Latest / The Derm Vet Podcast / 212. Feline Dermatology with Dr. Gary Marshall

Transcript

212. Feline Dermatology with Dr. Gary Marshall · The Derm Vet Podcast

• 0:00
  Welcome to the Dermvet Podcast. I'm Dr. Ashley Bujwa, a board certified veterinary dermatologist practicing in Portland, Oregon with animal dermatology clinics. I'm also a mom of two just trying to find the balance like everyone else. Let's learn to ditch the itch, cytology, everything, and make Derm more fun than frustrating. I love being able to have my friends on the podcast.
• 0:28
  I'm very excited today to welcome my good friend Dr. Gary Marshall to the Dermvet Podcast.
• 0:34
  He has an over quarter century experience being a feline practitioner. He practices at island cats veterinary hospital near the Seattle, Washington area, and he is currently the clinical director of student development. He's also very involved in organized veterinary medicine currently running for ABA and A. Vice President and has recently received Washington State University's Distinguished Alumni Award. I was so excited to have Gary on today to talk about cats to get the side of the practitioner who just deals with cats on what's realistic on how you can manage these cats, how to medicate these cats. Of course, I can speak from a dermatologist lens, but I love to have other people on the podcast to compare notes and just to see how things may be a bit different.
• 1:21
  So I really hope you enjoyed this episode of the Dermvet Podcast.
• 1:25
  Well, welcome everyone to another episode of the Dermvet Podcast. I am always excited to have guests on and it's just been thrilling to have more and more people back on the podcast as I get to more interview type episodes. But today is especially exciting because I have one of my really good friends Dr. Gary Marshall on the podcast today. Just a dear friend has been really supportive of my career and my family and I am just really excited to have a cat bet on. I know before we got on, you said, oh, I'm just a cat bet. Listen, cat, feline veterinarians, you guys are tough and a different breed. I mean, it is not easy to become so specialized in handling cats. So I am very excited to have you on the podcast today and learn from you and discuss things and hopefully teach other general practitioners how to manage these cats a bit better. So thank you so much for being on the podcast today. I am thrilled to be here Ashley. It's always fun to see you and especially to talk about cats.
• 2:23
  Cats, they are their own breed for sure isn't that true, their own species. Well, let's just kind of, you know, obviously don't be asking me about like fluted or anything crazy because I have no idea. But if we just talk about skin disease and cats, because I know you're still seeing a significant amount of dermatologic disease, even specializing in cats, what do you feel like the most common things you see if you thought, okay, the top two to three things I see as far as B-line dermatology? Probably the top three are all people with concerns about itchiness in their cats.
• 3:03
  Different forms of itchiness either they are like really itching and bothering the owners because they're sitting there are the owners are worried about them or that they've just got patchy hair loss or scabs or those types of things and that probably is leading to itchiness even though they're not as concerned about that just day in and day out. And do you feel like there's certain patterns of itchiness you see because what's always tough and I find this especially true for cats is they can show their itch in so many different ways. So if you think about a cat coming in a typical like clinical presentation or distribution you see what do you feel like you're not shocked to see come in your exam room? Oh yeah well with cats there's nothing super typical right? I loved your podcast a couple weeks ago about like the whole thing revolved around it depends because that's so true it was great. And we bonded on that. We bonded on that didn't we when you were doing cat class in you you say it depends for cats too I think that really is something simple that can hold true for most aspects of veterinary medicine. I'm running out of itchiness stickers but even in Texas this last weekend I was people were like up on the podium we're talking about itch depends and I would walk up and give them a sticker it was great because that's all the time. I I would say though when I have a cat come into the to the room I'm my brain is going to engage a little bit differently if it's bilateral or if it's unilateral or or focalized in one area of the cat and then we start thinking about okay what's gonna what's going on that would lead to these different patterns even though there could be you know five different bilaterally symmetric problems and they could all look different on different cats. And do you feel like you see a lot more like trunkal disease or like when I think about cats who come to see me which is definitely going to be a bit different than what you would see more commonly like I would say like ball belly cats you know like ball belly cats we see a lot of kind of the rump like back half of the body having less hair on it is something we see more commonly facial excoriations scratching towards the face is something we see fairly commonly do you feel like that mimics what you see in general practice or do you feel like it's different. No I think I see all those definitely the ball belly that the owners like that we find on a clinical exam that's not brought in for that and then we have to discuss that the the rump the ears face I also the ones that probably puzzle me the most is just patchy limbs and I don't have a good like oh it's patchy limbs that means this is what it is and this is what I'm going to do because they're those are all a little bit different and so those are definitely a is it bilaterally on the limbs or is it just one limb or those types of things that make me fine tune kind of my next steps. And I love the fact that you keep bringing up like bilateral versus like a focal area because I've heard you mentioned that a couple times and it is so important you know I am typically going to see a my practice is probably going to be more like a symmetrical or bilateral distribution of these signs because you know most of the time and not always they're referred to me because there's a suspicion of allergic dermatitis of some degree you know for those of you who don't know if we talk about environmental allergies and cats it's a really annoying name it's feline atopic skin syndrome just because of the different ways they manifest it that is kind of where we have landed which is a bit of a mouthful but essentially I'm usually getting referred cats to work up that I compare sites things of that nature but when we talk about certain things like just going after one limb or just having patchy alopecia on one limb or you know a focal area on the belly there are other things besides allergies that can cause hair loss in itch and cats right like a urinary tract infection right you probably see that I like hardly ever see that because usually the primaries ruled it out but is that something you see say like a bald belly cat and it's a certain distribution that you have seen like a urinary tract infection or fluted or anything like that cause those issues it's it's on the list definitely especially if it's like I think that they're just turning to one side and looking one side of their belly or one side of their flank we also think we can't rule out bilateral as you know if they're arthritic and they only want to turn one way you know they're just they're just doing more on one side than then both sides even though both sides probably do itch just as much and and I as far as like a just one spot we don't see what we think of as hot spots and cats very much I don't you probably do because they they come to you more than they do me but it's something that has to be on the on the list of is this cat just going at this one spot because there's something about that particular spot as opposed to a systemic type thing and other things that I that I hate having on that list and some of these cats that are really aggressive like it looks like a hot spot is like a hyperesthesia thing because those are so challenging and they're more you know potentially neuro or internal medicine than actually skin disease but that's where it's affected the most yeah I've seen videos of cats with hyperesthesia syndrome and it is awful in fact when I do some lecturing with darker pockel or friend who's a behavior is like he has some videos of that and they have discussions between neuro behavior internal medicine and those are ones where if I'm suspecting it when they come in to see me I'm like oh like I don't know that you're in the right place because I don't even know really what to do with that um but I like something else you mentioned that if they folk you mentioned feline arthritis and I think feline arthritis is gained a lot more attention right in the last like year or two because of slenceia coming out but they can also chew and like I think we see this a bit more with dogs that would probably be like my interpretation but recognizing feline osteoarthritis a bit more now like if they have a certain limb that's really arthritic they could chew like really bother a spot from that I don't feel like we see that as much in cats for you know behavior reasons if they're going after one spot like on the limb I feel like that I'd be doing x-rays or you know talking to their primary veterinarian to see if we need to work up that limb further rather than just assume we throw them on steroids would you agree with that? Yes but a lot of times I mean we don't we we can't just like take an x-ray and say this is arthritis or not because there's such a wide range of what that x-ray might look like um and you know I'm kind of I'm kind of old school and I kind of just made it up as I went along so a lot of my focus on these is gonna end up being response to therapy but if it's arthritis versus itchy you know you put them on steroids they're probably going to feel better in either one of those so so sometimes it's a it helps you as kind of a means to an end but it doesn't help you get closer to the to the answer unless they're limping and cats are so good at hiding anything from us um so then it comes down to education and a conversation because those owners are going to be such a good resource if you say no I'm trying to figure out if this cat is itchy or if it's sore somewhere and and letting the owner know like what this might look like a little bit differently at home versus obviously in the clinic so we can use them to help us figure out what's going on a little bit better than we can just do in the clinic and that is so important I mean cats in particular like history is so important in pretty much any aspect it is so important to really take the time to ask a cat owner these questions because cats are tricky like you mentioned and I obviously don't see ball belly cats as a specialist on an annual exam like they're coming because that's there but I hear many of my friends who are practitioners mentioned oh yeah we're doing they're like I'll do an annual exam owners won't even notice that there's a ball belly because cats are by nature groomers and so what is over grooming is always a really difficult question to have if there is multiple cats in the household sometimes it's helpful because you can say like oh do they groom more than your other cat but where do you draw the line right to decipher what's too much grooming versus not if you're not looking for that knowing it can be a clinical symptom of something that's tough that's so let's get the truth all the time every day yeah so let's focus a bit on cat allergies because you know predominantly that's what we're going to see a lot of these cats for and we're both in the Pacific Northwest you know you being in your the Seattle area me being in Portland and so we're in a pretty high allergenic areas you know we deal with things like not just pollen but molds because of the moisture and then ectoparasides obviously do you have the same struggle so when I think of cats and allergies I'm like you know for the love of goodness please please please please before you refer them to me have them on an isoxazling just please because then if they're better cool they don't have to spend the money to see me and if they're not better or they're only partially better cool you've just taken a very easy step away that I have to start out with that owner do you feel like you see the same like a lot of these cats with flea bite hypersensitivity that you can manage with flea control yeah it practicing on Mercer Island we don't let fleas come across the bridge on to Mercer Island so we don't have to worry about it as much but lucky lucky right if only yeah now we a good chunk of my patients are indoor only they are and the clients that that they live with don't have a lot of dogs with them so I don't see day in day out a lot of what I think is flea allergy dermatitis but you have trained me well and so the other local dermatologist that is like if we're gonna work this thing up further I don't think this is fleas but we're gonna use this otherwise I'm gonna get scolded when you go to the to the dermatologist because we we haven't been doing this consistently and but I there's some definitely but not a ton of those cases that they get back to me and say oh we don't need to do anything anymore and now that I've been you know using whatever everything's fine I just don't see that that much with my particular patient base and it's always important to realize that locations can be different right even being the Pacific Northwest maybe having that kind of island in that area is a bit more protected and even when I lecture you know people in like high desert climates were like nope we actually really don't have to worry about that but I think you can on something really important like I am not I I try to be really real life and realistic and yeah you know I'm not one to be like if you have an indoor cat and they're not itchy at all like yeah flea controls great but it's more of their symptomatic right like of course it's also nice in general but if they can't because of cost or whatever and they're a normal cat living their life and they're happy like I don't know if I'm losing sleep over that but the ones that are going to get to the point where they're like we are itchy you know we're uncomfortable things aren't working especially if you're like giving a serenade injection and they're not fully responding or you know you could kind of control it like that for a bit and now they're not really getting that length of time or duration that they once did it is just one of those things that I always say is an easy win like if we can give them an easy win and we don't have to medicate their cats orally or beyond medications or it just takes that step away from me when they come to see me that I can say oh you're on revolution plus credele overvecto you know whichever now they're next car combo like you're on one of those you've been consistent and I would say the other thing is making sure everyone in the household is so the dogs in the cats because I have had many a cat where because they're an indoor cat either they're not on flea prevention the dog is we just put the cat they get better but I actually had situations where the cat was because they were itchy so like the primary that had said hey they're itchy let's get them on flea control but the dog wasn't and so then I'll say well so it's the dog's we I don't blame the dog right but before I'm like before we allergy test and spend thousands of dollars on all this stuff like let's just again easy win and I have absolutely had cats were just putting the dog on flea control helps and what's important to realize about like do pairs like control it's not a force field right like everyone's like oh but they self-dipit like it's not a force field around them where like fleas can't come within three feet you're just really trying to minimize the population that that pet could be exposed to with a fast speed of kill product and that's why it's really important to have them all on it yeah but then when they come in to see me I can say okay that's controlled because we do see cats with multiple allergies and sometimes that's a hard part too people really want to see is with dogs and cats well we put them on flea prevention they didn't 100% get better so we stopped uh yeah what if flea in environmental then it's like well if flea prevention controls you know 40% of it and it's not fully controlled but that's controlled like maybe we will be more successful with immunotherapy maybe a topical will work better and we don't need steroids so that's kind of the hard thing too or these cats with multiple allergies yeah yeah one point that came up to me in there that isn't necessarily those derm patients but when when I am talking about flea control with my clients they're saying well I don't see any fleas it's like you know cat even if they're not itchy cats can harbor some fleas but also I really think that cats are just so good at grooming that they can slurp up all the evidence so even if you're flea combing them everything else so I tell owners not being able to find anything does not mean you don't have fleas in your house and so I use that as a as a statement to try to convince them to but it's important um especially you know with kids others in the house you know that everybody needs to be treated if there's any suspicion at all so yeah what do you think about food so let's say you have a cat that you're potentially going to do like a diet trial on you know cats can be exceptionally difficult with diet trials what kind of tips or success or things do you if you're going to have that conversation with an owner lean on or there's certain diets that you really enjoy or like for these cats that use respect to food allergy yeah that's that's a really good one I because cats are picky um I guess my go to is is really decreasing variables as much as possible so if they're on all sorts of treats and all sorts of other stuff and they're on can food and dry food and all this I try to really convince them it's like we're gonna do one thing and maybe your cat's not gonna love this the most but if it eats it gains it maintains its weight we're not gonna we're not gonna worry about all these other things for a period of time and that first thing that I can usually get cats to go for and the people is getting a bag of a hydrolyzed protein dry food I hope there's some hydrolyzed protein can foods coming out that a cat will eat but so far that's like a zero like so I don't even try with the can ones even though they say my cat loves can food but the hydrolyzed protein dry and maybe you can alter my recommendations but I say if if you go through a bag and your cat eats it and your cat's not better by the end of that bag it's like we got to look at other stuff but if you give me that length of time and we'll commit to this one bag then I think we can really decide where we go from there and then I'll try to introduce some limited ingredient single protein can foods or other stuff to that if we get that far.
• 19:25
  I think that's fair and again I think what we have to always recognize and I'm always respectful of this is clients who are just seeing you day to day and you guys are starting this are gonna we're gonna see different types of clients like predominantly right like I have the people who are kind of like simple things are not working so I love hydrolyzed personally and so what we tend to see with cats with food allergies a lot of facial pridest it doesn't have to be I've certainly had cats who don't but that is just with the studies show can be a little bit more common and there's a couple hydrolyzed so I mean these ZD can and I don't personally use a lot of ZD just based on some of the chicken allergies we know can flare with that but just to recognize that that is there and then blue hf has a canned version I've had a lot of cats not like it but I've had some really like it so again what I have learned about food I can have my favorites but in the end you can't tell me one diet that works for every single cat that every single cat will eat that every single owner is happy to feed like that is just the reality with food food is love people have opinions on it so I tried to be really open but I also will be very informative if you've gotten to me and I'm worried about a food allergy like we can't just say oh but I don't feed chicken so they're not food allergic like yes I do use a lot of the hydrolyzed diets but I always ask owners like I go eight weeks so kind of depends on the size of the cat out of 22 pound cat in the clinic yesterday so he probably gets served by a food pretty fast but it always depends on you right like so I say eight weeks and then I ask them like are you fine with just kibble what's your comfort level with this food you know can do you have to have a can well then maybe we do just need to do novel protein right off the get go so those are kind of the conversations that I have with them but it just depends on the owner and what they're willing to do and if it's just overwhelming and they're gonna like half commit to a diet trial I just tell them to wait till they can fully commit because I might only get one or two chances at a diet trial and if they're like well but Graham is coming over and she's still always gonna give this you know they're spending two weeks with us and like then we wait till two weeks we wait till they're gone because it is a diagnostic test and I think it's really important for people to recognize that and use that wording with owners too like I tell them like this trial is a diagnostic test so we want to do it correctly because at the end of it our goal is to hear yes or no your cat is food allergic or not and if it has not helped us at all then we get to move on with confidence and realize we're not missing something but I think that helps owners realize why it is so strict because it's a diagnostic test and then we can always pivot long term if we find out the the cat is food allergic and maybe they have different desires like of what they want to feed their cat yeah I think that's important because I I do a lot of that the same and I you know I tell my clients a lot of times I'm pretty simple there's a couple things I want to know first and for me to know these things sometimes it's a test sometimes it's a trial sometimes with it's with a drug sometimes with it's with food but like you said it's like if we can't do this thing for this long now then we're gonna wait because I'm not gonna learn anything and then we'll it'll be just I I won't be any closer to being able to help you if we don't aren't able to commit to it for whatever period to perfect definitely now let's move on to that bugger that is feel any two-pick skin syndrome so when we talk about these cats that you are suspecting there's an environmental allergy what does that conversation look like as far as the treatment options you know again totally respecting that I'm gonna have a different kind of clientele conversation and I think that would be expected or else my primary events are gonna love you know sending me cases if we're not having different conversations so what does that look like if you kind of come to the conclusion that a cat is environmentally allergic yeah I that's that's a good one because like we've talked about they're all so different and sometimes we have like for myself with being in practice for 25 years and we have you know the grandkids of some of my original clients or no clients of mine that we have we have we're in it for the long game so we're able to piece together a little bit more probably than you are with some of these histories and stuff that maybe it's seasonal maybe it's never happened until right now and we try to kind of figure out what may have changed to initiate that whether it's environmental or something else chemical or something in in the home so that will play a role in getting to that point and then I also try to weigh what's the the urgency in the panic of the client whether you know it's mild no big deal we want to really really learn and we want to know exactly what's going on and how we step into that in the diagnostic process or it's like I can't sleep my cats you know June a new hole in its leg or something like that and then in those patients I will jump more to a what is it going to take to prove that we can stop this problem and I will usually go to steroids on that or something like that first as opposed to you know atopica or something that is non-steroidal and just to get that do we get relief or not because I learn a lot from that and as opposed to you I do have a favorite injectable steroid I like to use in those particular situations because a lot of my clients are like you want me to give this pylp this frequently for this long it's and it's not then I'm again it comes back to that can we get this done and am I going to be certain with the answer to the question that I want and for me in that initial one a little injectable triumson alone is my favorite.
• 25:21
  Yeah and just to loop back to that when you say opposed to me so before you're and I hopped on or even when we when I first asked you like Dr. Marshall please be on my podcast you said well just don't like shape me about steroids and cats I'm like I use a ton of steroids and cats I think we have to be realistic there is not much unlabeled for cats and you can you do steroids are a great tool they can be a bad tool too right but they are a great tool and the reason that Dr. Marshall is mentioning like opposed to me I don't use a lot of injectable steroids but that does not mean I have any shame in a general practitioner doing it the reason that I don't is because the cats who just get like one or two triumson alone injections a year or one depot a year and they're hunky-dory the rest of the year are not the ones I am seeing like I am seeing the ones that we were on depot and now we it only last a few weeks you know like we are to the point where that is not going to be the solution and the reason we will lean more towards an oral steroid and yes everything you're saying about the complications of giving cats oral steroids is so true and I will work so diligently with owners whether it is we need a compound liquid doing need to you know we we don't just say give this if it's difficult but it's because I'm usually having to use them more consistently like a pimpicus cat or a really bad allergy cat and so then if I can get them to the point where they're more on like every other day steroid and we're controlled I personally see like less like diabetes or other issues so there is no shame for me because I think if I was in general practice and I just had to give a steroid you know shot and that made their life easier in the owner kind of knows the risk which honestly a lot of times cats handle them okay we think of the terrible stories that happen though right we have to make these cats comfortable like we don't want to be so afraid I see that all the time with feline otitis I know we're gonna talk briefly about that where I always get asked like what can you put in there what can you put in there what can you put in there and we all know they're ain't much right that's on label for cats but if we are so afraid to treat that year you know it's also not good for that year like a multi-drug resistance pseudomonas that we're not treating is also not good for that middle year so to your point like yes we have to be like thoughtful and we're gonna have different ways that we handle that but I just want people to have the comfort to know like cats are difficult and we have to provide a good quality of life for that we don't want to abuse them and not use them appropriately but they can be wonderful tools to make these cats comfortable yeah I love steroids listen I do steroid trials sometimes too like I've had some cats where I'm like I'm pretty sure you're allergic but like psychogenic alopecia is extremely rare but like I mean so if I give you steroids and I know you got better then it's not psychogenic alopecia but if I'm like tried my third or fourth type of steroid and you're not responding maybe I'm questioning myself a bit more so I do think like there's an appropriate way to do that but you also have to educate the owner right like well I need to know if there's a response and then we'll move on from there and then you mentioned a tope because let's talk a little bit about that so with a topical topic I kind of say both tell me about that when you're starting cats and eggs I believe we've had conversations where you primarily use the capsules is that correct yeah I the liquid even though it's labeled for cats is just nasty I I think I have one out of a few dozen patients that would actually take the liquid just because they they went to that because they couldn't get the capsule in but I really really like the the capsule and if not every client can get it in but I will see usually it's one that I've seen that it that the steroids will really benefit it and then I'll put them on atopica and for a long more a longer term I don't want to put them on steroids forever so let's try this instead and I get wonderful results if they truly are an atopic cat and so I I we're having a little bit more trouble getting it on some of the online ones to order it for people because and the my clinic as far as being able to inventory it now they'd say I don't want to spend all this money to have this stuff on my shelf and so some of the some of the online pharmacies veterinary ones specifically are like that's not a cat drug you can't order it for your clients even if we say you know it's okay off label that we've just seen a trend in this in the last literally the last month or so so I don't know if any of your listeners are going through any of that but I don't have a workaround for that just yet and if you're having trouble getting it just look for another source I guess look for another pharmacy yeah it's interesting we haven't had that issue but again we're using probably a lot and I use the liquid orcapsules I ask owners I and I tell them the liquid is bitter but I still have had owners that are successful with it and I in the capsules not tiny so you know I kind of give them the option either way and I just say the starting point we could always move but it is on label for cats liquid version and it really can be a great tool for these cats as long as they tolerate it and it's effective the dosing being five to ten makes per gig which a lot of cats like the labeled kind of serengyocene the liquids is seven milligram per kilogram dosing so you can kind of vary from that one trick I have had with some of the liquid if they won't take the capsule and it was gone for a while but slowly come back is there is it's off label what's hardly anything's not in cats but cyclovance which is a non-flavored liquid that verbat has it's on label for dogs with allergic dermatitis but and I write anything if I use apical and cats that like a tell-lone just off label but we actually had some we've had some fair success with it so it's non-flavored and some cats will take it really well but you just have again have to let them know that it's off label for them but we not gonna would haven't seen a lot of indications beyond just like normal cyclospor inside effects like vomiting and things of that nature and then yeah go ahead I was gonna say one one thing and maybe you have some advice on this is if I am starting them on atopika and it's the the capsules pretty much any cat I'll start on 25 milligram and if it works great then I'll just say let's try the 10 milligram because you really only have you know you can't break it in half you can't change the dose so you're either going one or the other so I'll usually go with a two week or four week supply of the higher dose and see how they're working and then see if we can get her way with the lower dose and sometimes we can't we go back up to the 25 yeah I just I dose it out so it usually is a 10 or 25 unless you have a huge cat just based on the limitations with the capsules I have occasionally had cats who are fairly big where we almost have to do both like it like they need like 35 milligrams but I think in general you're gonna get a large population of cats with that and then what are your feelings on allergy testing and cats is it something you recommend is it something you've seen success with do you do it on yourself or do you refer them out for that I don't deal with it and I will if they're if they're I tell them there are some options that I haven't had cases that have been really helpful to the options that we can still do after that and if they're really in into like I want to find this out I want to do the you know hyposensitization or whatever will refer them we have dermatologist here that will that will do that and yeah I don't exactly know what they're doing I just get a report back this is there allergic to this that and the other thing and it's like that's fine I'll help you with whatever you want us to do after that and that's not something that I've tried to fill my brain with how that all works and because a change is two and each one's a little different and how they do it and so it's like I trust them and we'll just go with whatever they decide but that's very few I a couple cats a year I think and I think that's told again realistic you know I don't I think if it's something that you're not confident in how to do it I think it's a really easy thing sometimes for people to say well we'll just do an allergy test but I actually love I'd prefer and then if you're not comfortable then we know therapy are describing that to your owners like I'd prefer owner you know just to say well this is not hitting your goals or your cat's not responding then we should refer you because dermatology is something that can be easy right we're not like doing a crazy surgery most of us so like it's pretty easy to do it within your practice but I always encourage like if you're going to do immunotherapy either really know how to do it or refer out for it and we have to be careful because allergy testing it's so easy for people to get caught in the weeds with that and say but this and they want to tear up their yards and you know it's it's not a test we do diagnostically it's one to guide or immunotherapy so but I will tell you I have had cats who do extremely well with immunotherapy and when we are limited on what we have available for cats or they don't want to take oral medications the owners that are willing to do it it's not that it's 100% successful but it often can allow me to lower the dose of e-topica or just use it seasonally or I've absolutely had cats that fully respond so if you are in a situation where they can't they can't medicate or it's not working I love referring because those are the cats that we might have the ability to help in a different way and I'll tell you Ash you probably a lot of that is not just that I don't want to invest the bandwidth in it to figure it out and to manage those issues it's more the that I want somebody else to have those conversations with these clients because it's a lot and that's kind of the in the last few years I finally said we finally said not doing international health certificates anymore it's like we can do them maybe we're supposed to do them but it's just a pain in the neck and there's other people that that's their business so we're going to refer them to that because they take up too much time and we we're plenty busy anyway and if there's somebody else that that's all they do and that's what they focus on they're going to be better for those clients and vice versa. I think that is great I mean I think we have to protect our bandwidth to some point like I said like I would much rather you say hey there is a possibility to do like allergy shots we're going to send you to someone who wants to do them like I honestly think I I hear all the time like I didn't even know you existed as a veterinary dermatologist like I think the people who are going to start to really actually consider that they are going to probably I mean I can ask questions by clients where I'm like I don't really know the answer to that like I may have to investigate for you so I I think that's great you want to talk about bandwidth anything that's not skin and ears I'm like we're going to have to ask your primary vet because I don't my dog has a primary vet because I don't I don't know what to do you know I can't give her a dental I can't like the primary vet or he's the important she's also like oh well you know we could just you know I could help you get the vaccines are I'm like no I need you to listen to her I need you to palpate her like I need some like I can I got her allergies don't worry about that but like beyond that like I am helpless you like to have to know everything you guys do is mind boggling to me and so I love that that if you're just like you know there's these options but I'm not just the right person for that that I mean that's how we work collaboratively right like that's why I do all this specialized training to know how to handle those patients for you but also like you are the pet's advocate as a general practitioner to be able to say there's other options but that I'm not the one to do it like you should go see someone who who has really learned how to do it so we can give you the best chance to respond and then the last thing I do want to ask you about this has been so wonderful I know we could chat forever um let's talk about ears and cats kind of as our closer because I do think that's difficult and we get asked a lot about and I've had I've had Dr. Diesel a dermatologist in Texas and I'm a few years ago we talked about catatitis in the podcast but it is really tough like what do you feel like the most common things if you see a cat with an ear infection that you're using or are you flushing cat ears I know that's always scary for people what do you what do you see in your practice yeah this um I don't love this topic because they're no one loves this topic Gary no one loves this topic and it's and and then it's even when you find out what then what the heck are you going to do about it because the ears are uncomfortable and you got to put stuff in the ears maybe maybe you don't maybe there's other ways um but cats hate it people hate doing it they're usually not nobody is usually able to do it well enough um at home to manage the problems completely topically I feel um and so it's it's it's it's frustrating and and they they they come back again and um and so this is one where I will sort of claim that and and usually we're seeing mixed things right we're seeing yeast and we're seeing bacteria and there's probably an allergic component all that kind of stuff and the products that I have on my shelf are they're going to have antibiotics in it they're going to have antifungals and they're going to have a steroid is opposed to just a one a one item just the antibiotic or just an antifungal that I'm putting in ears because because I want them to be soothed a little bit too and and maybe I just don't have enough experience by doing it just by myself with all the different plethora of products out there um and if possible I try to manage as much as I can systemically so I've I've found if I see bacteria in there and it smells like bacteria is just a nasty ear infection I think I get so much better benefit by a proper um oral antibiotic than I do with with topical stuff in those years a lot of times you have to do both but I so those are the ones I like to be able to make a big benefit on are the ones that are stinky gross nasty lots of bacteria it's going to have other stuff too but um and getting if we get a culture we um can put it on an antibiotic and I see those feel better so much better and a lot of times even you know once they get get rid of the infection a lot of times the yeast takes care of itself I think on some of those if we're cleaning them occasionally um but maybe I'm maybe maybe you'll tell me I'm doing it all wrong I mean I look at this but that's just what I'm looking at too it's just always different I'm never here to tell anyone they're doing something wrong because again I'm we are seeing different clientele's and different reasons right I would say to briefly end on v line a to otitis um for me so I do successfully get a lot of ownership to topical therapy again I am probably seeing a different form of clientele and I will always respect that um so don't get me wrong I've cat I have cats that that's not the case but I I'd say in general the ones who come to CS like it's it's an option um we know trezziderm is historically the one that's labeled in the US in other countries syrian is labeled for cats um but then you really don't have a ton of options in general most of us find things like betrall pretty safe so you'll see a lot of people compound different formulations and you can talk to compounding pharmacies about like betrall dexaline betrall dexconify of course you could use betrall odic but there's no steroid in it which to your point a lot of times can help with comfort um so but I've had wicked nasty ear infections that we have to reach for you know other things like momentum x pose dex and that can be scary but again a really nasty like pseudomonas is also scary for the middle ear my biggest thing I would kind of end on talking about feline otitis is please find out why it's there I would say more often than not I actually see feline otitis from an ear mass they can get it with their allergies for sure I've seen it we see it with food allergy things like that um but they don't tend to break out with otitis as much as dog dogs like you know allergies it's like ear infections all day long again not that it can't happen but often as we clear out that debris and we look again all of a sudden there's a mass hanging out there or we'll we'll send them for CT so especially if you're having a unilateral otitis or no tightest situation where one ear keeps being significantly worse and the other just got a little bit of infection just keep on keep in mind that we do see out on cats because then if they go to VO or surgery they often can do really well whenever we treat near infection we just want to know why it's there but yeah cats are limiting so if you have one you absolutely cannot touch and you culture and you feel like you get some good systemic options like I'm definitely not here to say that's wrong because there are cases where that can happen I've had dogs where they can't touch their ear and we have to reach for things like systemics even though we prefer not to so I think that's that's just real like medicine you know that we have to help these pets you know we can try to give them tools of how to do things but in the end if they just cannot do it and they can't bring them into you every day to put ear drops in for them like I just am not one to say well we got zero options for you then it can be frustrating but we still have to help them yeah make their pet feel better the best we can and I love me a good polyp those are so satisfying oh man I ending on a funny note so I have this we're older and keep trying to get in to see me I just yesterday I had a second cancellation for it's like a eight-month-old cat that has this a polyp and the second cancellation of can't catch cat like for the appointment and so there's our ass like our staff like what do we do the staff's like well we haven't seen them so like you need to talk to primary vet but you know like here's some don't try to catch them right one is time for the appointment you know or like get them desensitized the carrier so it's interesting because it's always like mostly young cats and then it's always like a bit of a squirrely situation yeah cats I know right in that we could end right there oh cats it depends well with that dog to Marshall I just want to thank you so much for being on the podcast just really good insight I think it's always nice to have people who you know the cats are difficult but I love having general practitioners on too because I think it's great for our practitioners out there listening to the podcast or technicians you just to see that there are some differences but ways that we can really help these cats whether it's referral or just learning or kind of using someone with a lot of experience like yourself so thank you so much for being on the Dermvet podcast it's been an honor so I was great to talk with you I hope that some of it was a little helpful well thank you so much Dr Marshall for being on the podcast today it was so awesome just to be able to see different insight from a v-line practitioner some things we may do similarly and differently I think what it really comes down to is we have to make sure with the limited options we do have with cats that we ask owners involve them what can they do what their expectations are and don't give up and it's okay to use steroids and cats I think that's the other thing of course we have to be aware of their side effects but these cats also deserve to have treatment so I hope you enjoyed listening just to our discussion our conversation as always please rate the podcast if it's something that you love that you find enjoyable and that you learn from so I can keep getting really good dermatology education out to you