Making dermatology cases more efficient in general practice

Content sponsored by Nextmune

At the Fetch dvm360® conference in San Diego, California, Ashley Bourgeois, DVM, DACVD, and Adam Christman, DVM, MBA, gave a shared presentation titled, “‘Itch Please!’ Approach to the Itchy Dog From The GP to The Derm Vet!” to share their advice on making dermatology cases more accessible and more manageable to the general practitioner.¹ Bourgeois told attendees, “I have a really big passion, as a dermatologist, to get really tangible, easy info out to you guys and [with better] access to care and access to education, just [wanting to share] content that's really easy to digest knowing that—as general practitioners—you guys have to do a lot.”

Bourgeois and Christman started with 4 tips for success in dermatology. These tips include:

1. Allow enough appointment time.

Bourgeois recommended scheduling dermatology appointments for at least 30 minutes in order to cover all the bases with the patient. She said, “It seems daunting to extend your appointment time, [but] it can be really important. And if we are able to set it aside that time, you're going to probably have less frustrated rechecks and have some of that time available in your schedule looking forward.”

2. Do a thorough physical exam

Christman said, “The most powerful tools are your hands and your expertise. So doing a thorough physical exam, [and] observing pruritus in the exam room [is crucial].” He said to use a pruritus Visual Analog Scale (VAS) to document the level of pruritus in the previous 24 hour and then do the dermatologic exam and look for dermatitis patterns, lesions, and/or fleas.

3. Formulate a diagnostic plan

Bourgeois and Christman suggested that the first step in most cases involves a skin scraping, cytology, and possibly a dermatophyte culture. Second tier tests include a bacterial culture and susceptibility test, particularly if there has been no response to treatment with an antibiotic, and/or a skin biopsy, which can be performed with a local anesthetic.

4. Schedule a recheck visit

Bourgeois and Christman suggested using hand-outs, written discharge instructions, and videos for better client comprehension and to make sure to schedule the follow-up appointment before the client leaves. If condition has improved, remind clients to continue therapy or preventative work up. If not improved, check compliance and perform additional test, and offer a referral to a dermatology specialist if needed.

With these 4 tips, Bourgeois and Christman hope that dermatology cases can seem more manageable for general practitioners, but also given more time to treat and follow-up with.

Pruritus

To close out their presentation, Bourgeois and Christman quickly explained an easy approach to pruritus. They recommended to first rule-out parasites, because not all itchy dogs are atopic dermatitis. If parasites are ruled-out or resolved, Bourgeois and Christman advised to identify if the pruritus is seasonal, because if it is nonseasonal, it could be a food allergy. However, if it is seasonal, it could be atopic dermatitis.

Is the patient still itchy and/or has nonseasonal pruritus?

Bourgeois and Christman recommended starting a prescription novel protein diet or a hydrolyzed protein diet trial for 8-12 weeks. The diet should be composed of food substances to which the dog has not been commonly exposed. According to Bourgeois, the most common food allergens in dogs are beef, dairy products, chicken and wheat.

Is the patient still itchy after diet trial or has seasonal pruritus?

If the patient continues to have nonseasonal pruritus despite ruling out parasites, infections, and food allergy, or initially presents with seasonal itch that does not respond to aggressive flea control, then Bourgeois advised to diagnose atopic dermatitis. This is a clinical diagnosis, not one based on serum or skin allergy test results, which only serve to help select allergens for immunotherapy, she said. Bourgeois said, “The disease is steroid-responsive and involves the face, ears, paws, axillae, and ventrum. These are high-maintenance dogs that generally require lifelong multimodal therapy. We are aiming for control, not cure.”

Reference

Bourgeois A, Christman A. Itch Please! Approach to the Itchy Dog From The GP to The Derm Vet! Presented at Fetch dvm360^® Conference; San Diego, California. December 2-4, 2022.