I am a firm believer that dermatology and management of skin disease is the best aspect of veterinary medicine! Of course that may be because I’m a dermatologist…..
I realise that may not be a sentiment shared by all of you, …..or most of you, or perhaps even any of you….. but hopefully with a little helpful information and tips on how to approach skin cases, any anxiety that you feel for dermatology case management can be alleviated. There are many of you in practice now and also many of you about to venture out into the world who will be on the front lines of managing patients with skin disease and clients with frustration and expectations. Here are some hints about how to navigate those situations that will hopefully be helpful to you in your clinical setting.
1. Schedule time for dermatology cases.
Each case of skin disease is different despite a similar clinical appearance. Obtaining a thorough history, performing a complete physical and skin exam and performing appropriate diagnostics simply take time. New patients with experienced dermatologists at referral dermatology clinics are usually scheduled for 45-60 minutes and if you are unable to allow this time in the schedule, this will negatively affect your ability to do the things necessary to make an accurate diagnosis and formulate a treatment plan.
2. Ask the right questions and observe.
History taking is an art that takes time to perfect. However once you get practiced at it, an accurate history will make your job easier and help you navigate through the litany of information that clients may want to give you in an attempt to be helpful. Clarifying in your mind and getting the answers to questions such as evidence of pruritus, location of clinical signs, presence of primary and secondary lesions and response to previous therapy will markedly improve your ability to manage skin disease.
3. Skin scrape any dog under 1 year and over 10 years.
Parasites come in many different presentations and they can occur at any age, but when we are specifically concerned about Demodex canis mites this is a good rule to live by. Remember most cases of demodicosis are not pruritic (unless there is secondary infection) so any dog with hair loss, scale or crusting on the head, extremities and trunk could have these mites. Demodex mites take advantage of suppressed immune responses so younger and older patients are at risk. Don’t miss these mites!
4. Perform cytology on almost every patient.
Cytological impression smears (assuming you are comfortable with a microscope and assessing cytology samples), whether you perform direct impression smears or tape preps, are the most valuable tools that you have at your disposal. This will direct your immediate therapy in almost all cases. If you aren’t comfortable identifying organisms and cells, get a reference book and educate yourself or take a cytology class to help. You can also take two samples, one to submit to your local clinicopathologist and one for your own evaluation. Compare your interpretation with the laboratory results. The immediate information that you gain from a well-performed and accurate cytological diagnosis is critical in getting started with skin cases.
5. Biopsy sooner than later.
In cases that are not responding to appropriate therapy, appear severe, present with ulcers, erosions or nodules or in patients that are systemically unwell, choose to biopsy those cases in the early stages. Many skin cases need a biopsy for definitive diagnosis and in some cases early intervention will result in better outcomes. Most skin biopsies on the body can be done with a sedative and local anaesthesia although energetic patients or biopsies in areas on the face, ears or distal extremities may require general anaesthesia.
6. Chronic relapsing skin or ear infections have a primary cause.
Remember that once you have made a diagnosis of a recurrent bacterial or Malassezia skin or ear infection, your diagnostic approach has not concluded. In fact, it has only begun. Infections are almost always secondary and there is an underlying trigger for these problems. Failure to pursue an underlying trigger and manage the primary disease will result in ongoing relapsing problems that will be a source of irritation for your client and the patient.
7. Educate yourself and the owner about the diagnosis.
If you perform the appropriate diagnostics and you get a diagnosis that you haven’t encountered before or you are unfamiliar with, educate yourself firstly. Have a good updated dermatology textbook on your shelf or reliable resource information at your disposal. Newly recognised diseases are reported continuously and novel and updated drug therapies and management strategies are being tested for diseases that have been around for years. Stay up to date on your management. Things change!
8. Educate the client about the diagnosis.
Once you have a firm grasp on the details about the disease condition. Talk to your clients about the condition including the prognosis and the therapeutic options that are available. If it is a chronic genetically based disorder (like atopic dermatitis), discuss with them the fact that this will be a chronic condition that will require chronic management. Discuss the options that you can offer them and also what limitations including time, expected recheck exams or financial constraints that they may have and discuss how this may impact their management. The most common source of frustration from referred clients is their lack of understanding of the aspects of the primary disease and what options are available for them.
9. Send home discharge instructions.
There is no substitute for clear, concise and very detailed discharge instructions in managing skin disease. Most clients will follow your instructions if they know what is expected of them It is imperative in most of our cases, that clients continue therapy until remission or control of the condition has been achieved and then a long term management plan can be instituted on follow up visit.
10. Let a dermatologist assist.
Dermatologists are specifically trained to be able to manage chronic skin problems. We actually enjoy it! There is nothing more satisfying to us then taking a patient that is unhappy and in some cases, miserable and has become an outcast in the home because of the look and smell from the skin and turning them back into a valued and huggable member of the family!
In cases that have become unresponsive or clients who would like additional dermatological input or management, using a dermatologist as a referral source is the best way to strengthen your relationship with your client.
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Dr Rusty Muse is a senior partner in the Animal Dermatology Clinics. ADC operates from ten locations in the United States of America and two in Western Australia. Rusty travels between the USA and Australia and sees patients in Orange County, California and Perth. He is a Diplomate of the American College of Veterinary Dermatology.
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