For this episode Sue, John & Paul invite the wonderful Victoria (Tori) Robinson onto the podcast - a dermatology specialist based in referral practice in Glasgow.
Intro
(00:00) - The Skin Flint team open the episode and introduce the guest for this itchy episode.
Chapter 1 – Summer itchin’, had me aghast...
(02:30) Sue welcomes Tori, who briefly introduces herself and her background.
(03:15) Sue asks what would we mean by 'summer itch' and Tori says this can mean a higher level of pollen, but also possibly parasites as there is more agricultural activity happening.
(04:25) John asks whether it is something that all dogs do - itch more as it gets hot? Tori replies that not all dogs should scratch, they may do occasionally but it is about noticing when it manifests into more of a problem with frequency and intensity (e.g. with patches of hair on the carpet or your dog not being able to be distracted from it). Then hair loss or reddened skin can be the next indicators of a problem and an owner should see a vet.
(05:44) Sue asks about brown staining on the coat and how this isn’t necessarily dirt – Tori shares how this is discolouration from excessive licking and can be a marker for a secondary infection such as a yeast overgrowth or bacterial overgrowth which in of themselves are very itchy, and so this discolouration can be an indication there is a problem.
(06:37) Sue asks whether quality of life is affected even if a pet doesn’t get sore from the itching. Tori says how for us it can be really bothersome to have an itch and so it is the same for animals. She says how sometimes it is not until an owner has begun to treat the itch, that they realise how much it has been affecting their pets health; with them becoming less irritable, sleeping and eating better and generally more comfortable. Sue clarifies that without even soreness, the increased saliva staining and scratching would be enough to need to investigate further and Tori echoes this, saying vigilance with your pet is important as this may be more obvious in some breeds than others.
(08:18) John asks what the most common causes of itching would be and Tori mentions this could be related to area or lifestyle, but could also be related to parasite infestation such as fleas, or harvest mites (which are geographically restricted) – or pollens and moulds. So there are lots of geographical things which can be a factor in summer itch.
Chapter 2 - Summer itchin’ happened so fast...
(09:38) John asks if there is anything a pet owner could do at home prior to going to the vet, to which Tori highlights how good parasite control can go a long way to helping the 10-40% of pets who present for routine treatment and have some form of parasite infestation. She also points out not all the parasite products are as good as each other and so it is still worth speaking to the vet to make sure you have the most appropriate treatment. She also points out how bathing the pet can really help to manage summer itch before it starts to wash of pollens and prevent secondary infections.
(10:54) Sue asks what Tori would means with a shampoo – what sort of active ingredients should an owner look for. Tori starts with soothing shampoos – saying they will have things like colloidal oatmeal in which can help with moisturising and phytosphingosine to help with skin barrier function; and all of these types of moisturising agents are designed to help build up the protective barrier the skin forms against things that the pet is allergic to. Tori then talks about the antiseptic shampoos, saying most will contain chlorhexidine when purchased from the vets; she warned against just buying something over the counter, particularly with human shampoos as he’s had a different pH which is not suitable for a pet.
(12:43) Sue asks about antihistamines and oil supplements which she may also buy over the counter and Tori discusses how antihistamines can be very effective if given preventatively, before the start of symptoms. She talks about how us humans take an antihistamine at the very first signs if we have an allergy, but it is not possible for a pet to tell the owner about the signs and so antihistamines in a pet are being used once the symptoms have been going on for a long time; and as histamine release is only one component of the itch, by this point it is too late.
(13:53) John asks why a vet would do tests rather than see a patient with an itch and prescribe something for the problem there and then. Tori says that as there are so many different potential causes of it, it is very important that the vet does the tests in order to ascertain the true cause and put forward an appropriate treatment. She uses the example of a bacterial or yeast infection needing something to treat it or a parasite infestation needing something totally different; so just putting up something to stop the itch will not be dealing necessarily with the appropriate cause.
(15:20) Sue clarifies this as treating a disease as opposed to treating a symptom and Tori fully agrees. Sue then goes on to ask what sort of tests a vet may do to find out the cause, to which Tori talks about the history being a really important part of this, and that a vet isn’t being nosy, but needs to get a blanket of information to understand the disease. This will mean questions like where are they walked and what do they sleep on etc. Then for tests she talks about Sellotape strips from areas that are red, slides pressed against oozing areas, hair plucks from affected places and skin scrapes to look for parasites. All of this helps to rule out what isn’t causing the itch or find out what is.
(17:35) Sue asked what the next steps may be if no underlying allergy has been found from all of these tests or a potential food trial. Tori says this can depend on the time of year – and so if it is the summer months they react it is more likely to be a pollen allergy than say a food allergy, which would be all year round. She says some of the level of work up may depend on whether you see your first opinion (GP) vet or whether you then go on to see a referral specialist dermatologist.
(18:43) John asks Tori to clarify the difference between a GP vet and a referral vet and Tori likens it to the difference between seeing your GP and a consultant when going to the doctors. She says a specialist would have done a residency on dermatology for anything between three and nine years as well as taken exams, they would also be doing extra learning to keep up to date. Sue and Tori then expand this saying a dermatologist will be more experienced in dealing with the more weird and wonderful diseases.
(20:43) John asks then if there are some things which are easier to treat than others and Tori says absolutely, a parasite burden for example is much easier to treat with an anti-parasitic then something like an allergy to a pollen, which could be difficult to exactly ascertain a lifelong to treat.
Chapter 3 – Tell me more tell me more...
(22:05) Sue mentions that previous podcasts for skinflint have discussed immunotherapy vaccines, as well as shampoos, so what else would or could a vet reach for if these have been unsuccessful or something else is required? Tori mentions drugs which can supress the itch such as glucocorticoids (often just called steroids) as well as Oclacitinib and Cyclosporin which modify the part of the immune system causing the itch. She goes on to mention biological therapies called monoclonal antibodies which are proteins which bind to the response which causes the itch to stop it – called Lokivetmab, and says these can be used alongside any other treatments which treat the cause of the itch.
(23:23) Sue asks whether these are safe and Tori says that of course - everything has a safety profile and glucoroticoids for example have a lot of side effects; however some of them can have great success in treating the itch and so this can still be necessary. Sue then clarifies that the monoclonal antibodies are newer and more specific action and Tori agrees, saying these have a much higher safety profile as they are not metabolised by the body anywhere near as much and in fact, human allergists are quite envious of these products the veterinary market has.
(26:04) John says these sound quite expensive and asks whether it is a straight choice between using one of these drugs if you have the finances, or using shampoo if you are looking for a cheaper alternative and Tori clarifies how it isn’t as simple as that. It goes back to how we have discussed the different causes of the itch and how different treatments may be needed, even to be used alongside one another in order to treat the disease. She says this can be challenging for owners to begin with, and with regards to cost she encourages owners to have an honest conversation with the vet, so the vet can select the different therapies needed around the budget.
(27:43) Sue summarises by saying there are lots of different treatments, and each case will need those treatments tailored around the specific needs for that patient symptoms, and potentially also for the owners financial situation and Tori completely agrees; she says how 80% of the cases she sees a referral practice are allergic skin disease and all of these go home with completely different treatment plans. She also adds that any given patient may need different treatment options over time as the disease evolves and develops, this isn’t necessarily that the patient is building up an immunity to the treatment, but more the disease itself changes over time.
(29:25) Sue also highlights the importance of the animals comfort in terms of welfare, and asks Tori what she would reach for if she wanted to make the pet comfortable quickly. Tori says this is where the speed of action of glucocorticoids, oclacitinib and lokivetmab mentioned previously are very useful working within a few days where appropriate – with cyclosporin being a few weeks and immunotherapy a few months
(30:50) Sue uses the analogy of these drugs being the fire extinguisher on the disease, to put out the initial problem, before then the other therapies being the smoke alarm on preventing the problem for returning.
(33:46) John says thankyou and farewell to Tori.
Outro
(34:43) John wraps up the podcast with another trademark silly question, this time asking Paul and Sue where they would choose to have an itch to scratch if they had to!
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