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April 2024
Challenges and Risks of Allergic Skin Diseases
Dermatology cases remain a critical issue for veterinary teams, even beyond their clinical challenges and patient miseries. Lengthy timelines and common frustrations also threaten client trust and retention, potentially breaking bonds with veterinarians and practices forever.
Helping Pets Feel Better and Protecting Client Bonds
Dermatology cases remain a critical issue for veterinary teams, even beyond their clinical challenges and patient miseries. Lengthy timelines and common frustrations also threaten client trust and retention, potentially breaking bonds with veterinarians and practices forever.
To help general practitioners and teams better handle the complexities of dermatology cases and client expectations, the 2023 AAHA Management of Allergic Skin Diseases in Dogs and Cats Guidelines provide insights, flowcharts, and recommendations for everything from diagnostics and treatment strategies to full-team utilization and client communication. Its publication came not a moment too soon, because dermatology caseloads continue to dominate daily practice with no end in sight.
For more than a decade, skin allergies have topped the list of most common health reasons for veterinary appointments in dogs, according to the most recent Nationwide pet insurance claims data released in April 2023. Otitis externa ranks second for dogs. Atopic or allergic dermatitis sits at number eight and otitis externa at number 10 for cats.
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Risks to client bonds come along with this abundance of need; the guidelines open with this statement: “Because atopy is a diagnosis of exclusion, the process may be time-consuming and frustrating for clients. Clear communication regarding timelines and expectations is crucial for successful results.”
The American College of Veterinary Dermatology also released results from a commissioned survey in May 2022 that revealed 73% of clients bringing pets in for dermatology issues hit a “tipping point of frustration” after the third veterinary visit with clients already having spent $925 on average. In the survey, 15% of respondents said they stopped using their general veterinary practice “altogether” after reaching this breaking point with a pets’ dermatology case. This data aligns with another otitis externa study where 18% of clients switched primary care practices because veterinarians didn’t refer their pets’ cases to a dermatology specialist sooner.
Fun and Educational Veterinary Dermatology Pros on Instagram |
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If you enjoy the tiny details of complex dermatology cases, follow these practitioners on IG: Ashley Bourgeois, DVM,DACVD Vancouver, Washington Jeff Tinsley, DVM, dermatology residentLouisville, Kentucky Andrea Hernández-Burés, DVM, DLACVDBradenton, Florida |
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First-Contact Leadership
By understanding the potential perils of dermatology cases, veterinary teams can approach all first skin-case appointments with the seriousness and comprehensive strategies required. An initial examination and history-taking, along with setting client expectations, provides the veterinary leadership and guidance people need.
“Your dermatological history is the most important diagnostic tool for your patients with skin disease. Don’t skip this crucial step with your patients.”
Alison Diesel, DVM, DACVD
Guidelines task force member Alison Diesel, DVM, DACVD, said, “Your dermatological history is the most important diagnostic tool for your patients with skin disease. Don’t skip this crucial step with your patients. Book extra time with dermatological patients to have these important discussions with clients.”
Diesel emphasized these points:
- Always pursue a complete and effective dermatological evaluation, including cytology.
- Don’t just jump to diagnosing allergies before ruling out other causes of pruritus.
- Don’t forget that infections (bacteria and yeast) need to be evaluated and treated.
She explained, “You will not see benefits from ‘anti-allergy therapy’ (e.g., Cytopoint, Apoquel, etc.) when a good amount of infection is present.”
As the guidelines explain: “With most of these patients, this is the start of a long journey, and clients should be informed that there are likely no quick fixes or cures, only lifetime management strategies.”
Making Referrals
Having worked as a general practitioner for several years before completing a dermatology residency, Andrew Simpson, DVM, MS, DACVD, who co-chaired the guidelines task force, brings experience with both ends of the referral relationship. He thinks about the potential challenges of making referrals to any type of specialist in several ways. Clients with strong trust, faith, and bonds with general practitioners may find it hard to make the leap.
“Technically, in my book, it’s never too early to refer a dermatology patient, but there are not enough dermatologists out there.”
Andrew Simpson, DVM, MS, DACVD
“I would hop on the phone with a specialist, then I, myself, would tell the owner, ‘They’re recommending this. Let’s do this,’ and they were on board with it. I was guiding them through it, but going to a different clinic, meeting a new doctor, and taking the advice directly is harder,” Simpson said.
He adds that awareness about veterinary dermatologists even existing feels low. He said, “I still get clients that come in, and they have 10- or 12-year-old dogs or cats, and they say, ‘If I would have known you existed 10 years ago, I would have been here then.’”
Of course, the other major challenge with all referrals now remains the high demand and longer wait times to get appointments. Rather than a drop during the early years of the pandemic due to lost incomes and such, veterinary dermatologists saw demand spikes. People staying home and working at home simply realized how miserable their pets were with skin issues and itching. The jing-jangling of tags, the thump-thump of scratching feet, and the gross noises of nonstop licking got on peoples’ already-frayed nerves. In the before-times, most of that happened while they were away. They simply didn’t know.
“Technically, in my book, it’s never too early to refer a dermatology patient, but there are not enough dermatologists out there,” Simpson said, “I want to say it’s about maybe a six- to eight-week waitlist for a new appointment.” Initial specialist appointments take at least an hour, and there are only so many hours each day.
Financial considerations pose another barrier to referral. However, earlier dermatology referrals may “provide more effective treatment and less cost to the client in the long run,” according to the guidelines.
An additional talking point addresses another potential concern, where people may feel abandoned. Simpson suggested saying, “This is not me giving up on you or giving up on your pet. This is me trying to hand you over to somebody who has more expertise who can help you get the best, optimal treatment for your pet.”
Zone Defense and Flares
Because patients often wait so long for the first specialty appointment, they worry about waiting that long always, which typically is not the case. Even if the dermatologist’s schedule looks impossible, Simpson counsels clients to contact the dermatology team first to see what can and cannot be done to get pets seen.
That said, some cases may need or benefit from a shared approach so that pets with skin issues don’t go too long between recheck appointments because of scheduling problems, which could leave them open to unnecessary setbacks. For example, general practices can step in to do recheck skin swabs to monitor secondary infection resolution (or not) if the dermatology team cannot fit in the patient. In addition, they can handle any required blood work monitoring along with a routine wellness visit and report back to the specialist, such as for patients needing cyclosporine.
Effective client communication that sets realistic expectations helps combat the feeling that flare ups equal failures.
“Cases we accepted and where we pulled out of the rut and got them on a smooth track,” Simpson said, of the types of cases that might revert to primary-care oversight, “then I’m a huge proponent of the specialist and general practitioner relationships. I can’t personally call every single one, but I never mind if they email me or leave a message saying, ‘Hey, we saw Max this week, and the ears were flared up again, do you have recommendations to get things under control before they can see you again?’”
However, chronic otitis externa cases probably require direct specialist care such as video otoscopy, so general practice oversight of those patients is unlikely.
If veterinary dermatology hollered a battle cry, it would be this: “Prepare for the flare!” The guidelines explain, “All atopic dogs will experience allergic flares regardless of how well managed they are.”
Clients may make inaccurate assumptions due to flare ups. Diesel explains, “Remember that treatment for allergies typically doesn’t just stop working. Rather, we need to investigate other causes of the increased itching (infections, parasites, etc.).”
Here’s the sticky part. Effective client communication that sets realistic expectations helps combat the feeling that flare ups equal failures. People blame themselves. They blame veterinary teams. They get cranky. Flares happen, so find the patterns and prepare for them with additional support as needed for each case. Flag those patterns, seasons, and solutions well in the medical records, so the next time Client A calls about redder-than-usual skin again in April, there’s already a workable and effective plan in place.
“I always warn owners, not in a doom-and-gloom type of attitude, that this is a reality of allergies. It’s a very dynamic type of disease,” Simpson said. “We try to find where’s that pattern. How can we beat that pattern, or outsmart it, at least.”
He explains that while both Cytopoint and Apoquel work quickly, some research shows that those therapies “can actually pre-emptively help with flare ups.”
Fresh Clarity in Guidelines
Celebrating Progress
With no cure, these cases require clients’ longtime commitment to treatment and follow-ups as well as their patience and partnership. It helps to share praise and encouragement with clients, with phrases like these:
- “I’m so glad you came in right away.”
- “Thank you for your hard work with at-home care.”
- “Great job taking care of [pet’s name]!”
- “Congratulations on getting through another seasonal flare.”
Direct acknowledgement encourages them to stay on course, even when things seem tough. Consider awarding fun paper or digital certificates of recognition or stickers—for joint celebrations of patient progress to solidify client bonds and potentially avoid the retention pitfalls of dermatology cases.
A few things in the guidelines may surprise general practice teams and clients. For example, the guidelines recommend judicious use of allergy testing: “Intradermal and serum allergy testing are NOT used to diagnose atopy. It should only be used if the client is interested in administering allergy immunotherapy.”
Clients need appropriate expectations about allergy testing. “Never refer pets to a dermatologist and say to the owners, ‘Oh, they will find out what your pet’s allergic to,’ with the logic that they’re going to find out what the pet is allergic to and then we can practice avoidance, and your dog or cat will be fine. That’s a big message in there. Unless they have full intention, or at least interest in immunotherapy, then there’s no point in skin testing or blood testing at all,” Simpson explains.
The old “ears and rears” mantra linking those affected areas as indications of food allergies is no longer accurate, according to the guidelines. Pay close attention to the latest thinking on the length of time required for diet trials as well.
The guidelines potentially introduce a new terminology for feline cases—feline atopic skin syndrome. Established since 2020 in the veterinary dermatology literature, the switch from calling it atopic dermatitis stems from feline cases looking very different clinically from those in dogs. “The pathogenesis in cats isn’t fully understood. I mean, it’s in its infancy compared to what it is for dogs,” Simpson said. “We don’t even know if it’s the same pathogenesis. So that’s pretty much why cats were given a different name.”
Rather than earth-shattering changes in diagnostics or treatments, Simpson explains that the guidelines compile all the principal factors in managing allergic patients in one place now, including opportunities for full veterinary technician utilization in skin cases. He said, “I think it’s more the completeness of the guidelines. It really covers so many aspects of allergy management that makes it more of a unique and clinically useful document.”
Roxanne Hawn brings over 25 years of experience writing about veterinary topics for professionals and consumers. She writes an award-winning site called Champion of My Heart and is the author of Heart Dog: Surviving the Loss of Your Canine Soul Mate. |
Photo credits: ©AAHA/Alison Silverman, bluebearry/iStock via Getty Images Plus, Jobalou/DigitalVision Vectors via Getty Images, Instagram@ahb_dermavet, Instagram@dermdogtorjeff, Instagram@thedermvet