Allergy treatment by Dr Bill Moore for Tequesta Vet Clinic
1. Start early.
The earlier a patient with allergy is started on a treatment program designed with aggressive avoidance practices, the easier the disease will be to control (this includes referral to a dermatologist). Patients that have chronic disease or recurrent infections have immune system changes as well as functional alteration in normal skin function which can make it more difficult to treat the dermatitis. By starting therapy early, cheaper, more simple therapies will likely work well to improve the patient's disease. "An ounce of prevention is worth a pound of cure".
2. Treat all secondary bacterial and yeast infections.
Allergic disease causes changes in the normal function of the skin that prevents it from preventing infections. As a result, up to 80% of allergic patients will have secondary infections. These infections can mimic other diseases making accurate diagnosis difficult. Additionally, the infections can cause severe itching and add to the inflammation of the allergic reaction.
Antibiotics for 21 to 42 days will be needed for each episode of bacterial folliculitis (pyoderma). Cefpodoxime is a common choice.
Yeast infections will require topical and/or systemic antifungal medications for at least 1 month. Terbinafine or fluconazole tablets are a good choice along with chlorhexidine 4%/ketoconazole shampoo used twice weekly with soak times of 5 to 10 minutes.
Ear infections usually require ear cleaning every 3-7 days and a topical medication to kill the bacterial or yeast. Often a topical steroid is used to decrease the inflammation caused by the allergy and infection. Easotic is simple and effective. A single infusion of Claro uses florfenicol as a novel antibiotic, terbinafine as the anti-yeast medication and mometasone as the corticosteroid. Claro is infused in the ear for two weeks to four weeks before any cleaning is recommended.
Infections of the feet (pododermatitis) are often treated with topical antimicrobial wipes, shampoos, or rinses used at least daily, ideally each time they come in from outside.
3. Avoid common allergens.
The most common allergens in the home environment are house dust mites, molds, and cigarette smoke. These as well as other allergens (wool, etc.) can often be reduced or avoided with several easy techniques.
Throw away any foam or stuffed dog bed that is older than 1 year. Dog beds are one of the most common sources of house dust mites. Wash all bedding every 7 days using hot water.
Do not allow anyone to smoke in the home.
Use a HEPA air filter to clean the air and vacuum frequently with a HEPA filter vacuum.
Dehumidify the home using a high efficiency dehumidifier to keep the humidity below 40%. This will help prevent house dust mites, mold growth, and fleas.
Consider using a spray to dissolve or denature the allergens and using a borate product to eliminate house dust mite exposure in the home. Dust mite testing kits are widely available.
5. Bathe your pet every 3-7 days using a mild antimicrobial shampoo.
This will wash off any allergens and help to kill and prevent the secondary infections caused by bacteria or yeast.
6. Use flea control every month.
Fleas are a year-round problem in south Florida and can increase the allergic reaction to all other allergens including house dust mites, pollens, molds, etc. Bravecto, Simparica, Nexgard and Credelio are all in a new class(isoxazoline) of flea control products. They are considered very safe and very effective. Bravecto is a higher concentration and is labeled for 12 weeks while the other 3 are labeled for 4 weeks. They can also treat demodex mites off label. Veterinary dermatologists have used Nexgard every 2 to 4 weeks for demodex mites and Bravecto is used as labeled as a single dose for demodex. Some of our allergy patients that are on immunosuppressive medications can have flare-ups of demodex so isoxazoline products can have better results than other types of flea and tick control. Monthly Sentinel Spectrum combines a monthly adulticide flea treatment with heartworm and intestinal parasite prevention. Our current recommendation is Sentinel Spectrum and Nexgard as the most complete combination for controlling parasites.
7. Consider changing the diet to a skin friendly food or even an aggressive food allergy trial.
Feeding a diet with high levels of essential fatty acids will help reduce any allergic reactions regardless of the cause. These are Hill’s Sensitive Stomach and Sensitive Skin, and Royal Canin Sensitive Skin Care. Although fish based diets can work well, many companies do not have acceptable quality control for itchy dogs.
If food allergy is suspected, feeding a strict diet with only 1 protein (rabbit, duck, kangaroo, or fish) and 1 carbohydrate (potato) for 10 weeks will help diagnosis any food allergy. During this time, NO other foods, treats, chew bones, or chewable medication can be administered. Hydrolyzed protein diets are the most restricted, but some dermatologists prefer using the limited ingredient diets. It is best not to use non-prescription dog food brands because unlike granola bars that warn people with nut allergies they are processed on machines handling nuts even if the granola bar is nut free- you never see that warning on a supposed beef free or grain free bag but independent testing has shown it happens. Since allergies are lifelong, it always is beneficial to try prescription Royal Canin or Science Diet for 10 weeks rather than just assuming your dog is allergic to common ingredients like gluten, corn, or every grain on earth. This is much more logical than thinking that NaturalX, WildX, OrganicX, no GMO dog chow is going to fix it.
8. Use symptomatic and topical therapy to help reduce the allergy and itch.
Antihistamines are cheap effective therapies with few side effects (clemastine, diphenhydramine, chlorpheniramine, hydroxyzine, amitriptyline).
Treat with oral high dose essential fatty acids (even if already in the diet). Supplement EFA’s based on EPA mg at 15 mg per pound. This is higher than human recommendations and double the dose of most canine supplements. Canada and Australia regulate supplements for potency, but USA doesn't. Start with an international company like Nutramax (Welactin) or Vetoquinol (AllerG-3 Liquid) and if it works well owner could try a cheaper brand that may not have the potency of what is listed on the label.
Anti-Itch conditioners after each bath (oatmeal, pramoxine, hydrocortisone, etc).
Use an anti-itch mild steroid spray to provide effective topical steroid therapy allowing the avoidance of oral or injectable steroids which are more likely to cause long-term problems.
Consider low dose (every-other-day) steroids to put out the "pruritic" fires if other medications are not working.
9. Allergy testing
Allergy skin testing or blood allergy testing can be used to identify which allergens are triggering patient reactions. This information can then be used to formulate an allergy vaccine to try to desensitize the immune system to those reactive allergens. This therapy has few side effects and helps improve approximately 75% of allergic patients.
10. Cyclosporine Therapy (Atopica, Novartis)
Cyclosporine is an effective treatment that stops the T lymphocytes from stimulating the allergic reaction. It is effective in 75% of patients and has few adverse effects but can be expensive, especially for larger dogs. The treatments start with every daily dosing but can usually be reduced to an every-other-day schedule, thus reducing the cost. In some patients, other medications (ketoconazole) can be added that may help further reduce the cost of the cyclosporine therapy.
Antipruritic oral medication- Start every 12 hours for the first 7 to 14 days then every 24 hours for maintenance. Continue to treat the underlying cause of itchy skin. Many dogs will become pruritic for 1-2 days when reducing dosage at 7 to 14 days. This usually is temporary so continue with once daily dosing. Some dogs need ongoing daily therapy. If a dog is continuing twice daily dosing long-term consider routine CBC testing to monitor for bone marrow suppression that can occur at high doses. Do not use if less than 12 months old or with demodex mites.
Finally, Cytopoint Interleukin 31 monoclonal antibody Injection. 4-12 weeks of anti-pruritic relief. The longer range is with ongoing traditional atopy treatments- weekly bathing, omega 3 FA, antihistamines. No side effects- none, nada, zero compared to placebo dogs in clinical trial.
Dr Bill Moore August, 2020
CLIENT HANDOUT by Dr Javiera Correa
Canine Atopic Dermatitis
Canine atopic dermatitis can also be known as allergic dermatitis, atopy, environmental dermatitis, hay fever, among other names.
What is atopic dermatitis?
Atopic dermatitis is one of the most common causes of chronic itching in dogs. Atopic dermatitis is caused by an allergic reaction (hypersensitivity) to one or more substances in the environment. Various substances, called allergens, can trigger atopic dermatitis. They are often the same allergens implicated in human allergic conditions such as hay fever and asthma. Florida is one of the climates where atopy is most prevalent. In Florida we see atopy cases in almost every breed and age of dogs.
What are the symptoms of atopic dermatitis?
Dogs with atopic dermatitis are usually itchy. The face and feet may seem particularly irritated. The skin on some parts of the body may be reddened, moist, or damaged due to scratching or chewing. Skin infections may also occur. The ears may also be inflamed, and recurrent ear infections are quite common in these patients. Less often, dogs with atopic dermatitis have other signs of “allergies” including runny eyes or nose. The symptoms usually start when the dog is 1 to 5 years old and may worsen over the first couple of years if not treated. Unlike many humans, dogs do not “grow out” of their allergies – so we almost always recommend a long-term treatment.
Why does atopic dermatitis develop?
A combination of factors predisposes dogs to atopic dermatitis. Both their genetic make-up and environment may interact to allow atopic dermatitis to develop. The condition is caused by an inappropriate immune reaction rather than by the allergens themselves.
How are dogs exposed to allergens?
Many allergens are airborne and found nearly everywhere. Some are present year-round (such as house dust, dust mites, and some molds) while others are found at high levels only at specific times during the year (such as pollens). Dogs may either inhale the allergens or contact them through the skin.
How is atopic dermatitis diagnosed?
The diagnosis is based on your observations and on our physical examination, as well as by ruling out other causes of allergies, primarily parasites (fleas and mites) and food.
Can we test my dog for allergies to find out to what he/she is allergic?
Allergy testing is useful in determining what allergens are specific to your pet, therefore we can formulate a plan to try and avoid the allergens. Allergy testing can be done via a blood sample (antibody test), and intradermal or a pin prick test. The former can be performed with your primary care veterinarian, and the latter two are performed with a veterinary dermatologist. One of Dr. Joi’s gifts to clients is offering allergy testing (the blood sample version mentioned above) AT COST. Most clinics charge several hundred dollars for this test, but we give it to you at $170. Pets should be at least 2 years old at the time of this blood test because it is an antibody test.
How is atopic dermatitis treated/managed?
Atopic dermatitis can be treated/managed in many ways. What works great for one dog may not help another dog. Limiting your pet’s exposure to his/her allergens is most effective, but not usually practical – it may mean relocating to a different climate! Other treatments are usually necessary. These include:
It is also very important for any dog with atopic dermatitis to be on a year-round, comprehensive flea control program. Atopic dogs tend to be more sensitive to the bites of fleas, so we would like even occasional flea bites to be prevented. The flea products that Dr. Joi, Dr. Javi, and Dr. Bill most often recommend are NexGard® or Bravecto®, but other options are available such as Revolution® if your pet has a severe food allergy. We also love Sentinel as our heartworm prevention because it has an ingredient to help break the flea life cycle, that we call flea birth control.
Anti-inflammatory and anti-itch treatments
Apoquel®, Atopica®, Cytopoint™, fatty acid supplements, prednisone, or other medications may be very helpful to reduce itching in your pet. Apoquel and Atopica are the only FDA-approved non-steroidal drugs for the management of canine atopic dermatitis. Apoquel (oclacitinib) blocks the receptor for IL-31, a molecule that signals itchiness in dogs. IL-31 can also be blocked with a monoclonal antibody, (Cytopoint™), given as a subcutaneous injection every 4-8 weeks. It can be truly amazing to provide chronically itchy dogs such quick relief without using steroids. Since each atopic dog is very much an individual, some dogs need a “trial” with different drugs to find the one or combination that works best. There are no known side effects to Cytopoint™ and often times pets come in for an appointment for Cytopoint™ with one of our vet nurses.
Medicated shampoos, topical sprays, and mousses can provide relief to many dogs. Bathing removes the allergens that are adhering to the surface of the skin, and the medicated ingredients also help to reduce itching and control/treat secondary infections. We particularly prefer Malaseb™ shampoo as it has 7 days of residual activity.
Antibacterial and antifungal medications
Dogs with atopic dermatitis are prone to recurrent bacterial and yeast infections of the skin and ears, therefore we may need to address these infections in addition to treating the atopic dermatitis. These might include oral antibiotics and antifungals alone but more often in combination with topical therapy with antibacterial and antifungal shampoos/sprays/mousse as mentioned above. Cleaning the ears on a regular basis and especially after the ears get wet with a medicated ear cleaner helps to reduce the risk for an ear infection.
This is the only treatment that can cure allergies. Beginning this treatment before the allergies are too severe increases the odds of a successful outcome. An extract made from allergens that your pet is sensitive to can be given to induce “tolerance” to these substances. When these substances are then encountered in the environment, your pet should be much less sensitive to them. Two routes of administration are available: subcutaneous injections or oral/sublingual. This form of treatment is performed with a veterinary dermatologist. We strongly prefer the sublingual route. Please note that the pet will be on the hypo-sensitization for years. 60-80% of atopic dogs respond to hypo-sensitization and it can take 8 to 12 months to take effect.
At times we may refer you and your pet to our local veterinary dermatologist for further care and testing.
Managing this lifelong condition takes some patience. By using various combinations of therapy, and altering the treatment based on the pet’s response, we can help atopic dogs feel and look their best!
Dr Javiera Correa August, 2020