept of primary care veterinarians informing clients that if their pet needs more than 3-4 months of medication per year (antibiotics, antipruritics, ear medication), referral to a dermatologist is recommended to help prevent progression of the underlying disease and deterioration of quality of life. Attendees also commented that certain breeds of atopic patients should be seen by a specialist sooner rather than later. Several attendees commented on the perception that industry supported educators may inadvertently encourage medication use instead of referral to a dermatologist.

Allergen specific immunotherapy is complex and can take many months before becoming effective.

Closing summary: Dermatology patients benefit from effective client communication in concert with primary care veterinarians and dermatologists. Antimicrobial stewardship and avoiding progression of underlying allergic diseases are reasons to provide “short communication points” to be emphasize with clients. Primary care practitioners, who often have a long-standing relationship with a client, may help a dermatologist consider what a client and their human family is able to do (physically, emotionally, financially) to help a patient with dermatitis. The short-term plan may be considerably different than the long-term plan. Primary care veterinarians may benefit from further education on the topics of cytologies, assessing bacterial culture/ sensitivities and work up/management of chronic dermatitis/otitis/pruritus.

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Available resources for reference were discussed and include. Consider making primary care veterinarian aware of these resources.

• Atopy/Atopic Syndrome (Canine/Feline) • Canine atopic dermatitis: detailed guidelines for diagnosis and allergen identification and endorsed by WAVD 2015 (13 pages) - click here to access the paper • Treatment of canine atopic dermatitis: 2015 updated guidelines from ICADA and endorsed by WAVD 2015 (15 pages) - click here to access the paper • Clinical signs and diagnosis of feline Atopic syndrome: detailed guidelines for a correct diagnosis from ICADA (20 pages) - click here to access the paper • Treatment of the feline atopic syndrome – a systematic review from ICADA (15 pages) click here to access the paper • Pyoderma • Pyoderma: Recommendations for approaches to Methicillin-resistant staphylococcal infections of small animals: diagnosis, therapeutic considerations and preventative measures. Clinical Consensus guidelines of WAVD 2017 (28 pages) - click here to access the paper • Pyoderma: Guidelines for the diagnosis and antimicrobial therapy of canine superficial bacterial folliculitis (Antimicrobial Guidelines Working Group of the International Society for Companion Animal Infectious diseases) (15 pages) - click here to access the paper • Dermatophyte • Diagnosis and treatment of dermatophytosis in dogs and cats: Clinical Consensus guidelines of WAVD 2020 (40 pages) - click here to access the paper • Demodex • Demodex: Diagnosis and treatment of demodicosis in dogs and cats: Clinical Consensus guidelines of WAVD 2020 (25 pages) - click here to access the paper • Malassezia: • Biology, Diagnosis and treatment of Malassezia dermatitis in dogs and cats: Clinical Consensus guidelines of WAVD 2020 (48 pages) - click here to access the paper • Malassezia Yeasts in Veterinary Dermatology: An Updated Overview (11 pages) click here to access the paper • Additional Options (books) • BSAVA Manual of Canine and Feline Dermatology. New edition coming soon • Chronic Disease Management for Small Animals. John Wiley & Sons, In 2018

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ROUNDTABLE SUMMARIES FELINE ATOPIC SKIN SYNDROME Moderators: Clarissa Souza, DVM, MS, PHD, DACVD – University of Illinois Attendees: 15 (10 United States, 1 Austria, 1 India, 1 Canada, 1 Italy, 1 Honk Kong) Different treatment options for feline atopic skin syndrome were listed to help guiding participants to share their experiences and to encourage discussion: Systemic glucocorticoids: • Most attendees agree that typically use glucocorticoids as initial treatment and the goal is to taper the medication to lowest possible dose or to get cats off completely if possible.

• Many participants advocated for baseline lab work prior to beginning therapy, then repeat it every quarter for monitoring. Steroids are an effective option but must be used with caution.

• Alicia Webb-Milum mentioned that steroid preference is largely based on how veterinarians were trained.

Prednisolone: • Prednisolone commonly used in many cases but due to short duration of action, the dosing frequency cannot be significantly reduced and still be effective.

• Clarissa Souza: Helpful that prednisolone does come in suspension formulation which can make administration easier in some cats as compared to tablet formulation.

• A comment was made about transdermal formulation of Prednisolone that is used by some practitioners.

Attendees agreed this is not a good option for delivering medications reliably and Clarissa Souza referenced a previous lecture given by Dr Papich at current conference.

• Jeanne Budgin commented on coaching clients/pet parents of cats to help them be more effective at medication administration including the establishment of specific feeding times to create a hungry cat which will take medication in a pill pocket or some other treat or crushed into a small amount of palatable food; Dexamethasone: • Alice Jeromin discussed that she uses dexamethasone in cases that clients have a hard time administering medication frequently (i.e. fractious cats or elderly clients) • 0.75 mg tablet: administer ½ - 1 tablet twice weekly after an initial loading administration for one to two weeks. She remembers of two cats maintained successfully on this protocol long-term, monitoring glucose and fructosamine every 4 - 6 months • Consider in cases which have become tolerant to prednisolone • Ann Mattise reported previously using dexamethasone SP injectable administered orally in fractious cats.

• 0.1 ml into mouth or onto a treat • Tasteless • No data to support, no protocol Continued on page 23

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• Dexamethasone and Triamcinolone in general: Both are more potent and longer acting but several members of the round table have more concern regarding their potential adverse effects as compared to prednisolone (heart disease/heart failure and development of diabetes mellitus) Triamcinolone: • Jeanne Budgin mentioned the concern for development of congestive heart failure and diabetes mellitus development for cats that need higher dosing to control disease (mostly experienced in cats with immunemediated diseases, i.e. Pemphigus foliaceus) • Alicia Webb Milum has not had any case developing diabetes while on triamcinolone (although it is a known risk), and checks lab work quarterly • Jeanne Budgin placed a question to the group about triamcinolone and dexamethasone potency. Do we all believe these drugs are 10x the potency of Prednisolone, or 6 to 10 x? Different attendees mentioned they calculate Prednisolone dose and divide it by 10 or 8 to 10.

• Alicia Webb Milum calculates prednisolone dosage then uses a glucocorticoid conversion calculator to determine an equivalent dosage in another formulation. She shared links for the conversion calculator with the group: www.mdcalc.com/steroid-conversion-calculator http://www.medcalc.com/steroid.html Shared article: Eva C. Ganz*, Craig E. Griffin†, Deborah A. Keys‡ and Tami A. Flatgard. Evaluation of methylprednisolone and triamcinolone for the induction and maintenance treatment of pruritus in allergic cats: a double-blinded, randomized, prospective study. Veterinary Dermatology 2012, 23: 387-e72.

• Question posed to the group by Jeanne Budgin: Who is currently using Feline pro BNP snap test to screen the heart for occult disease prior to starting glucocorticoid therapy?

Clarissa Souza, Alicia Webb Milum and Jeanne Budgin are not currently doing this in their practice but would like to consider adding it to their protocol after getting more information, familiarizing themselves with the specific test.

Alicia Webb Milum reiterated the recommendations that were discussed from a previous feline roundtable earlier in the current conference by Ally Kirby: • Baseline evaluation, then repeated in 4 -6 months, then annually thereafter • Idexx in-house snap test for cage side testing or reference lab • Jackie Campbell tries to get patients onto another form of therapy aside from steroids as soon as possible but she appreciates the safety recommendations and monitoring that are being discussed.

Cyclosporine (Atopica): • Considered by many in the group to be the next medication of choice after initial glucocorticoid therapy to control allergic cats.

• Clarissa Souza: Safer long-term option once disease is controlled with steroids or can even start Atopica while patient is on steroids due to extended time it takes for Atopica to be effective.

• Can be used concurrently during immunotherapy as well.

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• Clarissa Souza: initial dose is 7 mg/kg PO daily then trying to taper to every other day or a few times weekly as cat tolerates; less success with twice weekly dosing • Alice Jeromin advocated for starting patients (dogs included) at lower dosing from the start, to prevent many of the GI adverse events that patients experience. Clients get leery of a medication that causes GI signs.

• Recommends using regular 1cc syringe instead of the syringe that comes with the medication (lbs administration), so that she can dose her patients more precisely.

• Initially 0.1 ml of 100 mg/ml suspension (10 mg) daily for a few weeks, then a follow up call and increasing dosing as patient tolerates.

• She does not go over 0.2 ml (20 mg) dosing, she believes side effects can be dose related. She feels that she has maintained many patients on lower doses and has fewer adverse GI side effects.

• Once cat is stable, reduce dose to every other day or even on Mondays, Wednesdays, Fridays and give a weekend break. If flares are noticed during the weekend, cat may receive a low dose of steroids.

• She considers Cerenia for those patients that develop GI side effects.

• She also considers lower doses of Atopica in dogs with low body fat.

• Jeanne Budgin agrees that once a patient has GI side effects on Atopica (especially vomiting), it is difficult to get clients to continue to administer until side effects diminish, or start again if discontinued.

• Alice Jeromin and Alicia Webb Milum made a comment that human physicians are extremely reluctant to start Atopica based on their human experiences with this medication.

Question posed to the group by Alicia Webb Milum regarding screening prior to starting Atopica: • Toxoplasmosis: Most participants are not requiring screening prior to start, giving that patients are typically indoor only. Different comments were made: • Geographical risk may be a consideration: rural vs urban cats. Rural cats have more outdoor exposure and therefore may be a higher risk than strictly indoor cats.

• Alicia Webb Miliam mentioned that Dr Lappin’s previous publication showed naïve cats to be at higher risk for development of toxoplasmosis while on Atopica, as compared to cats which have been previously exposed. IgG and IgM are baseline tests used for assessment of risk exposure.

• Jackie Campbell recommends toxoplasmosis titers every 6 months for those cats that are indoor/outdoor and have risk of fighting behavior, compliance is tricky (cats may be going to rDVM for these tests). One indoor/outdoor patient on Atopica lost at a young age due to suspicious clinical signs of toxoplasmosis.

• Several attendees mentioned that they avoid Atopica use in indoor/outdoor cats, or cats on raw diets.

• Risk factor which many participants discuss with their clients for all patients on immunosuppressive medications: No raw meat diets should be fed.

• Alice Jeromin recalls 1 cat that developed toxoplasmosis pneumonia in 30 years of practice when using the cyclosporine human product (Neoral), years ago before Atopica.

• Nellie Choi inquired about pre-screening for Retrovirus Status (FeLV/FIV status): • Jeanne Budgin does not change medical therapy options and therefore is not a required diagnostic prior to starting Atopica (other costs associated with visit like lab work, medications, follow up exams could make screening for retrovirus cost prohibitive)

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• Jeanne Budgin has 5 FIV+ cats on Atopica currently. She believes it can be difficult to evaluate immune status in retrovirus disease positive cats – CBC/Chemistry can be used but is not a perfect assessment.

• Clarissa Souza reports that she has used Atopica in several FIV+ cats. Since there are already limited options for cats, Atopica can still be used for allergic cats with concurrent FIV infection.

• No major adverse effects have been noted by the clinicians • Jeanne Budgin: Upper respiratory infection signs or herpesvirus signs may be seen after starting steroids and/or Atopica due to latent diseases.

Oclacitinib (Apoquel): • Should be a last resort option if other therapies have not been successful or a patient cannot stay on long term steroids?

• Many attendees have concern about the long-term effects on cats since there is no data and no one knows definitely the consequences of long term administration • Higher doses and twice daily dosing are needed for cats as compared to dogs due to their shorter pharmacological half-life. Twice daily dosing for can be a challenging for cats.

• Clarissa Souza reported the protocol she has used for a few cats: start with 1 mg/kg twice daily for 2 weeks or until stable, then try to reduce by 0.2 mg/kg every two weeks to lowest possible dosage that keeps cat stable: She sees better success at higher dose. Recommends baseline CBC + chemistry, then repeat blood work every 3 months to monitor for possible adverse effects.

• Clarissa Souza reported one cat that developed pancytopenia after approximately 3 months of Apoquel therapy and administration had to be discontinued immediately. This cat’s CBC returned to normal after several weeks.

• Clarissa Souza is also starting immunotherapy along with Apoquel with hopes of being able to reduce or completely discontinue Apoquel use in the long term.

• Jackie Campbell reported her success rate of 50% with Apoquel in cats.

• Jackie Campbell and Alicia Webb Milum mentioned the cost of this medication along with twice daily dosing in a cat may not be feasible since cats are already difficult to medicate.

• Jackie Campbell mentioned her concern about referral cases from primary veterinarians which have been started on Apoquel prior to initial consultation. Some of these cats have completely bypassed Atopica as a therapy option. Are these primary veterinarians closely monitoring these cats for the adverse effects?

• Nellie Choi practices in Hong Kong and has seen referral cases which come to initial consultation on Apoquel but at the typical dog dosing (0.6 mg/kg once daily) and many of these cats are not showing any signs of allergy improvement. She also mentioned a case in Australia where an indoor/outdoor cat developed Toxoplasmosis after being on Apoquel.

As a routine for cats on Apoquel, she checks CBC/Chem/UA baseline and 1 month out, then quarterly.

• Jeanne Budgin reported about 10 patients (cats) on Apoquel that have been responding well to the therapy. Also uses it as a last resort.

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• Anisha Tiwari practices in India and mentioned that obtaining Apoquel in India is difficult. She is using prednisolone and Atopica for her patients. Inquired if the Apoquel we are referring to is different from the dog version: It was explained that dosing is twice daily, higher dose, off label usage but same medication that is used for dogs.

• Nellie Choi asked other attendees if they find Apoquel helpful for eosinophilic granuloma complex cases as she has not had great success (or much experience) treating cats with eosinophilic granuloma complex with Apoquel. For those participants using Apoquel, they are using it mostly for cats with pruritus only.

Nellie Choi also agrees that the effect of Apoquel over pruritus may be the most noticeable improvement.

• Jeanne Budgin shared a PDF of a poster of a case of feline ulcerative dermatitis responding favorably to Apoquel by K.E. Loft & B. Simon.

Maropitant (Cerenia): • Based on a recently published article (E Maina, J Fontaine. Use of maropitant for the control of pruritus in nonflea, non-food-induced feline hypersensitivity dermatitis: an open label, uncontrolled pilot study. Journal of Feline Medicine and Surgery 2018, 21: 967-972) describing the use of maropitant to control pruritus in cats, the attendees were asked about their experiences: • Clarissa Souza mentioned that has only used in two very challenging cases in combination with other allergy medications, but no improvement has been noted.

• Nellie Choi reported using Cerenia successfully in one challenging cat where all other therapies were not maintaining the cat completely stable.

Immunotherapy: • Jackie Campbell inquired about sedation protocol for intradermal test (IDT) in cats, other than dexmedetomidine.

• Jeanne Budgin recommends pre-visit administration of gabapentin.

• Alicia Webb Milum mentioned routinely using gabapentin as pre-medication before dexmedetomidine. She agreed with Jackie Campbell’s comments that IDT in cats can be frustrating, even when you add fluorescein dye to improve visualization for positive reactions, due to increased cortisol from stress. She also shared an article about the use of gabapentin: C Hudec and C. Griffin, Changes in the stress markers cortisol and glucose before and during intradermal testing in cats after a single dose of pre-appointment gabapentin, Journal of Feline Medicine and Surgery 2020, 22: 138-145.

• Jeanne Budgin suggested Propofol IV to effect, even with the understand that it may enhance some of the positive responses (dogs) and IM Torbugesic as pre-medication/sedative.

• Jackie Campbell has been considering for more fractious cats to use topical lidocaine and alfaxalone.

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