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SASH : Atopic dermatitis treatment by Dr Linda Vogelnest

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Veterinary consultancy content from SASH

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SASH : Atopic dermatitis treatment by Dr Linda Vogelnest

  1. 1. Atopic Dermatitis Linda Vogelnest BVSc MACVSc FACVSc
  2. 2. www.sashvets.com Atopic Dermatitis “Changing” disease…. New Definition: International Task Force (2002) canine atopic dermatitis - “Genetically-predisposed - Inflammatory & pruritic allergic skin disease - Characteristic clinical features - Associated most commonly with IgE antibodies to environmental allergens” OLIVRY, DE BOER, GRIFFIN, HALLIWELL et al (2001). Veterinary Immunology and Immunopathology 81: 143-146 2
  3. 3. www.sashvets.com Atopic Dermatitis Genetic Influence: 1. Immunological dysfunction – T-lymphocyte driven – Mast cells, IgE • 2 subsets: – High allergen-specific IgE producers – Low allergen-specific IgE producers 3
  4. 4. www.sashvets.com Atopic Dermatitis Genetic Influence: 1. Immunological dysfunction – T-lymphocyte driven 1. Skin barrier dysfunction – Lipid changes: • more heterogeneous, thinner, shorter lamellae • ↓ ceramides (non lesional & lesional skin) – Protein changes: ↓ filaggrin expression (beagles) 4 Microbes, allergens Water
  5. 5. www.sashvets.com Atopic Dermatitis Genetic Influence 1. Immunological dysfunction – T-lymphocyte driven 1. Skin barrier dysfunction – Lipid changes – Protein changes Environmental Influence – Allergen exposure – Microbe exposure (“hygiene hypothesis”) 5 Microbes, allergensWater
  6. 6. www.sashvets.com Atopic Dermatitis • Atopy = broad allergic group • Humans – allergic rhinitis – allergic asthma – atopic dermatitis (eczema, AD) • Dogs/Cats – AD most common 6
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  16. 16. www.sashvets.com AD: Treatment Multi-faceted approach 1.Acute flare plan 2.Long-term management plan Options: 1.Minimise allergen &/or irritant exposure 2.Immunotherapy 3.Symptomatic therapy 16 OLIVRY, DE BOER (2010). Treatment of canine atopic dermatitis: 2010 clinical practice guidelines from the International Task Force on Canine Atopic Dermatitis. Veterinary Dermatology 21: 3; 233-248.
  17. 17. www.sashvets.com AD: Treatment 1. Minimise allergen exposure – requires skin test (or allergen-specific IgE serum test) → id allergens – most useful dust mites, mould spores • see human literature 17
  18. 18. www.sashvets.com AD: Treatment 1. Minimise irritant exposure – variety of factors • grass • certain fabrics: wool • heat • dryness • shampoos (rarely) 18
  19. 19. www.sashvets.com AD: Treatment 1. Minimise allergen/irritant exposure 2. Immunotherapy – requires skin test (or allergen-specific IgE serum test) → id allergens 19
  20. 20. www.sashvets.com AD: Immunotherapy (allergen-specific) • Potentially changes allergic response – T-helper subset change (II to I) – 60-70% improve (20-30% excellent) • Recommended when – allergy severe – allergen avoidance not possible/not effective – symptomatic tx ineffective or → side effects – preferred to avoid medications 20
  21. 21. www.sashvets.com AD: Immunotherapy (allergen-specific) • Requires owner commitment – Ideally minimum 2-yr program – 6-12 months to see benefit in many – Average cost $10-15/wk (~$300 per 7mnths supply) • Side effects - very rare – ↑ itch (→ change dose) – Urticaria; Anaphylaxis - extremely rare 21
  22. 22. www.sashvets.com AD: Treatment 1. Minimise allergen exposure 2. Immunotherapy 3. Symptomatic tx 22
  23. 23. www.sashvets.com AD: Treatment 1. Minimise allergen exposure 2. Immunotherapy 3. Symptomatic treatment 1. Acute flare plan 2. Long-term management plan 23 OLIVRY, FOSTER et al (2010). Interventions for atopic dermatitis in dogs: a systematic review of randomized controlled trials. Veterinary Dermatology 21: 1; 4-22.
  24. 24. www.sashvets.com AD: Treatment 1. Minimise allergen exposure 2. Immunotherapy 3. Symptomatic treatment 1. Acute flare plan • Treat active infections – when present! • Soothing • Anti-inflammatory • Limit self-trauma 24
  25. 25. www.sashvets.com AD: Treatment 1. Minimise allergen exposure 2. Immunotherapy 3. Symptomatic treatment 1. Acute flare plan 2. Long-term management plan 1. Infection prevention – when relevant! 2. Anti-inflammatory 3. Skin barrier repair 25
  26. 26. www.sashvets.com AD: Symptomatic Tx A. Safest Options • Antihistamines • Fatty acids • Shampoos • Moisturisers/topical soothing products • Limit self-trauma NB Rarely spectacular response with severe acute flares; most effective as part of long-term plan 26
  27. 27. www.sashvets.com AD: Symptomatic Tx Antihistamines – Block histamine effects (not IgE, Langerhan’s cells, T cells, cytokines etc etc) – Safe – Variably effective (rarely spectacular) – Trial a number – Little pharmacokinetics (dogs or cats): dose rates? – Higher success cats, help some dogs 27
  28. 28. www.sashvets.com AD: Symptomatic Tx Fatty acids – ↓ pruritus? - altered eicosanoid production – improve barrier function (stratum corneum) • Omega-3 – fish oil (pump bottle, capsules); flax seed oil • Omega-6 – Evening primrose oil (50-100mg/kg sid) – Cold-pressed sunflower/safflower oils (2mls/kg sid) – borage oil, blackcurrant oil • Combinations e.g. Megaderm® – ↑ energy intake (↓ other dietary intake) – care with pancreatitis? 28
  29. 29. www.sashvets.com AD: Symptomatic Tx Shampoo Therapy – Regular appropriate shampoo therapy helps vast majority atopic dogs (& can help cats) • wkly → twice wkly • skin drying rarely problem • NOT too vigorous rubbing of coat against lay of hair • 10-minute contact time for medicated shampoo (use timer) • rinse well – Avoid drying shampoos in most cases: tar-based, selenium, benzoyl peroxide 29
  30. 30. www.sashvets.com AD: Symptomatic Tx Shampoo Therapy – Antibacterial/antifungal shampoos – Soothing – Barrier Repair 30
  31. 31. www.sashvets.com AD: Symptomatic Tx Shampoo Therapy – Antibacterial/antifungal shampoos FOR recurrent pyoderma/malassezia dermatitis •Mediderm® (piroctone olamine) •Pyoben-S or Pyohex® (chlorhexidine) •Malaseb® (chlorhex/miconazole) – Soothing – Barrier Repair 31
  32. 32. www.sashvets.com AD: Symptomatic Tx Shampoo Therapy – Antibacterial/antifungal shampoos – Soothing • Episoothe® (oatmeal); Allergroom® (emollient) • Aloveen® (aloe vera/oatmeal) • PAW sensitive skin® (no sulphates) 32
  33. 33. www.sashvets.com AD: Symptomatic Tx Shampoo Therapy – Antibacterial/antifungal shampoos – Soothing – Barrier Repair • Nutriderm® shampoo/conditioner 33
  34. 34. www.sashvets.com AD: Symptomatic Tx Moisturisers – mainstay of symptomatic tx for AD in people – rarely as effective in dogs, cats; important with dry scaly skin – Humectants • attract water e.g. lactic acid, urea - non-oily • prevent water loss e.g. propylene glycol, glycerine, sorbolene – Emollients • fill spaces between kc’s with oil e.g. Allergroom®, Alpha Keri® bath oil, other oils (almond, corn, safflower, sesame), animal fats (lanolin), hydrocarbons (mineral oil, paraffin oil, petrolatum) 34
  35. 35. www.sashvets.com AD: Symptomatic Tx Limit self trauma • E-collar • Body-suits • Bandages 35
  36. 36. www.sashvets.com AD: Symptomatic Tx A. Safest Options • Antihistamines • Fatty acids • Shampoos • Moisturisers/Topical soothing products • Limit self-trauma A. Stronger Anti-inflammatories • Topical GCs • Systemic GC • Cyclosporine • Other 36
  37. 37. www.sashvets.com AD: Symptomatic Tx Topical Glucocorticoids – mainstay of symptomatic tx for AD in people – may help minimally haired localised areas – more potent most effective: daily for short periods; 1-2X wkly longer-term; may thin skin and ↑ risk infections • Aristocort® cream/oint (triamcinalone) • Elocon® lotion/cream/oint (mometasone) • Panalog® oint (triamcinalone/neomycin) • Fuciderm® gel (betamethasone/fusidic acid) • Cortavance® spray (hydrocortisone aceponate) 37
  38. 38. www.sashvets.com AD: Symptomatic Tx Topical Glucocorticoids – Less potent options with more transient effect • Cort-Hex ®, Neocort® (hydrocortisone) creams, lotions, ointments – Absorption best from moist skin – Limit licking 10-mins after application 38
  39. 39. www.sashvets.com AD: Symptomatic Tx Systemic Glucocorticoids – most effective, cheap, fast-acting option for severe allergy flares (all) in many patients – short-acting forms reasonably safe intermittently at low doses if other options not effective • severe steroid side-effects with even low-dose short-term • high risk for side effects with long-term • cats more resistant some steroid side effects cf. dogs – still can be severe 39
  40. 40. www.sashvets.com AD: Symptomatic Tx Systemic Glucocorticoids – Measures to ↓ risk side effects: • Use short-acting only – often oral prednisolone – for severe flares injectable formulations (e.g. dexamethasone) more potent • Restrict to low doses for longer-term use – pred 0.1-0.2 (dogs) or 0.2-0.4 (cats) mg/kg eod or less • Low regular dosing (pred ≤0.5mg 2X wkly) to hold continual allergies at more comfortable level better than repeated tapering courses • Avoid long-acting preps (DepoMedrol®) – Recommend safer alternatives, steroid-sparing role 40
  41. 41. www.sashvets.com AD: Symptomatic Tx Cyclosporine – Severe, poorly-responsive AD MUCH easier • dogs + cats (off-label; oral solution in USA) • including cases with recurrent 2º infections – Potent immunosuppressive (more specific T-cells) – No general body metabolic side effects – Expensive!! – Slower onset effect (2-5wks for good control) – Doesn’t work for flea allergy, contact allergy • ENSURE AD FIRST! 41
  42. 42. www.sashvets.com AD: Symptomatic Tx Cyclosporine – Start 5mg/kg sid most; 7mg/kg cats, dogs <5kg • Dose with food initially – Continue until good control (by 6wks), then gradually taper in 2wk steps • ↓ dosing interval or daily dose • typical maintenance dose 1-3mg/kg sid – ↓ dose & cost by: • concurrent ketoconazole 5mg/kg bid or can combine to sid – GIT signs (inappetance, vomiting) some patients • concurrent grapefruit juice ? ~ 3-4 ice cubes/dog • dose on empty stomach (after ↓ to lower doses) 42
  43. 43. www.sashvets.com AD: Symptomatic Tx Cyclosporine - Side effects (few): – Diarrhoea most frequent, rarely severe; Vomiting (if no food) • both more likely at higher doses – Gingival hyperplasia, papillomatosis, hirsuitism - higher doses – Unusual infections: fungal osteomyelitis; papillomas – Fatal toxoplasmosis reported in cats • FIV/FeLV first • warn owners to act promptly if cat unwell (pyrexia?) • no clear evidence prophylactic Ab’s (clindamycin, TMS) ↓ risk • very rare, but increased risk cf. dogs 43
  44. 44. www.sashvets.com AD: Treatment 1. Minimise allergen/irritant exposure 2. Immunotherapy 3. Symptomatic tx 1. Acute Flare Plan 2. Longer-term Management Plan 44
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  46. 46. www.sashvets.com.au twitter: @SASHvets Phone - (02) 9889 0289 Fax - (02) 9889 0431 Level 1, 1 Richardson Place, North Ryde 2113, Sydney, NSW

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