Rear end itchiness and rear end skin lesions on a dog that is not on flea prevention should be considered due to flea allergy until proven otherwise.  Look at the chronic changes to the skin from the constant trauma from scratching.  This dog was rubbing its rear end on rocks.  Yikes!

Cytology of the skin showed bacteria and yeast which are also contributing to the itchiness. It will take weeks to months to get the skin to start looking normal again.  The treatment plan for this patient is NOT just flea prevention, it is also medications, both topical and oral, to treat the secondary infection.  Pruritus also needs to be controlled.

#fleaallergy #dogskinproblem #vetdermatology #petdermatology #vetmedicine #miamivet #miamiveterinarian #pets #petowner #petsofinstagram #petownersofinstagram #fleas #fleaprevention
Dogs with atopy or environmental allergies are prone to ear infections. Apoquel and Cytopoint have revolutionized how we manage the pruritus associated with environmental allergies. But these medications are not always very effective to control inflammation, or the itchiness associated with otitis for atopic dogs. It is important to prevent recurrent ear infections to avoid irreversible ear canal damage that could lead to total ear canal ablation surgery. The latter is especially important in brachycephalic breeds who already have narrowed ear canals to begin with.

For my atopic dog patients that have ear infections as part of their allergy presentation, I like to focus on ear cleaning and decreasing ear canal inflammation. The ear has a self-cleaning mechanism. Yes, the ear can clean itself by removing debris, wax, skin cells and microorganisms. This self-cleaning mechanism is interrupted when an ear is inflamed and can be permanently lost in an ear with chronic fibrotic changes from repeated infections. Therefore, in these types of patients the ear needs to be cleaned routinely to remove what accumulates in the ear canal. Just like I advise on maintenance baths for the atopic dog’s body, maintenance ear cleaning is part of my regimen for atopic dogs prone to ear infections. Depending on the patient, I may have the client clean once to twice weekly.

What ear cleaner to use? There are many ear cleaners out there. Good brands are Virbac, Duoxo and Dechra. Dechra makes an ear cleaner with hydrocortisone that helps reduce ear canal inflammation and helps reduce pruritus of the ear. A product like Zymox HC is also another consideration to manage inflammation. If necessary, stronger steroid topicals can be used when not contraindicated.

Take home message: the atopic ear needs maintenance care to prevent recurrent ear infections.

#dogearinfections #atopicdog #dogears #itchyears #otitis #vetdermatology #petdermatology #vetmedicine #miamivet #miamiveterinarian #pets #petowner
Ear polyp removal can be done via traction technique. This is a simple procedure where an endoscopy forceps is inserted through a video otoscopy port to grasp and pluck out the growth. This method of removal is most often very effective.  If you do not have video otoscopy and the polyp is easily visible, then other devices like forceps and hemostats can be used. Depending on the literature, there is a 30-50% chance that the polyp will regrow with plucking removal.

We often see satisfying videos of removal of these growths and I was hoping that same would occur with this patient.  Unfortunately, it did not.  This growth was very attached. When a polyp cannot be removed with traction then a ventral bulla osteotomy is the next option.  Ventral bulla osteotomy should be offered as a treatment option and a guaranteed procedure that the entire growth will be removed. However, the procedure is invasive and rarely chosen as a first option by pet owners, understandably so.

I wanted to post about this failure polyp removal because sometimes we do not get an easy win. 😔

#earpolypsincats #catowner #vetdermatology  #petdermatology #vetmedicine #catowner #catsofinstagram #pets
The conversation to manage environmental allergies in dogs can be daunting if you do not have experience talking about this disease.  Here is how I break down the conversation with a client. In my head I use the mnemonic MAX to discuss atopy management.

M is for Medications. I discuss the top allergy drug options to reduce itchiness: Apoquel, Cytopoint and Atopica.  I explain that it is important I put their dog on the right allergy drug that will keep the itchiness minimal to none. I want to make sure this allergy medicine keeps the pet relatively stable without many flare ups throughout the year.  It is important that we are following up on the patient through this process to make sure they are on the right allergy drug. 

A is for Allergy testing and allergy vaccines. Allergy testing will let us know what the pet is allergic to so that we can formulate an allergy vaccine for desensitization. The purpose of allergy testing is to start the pet on immunotherapy for desensitization. If the owner is not financially ready to do this or able to dedicate the time to the vaccines, then there is no need in spending the money on allergy testing. We cannot assume that a pet owner cannot afford allergy testing and vaccines. When explained properly many owners see the value of this testing. All pet owners whose dog have environmental allergies deserve the conversation that this form of therapy exists for their pet.

X is for Extras. This is where I talk to clients about skin barrier support, supplements, atopic diets, and topical therapy.  I recently posted on this subject. If I run out of time in the exam room, I have a handout that discusses this and where they can order the products. However, I do make it a point to stress the importance of medicated baths!!

Maximum benefits for an atopic dog come when various therapies are implemented: the multimodal approach!

It is important for pet owners to understand that these therapies are for the entire life of the pet.

#atopy #dogallergies #vetdermatology #vetmedicine #allergytherapies #pets
Most atopic dogs need long term use of allergy drugs like Apoquel, Cytopoint or Atopica to decrease their itchiness and be comfortable. However, are there other ways or other “nondrug” therapies to manage environmental allergies? Yes! I will often recommend these therapies in conjunction with allergy drugs. In those patients whose allergy symptoms are mild or just starting it possible that these therapies alone may be of benefit.

Supplements like omega fatty acids provide anti-inflammatory effects at the skin level and immune level. Redonyl or palmitoylethanolamide stabilize mast cells and reduce histamine levels, thus helping reduce allergic signs.

It has been shown that dogs with environmental allergies have a weak skin barrier allowing allergens and microorganisms to enter the body. Topical products that can replenish the skin barrier are another avenue to manage this allergy. There are various products that can do this, I post here on Dechra’s Atopivet line that contains sphingolipids. The mousse and spot-on have hyaluronic acid to hydrate the skin.

Diets for environmentally allergic dogs, like Royal Canin Skintopic, have been shown to reduce itchiness and skin inflammation by a combination of nutrients, vitamins, fatty acids, and ingredients like curcumin.

If you read my posts, you know how important baths are for atopic dogs. Bathing with a medicated shampoo and/or shampoos with ingredients to rebuild the skin barrier can be of great benefit in reducing itchiness.

Lastly, allergy testing to identify the exact allergens causing the allergy will allow the formulation of immunotherapy for desensitization purposes. Allergy vaccines can decrease a dog’s symptoms by up to 70%. Allergy vaccines are not drugs, but the same allergen your pet is allergic to given in incremental doses over 1-2 years to stimulate the pet’s immune system to tolerate its allergy better.

#atopy #vetdermatology #pets #petowner #vetmedicine #allergytherapies #nondrugtreatment
It is easy to get tunnel vision that every dog that is itchy likely has an allergy, and every French Bulldog with skin problems must have allergies.  Skin scrape testing is important for all itchy dogs.  Make sure to skin scrape until you see capillary bleeding.  You can see on this doggie two scrape spots on his back.  A lot of dogs are on isoxazoline flea prevention so it is not common to see demodectic mange.  This dog was not on an isoxazoline.  Love easy wins!

#demodexmites #demodecticmange #mites #frenchbulldog #frenchbulldogsofinstagram #frenchie #petowner #vetdermatology #petdermatology #vetmedicine #miamivet #miamiveterinarian #miamivetderm #gotitchypet
Cats that are overgrooming will often cause hair loss that looks like this.  There are various hair loss patterns associated with over grooming, commonly seen is hair loss on the rear end/rear leg area, over the dorsal trunk or the ventral aspect of the body.  It is important to remember that cats that look like this are over grooming because they are itchy.  Some cats are seen to be literally yanking their hair out that it can make you think they are stressed out and having a behavioral disorder.  However, psychogenic hair loss is an uncommon cause.

Some pet owners may not see their cat’s overgrooming behavior because it is done hidden, these are closet groomers.  The owner then thinks the hair is just falling off on its own.  Non itchy hair loss can be seen with hormonal disorders like hypothyroidism, but this is rare in cats. What is happening is that the cat is grooming excessively but the owner just does not see them.

If you are a veterinarian and in doubt if there is a stress component to the over grooming, you can do a trial course of oral steroids and if the itchiness stops then you know it’s dermatological.  The primary reason a cat will over groom is allergies.  I like to rule out mites too with an isoxazoline. Most of these cats need an allergy work up not Prozac!

 #baldcats #baldcatsofinstagram #catsofinstagram #catsagram #catowner #catownerproblems #petowner #vetdermatologist #vetdermatology #petdermatology #vetmedicine #lookatme
I am a dermatologist, and I am comfortable with using antifungal medications. My specialty in veterinary medicine uses it more than any other specialty and so I had to become comfortable. However, I was not always comfortable.

Early in my career, I had the fear of death of using these medications. I clearly remember in vet school learning about how antifungal medications, especially azoles, can be hepatotoxic. I am sure there were many Malassezia dogs that I let suffer because of my fear of antifungals. But once I got into my specialty, I learned not to be afraid. Using it in the right patient that is healthy, no history of liver disease, and not on any other medications that could interact with my antifungal of choice, I realized that these drugs can be safely used.

I do not necessarily do bloodwork on all my patients on antifungal medications. Most often these patients are on a short course of treatment that the risk of hepatotoxicity is low versus patients who are on long term treatment, for say a dermatophyte infection. 

I wanted to post about this because there are a lot of dogs out there that are suffering with a yeast skin infection that could benefit from treatment with a systemic antifungal medication. There are Malassezia infected dogs where topical therapy alone is just not enough. The degree of itchiness that Malassezia on the skin causes can be extreme. If it makes you feel better to do lab work before and after every case you start on an antifungal, there is nothing wrong with doing that. Just start getting comfortable.

 #antifungal #antifungalmedicine #yeastinfection #yeast #malassezia #vetdermatology #petdermatology #vetmedicine #pets #hepatotoxic #petsofinstagram #miamivet #dontbeafraid #rappersdelight #iwanttodance
Vet med clients can sure be funny! 

From the use of silly words to potty mouth words to describe their pet’s body parts, these pet owners, we love them, and they sure make the day entertaining.
And since I live in an area with Spanish speaking pet owners, I also have heard the Spanish version of silly and vulgar words for body parts 🤦🏽‍♀️.
I think I have heard it all. 
What about you?
#vetmedhumor #vetfun #vethumor #vetmedicine #vetdermatology #petdermatology #petowner #catowner #catskinproblems #catallergies #dharma
I thought this was an interesting case because the dog was super itchy of his paws, but on exam the paws did not really have any lesions.  I can see where a veterinarian may hesitate from doing cytology on a paw that looks like this.  But this was a good case to show you that infection can still be present without the paw having to look inflamed.  To me it was enough that the client said the paws were itchy that I needed to investigate further.  Also, this dog had recently received a depo Medrol and that still did not help reduce the paw pruritus.  This made me suspicious that there was an infection in the paws that was likely driving a lot of the itchiness.

I am sure many of you have heard of the toothpick method to sample the nail beds for cytology. I like to do something different; I like to take multi-task scotch tape and rub around the nail bed to pick up organisms this way.  I then stain the tape with Diff Quik, dry it while taped to a microscope slide and look under oil immersion.  And there you have it… YEAST on the nail beds. This is very likely the reason why this dog was licking his paws so much.

If you have a dog licking its paws and you are not getting much on the cytology of the feet, consider sampling the nail beds.

#pawitchiness #nailbed #dogpaws #itchypaws #vetdermatology #petdermatology #vetmedicine #miamivet #miamiveterinarian #pets #petsofinstagram #yeast #yeastinfection #malassezia
Treatment with fluoroquinolones (FQ) for the skin and ears should be based on culture. The use of enrofloxacin or any FQ for that matter for a bacterial skin infection should be avoided without a culture to support its use.
Most veterinary FQ have limited effect on gram positive bacteria, their primary activity is against gram negative bacteria. There are other classes of antibiotics, like cephalosporins, that are a better option for Staphylococcal infection than a FQ as a first line.
FQ are concentration dependent antibiotics. Their post antibiotic effect and long half-life allows for their once-a-day dosing which helps with compliance. FQ antibiotics work best at killing bacteria when used at a high dose once a day. Administering this class of antibiotics at a low dose for short duration of time increases the potential for antibiotic resistance. With that said, splitting a low once a day dose in half so twice a day dosing increases the chances of resistance and should be avoided.
There is evidence to suggest that the use of FQ may upregulate the genes (mec-A) responsible for methicillin resistance. This means that improper use of this class of antibiotics for skin infections will not only cause resistance to FQ but also methicillin resistance. The prevalence of MRSP infection has increased over the last decade. MRSP is not just showing resistance to beta-lactam antibiotics, it is now become a multi-drug resistant bacterium. There is now resistance to non-beta-lactam antibiotics, like FQ and potentiated sulfonamides. Due to this prevalence of multidrug resistant strains, empirically switching antibiotics when treating a staphylococcal infection that fails to respond to first line antibiotics (particularly beta lactam) NEEDS TO BE AVOIDED.
Do not reach for a big gun like a FQ just because a skin infection is not resolving. Please culture first! Let us use fluoroquinolones more wisely. Misuse of this class of antibiotics may lead to resistance of multiple antibiotic classes making it much harder to resolve skin infections in our pet patients. Share this with a colleague. 
#antibioticstewardship #antibiotics #vetdermatology #petdermatology
This is telangiectasia in a dog with Cushing’s disease. Telangiectasia is a common cutaneous feature of this endocrine condition, where the blood vessels are dilated and easily visible through the thin hairless skin.  You can even see how this dog has a pot belly, another common feature to Cushing’s disease in dogs. 

#cushingsdisease #cushingsindogs #endocrinedisorder #telangiectasia #vetdermatology #petdermatology #vetmedicine #miamivet #miamiveterinarian #pets #petsofinstagram #petowners #olddog
Allergies in dogs can present in many different ways and affect various areas of the body.  Some dogs have bumps or rashes on their skin that make them itchy.  Some dogs just lick their paws.  Some dogs get red and itchy. And some can just have ear problems with no skin lesions or itchiness.

Secondary infections are quite common in allergic dogs and can many times make the skin look worse than the allergy itself.

#vetdermatology #petdermatology #vetmedicine #miamivet #miamiveterinarian #pets #petsofinstagram #dogallergies #dogskinproblems #itstricky
Did you know the skin is an organ? It is the largest organ in the body, and it covers the body’s entire external surface. When a pet comes in for a dermatological exam, I will do a full body exam. I will check from the tip of the nose to the tip of the tail. The ears are examined as well because the ears are skin too. The ear is an extension of the skin! Checking the skin of a body full of fur requires meticulous inspection because I want to make sure I do not miss a lesion under the fur.
Veterinarians, I recommend not focusing on the one spot the pet owner noticed a lesion or the one spot they noticed itchiness at, make sure the entire body is examined as there may be more going on to clue you into the underlying cause. 
#vetexam #petexamination #vetdermatology #petdermatology #vetmedicine #miamivet #miamiveterinarian #skinisanorgan #largestorgan
Have you checked your dog’s itchy paws? When a dog’s paw is itchy it is important to check in between the toes and underneath the paw. The patient in this video had these areas of its paws inflamed and brown discolored from the chronic trauma of licking but also from secondary bacterial and yeast infections.

When I have owners treat paw infections, I emphasize the importance of working a good lather with a medicated shampoo and getting it in between the digits and underneath the paw. If the paw is the main area of the body affected, then washing the feet a few times a week can really help not only reduce the itchiness but also remove the infection that is making the pet itchy.

Dogs often lick their paws due to allergies. If your dog has itchy paws, have your veterinarian check for secondary infections and get a workup for allergies. 

#dogpaw #itchypaws #pets #petownerofinstagram #vetdermatology #petdermatology #vetmedicine #miamivet #miamiveterinarian
An elimination diet trial is the gold standard method to assess food allergies in pets. It is important when doing the diet trial that the pet only eats the prescription food prescribed. Other foods, like commercial dog food, people food, treats and flavored chew toys need to be avoided because these foods could have an ingredient that is making the pet allergic. 

You must believe your veterinarian when they say nothing else but the prescription food.  And, yes that small piece of your breakfast sandwich every morning can be enough to trigger an allergic reaction.

#vetdermatology #petdermatology #vetmedicine #pets #petownersofinstagram #dogfoodallergies #foodtrial #eliminationdiettrial #miamivet #miamiveterinarian #vethumor
Have you looked at your pet’s ear lately?  Some dogs and most cats have this fold of skin or pouch, called the marginal pouch, on the base of the ear flap. It is uncertain what the function of this pocket is, if any.  This dog’s marginal pouch had a bacterial infection.  It’s rare I see this area of the pinna affected but when I do I worry of autoimmune diseases. 

#petears #marginalpouch #vetdermatology #petdermatology #vetmedicine #dogearflap #pets #petsofinstagram #miamivet #miamiveterinarian #learnoninstagram #donaldtrump
This is a patient with signs of actinic solar dermatitis and allergies. What is most striking about this patient’s lesions is the significant secondary bacterial infection of his skin causing a lot of the inflammation, hair loss, crusts and draining tract lesions.  This dog had both superficial bacterial infection and deep bacterial infection. The after pictures are of him on 6 weeks of antibiotics.  Deep bacterial infections can require a prolonged course of antibiotics.  The left rear leg is still showing a few draining lesions and therefore I will be continuing this pet on its antibiotics. I know it sounds scary to keep a dog on antibiotics for such a long time, but many of these dogs with deep infections need it.  If each follow up visit you are seeing improvement, then you continue.  For deep infection, I will go one month past clinical resolution.  I would like to point out that I did not use steroids on this patient.  I can see where one may be tempted to do this because of the severe inflammation and itchiness this dog exhibited, but I find that if you can get the infection treated it is often not necessary to use steroids.  Steroids have powerful anti-inflammatory properties and can mask things, and I often worry it will not allow me to see if the antibiotic is really working. I did use Apoquel and found this to be a better alternative. 

#dogskininfection #deepbacterialinfection #beforeandafter #vetdermatology #petdermatology #vetmedicine #miamivet #miamiveterinarian #pets #petowners #petownersofinstagram #actinidermatitis #solarskindamage
Video otoscopy can be a terrific way to show a pet owner what is happening inside their dog’s ears. 

Today we had two patients, two pairs of ears, but each ear looked different. See if you catch the differences.

The first patient has just recently started with ear infections. On examination, the right ear is normal. You can see in the right ear the smooth pink ear canal and can get a glimpse of the eardrum. The left ear of this patient was the problem ear. You can see how the ear canal is inflamed and full of a brown discharge.

The second patient has had ear infections on and off in both ears for several months. Exam of the right ear showed a bulging structure in the ear canal. The right ear was not the ear of concern, and it was surprising to find this bulging structure which we suspect could be bulging pars flaccida or possibly a cyst. The left ear of this patient did not appear to have an ear drum and you can see the discharge inside the canal.

For the patient that is calm, cooperative and does not have painful ears, video otoscopy in the exam room can be quite a useful tool to educate a pet owner about their dog’s ear problems.

What questions do you have about ear exams?
(Thank you to Dr. Flores, our current extern, for taking the videos)

#videootoscopy #dogearexams #vetdermatology #petdermatology #vetmedicine #petowners #petownersofinstagram #dogearproblems #miamivet #miamiveterinarian
The lesion on this cat’s belly is an eosinophilic plaque. It is one of the worst plaque lesions that I have seen in a long time. The referring veterinarian had biopsied it and confirmed it was an eosinophilic plaque. The lesions had not resolved on anti-inflammatories. We performed cytology and it showed a considerable number of bacteria present on this lesion. These types of lesions are often secondarily infected. In my experience, veterinarians often do not think of doing cytology on cat skin, so they miss the infection. You will be surprised how a course of antibiotics can really help clear up these lesions.

Eosinophilic plaques are a clinical manifestation of allergies in a cat. Make sure to work up these cases for allergies.  Is the cat on strict flea control? If not, start there!! Get the infection treated. Alleviate the itchiness. In this cat patient we decided on a tapering course of oral steroids (i.e. I do not like to use long acting injectable steroids). I think for this patient treating the secondary infection and investigating the underlying cause were the missing factors to lack of improvement. We will re-evaluate this kitty in a few weeks. 

#catskinproblems #catallergies #eosinophilicplaque #cats #catowner #catsofinstagram #vetdermatology #petdermatology #vetmedicine #miamivet #miamiveterinarian
Pseudomonas ear infections are tops in my book for one of the most awful smelling infections. Rancid yeast skin infections are atrocious too. It is incredible what a pet owner will tolerate and I can empathize with their need to get in to see us ASAP to fix their dog’s skin and ear infections.

Anything else stinkier than Pseudomonas and yeast?

 #vethumor #dermpatientssmell #stinkyears #stinkyskin #vetdermatology #petdermatology #vetmedicine #pets #petsofinstagram #mayarudolph #miamivet #miamiveterinarian
Repeated use of the same antibiotic with no resolution to the skin infection should prompt a skin culture.  Empirically changing the antibiotic is another option, but the pet owner must understand that you are making an educated guess that could be wrong.

Avoid antibiotic roulette with your patients! You know what I mean, when one antibiotic does not work, then you try another one, and then if that does not work you try another and so forth.  We think we may be saving our client money by avoiding a culture, but in fact we are making them spend more money with each round of antibiotic and the pet continues to suffer.  If an antibiotic does not work then it is time for a skin culture.

I advise that if you are going to empirically change antibiotics, please avoid a big gun like fluoroquinolone (i.e. enrofloxacin). 

The patient in this video had a methicillin resistant staphylococcal infection, he had already been on cephalosporins and fluoroquinolones before he saw me.

Inspo for this reel @jorgeguzmanmvz

#antibioticresistance #antibioticstewardship #dogskininfections #vetdematology #petdermatology #veterinarydermatology #miamivet #miamiveterinarian #pets #petsofinstagram
Ear infections can happen in dogs with any kind of pinnal shape. A dog with floppy ears, erect ears and even cropped ears can get ear infections. There is a myth that cropping a dog’s ear will prevent it from getting infections. I see many dogs with cropped ears that have ear infections. Cropping a dog’s ear to prevent it from getting infections is just causing unnecessary pain to that dog. Dogs with floppy ears are said to be predisposed to ear infections because moisture is trapped in the ear, but these dogs are also prone to allergies which is typically the main cause of the ear infection. Allergies to food or environmental allergens are the number one reason a dog gets an ear infection. If the allergy is not addressed, the dog will continue to get ear infections.

#dogearinfections #earflaps #croppedears #pets #petsofinstagram #vetdermatology #petdermatology #veterinarydermatology #miamivet #miamiveterinarian
Why was Cytopoint not working for this dog?  Because there was an infection on the skin. 

Infection on the skin makes a dog itchy.  Make sure when you have an allergic dog that is continuously itchy that infection is not playing a role in that itchiness.  Sometimes infection on the skin is obvious because the skin looks inflamed and there are crusts and bumps.  But sometimes the skin may not look too bad and you do cytology and boom… bacteria or yeast or both are present.  Do not ignore the value of a skin cytology in all your patients that are itchy.  Cytology and culture of this dog’s skin showed a Staphylococcal infection. 

#cytopoint #cytology #dogallergies #itchydog #vetdermatology #petdermatology #veterinarydermatology #pet #petowner #petownersofinstagram #miamivet #miamiveterinarian
I had a client the other day tell me that Cytopoint used to last 6 months for her atopic dog and now it only lasts 4 weeks and therefore, she thought it was not working anymore. This comment is something I hear often from clients and there are two points I want to make about it.

First, Cytopoint is an injectable allergy medicine that only lasts 4-8 weeks. Cytopoint does not last 6 months. Second, it was not that Cytopoint was not working anymore for my client’s dog, it was that her dog’s allergies were no longer seasonal with a short period of itchiness, now her dog’s allergies were year-round. I want to make a strong emphasis on the latter point that allergies can start seasonal and for many dogs it can turn into non seasonal. As a dog gets older it can become allergic to more things in the environment turning their seasonal itchiness to year-round itchiness. Therefore, this patient of mine needed Cytopoint monthly now. And there is nothing wrong with giving Cytopoint monthly if it is keeping the dog minimally itchy and comfortable in that month. Atopy is a life long allergy that requires life long symptomatic therapy. 

Is your dog on Cytopoint? What has been your experience with this medication?

#cytopoint #dogallergies #pets #petowners #petownersofinstagram #cytopoint #vetdermatology #veterinarydermatology #vetmedicine #miamivet #miamiveterinarian