The Skin Flint Podcast

Pododermatitis Paw-dcast Part 2 – A Surgeon's Perspective (00:00) Intro - this month, Sue, John and Paul invite EBVS Specialist in Small Animal Surgery, Jakub Kaczmarek onto the platform to discuss the other side of pododermatitis - from the surgeon's perspective. Chapter 1 – Feet First - A Surgeon’s Take on Pododermatitis (03:12) John introduces Jakub, highlighting Ursula's recommendation following their fruitful discussion on pododermatitis. He invites Jakub to share his background. Jakub expresses gratitude for the invitation and mentions Ursula as a mentor during his residency in Germany. He discusses their collaboration on pododermatitis, combining dermatology and surgery. Jakub shares his educational journey from Poland, a semester in Vienna, and his internship in Germany, which focused on surgery and dermatology. He currently works in Cologne. (04:55) John acknowledges Jakub's expertise in dermatology and asks how a surgeon fits into managing pododermatitis in dogs. Jakub emphasises teamwork between dermatologists and orthopaedic specialists, noting the complexity of pododermatitis. He explains that it can arise from both skin-related and conformational issues, necessitating collaboration for optimal care. (06:16) John enquires about the types of lesions found on dogs' feet. Jakub explains that abnormal weight distribution from orthopaedic conditions, like developmental elbow disease, can cause pressure on specific paw digits, leading to abrasions, inflammation, and even local pyoderma. He describes hypertrophy on the paw's plantar surface, potentially forming "pseudoballs." Chronic irritation can result in excessive licking, leading to severe inflammation, which requires both orthopaedic and dermatologic management.   Chapter 2 - Toes: Lesions and Lameness (09:25) Sue comments on the dog's paw pad structure, noting that abnormal weight-bearing can lead to skin issues. She asks if this is the pathomechanism for pododermatitis. Jakub agrees and adds that while there are many potential causes, mechanical issues may also contribute. He supports Sue's idea that malalignment and weight distribution lead to abnormal weight-bearing and related problems. Sue clarifies that some cases of pododermatitis have dermatological causes, while others stem from orthopaedic issues. Jakub agrees but points out that breeds like Labrador Retrievers and Bulldogs often have both conditions, complicating the determination of the primary issue. Sue P recalls a study revealing Bulldogs walk on their toes, which could contribute to multiple health issues. She emphasises the need for a multidisciplinary approach. Jakub references a study by Tim Nuttall involving over 160 dogs, noting that factors like body condition and hair type are significant in causing pododermatitis and interdigital cysts. Sue P agrees, linking higher body condition scores to more weight on the front limbs, thus making pododermatitis more common there. Jakub clarifies that while pododermatitis is typically seen more in front limbs, conditions like hip dysplasia can also affect hind limbs. He explains that primary dermatological issues may affect both front limbs, while orthopaedic problems often involve a single limb. Sue P sums up that multiple limb involvement likely relates to skin conditions, while single limb issues could indicate orthopaedic problems. Jakub agrees, adding that orthopaedic conditions like OCD or FCP typically show changes in the affected limb. (14:53) John revisits Jakub's "top-down or bottom-up" approach, asking how it relates to recognising orthopaedic diseases as triggers for pododermatitis. Jakub explains that common orthopaedic triggers include developmental elbow diseases like OCD and FCP, as well as shoulder OCD, which causes dogs to alter their walking to reduce pain. He notes that patellar luxation often results from underlying angular limb deformities that shift the weight-bearing axis, exacerbating dermatological issues.   Chapter 3 - Surgical Solutions: From Lasers to Collaboration for Better Outcomes (17:30) Sue asks Jakub to elaborate on triggers, noting that predisposed breeds and age of onset play a role, citing Labradors as an example. Jakub confirms that Labrador Retrievers exhibit these issues, with signs of orthopaedic problems appearing as early as five to six months, and severe cases at four months. He mentions common large breeds prone to orthopaedic problems. (18:59) Sue asks about the timing of pododermatitis relative to orthopaedic diseases, questioning if lameness in young dogs could precede pododermatitis. Jakub notes that pododermatitis and orthopaedic diseases usually present in older dogs, around two years of age. He hasn't observed significant changes in younger dogs, suggesting it takes time for pododermatitis to develop due to malalignment and weight redistribution. Sue P agrees, noting that in her practice, older dogs often present with pododermatitis alongside a history of earlier orthopaedic problems. She suggests a compensatory mechanism may lead to conditions like interdigital cysts. Jakub agrees, highlighting that dermatological conditions like pododermatitis are painful due to inflammation, which can lead to chronic discomfort. He asks Sue if Labrador owners ever report lameness when presenting dermatological issues. Sue P mentions that owners usually don’t report pain, necessitating probing for details. She reflects on referring a three-year-old Labrador with recurrent interdigital lesions to an orthopaedic surgeon to assess joints. If swelling or crepitus is present, she recommends CT scans and emphasises early intervention. Jakub recalls Sue's 2012 publication linking interdigital lesions with elbow issues. He has observed that treating elbow conditions often leads to improvement in lesions, suggesting that combining orthopaedic corrections with topical treatments could yield better outcomes. (25:18) John asks Jakub to elaborate on surgical approaches for pododermatitis, including techniques like webectomy and podoplasty. Jakub notes he has not performed podoplasty but has seen it used successfully in severe cases. He prefers laser ablation, as it is quicker and effective when collaborating with a dermatologist who has tried conservative treatments. He recounts streamlining procedures significantly, reducing time from 1.5 hours to 30-35 minutes. Sue adds context, explaining webectomy and podoplasty. She contrasts her cold steel surgery experience with the benefits of laser surgery. Jakub explains that CO2 lasers are more precise and cause less collateral damage than diode lasers. He emphasises the advantages of laser treatment in sealing vessels, which minimises bleeding and post-op pain. He mentions a colleague who leaves wounds open post-surgery, but he prefers using honey treatments for healing. (34:06) John concludes by praising the collaboration between Jakub and dermatologists like Ursula, highlighting the importance of a multidisciplinary approach in managing complex cases like pododermatitis. Outro (37:07) Final thoughts John puts another bizarre question to Sue and Paul.

Chapter 1 – Companionship for Life on the Streets   (02:58) John asks Jade to introduce herself and her background as a vet and how she came to setup Streetvet. Jade shares her story of experiencing homelessness in London with a man called Dave and his dog brick, and using her past research on homelessness and dog owners coupled with her own experience in mental health challenges and how having a dog helped her, to drive her to want to help these dogs and their owners. She shares how she started going round with someone who who cut hair for homeless people, and used this as a launching pad for doing the same as a vet seeing the dogs of homeless people.   (10:05) Sue talks about the data showing the importance of companionship for homeless people with their pets, and Jade shares how there are papers and research showing that lots of factors from loyalty through to body heat show that they are vital, and her own experience maps onto that.   Chapter 2 – Building StreetVet: A Backpack and a Big Heart   (13:37) John asks Jade about how Streetvet started and what id does, and jade share how she and co-founder Sam Joseph set it up going out just the two of them, and calling themselves Streetvet – but they realised the size of the task and in 2019 set it up as a registered charity ad looked to grow it. She talks about how it picked up traction in the media through both the need for it – but also how the professional of vets needed it – with Vets and Nurses remaining in the profession providing this service reconnected them with their work. This was a completely unexpected thing for Jade.   (17:30) John asks how the service works and Jade shares that they go out with a backpack and do all the things they would in a consultation – so taking blood samples and urine samples etc. They look to empower the owner on feeling involved by doing this on the street – before then if they need to go into a practice and Streetvet have a network of practices that help provide inpatient services. Streetvet also started an accredited hostel scheme as less than 10% of hostels in the UK accept pets, to prevent owners from having to hose to remain on the street if they have one. She also mentions they offer boarding for times where the owner need to go into hospital for healthcare themselves and can’t take their pet with them.   (21:10) Sue asks about the management of chronic, long term illnesses in the Streetvet work, Jade shares that they have set times and set locations rather than approaching the owners on the street – so the owners come to them in those times. But this allows them to come back again, and jade has been surprised that they have been able to treat long term diseases like cushings and diabetes, in cases where the client is committed to the process – as they do keep coming back.   Chapter 5 – Tackling Skin Woes: Managing Dermatology in the StreetVet World   (27:00) John asks about specifically the management of skin disease in the Streetvet environment and Jade shares that they do treat these, but the challenges are very real. They have even had cases of clients performing a diet trial and long term management of skin disease. The challenges in the life of these people can make it very difficult for the owners to have consistency, but the clients are very good at coming for regular flea treatment and prophylactic skin care, in some way because of the social benefits to coming and sharing in the the streetvet community and this makes managing these cases easier than one may think.  Jade discussed the types of medications they have food they can help with, topical treatment and some antibiotics to help with these cases as well as steroids if needed. Then they do have access to other medications if needed which they wont carry in the backpack.   (32:35) Sue asks how this is funded and Jade again emphasises how great and supportive the veterinary profession has been – with companies supporting with pro bono products and vets and nurses fundraising.   (34:19) Sue asks about the size of Streetvet and Jade says they are on 24 locations in total, and over 400 volunteer vets and nurses. And Sue asks how people can be involved – Jade mentions the website where you can get involved in volunteering, whether a vet, vet nurse or someone wanting to help in some other way – or fundraising as well. Or follow on Facebook and Instagram. www.streetvet.org.uk https://www.facebook.com/streetvet https://www.instagram.com/streetvetuk_/   (37:02) – John, Sue and Paul wrap up the podcast.

Pododermatitis Paw-dcast Show Notes (00:00) John introduces the podcast and Sue introduces Ursula Mayer – the guest on the show. Chapter 1 - Paw-sibilities – introduction to pododermatitis. (02:21) John invites Ursula to introduce herself. Ursula discusses her background and passion for pododermatitis, its prevalence, and its impact on dogs' quality of life. (03:33) When asked to define pododermatitis, Ursula explains that it's inflammation of the paw skin, with a particular emphasis on chronic cases, known as C-PIF. She discusses the various signs to look out for, such as excessive licking, lameness, and specific changes in paw appearance as the condition progresses. (05:31) Sue talks about the complexity of pododermatitis, and Ursula draws parallels with chronic otitis in terms of the multifaceted factors involved. She emphasises the importance of considering predisposing factors, primary causes including orthopaedic issues, secondary influences, and perpetuating factors in diagnosing and managing the condition effectively. Chapter 2 - Paw-sibilities - Orthopaedic Influences and Breed Predispositions (06:57) Sue asks Ursula to explain how orthopaedic diseases can contribute to pododermatitis in dogs. Ursula explains that pain from orthopaedic conditions alters weight bearing, causing dogs to adjust their stance and potentially rub their paws together, leading to inflammation and abnormal walking patterns. She goes on to discuss specific orthopaedic diseases, including elbow dysplasia, hip dysplasia, and arthritis affecting joints such as toes, carpus, tarsus, elbows, hips, and the back. These conditions can disrupt normal weight distribution and contribute to the development of pododermatitis. (08:35) Sue further illustrates with an example and Ursula emphasizes the importance of referring chronic cases to orthopaedic specialists for thorough examinations and imaging. She acknowledges the complexity of diagnosing older dogs with multiple affected areas, stressing the need for integrated care across disciplines to effectively manage pododermatitis. (09:56) John asks if this is just dogs and Ursula confirms that while cats can also suffer from pododermatitis, the chronic form discussed, known as C-PIF, predominantly affects dogs and not cats. John then asks about breed predispositions, particularly in relation to posture-related issues in Labradors. Ursula elaborates that certain breeds, notably larger and heavier ones like bulldogs, French bulldogs, and pugs, are commonly affected. Labradors and Golden Retrievers also constitute a significant portion of cases. The characteristics such as short, bristly coats and broad, flat paws, may contribute to their susceptibility to the condition. Ursula notes that even without orthopaedic diseases, these breeds' anatomical traits appear to play a role in the development of pododermatitis. (12:20) Sue reflects on a study involving bulldogs walking on pressure plates, noting that those without interdigital lesions tended to walk more upright. She emphasises that dogs with flatter feet and heavier builds are more prone to issues due to their posture, suggesting a correlation between anatomical features and pododermatitis. She further discusses how these factors influence investigation and treatment approaches. Ursula agrees, highlighting the significant role of allergies alongside orthopaedic diseases in pododermatitis cases. She notes the complexity in distinguishing between underlying orthopaedic conditions and inherent anatomical predispositions in certain breeds. Ursula shares a case involving a dog initially treated for allergies, later developing orthopaedic issues that exacerbated pododermatitis, illustrating the interplay between these factors. (14:47) Sue outlines the investigative process, starting with a comprehensive history and dermatological examination, incorporating orthopaedic evaluations based on findings. Ursula explains her approach, emphasising the importance of ruling out issues, particularly Demodex, through rigorous testing methods. She discusses predisposing factors such as weight and breed characteristics, and systematically examines for primary diseases like allergies, orthopaedic issues, and endocrine disorders. Ursula stresses the need to assess secondary infections and carefully inspect paw conditions, especially ventrally, to identify specific dermatological and orthopaedic indicators. Chapter 3 – Paws-itive outcomes - Diagnostic and Treatment Approaches (18:24) Sue asks about infection management in pododermatitis cases. Ursula explains that for superficial cases of pododermatitis, she primarily employs topical treatments. However, in chronic cases where deep pyoderma is present, systemic antibiotics are often necessary. She emphasises the importance of not relying solely on antibiotics without addressing underlying factors, as this can lead to recurring infections and antibiotic resistance. In deciding whether to use systemic antibiotics, Ursula considers the overall treatment plan. If surgery such as laser therapy is planned, she may opt against systemic antibiotics. For cases where medical therapy alone may suffice, she stresses the need for culture and sensitivity testing to target treatment effectively and minimise antibiotic use. (20:17) John questions Ursula about the approach to treating infections and determining underlying causes simultaneously. Ursula explains her concurrent approach, emphasising the urgency in addressing both infections and underlying conditions early on to improve the dog's quality of life. (22:17) Sue asks about anti-inflammatory therapy options in pododermatitis and the efficacy of non-steroidal anti-inflammatories (NSAIDs) versus steroids, cyclosporine, tacrolimus, and anti-pruritic drugs like oclacitinib and lokivetmab.. Ursula details her approach, highlighting the need for potent anti-inflammatory agents in severe cases of pododermatitis. She explains that while drugs like oclacitinib can alleviate itching, they may not sufficiently address inflammation. For cases requiring robust anti-inflammatory action, Ursula often starts with systemic steroids and cyclosporine simultaneously, gradually tapering off steroids once cyclosporine takes full effect. She stresses the challenges and side effects associated with long-term steroid use, advocating for cyclosporine as a viable long-term treatment despite its delayed onset of action. Ursula discusses transitioning to topical therapies like tacrolimus or non-thinning glucocorticoids as conditions improve, aiming to minimise reliance on systemic medications over time. (25:16) Sue asks about the complexities faced by Ursula when treating animals with multiple conditions. Ursula acknowledges the multifaceted nature of these cases, stressing the importance of weight management as a foundational step due to its lack of side effects. She emphasises the need for collaboration with orthopaedic specialists to address underlying orthopaedic diseases like elbow dysplasia early on. For pain relief and inflammation management in the feet, Ursula initially uses systemic steroids and cyclosporine, with a cautious approach to long-term steroid use. (27:05) Sue asks about prioritising orthopaedic surgery to correct primary causes like ununited coronoid process before addressing pododermatitis. Ursula acknowledges this strategy, noting that while surgery can eliminate chronic factors perpetuating pododermatitis, the outcomes vary depending on the case's severity and the owner's preferences. She explains that surgical intervention in the paws may provide faster relief, especially when orthopaedic conditions are severe. However, she also highlights the challenge of reversing long-standing paw conditions even after correcting the primary cause. Ursula emphasises the importance of timing and individualised treatment plans tailored to each patient's specific needs and responses. (29:14) John enquires about the feasibility of surgical procedures for pododermatitis in general practice versus referral settings. Ursula explains that surgical suitability depends on the general practitioner's expertise in dermatology, orthopaedics, and surgical techniques. For interdigital web surgery using traditional methods, like cold steel, she mentions the challenge of post-operative management due to necessary rigid bandaging. She contrasts this with CO2 laser surgery, highlighting its advantages such as reduced bleeding, pain, and swelling post-surgery due to sealed lymphatic and blood vessels and nerve endings. Ursula notes that CO2 lasers offer precise, fine-tuned tissue removal while preserving healthy dorsal skin, promoting healing by second intention without sutures. This approach aims to restore normal paw anatomy, crucial for long-term health. Ursula cautions against using diode lasers due to their higher collateral heat damage potential, unsuitable for delicate pododermatitis cases requiring precise tissue control. (33:49) Sue summarises the distinctions between podoplasty and CO2 laser techniques: podoplasty involves excising interdigital tissue and suturing toes, whereas CO2 laser surgery delicately removes scar tissue and abnormal follicles, crucial for preventing recurrent infections. Ursula elaborates on using CO2 lasers in both painting and cutting modes depending on tissue conditions, emphasising its efficacy in restoring paw health through precise, controlled tissue removal. (35:03) John concludes the discussion and Ursula emphasises the significance of regular examination of paw pads, especially in predisposed breeds or suspected allergic patients, urging veterinary professionals to involve owners in observing early signs like erythema. She stresses the value of early referral when cases become challenging, highlighting proactive management as key.   (37:52) Sue and John wrap up with their thoughts on this month’s guest, before John asks the team a question that’s been bugging him all episode…

Unleashed: The Dawn of the Leishmania Intro Chapter 1: The Attack of the Sandfly 3.17 Sue introduces the topic of leishmaniasis, and Christian describes leishmaniasis as a multisystemic disease affecting humans and animals, primarily dogs. He notes its prevalence in regions like the Mediterranean and its expansion due to climate change and imported infected dogs. 5.19 Sue questions whether leishmaniasis occurs naturally in the UK or is solely imported. Christian mentions reported cases in the UK, suggesting transmission via infected phlebotomine flies brought back by travelers from endemic regions. The conversation shifts to the sandfly vector responsible for transmitting leishmaniasis. Christian describes the sandfly as small, silent, and potentially painless, emphasizing its absence in the UK but the possibility of migration due to global warming. Christian advises against using repellents on dogs in the UK due to environmental concerns but stresses the importance of monitoring the situation, given he acknowledges the likelihood of sandflies reaching the UK in the future. 7.27 John queries if leishmaniasis can be transmitted by other vectors like fleas. Christian affirms that sandflies are the primary vector for the disease, although other potential vectors are suspected but not proven. John then asks if humans can contract the disease from infected dogs. Christian explains that with the vector absent in the UK, human transmission from dogs is unlikely. However, he emphasizes the importance of isolating positive dogs to prevent transmission through blood transfusion. Chapter 2: The Haunting Symptoms and Diagnosis 9.11 The conversation then transitions to the clinical signs of leishmaniasis. Christian describes typical systemic symptoms such as anorexia, weight loss, lethargy, and mucous membrane pallor, along with some less common signs like polyuria and polydipsia. Christian also discusses characteristic skin lesions, including non-pruritic exfoliative dermatitis and erosive lesions. Sue adds her observations about the scaly appearance of affected dogs without itchiness, contrasting it with parasitic skin conditions. Christian concludes by stressing the importance of diagnostic assistance in accurately identifying the disease, especially considering its varied clinical presentations. 12.09 Sue brings up how leishmaniasis can affect nails, prompting Christian to elaborate on what clinicians might observe. He describes nails that grow unusually long and fast, resembling talons rather than being deformed. Christian notes that this sign is relatively rare in his experience, with scaly dermatitis or ulcerative dermatitis being more common presentations. 13.11 Sue then queries whether certain clinical presentations carry a better prognosis than others. Christian explains that prognosis depends on the severity of internal organ involvement, particularly kidney disease. The disease originates from the skin but can affect various body parts due to the immune system's reaction. 14.12 John asks how general clinicians diagnose it. Christian outlines that diagnosis relies on compatible clinical signs and specific clinical pathologies, notably anemia and changes in protein levels. While general practitioners can conduct serological tests, more specialized examinations may require referral to a laboratory. Christian emphasizes the importance of considering travel history and ruling out other conditions before treatment initiation. 16.40 Sue raises the issue of screening for leishmaniasis in dogs rescued from abroad, inquiring about the incubation period and when to start screening. Christian explains that the incubation period varies greatly, suggesting performing a quantitative serological test six months after returning from an endemic area. If positive, measures like using repellent and excluding the dog from blood transfusion banks are advised. Sue seeks more detail on the blood tests, and Christian elaborates on measuring the amount of Leishmania-specific antibodies using quantitative serological tests. These tests help detect high antibody levels, indicative of infection. Advert Ditty What products do we have now? Do we have a Zincoseb one, any shampoos? Chapter 3: Eternal Vigilance Against the Parasite 18.55 John then asks about therapy options for positive cases. Christian emphasizes the goal of controlling clinical signs and pathological abnormalities, as complete parasite elimination is rare. Therapy typically involves a combination of leishmanicidal drugs, which aim to kill the parasite, and leishmaniostatic drugs, which maintain a low parasitic level, together aiming to reduce the parasitic load and prevent relapses. He notes the need for topical treatments alongside systemic therapy to manage symptoms like scaly skin. 22.00 John asks about drug availability and Christian mentions challenges in drug availability and potential side effects, particularly with drugs like allopurinol, which can cause adverse urinary effects. He recommends monitoring for crystal formation in the urine and considering alternative treatments if needed, highlighting emerging immunomodulatory drugs as promising options. However, his leishmanicidal drugs of choice would be allopurinol and meglumine antimonate. 23.55 Sue then asks about the expected response time to treatment and the monitoring process. Christian explains that clinical improvement can be seen in about four weeks with meglumine antimonate and two months with Miltefosine, an oral drug. Monitoring every three to four months is crucial, although antibody titres may take longer to decrease. 24.55 John asks about the lifelong management of the disease. Christian confirms that the drugs can be expensive and may need to be imported, emphasizing the importance of compliance and regular check-ups to improve prognosis. 25.51 Sue concludes by highlighting the role of primary care vets and dermatologists in managing the disease. She also enquires about alternative treatments like turmeric and herbal concoctions. Christian stresses the importance of evidence-based treatments and mentions dietary nucleotides and active hexose correlated compounds as effective alternatives. 27.29 Sue thanks Christian and expresses concern about the potential spread of leishmaniasis in the UK due to warmer summers and increased animal movements across borders.

Welcome to a new episode of the Skinflint Podcast, celebrating our impressive milestone of 10,000 downloads. This episode is a deep dive into the crucial role of sustainability in veterinary dermatology, presented to you by Nextmune UK and Elearning.Vetand featuring Monika Linek.   Chapter 1: Setting the Sustainability Stage  (03:10) Sue introduces Monika to the podcast, who shares her experience as a German dermatologist and diplomat of the ECVD. Monika discusses her work in a referral practice in Germany and her involvement in "Parents for Future," advocating for climate justice and sustainability.   (05:20) Monika defines sustainability as meeting present needs without compromising future generations' ability to meet their own. It involves maintaining a balance to prevent depletion of natural resources and harm to ecosystems. Sue emphasizes the importance of sustainability in preserving the Earth for future generations. Sustainable practices ensure a lasting and enduring system for future generations.   (06:40) Sue raises the issue of sustainability in veterinary dermatology practices and asks Monika about potential improvements. Monika highlights several areas for improvement, including reducing carbon footprint from energy use, transportation, and waste management.   (07:39) Monika acknowledges the challenges of telemedicine in veterinary dermatology due to the necessity of physical examinations. However, she sees potential in remote consultations for follow-ups or initial assessments, particularly for referring practices. Finding a balance between technology and quality care is crucial. Monika also notes telemedicine's ability to reduce clients' carbon footprint by minimizing travel, a point Sue agrees with, emphasizing its role in complementing traditional consultations and promoting sustainability.   Chapter 2: Navigating Sustainable Solutions   (10:19)  John asks about areas in veterinary dermatology that could reduce carbon footprint. Monika underscores the importance of considering the environmental impact of drugs, particularly antibiotics and anti-parasitics. She notes the shift towards antibiotic stewardship and the need to rethink the use of topical anti-parasitics like chlorhexidine. Monika emphasizes the necessity of rethinking and changing practices regarding drug usage to minimize environmental impact.   (12:32) John appreciates Monika's insights and finds them encouraging, as these considerations align with responsible veterinary practices. He delves into the choice between systemic and topical treatments in dermatology, seeking Monika's opinion on their sustainability. Monika discusses the need for susceptibility testing before antibiotic use and emphasizes the benefits of combining topical treatments with antibiotics to reduce treatment duration. She advocates for avoiding systemic antibiotics when possible, relying on topical treatments alone for superficial pyoderma.   Regarding alternatives to chlorhexidine, Monika suggests hypochlorous acid as a more environmentally friendly option. Sue agrees, highlighting the importance of effective yet eco-friendly alternatives that do not compromise animal health.   (16:28) The conversation shifts to the development of technologies like photonic therapy as potential replacements for topical treatments. However, Sue acknowledges the challenge of balancing efficacy, cost, and environmental impact in private veterinary practice. Monika points out the need to address the pricing of eco-friendly products, highlighting the broader systemic issues surrounding their accessibility and affordability.   Chapter 3: Practical Sustainability   (18:36) John raises a practical question about the disposal of unused medications and antiseptics. Monika mentions new guidelines in the UK for returning unused or expired antibiotics and medicines to clinics for proper disposal. She highlights the importance of implementing better waste disposal systems for medicines in the future. Sue adds that the UK has an "antibiotic amnesty" campaign encouraging people to return unwanted antibiotics to designated drop-off points instead of disposing of them improperly. These drop-off points include pharmacies and veterinary clinics, which have appropriate methods for disposing of clinical waste.   (21:36) John raises the idea of reusing items in veterinary practice, such as scalpels and biopsy devices, instead of relying solely on single-use plastics. Monika suggests that while it may be challenging to revert to using glass syringes, there are still opportunities to explore reusable alternatives for certain items, such as surgical gowns and towels. Sue emphasizes the importance of putting pressure on manufacturers to produce more recyclable and sustainable products, even if it means paying a bit more. When discussing sterilization methods, Sue acknowledges that there are various factors to consider, such as the environmental impact of disposing of sterilizing solutions. Monika suggests that methods like autoclaving could be more sustainable if powered by renewable energy sources like solar or wind power, reducing their carbon footprint.   (26:53) John reflects on the complexity of sustainability discussions within veterinary practice, noting that while there may not always be clear answers, the important thing is that people are actively engaging in conversations and considering sustainable practices. Monika raises concerns about greenwashing and emphasizes the need for genuine action rather than just slogans. Sue adds that changing habits can be challenging but underscores the importance of prioritizing sustainability in everyday actions, even those seemingly small, like shutting down computers.   (29:00) Shifting the conversation to dietary choices for animals, Sue asks about sustainable options for food trials, particularly considering allergies. Monika discusses the challenges of finding novel protein sources and suggests that home-cooked diets may be more sustainable, though caution is needed, especially with cats. She also highlights the need for transparency from pet food manufacturers regarding the carbon footprint of their products, echoing the call for informed decision-making and accountability in veterinary practice.   (34:35) Monika highlights three key tips for sustainable veterinary dermatology practice: rethinking antibiotic and antiparasitic use, addressing waste management through the waste hierarchy, and reducing paper consumption by embracing digital solutions. Sue acknowledges the importance of these tips, emphasizing their relevance for all veterinarians. John expresses gratitude to Monika for her insights and contribution to the discussion on sustainability in veterinary dermatology.

Chapter 1: "The Dermatological Agent: Ross's Malassezia Mission"   02.42 - John begins by welcoming Ross to the Skinflint podcast and acknowledges Ross's expertise in "Malassezia." He asks Ross to share his background and explain what Malassezia is.   Ross introduces himself as a professor of veterinary dermatology, detailing his experience in farm practice and later transitioning to small animal practice. He pursued further studies and a Ph.D. specifically focusing on Malassezia, and so has been interested in them for more than 30 years.   03.44 - John asks Ross to elaborate on Malassezia, describing it for listeners who might not be familiar with the term.   Ross explains that Malassezia is a group of yeast found naturally on the skin of various mammals and birds, thriving in lipid-rich environments. It typically exists as a commensal organism on the skin but can become an opportunistic pathogen, leading to dermatitis and otitis in dogs and occasionally in cats and horses.   05:27 - Sue asks if Malassezia is the same across different species or if there are variations.   Ross explains that there are 18 known species of Malassezia, each potentially adapted to a specific host. He discusses examples like M. cunicui in rabbits, M. caprae in goats, and M. equina in horses. He notes M. pachydermatitis as the dominant species in dogs, which is unique as it can grow on routine culture media, unlike other species requiring lipid supplementation. In contrast, cats may have different species like M. nana and M. slooffiae, among others, leading to variations in yeast colonisation. There's a discrepancy between what's identified molecularly and what's observed in cultures, particularly in dogs, highlighting an unexplained scientific disparity.     Chapter 2: "Species Confidential: Malassezia's Breed of Intrigue"   8.44 - John asks Ross about the location of Malassezia on animals.   Ross mentions that, in dogs, Malassezia is predominantly found in web spaces (75-80%), lip fold regions (similar proportion), and ear canals (about one-third). Lower levels are detected on the trunk, axilla, groin, and dorsum due to their warm, moist nature.   10.00 - John inquires about identifying Malassezia in cytology with dermatology tests like tape strips or impression smears.   07:35.54 - Ross confirms that Malassezia has a characteristic peanut-shaped morphology, identifiable under microscopy, usually abundant in specimens obtained from areas like a friendly basset hound's ear wax or neck fold wax, which are good teaching examples.   08:17.63 - Sue asks Ross about determining the relevance of Malassezia presence in ears or skin. Ross explains breed-specific variations in normal yeast population, how certain breeds might have high yeast counts without causing issues, and that the anatomical site also influences yeast populations. He notes that there's no clear clinical cut-off for relevance; treatment response often helps assess its significance, as excessive yeast might not always correlate with clinical symptoms.   14.39 - John asks Ross about the clinical signs indicating an overgrowth of Malassezia.   Ross explains that signs like inflamed or greasy skin, particularly in folded areas, ears, neck, or groin, are indicative of a potential Malassezia issue, especially in predisposed breeds (he names some).   16.48 - Sue asks Ross about Malassezia as a primary or secondary disease and its relation to underlying issues. Ross mentions that Malassezia is a commensal yeast and when it causes disease, it's often secondary to an underlying problem, involving immune system imbalances or hypersensitivity responses. Ross confirms that even in breeds prone to Malassezia, like Basset Hounds, there's usually an underlying cause for yeast proliferation. He mentions high Malassezia colonisation in mucosal populations of Basset Hounds, indicating more than just skin folds contributing to the issue.     Chapter 3: "Fungal Intrigue and Secret Signs: Unravelling Malassezia's Plot"   20.33 - John discusses the common misconception regarding skin folds and Malassezia issues in certain dog breeds with Ross. They touch upon the possibility of Malassezia hypersensitivity, its occurrence in certain dogs, and its association with atopic dermatitis.   Ross explains that while Malassezia hypersensitivity exists, its clinical presentation might not always correlate with immediate hypersensitivity reactions. He discusses intradermal testing in Bassett Hounds and the presence of IGE reactivity in some dogs, especially those with atopic tendencies.   25.19 - Sue asks Ross about primary care veterinary surgeons' preferred methods for diagnosing Malassezia dermatitis. Ross recommends simple techniques like ear swabs, tape strips, and microscopic examination for diagnosing Malassezia in primary care settings.   26.21 – John asks about whether this can be transferred between pets and humans.  Ross discusses the potential for Malassezia transfer between pets but emphasises that transferring Malassezia Pachydermatitis from pets to healthy owners is quite unlikely. He mentions instances in neonatal care units where Malassezia-related infections traced back to pet dogs have been observed, emphasising the importance of handwashing in preventing transmission.   28.18 - John inquires about treatment recommendations for Malassezia infections. Ross emphasises the accessibility of Malassezia yeasts for topical treatment and discusses the practical challenges in applying topical therapy to dogs with dense hair coats. He highlights the efficacy of 2% miconazole/2% chlorhexidine and 3% chlorhexidine shampoos based on consensus guidelines, alongside systemic treatments like itraconazole and ketoconazole.     34.29 - Sue asks Ross about the role of steroids in managing chronic Malassezia otitis and skin infections. Ross explains the importance of oral prednisolone for reversing stenosis in the ear canal and discusses the use of steroids in chronic Malassezia dermatitis, particularly in cases with allergic components, thickened skin, and hyperpigmentation.   39.44 - Ross provides a summary of the approach to Malassezia otitis externa and skin infections, suggesting a varied approach depending on the severity of the condition. He highlights situations where combining prednisolone with antifungal treatment may be necessary.   Sue and John express their gratitude to Ross for his expertise and wealth of information on Malassezia. They acknowledge the complexity of the subject and appreciate the insights shared during the discussion.

John introduces the podcast and the co-hosts for this conversation; the guest on this episode is RCVS Specialist in Veterinary Oncology, David Killick.   Chapter 1 – Little Miss Diagnosis David's Background: 2.14 - David began in general practice in 2003 and later specialized in medical oncology at the University of Liverpool, earning a PhD at the RVC in London. He is now the professor of veterinary oncology at the University of Liverpool.   Malignant vs. Benign: 3.19 - Benign growths stay localized, mostly causing no problems during a pet's lifetime, while malignant growths can invade nearby tissues and spread. 4.49 - Approximately 40-50% of skin growths in dogs are malignant.   Investigate All Lumps 5.30 - Investigate All Lumps: Investigating all skin lumps is essential, even if no immediate action is taken. Initial investigation involves history-taking and examination, looking for signs like attachment to underlying structures or enlarged lymph nodes.   Biopsy Importance 8.05 - Diagnostic biopsy samples, including fine needle aspiration (FNA), are invaluable in veterinary medicine. FNA is minimally invasive, providing initial insights in 80-90% of cases. It may not offer a precise diagnosis but guides further steps. David suggests fine needle aspiration as a cost-effective initial diagnostic tool, emphasizing its utility in informed decision-making. Other options include incisional and excisional biopsies, each with its own considerations regarding risks and benefits. By prioritizing fine needle aspiration, veterinarians can efficiently navigate the path toward accurate diagnoses and appropriate treatment plans.   Factors Influencing Animal Skin Tumours 11.05 - Sue inquires about factors influencing susceptibility to skin tumours in animals, such as age, breed, and sex. David discusses breed-related associations with specific diseases in veterinary oncology, citing mast cell tumours in bulldogs, boxers, and retrievers. He mentions melanomas more common in Scotties and Schnauzers and highlights characteristics like rapid growth and tissue attachment raising malignancy concerns.   Identifying Common Benign Lumps Visually 13.18 - John seeks insights into visually identifying common benign lumps. David notes some, like skin tags, papillomas, and sebaceous adenomas, can be recognized by appearance. Skin tags are outgrowths, papillomas breed-specific, and sebaceous adenomas common in aging Cocker Spaniels. David advises monitoring, measuring, and fine needle aspiration for accurate identification.   Understanding Pigmented Tumours in Dogs, Especially Melanomas 16.33 - Sue asks about pigmented tumours in dogs, melanomas specifically. David explains not all pigmented tumours are melanomas. Dark or black lesions suggest melanomas, including malignant melanoma and benign melanocytoma. Skin melanomas may require removal if melanocytes are detected, with digital and oral melanomas requiring active management.   Identifying Melanocytes in Fine Needle Aspirations 18.00 - Sue questions melanocyte identification in fine needle aspirations. David notes pigmented tumours are usually melanomas, with characteristic black granules in cells. He mentions amelanotic melanomas' rare occurrence, especially in oral cases.   Chapter 2 – Introducing Mr Mast Cell Insight into Mast Cell Tumours 18.52 - John seeks insight into mast cell tumours (MCTs). David explains their origin from mast cells, which release histamine and cause itchiness and redness. MCTs may periodically change size upon palpation. They are common in dogs, especially specific breeds, potentially requiring multiple management due to recurrence.                       Using Fine Needle Aspirations (FNAs) for Diagnosis and the Role of Veterinary Nurses 22.10 - John inquires about using fine needle aspirations (FNAs) for diagnosis and the role of veterinary nurses in interpreting samples. He wonders if preliminary assessments in practice are acceptable due to budget constraints and potential risks. David encourages practitioners, including vets and nurses, to develop cytology skills, which are enjoyable and relatively easy to learn. He suggests self-examining slides in their lab, writing reports, and seeking feedback for skill improvement. David notes that mast cell tumours are an excellent starting point for cytology learning as they often feature distinctive "fried egg-like" cells with blue to purplish granules. However, expert consultation is crucial for tumours with unusual characteristics or more aggressive features.   The Necessity of Biopsies for Tumour Grading After FNAs 25.15 - Sue questions the necessity of biopsies after fine needle aspirates (FNAs) for tumour grading. David notes FNA's value in general practice and good correlation with histological grade. He emphasizes combining clinical tools and considering staging, especially for higher-grade tumours. For less aggressive cases, FNA of the draining lymph node may rule out lymph node involvement before surgery. David discusses grading schemes, including the pattern grading scheme and Kiupel system.   Chapter 3 – Mr and Mrs Outcome Treatment Options for Mast Cell Tumours 29.55 - John inquires about mast cell tumour treatments and whether they're managed in primary vet settings or by specialists. David explains treatment involves addressing the local tumour through surgery or radiation therapy, with staging for potential metastasis. Medical therapies like chemotherapy or growth factor inhibitors are considered if metastasis is found. Emerging therapies like Tigilanol tiglate and Electro Chemotherapy are mentioned, particularly for challenging cases.   Prognosis of Mast Cell Tumours 35.52 - John inquires about mast cell tumour prognosis. David explains that low and intermediate-grade tumours have a generally favourable prognosis with surgery, even if some cells remain at the margins. However, high-grade tumours, especially if they've spread, often require ongoing medical therapy and monitoring, with potential recurrence.   Key Points on Dealing with Dog Lumps and Seeking Specialist Guidance 37.54 - Sue summarizes key points: Urges not to ignore lumps on dogs, as up to 50% can be malignant. Recommends consulting specialists like David instead of relying on online sources for accurate guidance and evolving treatment options. David appreciates the summary, emphasizing the dynamic nature of oncology and the limitations of online information.   https://www.liverpool.ac.uk/sath/about-us/   43.44: John wraps the pod with another daft questions.

Log this CPD with 1CPD here    (00:00) John introduces the podcast and welcomes our guest for this episode - the founder of the Dermatology Referral Service in Glasgow, Peter Forsythe.   Chapter 1 – The Ears   (02:58) John welcomes Peter Forsythe, who talks about how he got involved in dermatology and how ear disease makes up half the caseload in the referral practice he works at.   (04:41) John asks why it is important dogs have clean ears and Peter discusses the long tube made up of the auricular and annular cartilages which are lines with glandular skin which produces wax - which combines with skin cells to make up what we know as wax. He says a build-up can alter the environment on the ear canal, increasing humidity and increasing the number of microbes such as bacteria and yeast, which - whilst normally present - can develop into an overgrowth or even infection. He also talks about the concretions, or balls of ear wax which can form adjacent to the tympanic membrane or ear drum, and they are called ceruminoliths and can sit on the ear drum and damage and even perforate it. So it is important to manage this ear wax and keep the ear clean.   (07:55) Sue asks about the ‘self cleaning’ mechanism the ear called epithelial migration and Peter describes this as similar to the shedding of cells we have on our continuously growing skin cells, but in the ear these have a sliding, upward motion to them as they do this, and this slowly carries cells and wax up and out the ear like a slow moving escalator – at the speed our nails grow at.   (09:49) Sue asks if this changes with age and Peter says there isn’t information on age changes, but in cases of inflammation or disease this is affected, slowing it down and then leading to increased build up of wax. Peter says the human ear produces 2 kilos of wax in a lifetime!   (11:32) Sue asks what Peter recommends to clients in terms of ear cleaning with puppies and he doesn’t recommend routine ear cleaning in puppies if they are healthy, as the mechanism is working well; however, he does think in those breeds where they are prone to ear disease, that it is good to get them used to you handling their ears at a young age.   Chapter 2 – The Cleaning   (13:34) Sue asks about hairy ear canals or plucking ears and Peter says in his view plucking hairy ear canals in poodles and bichons for example, where the hair can trap the wax, can irritate and inflame the ear and begin ear disease, so he wouldn’t pluck them. If the dog has got ear disease (otitis) then some plucking maybe necessary – but ear phobia – where a dog has had bad experiences and they won’t let people go near their ears, is more of an issue and plucking can lead to this. He would prefer then to begin cleaning if you can see wax building up. This is the same with a dog with a pendulous (flappy outer) ear (which can also contribute to ear disease) – but he does point out too much cleaning can overly wet the ear and cause more problems – so each case must be considered carefully.     (17:15) Sue asks as a pet owner who can see so many different ear cleaners, what can help you decide and what to look for and Peter divides these into two. Firstly softening or dissolving ear wax products called cerumenolytics, containing things like propylene glycol, mineral oils, glycerine; through to secondly salicylic acid or even stronger sodium docusate (DOSS) or carbamide peroxide (which is only recommended in anaesthetised dogs) which dissolves. Sue clarifies then this depends on how waxy the ear is as to which you reach for and Peter says it is recommended to talk to the vet about it rather than purchasing straight from the internet.   (21:10) John points out it is important then for any nurse or vet to have a good understanding of the ear cleaners on their shelves and Peter wholeheartedly agrees, saying for example a more water based ear cleaner being used to dissolve and remove wax doesn’t make sense and also cleaning isn’t comfortable for the dog; so it is important to demonstrate the use of a product to an owner, and give them tips such as warming the ear cleaner a little to make it more comfortable.   Chapter 3 – The Cleaners   (24:20) John asks about powders and Peter remembers when they were used more frequently, but he does not recommend them at all as they mix with the wax and make it stickier and dryer. John goes on to ask what changes in the ear once disease starts to set in; Peter says if a dog has had ear disease once, it is very likely to happen again and can happen repeatedly. Over time this changes detrimentally the ear canal; the lining becomes thicker and the tissues become swollen and oedematous, the glands become enlarged and even massive over time; all this narrows the ear canal and impairs the epithelial migration and so you have an increased build up or wax in a smaller canal and this favours the further build up of bacteria and/or yeast in the ear. He also says the ear drum can then weaken and even perforate, so a hole can appear and then infection can get into the middle ear which is both more serious and hard to treat. He points out if the ear disease being allowed to continue year on year this can then result in long term changes where the ear cartilage becomes calcified, so effectively into bone – at this point often only surgery can help.   (29:38) Sue mentions these dogs all have underlying issues which cause these ear problems, and flags this for a further podcast. Sue then asks about the cases where we have these changes and the presence of yeast and bacteria and asks if there should be cleaning in all of these cases; Peter replies that there is strong evidence to say that due to the increase in discharge they should all be having regular cleaning – as the normal treatment for these cases - antibiotic and or antifungal ear drops - need to be able to get to the lining of the ear through this discharge in order to work. So, they need cleaning prior to the drops going in. Sue asks if these are the antiseptic cleaners we would use and Peter agrees, saying you want the cleaner to both remove the wax build up but also have an antiseptic effect, he mentions isopropyl alcohol, para-chloro-meta-xylenol (PCMX) and in particular chlorhexidine with Tris EDTA as a common effective combination for these cases – which in some cases can resolve the disease when used as a sole treatment. Sue reflects that as in Scandinavia as heard on a previous SkinFlint, more thought is going into using these to avoid antibiotic use.   (32:47) Sue asks Peter what a practice would have as three key ear cleaners for stocking their pharmacy, Peter says three is a good number and they would want a soothing, wax softening cleaner for the low symptom waxy ears – such as a glycerine, propylene glycol or mineral oil with camomile for example. Then a more potent, cerumenolytic ear cleaner, possibly with a detergent such as DOSS or chlorhexidine or alcohol. Then the third would be an aqueous ear cleaner for use in the purulent, pus based discharge in severe cases such as a pseudomonas infection, and this would be the chlorhexidine and Tris EDTA combination as discussed.   (36:34) John wraps up and summarises the conversation.   (41:35) John asks his co-hosts the usual daft questions so we don’t take ourselves too seriously!

Log this CPD with 1CPD here    (00:00) John introduces today’s guest - host of another veterinary dermatology podcast The Derm Vet, Ashely Bourgeois.   Chapter 1: UK vs US Dermatology   (02:50) Sue asks Ashley how she started out in podcasts and Ashley shares her story, wanting to stay involved in dermatology whilst also raising children and not wanting to lose that knowledge base, and helping  others in that kind of position.   (04:33) John asks Ashely and Sue what the difference between the UK and US in approach to dermatology. Sue says the approach is the same, but the system is slightly different and there isn’t so much of a referral process in the US as here in the UK. Ashley agrees, saying often people will come direct, but that they have good relationships with first opinion practices in order that clients are aware dermatologists exist.   (06:45) Sue says the board certified dermatologists exist in both regions, but in the UK we have an intermediate tier of advanced practitioners which doesn’t exist in the states; therefore asking Ashley if there are any areas in the US which aren’t covered well geographically with specialists. Ashley says there are areas without specialists, and there is work to see if they can develop better coverage; including the possibility of telemedicine in for example a state that doesn’t have dermatologists.   (08:58) Sue asks if the rules around dermatology prescribing through telemedicine differs state to state and Ashley confirms this, saying in her state for example, they must see a client at least once a year whereas in other states this is possible long term remotely.   Chapter 2: UK vs US Antibiotic Use   (11:30) Ashley then asks Sue if it differs in relation to staphylococcus infections in the UK and US and Sue says it really does, and also across Europe from the UK. She points out in Scandinavia they hardly use antibiotics at all and use antiseptics much more, and this seems to really correlate to having less resistance. Sue asks for example if Ashely would use vancomycin and Ashely says whilst she hasn’t for this one she has had to use rifampin and chloramphenicol. She reflects there is a shift in the mindset with the use of antibiotics because of the number of times they will only have one or two choices left due to resistance.   (14:45) Sue asks if it is right you can buy neomycin, polymyxin, bacitracin over the counter and Ashely says you can for topicals, and said she even had a client who had fish antibiotics they were giving to their dog whenever they felt there was an infection. Sue reflects what would be available by comparison in the UK.   Chapter 3: UK vs US In Practice   (17:17) John asks whether a clients expectation would differ in terms of approach to a skin case in the states than in the UK and Ashley says there is much the same issue in terms of clients not understanding the long term nature of skin management, particularly in allergy and also the multimodal approach; where often more than one therapy is going to manage the patients skin. She is always quick to point out to owners these cases will change and even when well managed, this will change and they will flare up.   (20:14) John reflects that in the US the Vet nurses or Vet Techs as they are called there are still as important to case management as here in the UK and Ashely passionately agrees, saying they are critical to the solidification of a case management – instilling confidence in the owners to the treatment plan long term. They also catch mistakes and understand the cases very well.   (23:05) John asks Ashely about the education side in terms of the difference with logging CPD and education. Ashley says the regulations are quite strict in terms of whether she can talk off label at lectures and online and her and Paul reflect on some of these aspects.   Chapter 3: UK vs US Dermatology Top Trumps   (26:27) Sue asks Ashley for most common presentations and Ashley and Sue spend some time reflecting on the differing cases and presentations seen both in the US and UK. Where Ashely is in the US the climate is similar but Sue reflects it is interesting how the diseases are so different.   (33:50) John wraps the podcast by asking Sue and Ashley what their favourite and least favourite disease it. Pemphigus comes out well whilst sterile nodular panniculitis and bald Pomeranians/alopecia X and lick granulomas really don’t!     Visit Ashley’s Website HERE   Search The Derm Vet Podcast on your podcast platform, or follow the link HERE

Ep.16 Show Notes   In this Skin Flints episode, Sue, John and Paul welcomed Dr Arielle Griffiths to the platform to discuss a very topical subject - sustainable pet food.   (00:00) Introduction   Chapter 1: “Understanding the Urgency: Why Sustainable Food is Necessary for Our Pets”   (03:44)  John welcomes Arielle to the pod, who talks about her work in the industry and in setting up the Sustainable Pet Food Association. As a GP vet she became involved in nutrition and did extensive research before also becoming environmentally and sustainably focused as a result of seeing a change in the world.   (07:31) Sue asks Arielle to clarify what is meant by obesity-based diets and Arielle says this is where owners are (through love) overfeeding their pets and potentially causing arthritis, heart disease and a number of conditions relating to the excess weight. This tipped her to realise the use of plants as a base in food can really help, which was a big factor in her  becoming vegan herself.   (09:08) Sue clarifies we are talking about people feeding too much or an imbalanced diet and the carbon footprint of that diet – and that we are discussing dogs here and not cats. Arielle says that the need for palatability in foods has resulted in an excess of protein in the diet and more meat being used than needed, affecting the sustainability. She shared that wet, meat-based diets have the largest carbon footprint, including raw lean diets – with one study in Brazil demonstrating a dog on this diet matched that of a human in that country.   Chapter 2: "Exploring the Landscape: What Constitutes Sustainable Food?"   (11:49) John asks why vegetarian or vegan food is a more sustainable option and Arielle says it is proven that animal agriculture for the use in pet food accounts for 2.5 - 3% of the entire carbon footprint of the world. This comes from deforestation to provide this food and the by-products of the food as a result of the market.   (13:40) Sue clarifies this as methane production from the animals used increasing the carbon emissions along with the deforestations. Livestock accounts for over 70% of global farming land use but only produces 18% of the world’s calories and 37% of total protein - with dog and cat food being equivalent to an entire country’s worth of production. But Arielle says the health benefits are what turned her more to vegetable based foods.    (15:29) Sue comments on the information on the human side for the health benefits, with more GPs suggesting it – she asks if there is evidence to support this on the pet side. Arielle says there is and comments on how in the 27,000 years of domestic evolution dogs have developed to require 52% of their diet to be carbohydrate due to the change in their genes over that time compared to the wolf they descended from, which only needs 1.2% carbohydrate. She also says dogs 3,000 years ago were primarily plant based.   (17:09) John asks if the theory of raw feeding being more natural for dogs is therefore unmerited and Arielle agrees, explaining that dogs obviously love eating food like this which is the success of the industry – but in terms of the environment there is significant evidence that resistant bacteria has been shown to be happening as a result of raw feeding, as well as it not being healthy for the dog. And she reiterates - a dog is not a wolf!   (19:18) John goes on to clarify Arielle is advocating a formulated dog food which is vegetable based and asks if it could be insect based. Arielle says it could and there are a number of companies for this, but she focuses on vegetable based and insects are just using another way of recycling protein and therefore whilst they are more substantiable – they are not as much so as the vegetable equivalents. She mentions how she was one of three vets speaking on the subject at London Vet Show along with Professor Andrew Knight and Dr Mike Davies - talking about animal nutrition and the evidence for vegetable based diets, which previously had looked to have a vegan diet, but a new independent study from Australia and Mexico reviewing all the papers indicated the evidence is sound. She argues now we know they are healthier for our pets and our planet there is an urgency.   Chapter 3: "Making Informed Choices: Considerations for a Sustainable Diet"   (24:40) Sue asks what we do about different life stages and different conditions and Arielle says there is a puppy plant based food and a senior plant based food – and in fact any plant based food is good for senior dog.   (26:12) Sue asks about particular conditions as well (e.g.) skin conditions and Arielle says she’s getting 2 or 3 people a day asking her to transition their dogs from meat diets because of an intolerance to it, and much has been shown to evidence the gut microbiome health being linked to that of the sin and therefore the skin health.   (28:19) Sue asks if you can transition to a plant based diet overnight. Arielle advises that the cases where they are really uncontrolled and unhappy on the food can transition overnight with a care to not over feed. But for the majority of dogs - as with any dietary change - a slow transition over 2-3 weeks is better; 4-5 weeks for raw fed dogs, in order to allow the gut to adapt to the change.   (29:29) Sue asks about the evidence suggesting grain free diets can lead to heart disease and Arielle says this came about in 2018 with increased instances of dilated cardio myopathy in breeds you wouldn’t normally see. She explains this is a result of substitute ingredients and is resolved with the addition of taurine to diets – which is an important reason to use a formulated diet. The number of cases has now dropped as a result of these changes.   (32:45) John wraps the conversation and asks Arielle if there are any resources to highlight and Arielle again recommends the Sustainable Pet Food Association as a great resource to find out more, and find the right food.   (36:18) Outro – Sue raps up as an ever-wise voice of reason.   (40:57) John asks Sue and Paul - Beef or beans?!

Ep.15 Show Notes   In this Skin Flints episode, the team were delighted to host one of the giants of the equine world - the brilliant Derek Knottenbelt (or Knotty, as he is also known).   Log this CPD with 1CPD here    Chapter one: Knotty   (03:49) Sue introduces Derek Knottenbelt who gives his background in the industry and his practical emphasis.   (05:09) Sue asks Derek "what is a sarcoid?". He describes it as a reactive skin tumour – so skin cancer is the best way to think about it and not viral as it has been before which has resulting in an incorrect approach; a multi-morphology skin tumour affecting all equid species and continuing to puzzle the scientific world.   (07:00) Sue asks whether it can be contagious given it is a tumour and Derek says that it is his contention that it is transmissible with circumstantial evidence to suggest this, but the mechanism for this is very little understood – it has some relationship with the bovine papilloma virus.   (08:06) Sue asks flies are spreading this and Derek says it is – where sarcoids occur tend to be where the skin is thin – where flies can feed with impunity – where it sweats and there is less hair and therefore where flies feed. Derek doesn’t believe it is the biting fly that transmits it – but a surface feeding fly which feeds on a sarcoid and then transfers the sarcoid element into the site of skin trauma on another horse – which could include where a biting fly had caused tissue damage.   (10:12) Sue says this would fit with periocular sarcoids as flies tend to feed there and Derek again agrees, saying wherever sarcoids occur rarely, they are always associated with wounds which further demonstrates this. Derek uses the analogy of surface feeding flies being like teenagers going to MacDonalds, where the food is greasy, warm and available at almost no cost – whereas biting flies are like Richard Branson who wouldn’t dream of going to MacDonalds but a 5 star Michelin star restaurant – before then saying sometimes the biting flies go there after and have a pub drink and transfer the sarcoid. This all fits the epidemiology of the disease – but the process of exactly how this happens and the link to bovine papilloma virus is not yet fully understood.   (12:36) John summarises the conversation so far and Derek goes on to show how in 1985 in a survey 2.5% of British horses had sarcoids, with an average of 2.5 sarcoids each. In 2018 this had risen to 8% of British horses with an average of 24 sarcoids each - so this disease is steadily increasing.   Chapter 2: Sarcoidy   (15:06) John asks if there are any breeds, ages or predispositions which are more susceptible and Derek says that whilst some studies have demonstrated this he does not think it is so simple having seen sarcoids in just about every breed that is available – he says there are genes which impart susceptibility as there have been outbreaks within families of horses. So it is very difficult to isolate. He also studied age of onset within a study of close to 30,000 horses and the numbers merely mimicked the population – so no definitive evidence, and he has seen 40 year old and 17 day old horses with sarcoids. He is more convinced of conditional, situation and environmental factors over any of age, breed, gender and colour.   (19:05) Sue asks about sarcoids themselves – what do they look like? Derek says it is often misdiagnosed as something else because of how multiformal it is. Because it is a tumour of fibroblasts and not epithelial cells often what you see bears no relation to what you would perceive as a fibroblastic tumour. This is because of the effect of the viral component on the disease and the impact this has on the surround tissues. So firstly the occult form of sarcoid is not the occult tumour – but may contain the tumour – and this must be kept in mind. He goes on to say the circular nature of this form is in effect a result of the mediators diffusing out from the centre. Then the centre begins to develop and become more dermal / epidermal and morphs into something more like a wart, but is not a wart but a ‘vericosal, wart like tumour’, the next from of sarcoid. Then the next stage/form is either a hard mass-like nodule of fibroblasts called a type A nodule and is completely subcutaneous, or a type B nodule which is attached to the skin dermis. These are easy to identify and are very easily characterised. Then there is a fleshy form which is very aggressive, vascularised and ulcerated (usually infected) tumour which appears like granulation tissue. Derek says each of these types has its own potential differential diagnosis which makes them very open to misdiagnosis.   (27:07) Sue asks what causes the transition of one for, to another and if that should point to biopsy. Derek says that with the age of the tumour there is a constant progression, and traumatising the lesion will only accelerate this process (such as with a harness or a buckle, or the movement of the skin in mobile areas). This means biopsy, whilst definitely useful, is only worth doing if you have a plan of what to do when you find it is a sarcoid - as it will otherwise just exacerbate the problem.   Chapter 3: Treatmenty   (30:53) John asks then what the treatments are for a sarcoid and Derek says superficial lesions require less interventions and a 5% or 10% floriorisol and if this does not work a imiquimod – but it is important to bear in mind they are still dangerous because they don’t like being treated, so if you aren’t successful they worsen and a real determination is needed with the disease to keep progressing to the next step. A surgical or laser excision could be considered but it is critical these are sent for pathology for margins to know if you have removed it all – as not doing so require further action.   (35:04) Sue asks what the prognosis is, with good margins and without; Derek says a successful, safe margin of removal is a good base for a start – however there can be tumour cells seeded during surgery and indeed after on the scar from fly attack -so this must still be treated cautiously. If you haven’t got a successful margin you will get deep root recurrence – so by the time you see the tumour it will be twice as big. In this instance Derek likes multimodal therapy, using immunologic methods such as immunosiden, BSG or radiation, or local chemotherapy. Derek goes on to discuss types of localised chemotherapy – also pointing out you can add other therapy such as cryosurgery on top as well. Each time you are adding on a little prognosis – but Derek points out the only thing predictable about a sarcoid is that it is unpredictable and there are over 40 treatments to consider in managing these with new therapies coming out all the time and he lists some of these, but warns against the nonsense brigade – with poor evidence based treatments on the market such as marmite or toothpaste – successes in these instances are coincidental to spontaneous resolution.   (44:55) John wraps up the conversation and summarises, while sue mentions Equine Medical Solutions (Derek’s app).   Outro   (46:58) John brings the podcast to a close by putting Sue and Paul on the spot was another probing question...

In this episode of the Skin Flint podcast, Sue, John and Paul welcome Katarina Varjonen to the platform to discuss the Scandinavian approach to responsible veterinary antibiotic usage. Log this CPD with 1CPD here Chapter 1 – A Scandinavian Success Story   (02:46) Katarina introduces herself and her experience as a dermatologist; Sue clarifies she is also the incoming president of the European Society of Veterinary Dermatology.   (04:00) Sue talks Katarina's career, working in Scandinavia, the UK and the USA, commenting on how good Scandinavia is on managing antibiotic usage. Sue then asks why responsible antibiotic use is important and Katarina says the one health consideration ties in and is really important across the profession in order to avoid using them longer than needed to prevent resistance. She feels most countries have put a lot of work into eliminating unnecessary use.   (06:39) Sue asks Katarina to outline the advanced approach Scandinavia has to this and Katarina says antibiotics are not completely off limits, but the guidelines are strict for recommendations – as well as limitations to what is available on the market. So for a number of years now fluroquinolones and 3rd generation cephalosporins are limited to life threatening situations, requiring culture tests as proof. Sue clarifies these are classed as critically important antibiotics in humans.   (08:23) John says this sounds quite extreme in comparison to what we do in the UK and asks if this would be considered a few years ahead of the UK and what is happening in the US. Katarina comments on it more as a cultural difference, feeling that the smaller industry in Scandinavia has helped to spread the message from within, along with the government and health sector working hard to spread the message to the public. As a result they don’t get pressure so much from clients to use the antibiotics in the first place.   (10:19) Sue asks if it is easier to treat a disease in Scandinavia because there is less resistance to antibiotics, or whether it is harder because you have less access to antibiotics. Katarina says that actually they still have the same access, but the big difference in the case management is that in Scandinavia they are far more keyed into preventative approach to a disease, meaning the cases are better managed in the first place and therefore cases are less severe from the outset.   (12:10) John asks if this comes at all from the owners side, with them being more in-tune with identifying issues early and Katarina doesn’t believe so – she feels this comes entirely from the veterinary side.   Chapter 2 – The Prologue to a Case   (13:52) John asks Katarina to share what things would help with that early identification and Katarina says scratching and head shaking is the early sign, and whilst the approach to these first symptoms will be the same for treatment, the conversation about underlying causes is begun at this stage, which is almost always allergy. Katarina herself describes this to owners as the dog equivalent of allergic eczema but in the ear.   (16:20) Sue asks Katarina to talk through her approach to a case. Katarina says she would start by feeling the ear canal on the outside, is it firm or soft to suggest issues – it also helps the dog to get used to being handled. Then she has a look with an otoscope down the ear if the dog tolerates - or she may sedate at this stage if not – in order to examine and perform cytology. If the canal is inflamed she will go to cleaners and anti-inflammatories to open up the canal, even before thinking about treatment of the infection.   (18:07) Sue asks Katarina to clarify what is meant by Cytology and Katarina describes this as the basic and easy to perform diagnostic tool for these cases, using a Q-Tip (cotton bud) to gather material from the upper ear canal and roll onto a microscope slide before staining with Diff Quick (or similar) to look for bacteria, round or rod shaped, yeasts or inflammatory cells. As well as assessing the level of the load.   (19:43) John says this sounds quite straightforward, asking if this is something a specialist needs to do or whether a non-specialist / nurse could perform this; Katarina says that actually even in referral practice it is mostly the veterinary nurse who will do this, taking the sample, staining and even examining under the microscope. It is not specialist cytology and only takes a couple of minutes. Katarina shares that for fractious dogs a clean finger rather than a cotton bud, into the entry to the canal and rolled onto a slide will also work.   (23:18) John asks if the cytology is something that is done just initially, or whether this would be done in follow-ups and Katarina shares that she performed cytology all the time at every visit as standard. This is because as she is using anti-inflammatories and other treatments she will see an improvement visually so cytology is the only way to know whether she is resolving the actual infection.   (23:57) Sue clarifies then the switch from treatment to maintenance would be made once she observes the levels of microbes dropping to what would be considered normal rather than symptoms.   Chapter 3 – Chapter and Verse on Treatment   (25:21) Sue asks what kind of actives (stuff in the products) Katarina would use in terms of anti-inflammatories and cleaners having done cytology and found microbes present. Katarina says the texture of the discharge from the ear, whether this is fatty/lipid or ceruminous/waxy in which case she would reach for a squalene based cleaner or if it is a liquid based discharge with pus forming she would use a chlorhexidine/tris EDTA based cleaner. If she suspects a biofilm in the ear as well from slimy discharge she would add in an an-acetal cysteine flush to the cleaner.   (26:59) Sue asks what anti-inflammatories she would use and Katarina clarifies this would depend on thickening of the skin in the ear – so if the ear is stenosed/narrow she would use oral steroids in addition to topical steroid in the ear, but if it was more minor she would only use a topical. This also reduces pus formation. Sue asks how you would use a topical steroid without using the other antibiotic and antimycotic treatments that are in licensed, steroid containing topical products. Katarina says she would use a steroid on its own without the others even though the licensed products are next on the cascade, because the antibiotic stewardship wins over the grey zone element of the cascade in these instances. John summarises this and Katarina clarifies that the preparation of the ear and selection for antibiotics is critical to making sure that when she does then reach for it, it is effective as it can possibly be.   (32:33) John asks what ear cleaners when used in preparation of the ear also have some effect on the microbes we are seeing in the ear at the same time and Katarina says that actually even just cleaning out the ear gives the body and immune system a chance to start helping in fighting the infection – so begins the process. Then the likes of chlorhexidine and Tris EDTA combined, and an acetal cysteine help further to fight this if they are present in the cleaners, hypochlorous acid as well.   (35:30) Sue asks if Katarina feels that maybe in the UK we are tempted to reach for antibiotics too soon and Katarina says often we feel safer doing this because we want to manage these cases, and it is a big step to understand there are steps we can take first before assessing to see how well they have worked, in order to manage the cases which don't need antibiotics and identify the ones which do. She would try for two weeks generally first before reaching for antibiotics if there hasn’t been a reduction in the number of microbes in the ear. Sue and Katarina summarise the importance of the use of topicals to try and push forward the appropriate use of antibiotics.   (37:40) John asks one final question to Sue and Katarina on how important this is, whether people need to really take this seriously and whether there should be any pressure from the authorities on this. Katarina says we do need to take it seriously, perhaps less to with topical antibiotics than systemic (oral/injectable), but this is still very important to strive for this. Sue says that the use of cytology is critical and underperformed in terms of understanding whether there is infection present in the first place, and whether we have completely eliminated the infection at the end of treatment. We need these drugs and we turn on the resistance when we feed the bugs these drugs, and we are moving in the right direction together. Katarina echoes this, showing a lot has happened even in the last few years.   Outro   (43:55) John and Sue wrap up before John asks his usual silly question (ask your own sensible or silly question by emailing hello@elearning.vet ) – Sue and Paul are asked what frustration they would most like a drug to rid their lives of, walking into a put down by Paul!

For this episode Sue, John & Paul invite the wonderful Victoria (Tori) Robinson onto the podcast - a dermatology specialist based in referral practice in Glasgow. Log this CPD with 1CPD here 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!

In this episode John, Sue and Paul welcome Georgie Hollis back to the platform for the second half of their discussion of all things wound-related.   Log this CPD with 1CPD here   SHOW NOTES Intro (00:14) John re-introduces the ‘Queen of Wounds’ conversation from last episode’s part one.   Chapter 1 – Debridement or indeed 'debridement' in French   (01:00) Sue asks about biofilms and how she would suggest dealing with this slime over the wound. Georgie touches on diabetic foot ulcers and uses a pepper analogy for bacteria, saying a sprinkling of bacteria like pepper on the chips is where you can shake the chips and the pepper comes off. Colonisation is where the pepper is sticking to the chips and isn’t going to move, and biofilm is where the pepper has now forming its own protein coat around it and the vinegar is not going to penetrate it. So, biofilm formation is an important consideration as the body can’t remove them – it is hard to see them and know when you have them and so it is hard to know if you have removed them. You can use some antiseptic solutions to help remove these such as hypochlorous or PHMVs.   (03:35) Sue asks about honey and whether this is helpful. Georgie says honey is useful for wounds with yellow debris, as this has some properties to remove dead tissue and so is a debriding agent as well as an antiseptic. So using the yellow stuff on the yellow wounds, which gets rid of the bioburden and then the antiseptic gets rid of the contamination.   (05:27) John asks about debridement and when you would do this. Georgie says debridement gets rid of non viable tissue, where it had been damaged and the blood supply has been cut off – this is protein rich material and the bacteria will eat this and therefore you don’t want it in the wound. Manual removal of as much as possible using a scalpel under anaesthetic or with products such as honey, called autolytic debridement which uses osmosis by using sugar to draw out the dead stuff much like a poultice   (07:24) Sue asks about medical maggots and Georgie says these rather than autolytic debridement magots use enzymatic debridement where you use enzymes to break down dead tissue. So the maggots vomit the enzyme protease into the wound and this makes a protein soup which they then eat and then they poo into the wound which has been shown to have beneficial effects on granulation tissue.   (08:41) John asks then whether this pushes the owners again to go to the vet to make the decision as to whether debridement is necessary. Georgie agrees and says this goes further, where there may be different times when this is necessary, talking about a process of demarcation; so it may not be that you can tell which part of the wound is going to die and need debridement straight away. This is an important consideration, because you don’t want to cut off skin which may still be viable, meaning that it still has a blood supply and could play an important role in reducing the size of the wound.   Chapter 2 - Dressings   (10:03) Sue asks about what considerations there are with selection of wound dressings and Georgie says you need three boxes in the cupboard. 1) dressings that help you debride, and clean the wound up and help it granulate. 2) dressings that donate moisture, to stop the wound drying out – citing a study from 1962 be George Winter which showed from pigs with wounds left open to the air that they healed 30-50% slower that wounds kept moist and covered. All of our modern selection of dressings is based upon this principle of keeping the wound moist as a result of this understanding, and it is important that these dressings are left in place long enough for the wound to heal, as changing the dressing too regularly can remove cells regenerated on the wound. 3) dressings that absorb moisture absorb exudate and hold moisture to the wound as long as possible to aid healing, such as super absorbent foam dressings for large wounds. So, this is a balancing act and an art, selecting the dressing according to the type of wound and what any given wound is doing at any given time. For example, in the inflammatory, early stage there is a lot of exudate as the white blood cells work on the wound and then as the wound begins to granulate it starts to dry and a different dressing would be needed. There are many factors which will affect when and how a wound will be at each stage and Georgie lists some of these in context of areas and breeds and species.   (15:07) John asks if there are any tips on bandaging difficult areas and Georgie says there are and cites an example, a good product is a fingertip gauze you can tape on to protect the tail and John mentioned dog ends as a product on the veterinary market for this. Georgie stresses the important of anchoring this to the tail and describes this.   Chapter 3 – Georgie’s 10 Top Tips   (17:44) John asks for Georgie’s top ten hints for caring for wounds.   Nominate a wound nurse, to look after dressings and help people in the practice.Be sure to lavage a wound and as soon as possible.Don’t use toxic antimicrobials in wounds as discussed.Organise the dressing cupboard in ways as discussed.Chuck out sudocreme! Georgie feels there are better products out there.Review bandaging techniques as this might not be the best.Don’t use honey out of a jar, medical grade honey should be used, as there could be contamination in a jar of honey for food.First aid kit, having a salt solution in a water bottle and hypochlorous and get your pet to the vet as soon as possible.Puncture wounds can be serious.Sue says if it isn’t working ask for help, whether an owner, nurse or vet. As muddling on isn’t on the animal’s best interest, and Georgie wholeheartedly agrees.  (24:51) Sue asks about sustainability and how sustainable wound care is and Georgie has been thinking about this recently. Wound dressing manufacture for example is a factor, citing that manuka honey being derived from New Zealand, shipped to the UK for manufacture and then shipped back to New Zealand. She also talks about the repeat use of a Robert Jones bandaging as a huge use of recourses and sustainability gives a good reason to use a cast for this bandage type.   Outro (29:39) John wraps up the conversation with a final-off-the-wall question and Georgie plugs a friend’s company which sustainably repairs surgical equipment Fix Your Kit

This week Sue, John and Paul welcome a very friendly face (voice?!) to the podcast - one Georgie Hollis. Georgie is a wound specialist who built her career in the human healthcare industry but moved over to veterinary and created The Vet Wound Library as an incredibly useful resource for vets and nurses.   Log this CPD with 1CPD here   SHOW NOTES   Intro (00:00) John introduces the podcast team and Georgie Hollis   Chapter 1 – The queen of wound management and her wound angels   (02:16) Sue asks Georgie to introduce herself and Georgie explains her origins were in podiatry and human patients with wounds and dressings; now she has taken that understanding to the veterinary world, as there has been a lack of understanding in this area of the veterinary profession.   (04:00) Sue introduces the Veterinary Wound Library and Georgie explains how she identified that she could either become a distributor for product or independently set up a platform for vets and nurses to come and get help on choosing dressings and with cases; she then set up the library for this, with a team of specialists to help answer questions on wound surgery and dressings. Georgie talks about the ‘bandaging angels’ who go in and help practices in dealing with bandaging issues and improve their wound management.   (06:48) John asks what a wound is, and Georgie describes this as any break in the skin, caused by a surgical instrument or by accident – she goes on to say that surgical wounds are kept as clean as possible and accidental wounds are from injury and involve more damage and contamination, as well as potentially including bruises and contusions where you may have an impact.   Chapter 2 – Wounds At Home   (08:27) John then asks about whether healing is different between the two types of wound – Georgie uses an example of a cut from glass being a laceration vs a scrape along the ground which would be an abrasion, stressing all of these all need cleansing and preparing in order to allow them to heal – and this healing may not be necessarily in the way the owner would expect.   (09:30) John asks what would lead you to decide whether a wound would need stitching / leaving open / or more drastic action such as a skin graft. Georgie says one of the biggest considerations is how old the wound is, the time between when the wound happens and when it is cleaned is critical. She mentions a study where they looked at wounds in goats and saw a marked reduction in bacterial growth when the wound was new, and the research shows that for every hour earlier a wound is washed, the bacteria present was reduced by half. The multiplication of bacteria in a wound reaches a point where it overcomes the hosts response – so the earlier the wound is washed the greater chance to prevent this from happening – therefore the wounds cleaned the earliest are the most likely to heal successfully.   (11:26) Sue asks how an owner would clean a wound. And Georgie advocates the use of saline – saying this balances with the body’s own cells and citing the example of the skin becoming wrinkly in the bath. This happens because the bath water is less salty than the skin and the skin cells swell – which causes some damage. So, this is preferable to normal water and can be made with a teaspoon a salt in a pint of previously boiled water.   (13:25) Sue clarifies what is meant by an isotonic solution. Georgie does say a bottle of water to flush the wound is preferable to not flushing the wound however.   (14:08) Sue asks how the owner would then use this saline solution on a wound and Georgie speaks of the water bottles with the type of end to suck or squirt the water from, as ideal as this creates a bit more of a flush – even a clean garden sprayer. The ideal pressure is 8-15 pounds per square inch - this is a like a high pressure jet of water.   (16:20) John asks whether a pet should be allowed to lick a wound and Georgie says alpha amylase in saliva is a good thing for cleaning wounds, as this is cleaning and removing all the dead stuff from the wound, which they refer to as wound bed preparation – however the tongue is very abrasive and the mouth can be contaminated, and so they don’t suggest that licking is allowed. Georgie does also point out a patient continually trying to interfere with a wound may be a sign that things aren’t great.   Chapter 3 – Wounds At The Vets   (19:09) Sue then asks what products vets or nurses should use once they see the wound and Georgie says Saline would be advocated, or Hartmanns solution or lactated ringers solution.   (19:50) Sue clarifies that Georgie is saying she would advise that a vet or nurse flushes as the client would, with an isotonic solution and not immediately use a disinfectant such as chlorhexidine. Georgie says it is always best to flush again with this isotonic solution again anyway, and uses the analogy of poo in a toilet, and how you would flush the chain to get rid of it rather than just spraying it with disinfectant.   (21:20) Sue asks what antiseptic Georgie would then recommend going onto and Georgie says there is controversy and confusion around this, which drives people to use toxic substances such as chlorhexidine in wounds. This is known to damage cells which are involved in the regeneration of wounds, meaning the use of this in a wound which is healing will actually slow this process; this is the same for iodine when too concentrated. They will kill bacteria as they are intended to, but they will also damage cells and delay wound healing and so must be used carefully, if at all. Georgie goes on to say there are antiseptics which are much more wound friendly, including hypochlorous acid (see previous podcast episode)   (25:55) Sue asks about how different species react and whether as a horse owner, knowing that horses have a lot of granulation tissue, she would suggest hypochlorous over chlorhexidine or any other products for equine wounds. Georgie says all mammals heal in the same way with some subtle differences, which in horses does means more granulation tissue, but highlights what is most important, going onto list some of the important factors which will cause wounds to fail or be inhibited. 1 Necrotic Tissue – Dead tissue around and in the wound 2 Foreign Body – Something in the wound 3 Movement – a key one where movement in the wound constantly traumatises the cells and delays healing. 4 Proud flesh – but this is often a consequence of the above 5 infection – which again is a result of the above or contamination, and the growth of bacteria will then prevent the wound from healing properly. Georgie says it doesn’t matter what species you are dealing with, the mammalian response is the same to wound healing across species; which is first for the body to stop any bleeding, then inflammation where the body digest any bugs or dead tissue around the wound, then granulation where it remodels and regrows new granulation tissue and blood cells, which acts as a carpet underlay for the epithelial cells of the skin to then re-migrate across and close over the wound. The wound will at this point also contract by 30-50% of its original size at this time, so that a scar is never the same size as the original wound. So thorough lavage with a non toxic substance during this process is best and hypochlorous or saline would support this.   (29:41) Sue clarifies then that something like hypochlorous would be better in a wound first aid box than something like hibiscrub (a soap scrub containing chlorhexidine used in veterinary practice). Georgie in response to this stresses that there is no place for hibiscrub in the management of wounds – as this is a ‘scrub’ and has soap elements and is used for the cleaning of the surface of the skin for example in a skin prep for surgery and has no place for use with broken skin – so hypochlorous would be far preferable.   (30:36) John asks if there are any top tips to approach managing wounds. Georgie talks about prepare, promote and protect as a way of summarising the steps for managing wounds, and suggests a vet nurse in a practice as the perfect person to establish a trolly in the practice and divide it into those three sections. So you can’t go to the promote and protect drawers before you have done the prepare. Prepare: Clipping, cleaning and getting rid of dead stuff – which she clarifies is debriding the wound and prepares the wound bed for healing. Promote: Is about dressing selection to encouraging a healthy granulation wound bed to help the wound through the healing phases, so granulation tissue at 4 days, start to fill in 7-10 days and wound contraction occurs around that time. If there is a lot of granulation tissue at this time a decision needs to be made as to whether to now close this surgically or allow to heal by granulation alone. She says that at the veterinary wound library they have seen many cases where the wrong decision has been made here and the wind has been left to heal for too long. Protect: Is looking at the inhibitors of healing as discussed previously plus interference, cell transformation such history of tumours meaning the wound wouldn’t heal as you would expect, client compliance (owners being able to follow the right treatment plan correctly), correct products used as discussed before. Applying this logic to the wound to make sure it is encouraged to heal as sympathetically as possible.   OUTRO (34:14) John wraps up part one and says to look out for the next episode where we continue the conversation with Georgie. (35:00) HIDDEN OUTTAKE: distribution of contamination secret 'easter egg'...

In this episode Sue, John & Paul invite Molly Varga to chat with them about a non-traditional companion animal - the rabbit. Molly heads up the exciting new specialist exotic pets service at Rutlland House Referral Hospital in St Helens, Merseyside.   Log this CPD with 1CPD here   SHOW NOTES:   INTRO (00:00) John, Sue and Paul introduce the podcast the guest, Molly Varga (diploma in zoological medicine).     Chapter 1 – Rabbit Owners   (02:13) Sue asks Molly to introduce herself and Molly shares that she works in a multidiscipline referral hospital practice in the northwest seeing everything that isn’t a dog or cat and she has lectured and written on the subjects.   (03:46) Sue asks whether the popularity of rabbits has grown, Molly says they are the third most popular pet after cats and dogs and over lockdown there has been a disproportionate growth in the ownership of rabbits.   (04:31) Sue asks what the advantages are with having a rabbit, and Molly says that the unique nature of rabbits, and the higher need for care mean people engage with them as pets with their personalities - with more people keeping them as house pets, with them being less independent than cats. They are often seen as a precursor to children or a pet people have instead of having children.   (05:46) John asks where the best source of information for rabbit ownership could be found and Molly says the vets unfortunately may not always be the best source of information, so she would advise the Rabbit Welfare Association as the best source, with the PDSA, the RSPCA and the Blue Cross also have good information as well as some pet food companies. For more advanced information The Veterinary information Network.   (07:52) Sue asks if inappropriate diet and husbandry is indeed the main cause of issues with rabbits and Molly agrees with this, saying they are shifting to more rabbits being kept indoors and this can help with companionship but cause some issues with their legs from a different use of those indoors. She also says there are fewer dental issues from poor diet than there used to be.   (09:21) John asks if dental issues are the most common problem with rabbits, and Molly confirms that this and gut stasis are the most common presentations, both of which are interlinked and can be a primary issue or most commonly a consequence of something else which has reduced the appetite such as pain. It is important we remember that often the symptoms we are presented with a part of a bigger picture.   Chapter 2 - Rabbit Skin   (11:02) John asks about if the underlying cause is ever a skin issue and Molly says they are presented with a lot of skin problem because the owners can see it, but again this is often part of a larger picture, so they see ectoparasites and ear based swellings, and alopecia, wounds and abscesses are very common.   (12:13) Sue asks if there are things owners can do at home or whether they should go straight to the vet when faced with a skin problem and Molly says there are things owners can do at home and there are over the counter preparations they can use – but this does often miss the bigger picture mentioned, and so an assessment can pick up these interrelated issues – such as a lack of grooming because of other factors leading to a mite infestation. So if something isn’t working it isn’t worth persisting but would be better to seek professional advice.   (13:41) Sue asks about the over-the-counter preparations, and whether there are any of these owners should avoid and Molly concurs and says fipronil as a red flag product which should never be used in rabbits. She advises a permethrin based antiseptic spray is very useful as long as there are no cats in the household – But for more specific products it would be better to reach for license products, authorise products or products used under the cascade.   (15:03) Sue asks for other ingredients useful for treating skin problems in rabbits and Molly advises imidacloprid as generally safe and authorised for fleas, whilst fleas are not typically the main problem for rabbits. Another is cyromazine – but increasingly we are moving towards products like selamectin, moxidectin and milbemycin being used under the cascade, which means they are safe and evidence based but are just not authorised at the current time for use on rabbits in this country. So this then comes back to a vet having a look at the patients and doing tape strips or swab tests and seeing what is happening to select the appropriate product.   (16:50) Sue summarises and asks what are the clinical signs seen with rabbit skin disease and if this can be a zoonosis – where the condition can be passed to humans. Molly says the white flaky dandruff is quite typical with rabbits and these are mostly rabbit fur mites but can be Cheyletiella and this can be transferred to people. Most of the other parasites seen are not zoonotic – and Sue clarifies it would be seen as an itchy rash.   Chapter 3 - Rabbit Ears   (18:20) John asks about the problem Molly mentioned earlier about swelling at the ear base and asks if rabbits typically get ear problems. Molly confirms these are regular and in her experience there is less otitis externa (outer ear infection) and more commonly either ear mites (presenting as red, sore, itchy (pruritic) ears) or ear base swellings. Molly talks about the layout of a rabbits ear describing the diverticulum (outpouching of a hollow (or a fluid-filled) structure in the body) and this will often become be filled with either waxy debris or pus, particularly in lop eared rabbits.   (19:30) John asks how you would approach this in terms of diagnosing it and whether a vet would approach this the same way as they were a dog or a cat. Molly would mention additional challenges in treating rabbits, the L shaped ear canal makes it harder to see down the ear and check the tympanic membrane (ear drum) – so she would look at cytology (microscopic examination) of any discharge to see if there is any inflammatory response to see what the issue is. John confirms this would be looking at a swab taken from the air and rolled on a slide and stained and view done a microscope, and Molly says yes this will be the same for rabbits.   (21:02) John goes on to ask but rabbit pus looks like and Molly says rabbit pus is creamy, yellowy, thick toothpaste like material and the ceruminous (waxy, so more normal) discharge that is not yet dry can look very similar – so all the more reason to check this down the microscope.   (22:11) Sue does clarify that the bacteria found in a rabbits ear is different than the bacteria a vet would see down a dog or cats ear and Molly says the culture down a rabbits ear will not match up well with what the ear looks like – so a very dramatic culture could be found in a very normal here, but equally a very abnormal looking ear could present a very normal looking culture. So Molly advises doing cytology in the practice (vets) in order to see if there are inflammatory cells and would advise against jumping towards using steroids or antibiotics in the ear without confirming this.   (23:34)  Sue asks what Molly would reach for in cleaning a rabbits ear and molly advises Tris-EDTA products, with something that dissolves the waxy material, so she uses Tris-NAC in practice and also flushes the ear with Hyaluronidase in saline as pus lacks the Myeloperoxidase needed to make it liquid so if you put another enzyme in the ear, and people have tried trypsin historically but she uses Hyaluronidase – this then disperses the pus and removes the pus from the ear.   (24:49) Sue asks about chlorhexidine and Molly tends to avoid this as she prefers other products as it can sometimes cause reactions in the ear – Sue likes cleaners with salicylic acid in and low doses of squalene for rabbits ears. Sue asks if molly has used hypochlorous acid in the ear and Molly has not yet tried this (see our previous podcast episode).   Chapter 4 - Rabbit pain   (26:24) Sue asks about recognising and managing pain and rabbits and Molly says it very difficult to recognise pain in rabbits and this then makes the pain difficult to manage. She discusses the Rabbit Grimace Scale as a method of identifying pain with the help of the owners, as other indicators normally used in pets do not work so well in rabbits. She also uses other indicative pain behaviours such as flinching or belly pressing which can indicate pain and adds these together to give an impression of the pain but there is currently no validated pain score for rabbits. All rabbit vets used meloxicam, but also things like gabapentin and tramadol and even paracetamol.   (29:14) John asks how easy is it to medicate rabbits and are there risks which should be considered with how regularly we medicate rabbits. Molly points out the importance of considering the balance of stress and pain management in rabbits, which are a prey species; she points out as a prey species they have a wide range of vision and the medication is going somewhere they feel vulnerable – so training the owners to positively reinforce this with using something the rabbit likes the taste of.   (31:37) John asks if Molly would use antibiotics and she confirms there are safe options, but she is cautious of the effect on the population on the flora in the gut, and so actually broad-spectrum antibiotics are generally safer and the gram positive spectrum antibiotics are not so idea. So there are potentiated Sulphonamide as well as a enrofloxacin authorised for rabbits in the UK as well as known to be safe drugs such as doxycycline and azithromycin which have been given long term to rabbits with little or no side effects.   (33:04) Sue says farewell to Molly and they clarify the term for rabbits is non traditional companion animals, no longer ‘exotics’.   Outro (34:35) John Sue and Paul wrap up the conversation discussing who their favourite famous rabbits are.

Intro (00:00) John introduces the team of Sue Paterson and Paul Heasman, ready for another fascinating conversation with the special guest, Ross Walker.   Log this CPD with 1CPD here   Chapter 1 – What is hypochlorous? (02:05) Sue introduces Ross Walker to the podcast. Ross describes himself as Director of Clinical Health Technologies, which manufacture products based on a high purity of hypochlorous solution; this has been in the human market with the Clinisept brand, and is now moving into the animal sector with the Contego brand via Nextmune.   (02:52) Sue asks Ross how he got into working with hypochlorous acid. Ross says having worked in London and then wanting to change, he was approached to work in the field of producing a highly stabilised hypochlorous acid.   (03:35) Sue asks what hypochlorous acid is and Ross describes it as the most effective disinfectant agent known to man, but is also completely skin compatible to any mammals- so it kills things you want to get rid of without doing any harm to humans or animals.   (04:12) Sue asks how this works, and why it isn't a concern that it has the word acid in it. Ross says this is because it is an acid with a skin neutral pH, so it is non-irritant, non-sensitising and non-cytotoxic. He says it originates in our body in order to deal with invading organisms, through the process of phagocytosis - the blood cells in our body produce low concentrations  and low quantities of hypochlorous.   (05:37) John ponders what the catch is and why this isn’t already widely used in the human sector and more generally. Ross describes hypochlorous Archilles’ heel - describing the first discovery of hypochlorous occurring during the first world war in 1915, where when soldiers had severe wounds as well as having been exposed to chlorine gas, it was discovered that they healed much quicker than those who had had the severe wounds without the exposure to chlorine gas. This was found to be due to the chlorine forming a solution in the water within the trenches, and this forming a level of cleanliness. The soldiers exposed to the chlorine gas we're also found to have high levels of cleanliness within the wounds. The papers published at the time concluded three things: firstly that hypochlorous was a very effective disinfectant, being bactericidal, fungicidal, viricidal and sporicidal. Secondly that it had a skin neutral pH, so therefore was contributing bacterial resistance without causing skin trauma. And thirdly, that this contributed to the perfect environment for skin healing, maintaining cleanliness without causing tissue trauma.   (08:19) Sue asks the difference between this and hypochlorite (bleach). Ross says that the two are derived from the chlorine chemistry, but that hypochlorite or bleach, is far more skin irritant, as many with no not wanting to have bleach on the skin. But that it is actually also much less effective in killing bacteria then hypochlorous. Ross demonstrates this by saying that an examination of a bottle of bleach would show a very high parts per million concentration, because hypochlorite has to be in very high concentrations in order to be effective; whereas hypochlorous can be in a much lower concentration in order to achieve the same level of efficacy.   Chapter 2: Why isn’t it being used in people? (09:51) John asks again whether this is something that is available on the human market and Ross confirms that over the years the number of companies have bought this product in the market, and much research has been done. However, it never achieves its potential because of the Achilles heel mentioned previously. Hypochlorous has a half life of 48 hours, meaning if you manufacture it you need  do something with it quickly before it starts to decay; this is due to its manufacture, which in 1915 was by electrolysis – passing an electric current through a saline solution and generating a quantity of hypochlorous from the anode. This method of manufacture has remained since 1915 until recently, when a new method that Ross uses came in (using a chemical method to manufacturer it). Stabilising techniques used on the electrolysis method, have always produced a low level of concentration, a low level of stability and a low level of purity. Ross says their method pulls the rug from under these Achilles’ heels, providing a shelf life of two years, as well as a high level of stability and of concentration - in excess of 90% hypochlorous in comparison to the previous iterations of around 60%   (12:13) Sue asks about the applications being used in the human field already. Ross shares that they initially needed to verify the efficacy of their version of hypochlorous, and so they compiled a study involving ear piercing, with the largest manufacturer of ear piercings and the largest ear-piercing company, and have pierced in excess of 20 million ears using their version of hypochlorous as the after-care. During that time they have had zero reports of infection following the piercing, and that it has enabled the manufacturer to halve the healing time from six weeks, down to 3 weeks. They then launched in the aesthetic sector, so it is used in the cosmetic industry and following the launch in June 2017 it had (by December 17) been given the 'Product of the Year' award in that sector. They have also since gone on to work in the podiatry sector as well as the dental sector with a mouth rinse - in all of these instances the product is doing exactly the same thing, maintaining cleanliness without damaging the tissue and therefore improving skin healing time.  Ross adds that it has applications in venous and diabetic leg ulcers, where it is very effective due to its efficacy on removing biofilms.   Chapter 3: How can it help animals? (15:13) John asked whether this is safe to use in animals as well as people, and what species. And Ross confirms that it is safe to use in all mammals, so including small animals and large animals such as livestock and horses. John goes on to ask the application in these animals and Ross says this application is very widespread, not simply for wound healing applications but also for instances of skin contamination, eczema and dermatitis.   (16:28) Sue asks what papers have been published in the human field to demonstrate the efficacy of hypochlorous against things like yeast, staphylococcus and pseudomonas. Ross says a Wikipedia search will reveal approximately 3,500 papers published on the efficacy of the substance in disinfectant in these instances - and Ross says many papers have been published to prove its efficacy in European Normative standards. Hypochlorous uses an oxidising method of action to dissolve cell walls make it very quick in its effect, rather than those using a toxic method which is slower and can result in resistance as well as sometimes being toxic to the skin in too higher concentrations.   (18:27) Sue clarifies that this includes Malassezia, staphylococcus and pseudomonas and Ross confirms these are well within the capabilities of hypochlorous to kill these within 15 seconds.   (18:41) John asks about its effect with pus and cases of biofilm, with Ross saying it is very effective in these instances, crucially dissolving biofilm film as well as killing it. This means that with repeated application you can quickly remove the biofilm from the surface. Ross points out the physical action of rinsing is also beneficial to wash away the biofilm whilst also dissolving it, and Sue agrees that the resistant nature of biofilm contributes to the chance of resistance, and so disinfectant is a great benefit here. Ross confirms and points out a low level of infection can contribute to a biofilm which will delay healing and that there are many papers published in biofilm application for hypochlorous.   Chapter 3: Where does it fit with existing products? (22:25) Sue asks about the development of the use of topical therapy in treating bacterial overgrowth and infection on the skin, and whether hypochlorous could be used in a similar way to chlorhexidine in this application. Ross says that not only could it be used in this way, but it would do a much better job. Stating that chlorhexidine uses the aforementioned toxic method for killing bacteria, but this can also have some toxicity with the skin and slow skin healing in a way that hypochlorous doesn’t. He also states there are growing number of plastic surgeons who are no longer prescribing routine antibiotics post-surgery when using hypochlorous, because they are so confident that it will prevent an infection from ever establishing!   (24:20) Sue asks about the possibility of hypochlorous being available as a shampoo rather than just a spray, because of the useful nature of a shampoo regardless of what is in it. Ross points out that the nature of hypochlorous means that it does not respond well to being mixed with other chemistry and so could never be formulated, as such there will always be a place for chlorhexidine-based formulations such as shampoos. Sue says that this therefore gives us a great choice for skin care and Ross echoes this.   (25:46) John asks how environmentally friendly hypochlorous is and Ross shares that hypochlorous has been given a category five by the environmental protection agency on their toxicity scale, which is the highest classification for environmental safety. Ross says that the nature of hypochlorous action, means that it uses up its efficacy as it decontaminates, so as it pours down the drain you will have a very clean first few metres of drain but by the time it makes it into the waterways it is benign.   (26:50) Sue summarises what we have learnt on the podcast and Ross agrees, saying it very quickly garnered the nickname 'game changer' when first launched. John asks how people may get hold of this and Ross says this is available over the counter via Nextmune to the animal industry.   Outro 29.36 John and Sue wrap up another insightful episode, with some musings of times gone by when hypochlorous acid might have been useful to the podcast panel.   Hypochlorous is available as Contego, from Nextmune UK – for information on how to order email salesenquiries.uk@nextmune.com   References A pilot study comparing in vitro efficacy of topical preparations against veterinary pathogens.  Uri, M. Buckley, L. Marriage, L. McEwan, N. Schmidt, V. (2016). Veterinary Dermatology. 27 (34), 152.   Antimicrobial efficacy of a very stable hypochlorous acid formula compared with other antiseptics used in treating wounds: in-vitro study on micro-organisms with or without biofilm Herruzo, R. Herruzo, I. Journal of Hospital Infection June 2020 105(2):289-294   Antibiofilm Efficacy of Polihexanide, Octenidine and Sodium Hypochlorite/Hypochlorous Acid Based Wound Irrigation Solutions against Staphylococcus aureus, Pseudomonas aeruginosa and a Multispecies Biofilm                                                                                                          Anne-Marie Salisbury, Marc Mullin, Rui Chen, Steven L. Percival 26 June 2021 pp 1-15 Advances in Experimental Medicine and Biology    Wound cleansing: benefits of hypochlorous acid. Joachim D, Journal of wound care [J Wound Care 2020 Oct 01; Vol. 29 (Sup10a), pp. S4-S8;

This month the Skin Flint team invited outgoing WAVD President Kenneth Kwochka onto the show to discuss what the WAVD does and how vets and nurses around the world can benefit from their work.   Log this CPD with 1CPD here   Show Notes   Introduction (00:00) John introduces the podcast with producer Paul and European leading dermatologist Sue Paterson, who herself introduces the guest, the retiring president of the WAVD, Ken Kwochka.   Chapter 1 - What is the WAVD? (02:58) Sue introduces Ken and asks him to introduce himself. Ken says he is a US-based vet with 40 years of experience, who is now the head of dermatology at Elanco and current president of the WAVD - retiring and handing over to our own Sue Paterson very soon.   (04:19) Sue asks Ken to clarify what WAVD is and he clarifies it is the World Association for Veterinary Dermatology, which has existed since the mid-to-late 1980s in order to promote the worldwide advancement of Veterinary Dermatology.   (05:06) Sue then asks whether the WAVD is truly global and Ken confirms this, saying whilst it was initially strong in Europe and the US, they looked to take it out to the rest of the world with the first meeting for this purpose in Dijon, France in 1989 (involving 600 people from 35 different countries!). It now is supported by two organisations in the USA, one in Canada, one in Latin America, two in Europe, one in Australia/New Zealand and two in Asia.   (07:11) Sue asks how well Veterinary Dermatology is developed in other parts of the world and Ken does say some areas are playing catchup with the US and Europe, but that there is great interest in advancing it from within in those areas. This is the primary role of the WAVD: Education, Education, Education as dermatology is the second biggest reason to vaccinations for people to bring their pets to the vets.    Chapter 2 - What does the WAVD do? (09:07) John asks what type of work WAVD does in this area and Ken says this has expanded greatly in the last 15-20 years. Initially it was primarily a World Congress of Dermatology every 4 years, but some people had difficulty getting to this, so WAVD now provides 20-30 vets from those underserved areas a scholarship to attend, in order to help the outreach. These then return and teach the information to their colleagues in order to grow dermatology in their regions. Also one of the WAVD affiliated groups, the Global Veterinary Dermatology Education Group provide education by going to those countries and educating in dermatology in places such as Africa and Eastern Europe.   (11:49) Sue asks about Vet Nurses or Vet Technicians, and what place they have with WAVD; Ken totally agrees on the importance of Vet Nurses/Technicians in dermatology and shares that there are training recourses for them, including another WAVD affiliate group, the Academy of Dermatology Veterinary Technicians which is global and provides training for Nurses/Techs interested in dermatology, allowing them also to become certified in dermatology as vets can be.    (14:29) Sue asks what other resources are available for people and Ken suggests people go to the WAVD website and look at the list of member organisation for their own geographic region; also on the site is the WAVD Foundation Course which consists of 31 foundational webinars free of charge, designed to cover the core principles needed to practice Veterinary Dermatology. Clinical Consensus Guidelines are also available from the WAVD, whereby experts have reviewed important recent studies in order to give guiding principles for clinicians in key areas of dermatology, as well as proceedings from the World Veterinary Congress; all are available for free.   (17:34) Ken and Sue clarify the nature of the foundation course and those delivering the content as part of its great value, discussing how is is useful for vets, nurses/techs and specialists; Veterinary Schools have even used this course for educating their students, as they the lecturers are a world authority.   (20:30) John and Ken clarify again this is all available on the WAVD website and their Facebook page. John asks how you would become a member of WAVD and Ken clarifies, as it is global and made up of affiliate/member groups from different regions you don’t become a direct member of WAVD but become a member of those organisations.   (23:00) John asks when the next World Congress is and who can go, to which Ken replies that the next event is in Boston (USA) in July 2024, which is open to all vets and nurses/techs with an interest in dermatology. There will be lectures and workshops over 4 days along with social events in the evenings, with all profits from the organisation go back into the education work the WAVD does, including supporting the local member groups.   Chapter 3 - Where does the WAVD go now? (25:58) John asks what Ken’s work involves and what Sue has to look forward to. As part of the first congress in 1989, Ken says it has been a rewarding role of setting the agenda for the organisation, developing projects and continuing to improve and develop the field of dermatology over the world.   (27:58) Sue shares her excitement at the recent involvement of the Indian Dermatology Group, stating that this is a great development and they discuss the development of the WAVD work all over the world - including Ken sharing that this information is two way, with those types of regions sharing diseases which existing WAVD member regions haven’t yet experienced.   (30:12) Sue asks how Covid had changed the way people work in dermatology and Ken says this real challenge has led to more remote working, but this has been beneficial in developing this remote way of working and educating and in turn this allows more people to be involved; so Ken feels a hybrid model, for example with the World Congress, will be the way moving forward to reach even more areas.   (32:58) Sue and John say farewell to Ken and ask for a final thought on where Ken would like to see Veterinary Dermatology in 10 years, Ken says seeing less developed areas in Veterinary Dermatology become on par with for example the US and Central Europe in dermatology would be his wish.   Outro (36:20) Sue, John and Paul wrap up the podcast talking about the job ahead for Sue as WAVD president, as well as discussing the upcoming podcasts in 2022 with Skin Flint. John and Paul invite people to send their requests and feedback to hello@elearning.vet or via the Elearning.Vet social media channels: Facebook, Instagram, Twitter or LinkedIn.

In Episode 7 of the Skin Flint Podcast we invited Jill Maddison to come chat with us. Jill is Professor of General Practice, Director of Professional Development and Director of the BVetMed course at the Royal Veterinary College (RVC).   Log this CPD with 1CPD here   Show Notes   Introduction (00:00) John introduces the podcast topic, along with producer Paul and Sue Paterson - who introduces us to the topic of compliance as well as the guest, Jill Maddison, the professor of general practice at the Royal Vet College in London who is published on the subject of compliance with a strong practical background. Chapter 1 - Understanding Compliance. (02:53) Jill introduces herself and her specialities in compliance and clinical reasoning and how they meet.   (04:02) Sue asks Jill about the importance of compliance when administering medications and Jill points out it doesn’t matter how carefully the medication is chosen, if the client doesn’t administer it the therapy won’t be effective and this is often taken for granted in veterinary medicine.   (04:49) Sue asks Jill to define complicate and Jill shares that compliance, or adherence as it is often called, is where the owner gives the medication as prescribed, in terms of the frequency, dosage and length of treatment. A client not 100% compliant might miss doses or not finish a course.   (06:06) John then asks Jill to outline some of the issues which could arise from a loss of that compliance. Jills says that therapeutic success is better with closest to 100% compliance, but also with some classes of drugs such as antibiotics, poor compliance could lead to resistance to that drug because the plasma levels drop below the required amount. Then also in a long term treatment regime such as epilepsy there can be poor therapeutic outcome, but also the patient can need more drugs in the long term because they are not managed effectively, which could lead to more side effects. Also with pain management, they could be in more pain as a result of poor management of the pain due to an insufficient level of pain relief. And finally in diseases where the condition goes into remission but the drug should be continued, the client may stop the medication leading to the return or exacerbation of the issue. Jill uses the example of us with a cold for which we do end up on antibiotics, but then we stop them as we start to feel better because we forget to take it them.    Chapter 2 - Recognising Compliance (10:53) - John asks what factors from an owners perspective would halt compliance to a therapy and Jill reflects that allergic skin disease is a very applicable condition to this problem, showing that if an owner doesn’t fully understand the reason for a therapy they may not comply and so more of the treatment may be needed long term, for example if they don’t understand that the disease won’t be cured. Jill points out this all comes down to the relationship between the client and the clinician, as communication is so important. She shares the results of an online survey, and trust was a common theme - with owners least happy with the consultation were the least likely to comply with the medication - with 80% of owners complying well but 20% very poorly and evidence showing these people made their own clinical judgment as a result of a breakdown in that relationship between client and clinician.   (16:39) Sue asks if this relationship is better or worse with a nurse, suggesting that they may find nurses more approachable. Jill says there are studies in human literature to suggest information was better received from nurses, and they were more likely to admit not compliance to a nurse - So Jill feels nurses are very important to this aspect of veterinary care, maintaining that communication and relationship with more dedicated time with the owner.   (19:00) Sue also points out nurses are generally better at speaking in plain English and Jill agrees they are excellent for demonstrating medications and educating owners, provided they themselves are educated properly in the therapy themselves.   Chapter 3 - Helping Compliance (20:52) John shares this resonates with him personally from running a dermatology clinic, and how he came to understand the role of compliance through these ongoing conversations with clients. And also how the 20% of owners making their own clinical judgment may be more likely to share this with the nurse, precisely because they haven’t themselves suggested the judgment the client disagrees with. He asks Jill if there are any key things clinicians can work on covering with the client. Jill says the clients who are not asking questions are also the ones who aren’t compliant - so asking them the questions on what their particular issue with giving a medication might be is important in order to put in systems in place to help that; ‘naming the fear’ and finding a solution together.   (25:50) Sue then asks about topical medication and what sort of key questions should we be asking on those. Jill says with an ear drop for example, the first question is whether or not they can do it at all - talking through how we do it and how it needs to be done properly and asking them to demonstrate, but recognising that is in the artificial environment of the consult room.   (27:22) Sue asks about the complexity of therapy, where a clinician might have given the owner too much to do and whether we need to rationalise therapy. Jill says it is very clear from studies in human medicine that the more medications given the worse the compliance, so we must ascertain which medication is essential.   (29:34) Sue asks if it worth considering how compliant an owner is before choosing how much medication to give and Jill shares that the challenge with this is that we don’t know which ones are poorly compliant, so you have to treat all clients as potentially poorly compliant and spend time explaining the reason for the medication.   (29:26) Sue asks if different formats of communication such as visual support is useful, and Jill agrees that this can be really helpful as many may seek out unhelpful support on the internet anyway, also giving handouts to back up what you have told them in person and support materials on the particular condition they have.   (31:26) Sue thanks Jill and asks for any final thoughts and Jill feels like all the studies on compliance speak to our diagnostic recommendations as well, so using the same communications and relationship models to aid compliance in diagnostic regimes. And Sue and Jill roundup the thoughts on the conversation.   Outro (35:35) John ends the podcast reflecting with Sue and Paul on the conversations and asking them what their worst example of compliance is.

In Episode 6 we were delighted to be joined by one of the giants of global veterinary dermatology - Ralf Mueller (Dr. med. vet., MANZCVSc (Canine Medicine), Dip. ACVD, FANZCVSDc (Dermatology), Dip. ECVD). Ralf has published over 250 studies, articles, book chapters and books and given more than twelve hundred seminars, lectures and talks all over the world - plus at least one podcast now! Log this CPD with 1CPD here   Introduction (00:00) John introduces the podcast with co-hosts Sue and Paul; Sue introduces us to Ralf Mueller and his work in dermatology.   Chapter 1 - Why Immunotherapy?   (02:37) Sue welcomes Ralf and asks him to introduce himself. Ralf shares details of his wealth of experience in dermatology and allergy.   (03:23) Sue asks about Ralf's approach to allergies and Ralf shares that firstly he makes sure he is happy that the patient is allergic and without other skin issues. Following this he would ensure thorough ectoparasite control to prevent flea allergy confusing the matter, before ruling out food allergy with an elimination diet in order to ascertain an environmental; then he would discuss this management long term with the owners.   (04:53) Sue asks if this approach would change depending on the patient or if this is set in stone and Ralf says he would build it around the patient and the owners and what will work for that case - with Allergen Specific Immunotherapy (ASIT) being his number one preference for environmental allergies as well as liking monoclonal antibody therapy; but he also uses a variety of other medications depending on the lifestyle, symptom and needs of that patient and owners.   (05:50) Sue asks for Ralf to clarify what ASIT is; Ralf clarifies it as 'taking an allergen a patent is allergic to and injecting them with it to expose them to it until the immune system tolerates it'.    (06:45) John asks Ralf to walk through the advantages and disadvantages. He says the first big advantage is relatively low side effects - anaphylactic reaction being one, however he has only seen 5 cases of this in 30 years in dogs and 2 or 3 in cats, so it's very rare. He mentions there is occasionally increased pruritus initially from the therapy, but this can be managed by tweaking the therapy regime. The other big advantage is how specific the therapy is, with other medications being like a band aid and immunotherapy approaching the problem directly by normalising the immune system. The third big advantage is that (medium to long term) it is one of the cheaper therapies. He counters that the disadvantages are that is doesn’t always work for every patient - working well in one third of patients, working not so much in another third and not at all in the final third. It can also take time for the patient to improve and Ralf asks his owners to stick with the therapy for a year before deciding it hasn’t worked. But it is the best long term treatment option available for those patients it does work for.   Chapter 2 - How Immunotherapy?   (11:13) Sue then asks how you select the right allergens to put in the vaccine. Ralf shares his approach - which is firstly to use allergens specific to that dog which has been shown to be more effective than using random allergens. Then he also discusses the number of allergens which can be added to a vial. He listens to the history of the patient - whether it is seasonal and how much they go outside and where - before looking at an allergy test and the positive results on it, in order to to ascertain which allergens are most relevant. Ralf then lists some examples with specific patient lifestyles to demonstrate this process and build a vaccine with the 4 to 10 most relevant allergens, taking into account the prevalence of those allergens in the area the patient lives.   (15:52) Sue then asks if an unsuccessful experience from a vet with immunotherapy may be down to them having simply added all the allergens in a positive test to a vaccine. Ralf feels like this could be a contributing factor, but does say there isn’t much evidence yet on whether putting too many in reduces the effect, this is just his, more specific approach.   (17:00) John asks how Ralf goes about adapting the therapy, and if he uses other treatments alongside immunotherapy. Ralf says it again depends on the patient, and that when he says adapting the therapy he is referring to a flexible approach to the administration of the immunotherapy itself - so giving a smaller dose if they are reacting more, or increasing the frequency if the patient begins to regress before the next month's dose (two-thirds of his patients are not on a standard protocol). He then speaks into concurrent therapy, using a product alongside the immunotherapy, and this is something he will nearly always do to manage the itch to a comfortable level in order to allow the therapy to take the time needed to work.   (20:34) John then asks if this is only aimed at dogs, but Ralf shares his experiences of using it in cats, horses, sea lions, leopards and more, so it is definitely suitable for other species!   Chapter 3 - Rush Immunotherapy?   (21:36) Sue then asks about rush therapy - using a different process for tapering up the dose in order to help the response build more quickly. Ralf shares that he offers rush therapy as routine and 90% of his clients take this up. He mentions a study being released soon which compares rush therapy and normal therapy with no difference in success - so rush remains the standard for him due to its speed. Ralf then expands on rush to describe it as keeping the patients in hospital, with a premedication of antihistamine for safety, before using the same protocol in terms of dosage which comes with the therapy but dosing every half an hour or an hour rather than once a week or every other week. Temperature and heart rate etc. are monitored during the therapy, with very few reactions.  Ralf shares details of another study he completed which showed the biggest improvement in a rush case was 6 months (versus 9 months for the normal protocol), and he believes it to be even faster in his experience with other cases.   (25:54) John then asks if these adaptive methods of using immunotherapy are possible within normal first opinion practice. Ralf thinks this could be to a practitioner with an interest in dermatology and allergy then this could be possible with application and support - and also from utilising referral if they feel less comfortable.   (27:37) John then asks if Veterinary Nurses can help facilitate this and Ralf agrees, suggesting that actually they could be more crucial than the vet in order to maintain communication with the owners and a complete understanding of the nature of allergy; Ralf says he uses his nurses heavily in this process.   (28:46) Sue shares that she always starts urgent cases by apologising to owners that they likely won't be fixed quickly, but does feel that with immunotherapy they can dangle the carrot of a (close to) cure/remission long term and Ralf agrees, again sharing his feeling for the rule of thirds, with a third completely improving, a third partially improving and a third not improving, and his desire to wait at least a year before beginning to make a judgment on this.   Outro   (32:10) Having said farewell to Ralf, Sue, John and Paul reflect on a fascinating conversation before then going on to wrap end the podcast (as ever) with an interesting thought...