Wild Crazy Immune System - VETgirl · Swollen pads, striae, and blue/violet discoloration ! Bridge of nose can be affected ! Diagnosis--clinical appearance or histopathology ! Treatment

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Introduction

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Dr. Amy Haarstad, DACVD !  North Carolina State University-

DVM 2001

!  Purdue University Small Animal Internship 2001-2002

!  Small animal private practice for 9 years

!  Dermatology residency at McKeever Dermatology Clinics in Minnesota 2011-2014

!  Diplomate of ACVD 2014

!  Veterinary Dermatologist at McKeever Dermatology Clinics

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The Wild and Crazy Immune System…and how it affects the

skin

Diseases !  Discoid Lupus Erythematosus (DLE)

!  Symmetrical Lupoid Onychodystrophy (SLO)

!  Pemphigus Foliaceus (PF)

!  Sterile Nodular Panniculitis

!  Perianal Fistulas

!  Sebaceous Adenitis

!  Dermatomyositis

!  Ear Margin Vasculitis

Total cases in 9 years !  DLE=2

!  SLO=1

!  Pemphigus Foliaceus=1 in a cat

!  Panniculitis=0

!  Perianal Fistulas=1

!  Sebaceous Adenitis=2

!  Dermatomyositis=0

!  Ear Margin Vasculitis=2

!  Plasma Cell Pododermatitis=0

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Why is this happening? !  Most cases are idiopathic

!  Recent vaccination

!  Medication history

Cutaneous adverse drug reactions in dogs and cats

Dogs

!  Pemphigus foliaceus-sulfonamides, ampicillin, penicillin, cephalosporins, diethylcarbamazine, metaflumazone/amitraz

!  Panniculitis-rabies vaccine, others

!  Vasculitis-rabies vaccine, others

Cats

!  Pemphigus foliaceus-ampicillin, cimetidine, doxycycline, cephalexin, sulfonamides

!  Panniculitis-vaccines, glucocorticoids

!  Vasculitis-vaccines, ivermectin, antibiotics

Diagnosis !  Clinical Appearance

!  Dermatohistopathology

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Quick Reminder !  Cytology

!  Skin scrape

!  Dermatophyte culture

!  Bacterial culture and sensitivity

Tape IT! !  Tape prep

!  Scotch 3M® packaging tape

!  Microscope slide size

!  Stain with orange and purple only

!  Impression smear

!  Use for moist lesions

My top 5 tips for performing a skin biopsy

1.  Keep it DIRTY

2.  Keep it HAIRY

“Do you feel lucky, well, do ya?”

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My top 5 tips for performing a skin biopsy

3. Just say NO

!  to ulcerated skin

!  to normal skin

4. Keep that CRUST!

5. Get the FAT!

Drugs and Vitamins !  Glucocorticoids

!  Azathioprine

!  Atopica®

!  modified cyclosporine

!  Minocycline/Doxycycline

!  with Niacinamide

!  Topical tacrolimus

!  Nutritional supplements (Omega-3s, Vitamin E, A)

Treatment Phases !  Induction

!  Transition

!  Maintenance

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How Low Can You GO?

Glucocorticoids !  Every Other Day

!  Transition and Maintenance phases

What’s up with that sore sniffer?

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Discoid Lupus Erythematosus !  Most common immune-mediated dermatosis

!  Localized, photoaggravated skin lesions

!  Shetland Sheepdogs, Rough Collies, German Shepherds, and Siberian Huskies are predisposed

!  Nose and nasal planum

!  Alopecia, erythema, and varying depigmentation

!  Absence of systemic signs

!  Epitheliotropic lymphoma-Ddx

Biopsy Buzz Words

!  DLE

!  Interface basal cell degeneration

!  Apoptotic keratinocytes only in the basal layer

!  Lichenoid inflammation or band-like infiltrate

!  Lymphocytes, plasma cells, histiocytes

!  Pigmentary incontinence

!  Melanin drops out into the dermis

Discoid Lupus Erythematosus

!  Management

!  *Minocycline or doxycycline/Niacinamide*

!  *Topical 0.1% tacrolimus ointment (Protopic®)*

!  Prednisone

!  Modified cyclosporine A (Atopica®)

!  Vitamin E

!  Topical corticosteroids (ie. Betamethasone cream)

!  *Topical sun-blocking creams and sun avoidance*

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Symmetrical Lupoid Onychodystrophy

!  SLO

!  Sloughing of claws

!  Early lesions 1-3 nails

!  Remove loose nails

!  Bandage if needed

!  Treat secondary bacterial infection

SLO !  Diagnosis

!  History

!  Clinical appearance

!  Biopsy-usually not

!  Management

!  *Minocycline or doxycycline/niacinamide*

!  Atopica® (modified cyclosporine)

!  Corticosteroids

!  *Omega-3 fatty acids*

!  Frequent nail trims

!  Expectations-more nails to follow

Crusty Crusts on Crusts

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Pemphigus Foliaceus !  Pathogenesis

!  Type II Hypersensitivity

!  Autoantibody (IgG) against desmocollin-1

!  Signalment:

!  Chow, Akita, Bearded Collie, etc.

!  Many breeds

Pemphigus Foliaceus !  Clinical signs

!  Pustular dermatitis

!  Secondary erythema, scale, alopecia, erosion, crusts

!  Dorsal muzzle, face, pinnae, pawpads, generalized

!  Systemic signs

PF in cats

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Acantholytic Cells

Pemphigus Foliaceus !  Diagnosis

!  Cytology

!  Neutrophils

!  Acantholytic cells

!  Dermatophyte culture

!  R/O Trichophyton mentagrophytes

!  Histopathology

!  Keep those crusts

!  Special stains

!  GMS or PAS

Biopsy Buzz Words

!  Pemphigus foliaceus

!  Superficial epidermal pustules

!  Acantholysis

!  Lack of infectious organisms

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Pemphigus Foliaceus !  Treatment

!  *Glucocorticoids*

!  *Azathioprine*

!  Minocycline or doxycycline/niacinamide


!  Mycophenolate

Sterile Nodular Panniculitis

!  Damaged lipocytes

!  Solitary or multiple draining nodules

!  Dachshunds most frequent breed affected

!  Diagnosis

!  Excisional or wedge biopsy

!  Fungal and acid fast stains

!  Rule out fungal disease (ie. blastomycosis), nocardiosis, mycobacterial infection)

Draining Lesions

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Biopsy Buzz Words

!  Sterile Nodular Panniculitis

!  Epidermis may be normal or acanthotic (thick)

!  Epidermis may be ulcerated in area of draining tract

!  Pyogranulomas replacing adipose tissue

!  Special stains are negative

Sterile Nodular Panniculitis

!  Treatment

!  *Minocycline or doxycycline/niacinamide*


!  Methylprednisolone or prednisone

!  Vitamin E

Straining?

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Perianal Fistulas !  Unknown cause

!  German Shepherd Dogs

!  Tenesmus

!  Erythema, ulcers, fistulous tracts

!  Diagnosis based on history and clinical findings

!  Treatment of choice

!  *Atopica® (modified cyclosporine)*

Treatment on a Budget !  Elimination Diet

!  Limited ingredient or Hydrolyzed

!  Sulfasalazine

!  Prednisone

!  1 mg/kg once daily until resolution of lesions, then dose is reduced to 0.5 mg/kg Q24h for 6-8 weeks, then lowest every other day dose.

!  Topical tacrolimus 0.1% twice daily

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Sebaceous Adenitis !  Autoimmune destruction of sebaceous glands

!  Young adult to middle aged

!  Breeds--Standard Poodles, Vizslas, Akitas, Samoyeds, etc.

!  Autosomal recessive

!  Clinical

!  Follicular casts, scaling, alopecia or poor coat

!  Dorsum of neck and back, top of head, bridge of nose, ears

!  In short coated dogs scales fine and non-adherent. Longer-coated have tightly adherent scales. Akitas may be greasy

!  Diagnosis--clinical and histopathology

Biopsy Buzz Words

!  Sebaceous adentitis

!  Follicular plugging or casts

!  Absence of sebaceous glands

Management !  *Bathe with Douxo Chlorhexidine PS shampoo weekly*

!  *Propylene glycol or baby oil 50% in water weekly for 4-6 weeks then 1-2 times a month*

!  *Vitamin A*


!  Can regrow sebaceous glands

!  Prednisone or methylprednisolone


!  Retinoids (ie. Acitretin)

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Dermatomyositis

Dermatomyositis !  Hereditary inflammatory disease

!  Collies and Shetland Sheepdogs

!  <6 months of age

!  Symmetrical scarring alopecia of face and limbs

!  Atrophy of muscles of mastication

!  Waxing and waning

!  Not pruritic or painful

Dermatomyositis !  Diagnosis

!  Physical exam

!  Electromyography (EMG)

!  Histopathology

!  Management

!  *Pentoxifylline*

!  *Vitamin E*

!  Prednisone



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Naked and Notched Ears

Ear Margin Vasculitis !  Ulcerative lesions affecting pinna

!  Dachshunds predisposed

!  Alopecia#Pigmented#Thickened#Necrosis

!  Diagnosis—clinical findings and biopsy

!  Management

!  Sulfasalazine


!  Minocycline or doxycycline/Niacinamide

!  Pentoxifylline

!  Prednisone

Plasma Cell Pododermatitis

!  Cats

!  Plasma cell infiltration into one or more footpads

!  Swollen pads, striae, and blue/violet discoloration

!  Bridge of nose can be affected

!  Diagnosis--clinical appearance or histopathology

!  Treatment

!  *Doxycycline*


!  Glucocorticoids

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Medication doses !  Minocycline/doxycycline 5mg/kg BID-TID

!  Niacinamide (with mino or doxy)

!  <15 kg give 250 mg BID-TID

!  >15 kg give 500 mg BID-TID

!  Prednisone 1-4 mg/kg Q24 initially, then lowest effective EOD

!  Atopica® (modified cyclosporine) 5 mg/kg Q24 then taper

!  Azathioprine 2 mg/kg EOD

!  Vitamin E 200-800 IU/day

Medication doses !  Omega-3 fatty acids 180mg EPA per 10lbs per day

!  Sulfasalazine 10-20 mg/kg TID

!  Pentoxifylline 10-15 mg/kg BID

!  Vitamin A 8,000-10,000 IU/20 lb. PO Q24h

!  Acitretin 1 mg/kg PO q 12-24h

References !  Scott, DW, et al. Immune mediated dermatoses in domestic animals: Ten

years after. Part I. Compend Contin Educ Small Anim Pract. 1987;9:423

!  Scott, DW, Miller, WHJ. Idiosyncratic cutaneous adverse drug reactions in the cat: Literature review and report of 14 cases (1990-1996). Feline Pract. 1998;26(4):10-14

!  Scott, DW, Miller, WHJ. Idiosyncratic cutaneous adverse drug reactions in the dog: Literature review and report of 101 cases (1990-1996). Canine Pract. 1999;24(5):16-22.

!  Nuttall, T, Harvey, RG & McKeever, PJ. Skin Diseases of the Dog and Cat. 2nd edn, Manson Publishing Limited, 2009.

!  Gross, TL, Ihrke, PJ, Walder, EJ, Affolter, AK. Skin Diseases of the Dog and Cat. 2nd edn, Blackwell Publishing, 2005.

!  Miller, WJ, Griffin, C, Campbell, K. Muller and Kirk’s Small Animal Dermatology. 7th edn, Saunders-Elsevier, 2013.

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Wild Crazy Immune System - VETgirl · Swollen pads, striae, and blue/violet discoloration ! Bridge of nose can be affected ! Diagnosis--clinical appearance or histopathology ! Treatment