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Start From Scratch in Itch Cases

Every clinic team member should be alert to pertinent dermatologic clues, beginning with a thorough patient history.

Start From Scratch in Itch Cases
A comprehensive patient history is the most important step in working up dermatology cases.

Nothing’s easy in veterinary dermatology. “Every itch complaint looks the same,” said Jennie Tait, AHT, RVT, a charter member of the Academy of Dermatology Veterinary Technicians. “There are no magic bullets. Because everything looks the same, it will take multiple appointments to work the itchy animal up. What you’re seeing is most likely just the tip of the iceberg.”

Dermatology is not one and done, she emphasized. “It’s a matter of lifelong management versus cure unless the cause is something like mange,” Tait said. “We can fix that and move on.”


EDITOR’S NOTE

This article is the first in a three-part series on veterinary dermatology and the practice team’s role.


Rusty Muse, DVM, DACVD, said the most common cause of itching in pets is an allergic skin disease. This includes allergies related to the environment, fleas and food. Dr. Muse is the medical director at Animal Dermatology Group, which comprises dermatology specialty practices throughout the United States, Australia and New Zealand.

Good flea control is always important, even for pets that do little itching or scratching, he said. If a dog has a true flea allergy, an arsenal of things can be helpful, but flea control is paramount. Most veterinary dermatologists prescribe oral flea control, he said.

Chronic allergies have two contributing parts. “One is an abnormal immune response, which triggers itching that a normal dog wouldn’t react to, like pollen and house dust mites,” Dr. Muse said. “They can cause a cascade of symptoms.

“The second is an abnormal skin barrier that contributes to secondary infections. We have to manage both aspects to control the itch and control secondary infections. This [second step] is often overlooked.”

Don’t Rush Things

Therapies for managing the itch alone won’t stop the chronic problem, Dr. Muse said. Steroids might control the itch at first, but the animal remains prone to secondary infections. In such a case, the itching will return.

“We have to control the infective organisms while sorting out the problem,” Dr. Muse said. “Routine bathing becomes critical. It’s a myth that you shouldn’t bathe a dog too often.

“Allergies are a chronic disease, and general practitioners have to be interested in chronic management,” he said. “When we schedule a new appointment, we schedule an hour. It takes time to go through a patient’s history, and a good dermatology workup needs a good history.

“Sometimes, this is a problem in general practice because of time constraints. The time commitment is always a challenge. We have to educate the client. If people understand what needs to be done, they are willing to commit to the lengthy process. They want to know why.”

Check for Visual Signs

Dr. Muse asks his clients to provide a thorough patient history before the visit. The next step — whether by a general practitioner or specialist — is a complete physical exam.

“The clues are there on the dog’s skin,” Dr. Muse said. “Take the time to look at it and understand what’s going on. Is there redness? Crusting? Are there scales? Papules? Lesions on the pads? All are important in putting the picture together. Then perform diagnostics to confirm what you suspect.

“Lots of different disorders cause itching and scratching. They can be primary or secondary. Itchy skin disease management is multimodal. Sometimes it’s easy, as in the case of mites. But most are chronic, though still manageable and treatable.”

The American College of Veterinary Dermatology advises that to distinguish between different diseases, proper interpretation of the history and clinical signs, together with cytology and possibly cultures, can be necessary for achieving the correct diagnosis and treatment.

Follow-up is essential, Dr. Muse noted. “Veterinarians and dermatologists need to see if the pet has completely responded,” he said, “so checking clinical signs is critically important. We usually see a pet six to seven times a year.”

Teamwork Pays Off

Treating chronic skin conditions is a team sport, said Tait, of the Academy of Dermatology Veterinary Technicians. Therefore, every practice team member should be attuned to recognizing that an itchy pet should see a veterinarian.

That training should start on each team member’s first day in the clinic, Tait said. “Everybody should know what the plan is for dealing with dermatology issues. Customer service representatives and reception staff are the front line, the first people your clients contact. Make it a good experience for them. With dermatology, you want to set up realistic expectations for owners.

“Dermatology cases are always complicated,” she said, “and there are often years of history by the time a pet gets to the specialist.”

Tait also serves on the executive committee of the Canadian Academy for Veterinary Dermatology, whose “Empathy for Itch” campaign is designed to educate the practice staff and pet owners on what itchiness looks like. For example, licking indicates itchiness. So, if a pet’s evening routine is to lick its paws, the veterinarian needs to know. Also, pink skin isn’t normal, she said; it should be white.

The Client’s Role

Tait advises against offering dermatology care suggestions over the phone. “If the client is concerned, we should be concerned, and the pet should see the veterinarian,” she said.

Sometimes, the primary reason for a visit isn’t the itching. But a random comment from the owner that the pet has been chewing, biting, rubbing or scratching should trigger questions.

The veterinary technician can be the liaison to the client and is often the first to do the dermatology exam and take the patient history if empowered to do so, Tait said. The technician’s main role, however, is client education.

All team members should know that infestation, infection and allergies are the three main causes of itching, Tait said.

“Almost every case needs to have cytology done. A secondary infection might look like yeast, but antifungals won’t work on bacterial infections, and you don’t know the difference until you look under a microscope,” she said. “This allows for accurate diagnosis.”

Technicians at Veterinary Allergy Dermatology & Ear Referral (VADER) in Ontario, Canada, where Tait works, do the initial dermatological exam. They go over a history form with the client, do skin scrapings and examine the samples under a microscope. The clinician then sees the patient.

VADER technicians also handle patient summaries, sedation, anesthesia, skin biopsies and discharge. Besides freeing the dermatologist for more involved medical issues, “This allows clients to bond with the technicians,” Tait said. “It spreads the wealth and strengthens a client’s bond with the clinic. It shows the client that technicians are valued members of the veterinary care team.”

The veterinarian summarizes the findings and tailors a diagnostic plan, understanding that client education is a component.

Do It in Writing

At VADER, clients receive a written summary. “It’s worth its weight in gold,” Tait said. “It gives both the client and team something to look back at. And we attach any appropriate client handouts to the summary. Putting things in writing allows the pet parent to go home and study what’s going on.”

The summary covers a possible diagnosis, the tests being done and prescribed medications. “It helps the client understand why we seem to be doing 5 million things,” Tait said.

Clients are frequently frustrated by the time they get to the dermatologist. “They often aren’t receiving the information that I’m sure the family vets are trying to get them,” Tait said. “It results from trying to educate clients in a 20-minute appointment. Lots of information in a small window of time is difficult to absorb.”

She suggests booking double appointments as a way for general practitioners to get started with a dermatology case. “There’s no justice in a 20-minute appointment,” she said.

Listen Up

Clinic staff should listen for client remarks that might indicate itchiness, said Andrea Crabtree, CVPM, SPHR, CCFP, of FurPaws Consulting. “Sometimes a client brings in a pet for something else but says something like, ‘Oh, he’s always had that red spot’ or ‘He’s been scratchy this month.’”

The team member should mention such comments to the veterinarian. “Train staff to listen for clues that clients are giving us,” Crabtree said. “Sometimes we have to extrapolate information that they don’t always know they have.”

When a client calls to make an appointment, the receptionist should ask questions. By inquiring about any itchiness, vomiting, diarrhea, hair loss, head shaking or appetite changes, the staff might learn that what was to be as an annual exam is now a medical case.

“The timing allowed for the appointment could change between a sick pet and well-pet exam,” Crabtree said. “It can feel like pulling teeth to get the relevant information.”

The advent of curbside care has allowed some streamlining of care. “It used to be that the front office or technician took a history, then presented the case to the doctor, who went into the exam room and went over the same information,” Crabtree said. “It’s different now with curbside.

“Now, technicians often have pre-appointment history questionnaires filled out before the client comes in. This saves time and is more efficient.”

Crabtree recommends training the entire team to be more inquisitive. When the front office team knows the right questions, time is saved in deciding whether the patient should be seen immediately.

She has found that clients’ most common questions on itchiness involve the one thing pet owners have control over: Can it be the animal’s diet?

“They often think it’s something they’re doing wrong,” she said. “Usually, though, it’s not their fault. This is where education comes in.”

Marilyn Iturri is a former editor of Veterinary Practice News magazine who has worked in the veterinary and pet publishing sector for 20 years. Also a veteran of daily newspapers, she freelances as an editor and writer for diverse clients. She lives in Southern California and may be reached at [email protected]


WHAT TO ASK

According to the American College of Veterinary Dermatology, clients should be asked these questions to help determine whether a treatable dermatologic condition is present.

  • Does the pet constantly lick, chew, bite, scratch or shake its head?
  • Does the pet have hair loss, scabs or dandruff?
  • Have you noticed a change in the pet’s skin or coat color or texture?
  • Do the pet’s skin or ears emit a foul odor?

INFORMATION, PLEASE

A comprehensive patient history is the most important step in working up dermatology cases, said Rusty Muse, DVM, DACVD, of Animal Dermatology Group.

“The first 15 minutes of our initial appointments about itching involve clinical signs, seasonality, what the client sees, any previous therapies, what the animal eats and any topicals used on the pet,” he said.

Most itching is due to chronic disease, Dr. Muse said, so veterinary professionals need to be interested in its management as well.

“When we schedule a new appointment, we schedule an hour. It takes time to go through a pet’s history. A good dermatology workup needs a good history. This can be a problem in general practice, where there are so many time constraints.”

Questions on Animal Dermatology Group’s new-patient form (click here) include:

  • The pet’s age and when the problem started.
  • The times when the problem is less severe.
  • On which part of the body the problem began.
  • Whether other animals in the home are affected.

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