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211. How to use less drugs with environmental allergies · 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. Welcome to the Dermvet Podcast. I am so excited to give you some tips on how to manage pets with atopic dermatitis with less medication. And isn't that what all of our clients want? They come in and say, "I just wish I'd love to give no drugs at all," which of course we know that's not always realistic for our pets with allergies. But what are some things that we could consider if owners are wanting to lessen the amount of medication they're giving or realistically try to have times of the year where they don't have to give medications?
• 0:59
  We think of things like atopic dermatitis and dogs and feline atopic skin syndrome as a seasonal disorder, but we see plenty of dogs and cats and horses and other animals that have environmental allergies year-round. We know there's things like dust, mice, and storage, mites, and you know, certain areas like where I live in Portland, Oregon where it's a really temperament environment, and we just have things all year round that are blooming and causing issues for these pets.
• 1:27
  And again, we have to be realistic and set up good expectation for owners that that's not always going to be the case that we can have no medications to control their pet. But there are things that we can attempt or try to minimize those things or at least minimize things like breakouts and want to go over some of the main ones that I really consider in these pets.
• 1:49
  The first one's going to sound really obvious and simple, but you have to do the workup and get the diagnosis correct. Of course atopic dermatitis is difficult on its own, but one thing we have to recognize are a lot of these pets have multiple allergies. So if you just reach, let's say in a dog, if you just reach for apaquil in it, they respond pretty decently to it, that's great. But if there's a portion of their allergic dermatitis that is related to food, we are going to potentially not have the opportunity to stop that medication during certain seasons or maybe break out with otitis and pyadermin more than we would really like. We know there's a significant amount of pets, especially some literature we have in dogs where a decent amount of atopic dogs can also have food allergy. So we think, oh, well, they didn't fully respond to that diet trial. So I guess we can just stop the food and not worry about it, but we have to look for a degree of improvement. We have to look for other portions of the body. So for example, maybe with the food change, their otitis is pretty controlled, but yeah, they still lick into their paws if they don't get a symptomatic treatment like apaquil, cytopoeinary topic cup. So we have to still do the workup in these patients, even if they initially respond to symptomatic treatment, because we do have pets who have multiple allergies. That's also why depending on where you live, you see us really, really pushing ectoparasite control. So as we know, there's a decent amount of dogs with atopic dermatitis or cats with philanetopic skin syndrome that concurrently have flee by hypersensitivity.
• 3:36
  And we might become more dependent on those pharmaceuticals if we don't control that aspect of the disease. So we have to make sure that we do the workup, we control the things we need to control so that we don't struggle and become more dependent on medications, or maybe if we did control that aspect, had them on a diet they didn't flare to have them on good ectoparasite control.
• 4:03
  I have plenty of dogs and cats who have all three, the little trifecta, flee and food and environmental. And if I do not control those first two, then I end up struggling to have breaks from the pharmaceuticals. So it sounds really simple, but we have to make sure that we are getting the diagnosis appropriate, looking for other things too. Like don't assume because they broke out with an infection. It has to be because they're atopic dermatitis layered. You may be as they've gotten older, they've developed typo thyroidism. If we just keep pushing an allergy medication because they're breaking with infection, but something else could be going on, we are going to have a hard time. Again, long term, not just trying to use medications that maybe aren't necessary for that pet. So that's why we have to look at some of these cases with the fresh lens every now and again. We have to make sure we dive into the history. We ask the questions, don't just assume what's happened the past five years is exactly what's going on. If all of a sudden the frequency of infections are getting worse, we're having a hard time controlling them. We feel like we have to put them on an allergy medication more often. If that's not necessarily the thing that's really causing them to break out. So definitely making sure we get the diagnosis right, recognizing there can be multiple allergies in these pets, becomes extremely, extremely important. The next thing you're all going to feed off each other, but there's different ways. And I think again, every pet is very different. And every owner is very different. Every clinician is very different. I've changed the way that I've done some of these things.
• 5:36
  And that is focusing on different ways we can help skin barrier. Again, we focus on stopping the edge. And that's extremely important. But we know the allergies are multifaceted. There's many things that are genetically wrong with these pets. And it's not just that they're more itchy because of you know, interleukin and cytokine production. It's also that they have a defective skin barrier.
• 6:00
  So those pollens, they allow to absorb a bit easier. So when we talk about the importance of restoring that skin barrier, it may allow us during certain times of the year or maybe if it's a pet that's, allergies are pretty mild, that we may be able to back away from symptomatic treatment or at least use it more sparingly versus if we don't do anything to help the skin barrier. So the first thing I want to talk about that can help the skin barrier would be nutrition. Again, say we have a pet that's not food allergic that we feel like, okay, we've ruled out a food allergy. But is there a way nutritionally that we could potentially help that skin barrier if owners are open to it?
• 6:40
  And some of the main diets that are out right now that can help with skin barrier associated with atopic dermatitis for dogs at least. You don't have options really for cats at this point would be Hills Derm complete, which is an egg protein, which is a very minimal allergen based on the literature, but helps to restore skin barrier and reduce some mild paritis.
• 7:01
  Prinas had DR, DRM for a long time, which helps with things like fatty acids to restore the skin.
• 7:08
  And then royal cane and used to have skin support and now of skin topic, which is kind of their new version of skin restoration with things like environmental allergies in dogs. That has many things in it, but glute cans, lookers, root, different things that we know can help restore that skin barrier.
• 7:26
  So if owners are going to feed a diet anyway and are open to doing something that can restore that skin barrier, it's a great option to help keep potentially less systemic medications on board.
• 7:38
  The next way we can help with skin barrier is supplements, which I will be honest, I have been traditionally used at a lot of supplements in my patients. I have just been one that's more topically based or nutrition based, but I've been asked more questions about it. I've had owners that really want to give us supplement. I've had veterinarians who have told me some good experiences that they've had when I've been lecturing. And so I've definitely become more open to implementing those more. There are just some owners that don't necessarily want to do a food, but they're really open to doing something like a supplement. There's plenty out there. And of course, you can do things like oral fatty acids, things like that. But the two that I usually see in the veterinary literature that actually have research behind them would be one dermaquin by Nutermax.
• 8:26
  So this is interesting. It's got a few different things in it like ceramides, gamma-linolake acid. They also have beta-clucans and hearty kiwi, which is a unique ingredient, which is used in different eastern medicine in the human field and can be helpful for things like tolerance of allergens. And so that's one that I've actually had friends who've had good success with.
• 8:47
  And I'm kind of experimenting with my own atopic dog right now. And I think there's been some benefit.
• 8:52
  And then Dekra has redinal ultra redinal ultra. So I should mention dermaquin has cats and dog availability. So it is redinal ultra for dogs. It's chewable in the redinal ultra and cats is like a powder you put on their food. But it has a really long name. I'll probably watch this, but Pometeal Ethelamine or PEA. So it's another ingredient that helps with skin barrier restoration. It can minimize things like some pridus. And so just having the availability to use supplements that are actually backed by research can be really beneficial in owners who are seeking that.
• 9:28
  And then of course the last big thing with skin barrier restoration that we think about is topicals. We love topicals. And you think sometimes people get stuck on just utilizing topicals for things like infection. Maintenance topicals can be so so helpful. Not only are you utilizing things like baths to remove problems from their skin so they don't have as long to absorb or using wipes on things like the paws to do the same thing. But you can utilize products that can actually help the skin barrier as well when they're bathing or using other forms. If they can't bathe like mousse's wipes as I mentioned sprays anything that can help get on the skin. So we think of things in maintenance like you know degras germale which is like an oatmeal which can be soothing.
• 10:17
  See that has duxos3com which can be helpful. There's lots of dermiscent products that can be really helpful that not only have mousse's and shampoos but also have spot on. But then within factions we want to make sure not only we get owners through a current infection but giving them tools if they recognize things happening in the future that they could get on top of topically so we can minimize them either having to go on systemic antimicrobials or minimizing them you know again having to come into the clinic and we're all busy and spending time if we can educate these clients how to treat infections quickly that can be really helpful. And so that's where we will utilize a lot of products that have chlorhexidine in them so duxos3pio you know trizzoclor4bidecra things that people can use if they start to notice some inflamed areas some crusty areas areas of hair loss as you manage these cases more long term then you really start to get to the point you can train clients. And I love being able to say okay they're looking great right now let's utilize something like a maintenance therapy for topicals to restore the skin but we know spring is always a time that they can start to flare so if you start to notice little areas of crusting or hair loss you use this chlorhexidine moves right away and let's see if we can control it that way. If we can give owners these tools it can help minimize them from breaking out and again restoring that skin we hope to be less dependent on medications.
• 11:48
  And then finally of course the last thing I'm going to talk about to help minimize long term systemic drugs and these allergic patients is good old allergic allergen specific immunotherapy you know there's a reason that we love immunotherapy especially for owners that come in and say really want to try anything I can to not have to use you know drugs long term in my pet.
• 12:09
  immunotherapies the best option we have for dogs and cats it identifies with their allergic to it gives it to them in small amounts so that they get used to it and I tell owners you know it is natural it's just the proteins of what they're allergic to it can take time but we do need to make sure owners know that most pets are going to remain on that therapy life long if they're successful with it so we reevaluate 12 to 18 months to see how they're doing maybe it's not that they can just stop all systemic medications but maybe instead of year round apaquil or cytopoeinary topica maybe they just need it in the spring or summer maybe it makes it so instead of needing systemic antimicrobials when they break out we do manage those infections topically when they happen those would all be things that would be very successful in immunotherapy of course you know we've had past podcast cast episodes that I've looked at sublingual versus subcutaneous and we've talked about serum versus skin and there's all pros and cons to all of that but however you're going to implement it or if you're going to refer to implement it we have to make sure owners understand what success can look like it gives us the ability to potentially get off medications but even if we can get to the point where we use less antimicrobials they don't progress with their disease as they get older that can all be beneficial so the main things I think about when an owner says okay I really don't use drugs as much as possible one is making sure I have rolled out the things that would allow us to limit those long term medications like food, flea allergy, other diseases that can cause skin issues supporting the skin barrier whether that's through nutrition supplements topical therapy or some kind of combination depending on what the owner prefers and then of course immunotherapy so we can try to desensitize these pets and become less dependent on systemic medications those are all things that you don't want to forget about it doesn't mean you're going to do all of this on the first exam but those are some of the options that we want to keep in mind so that we can best serve these pets these owners and have better long term management but we have to communicate with owners that depending on the severity of their pets disease you know may not be realistic to get all of all systemic medications but we have options that we can try to see if we can minimize those long term the best that we can