Setting up a treatment plan for atopic dermatitis

Atopic dermatitis (AD) results from an inherited predisposition to develop hypersensitivities to environmental allergens that do not induce a problem in non-allergic individuals. Allergens can include dust mites, pollens, danders, insect particles, and molds.

The paws, axillae, abdomen, and face are common areas to develop pruritus and secondary lesions. Secondary skin infections or otitis externa with Malassezia pachydermatis and/or Staphylococcus pseudintermedius are common complications of AD. Clinical signs can be seasonal or nonseasonal. It is common for dogs to start developing signs between 1-3 years old though any age is possible. Symptoms can also progress and it is common for pruritus to start out seasonally and become year-round as the dog gets older. Identifying early signs and starting an allergic workup right away is extremely important.

Developing a treatment plan for an allergic pet is not universal. There are different reasons to select certain therapies depending on the pet’s behavior, owner’s ability, symptoms, comorbidities, etc. Three categories should be considered when managing dogs with atopic dermatitis: addressing infection, symptomatic pruritus treatment, and long-term goals.

• Addressing infection means cytology should be collected often. If there is abnormal skin, then grab a slide and take a look under the microscope. Systemic antimicrobials are important when warranted. But, topical therapy should be considered when possible. Not only to treat the active infection, but as maintenance therapy to help keep prevent future infections. Products containing chlorhexidine, salicylic acid, and sodium hypochlorite can be beneficial for the treatment of pyoderma and as maintenance therapy. Missing infection can cause allergy medications to appear they are ineffective when they may be a great treatment option for that pet.

• Symptomatic treatment includes antipruritics that can provide more immediate comfort to improve the dog’s quality of life. There are many different options including a fast-acting daily oral tablet (oclacitinib) and an injectable monoclonal antibody (lokivetmab) that can provide 4-8 weeks of comfort. These medications have less side effects than traditional anti-inflammatory drugs such as corticosteroids.

• Setting up a client’s expectation that AD is a chronic, lifelong disease from the first exam will avoid a lot of frustration. Figure out what the client’s goals are for management. The best long-term therapy includes allergen specific immunotherapy formulated from environmental allergy testing. It is the safest therapy and the only one that can help reverse the pathogenesis of the disease itself.

Client communication could be the most important part of dealing with dermatology patients. Relate and empathize with the owner over the chronicity and expense of allergies. A lot of frustration can be avoided by letting the owner know the long-term nature of allergies (flares, etc.) and therapy in the beginning. Also, finding out what is realistic for the owner regarding finances, topical therapy, diet trial, etc.

If you have a board certified dermatologist in your area, refer early! Dermatologists love to see cases at the beginning of their allergy journey so we can prevent resistant infections and keep pets comfortable.