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December 2023
2023 AAHA Management of Allergic Skin Diseases in Dogs and Cats Guidelines
This executive summary gives an overview of these new guidelines, with their systematic approach to diagnosis, treatment, and management of allergic skin diseases in dogs and cats. The guidelines describe detailed diagnosis and treatment plans for flea allergy, food allergy, and atopy in dogs and for flea allergy, food allergy, and feline atopic skin syndrome in cats.
Executive Summary
by Constance Hardesty
These guidelines were prepared by a task force of experts convened by the American Animal Hospital Association. This document is intended as a guideline only, not an AAHA standard of care. These guidelines and recommendations should not be construed as dictating an exclusive protocol, course of treatment, or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to each individual practice setting. Evidence-guided support for specific recommendations has been cited whenever possible and appropriate. Other recommendations are based on practical clinical experience and a consensus of expert opinion. Further research is needed to document some of these recommendations. Drug approvals and labeling are current at the time of writing but may change over time. Because each case is different, veterinarians must base their decisions on the best available scientific evidence in conjunction with their own knowledge and experience.
The 2023 AAHA Management of Allergic Skin Diseases in Dogs and Cats Guidelines are generously supported by Hill’s Pet Nutrition, Merck Animal Health, and Zoetis.
This executive summary is not a replacement for reading the guidelines in their entirety. The full guidelines are published in the Nov/Dec 2023 issue of the Journal of the American Animal Hospital Association (jaaha.org) and available online at aaha.org/allergic-diseases.
Overview
These guidelines present a systematic approach to diagnosis, treatment, and management of allergic skin diseases in dogs and cats. The guidelines describe detailed diagnosis and treatment plans for flea allergy, food allergy, and atopy in dogs and for flea allergy, food allergy, and feline atopic skin syndrome in cats.
These guidelines offer a step-by-step approach to diagnose and manage flea allergy, food allergy, and atopy in the dog and cat.
Management of the allergic patient entails a multimodal approach with frequent and ongoing communication with the client. Obtaining a comprehensive history is crucial for diagnosis and treatment of allergic skin diseases, and the guidelines describe key questions to ask when presented with allergic canine and feline patients. Once a detailed history is obtained, a physical examination should be performed, a minimum dermatologic database collected, and treatment for secondary infection, ectoparasites, and pruritus (where indicated) initiated.
The veterinary technician is an invaluable asset in dermatologic appointments. From taking comprehensive clinical histories to educating clients, technicians serve a vital role in the workup and successful management of pruritic patients.
The process of diagnosing and managing allergic skin disease can be prolonged and frustrating for clients. The guidelines offer recommendations and tips for client communication and when referral to a dermatologist should be considered to improve client satisfaction and optimize patient outcomes.
Introduction
An itchy pet is one of the most common reasons a client seeks veterinary care. Allergic skin diseases can cause discomfort and distress to the animal and stress to the pet’s family members.
Identifying the cause(s) of an allergic condition can be a long, often frustrating process for both clients and veterinary staff. Multiple follow-up visits may be required before a final diagnosis is achieved. 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. Patients with allergic skin disease often require lifelong management to optimize their quality of life.
To manage client expectations, prepare a realistic diagnosis and treatment plan that incorporates individual factors, including financial considerations. Prepare clients for long-term commitment and for the fact that occasional flares can occur in even the most well-managed patients.
Photographs, tables, algorithms, and flowcharts play a central, essential role in supporting the guidelines. These include photographs of pruritic patients and cytology to aid diagnosis, tables of recommended treatment options, decision trees, and a flowchart that illustrates the important contributions of technicians every step of the way.
Section-by-Section Summary
The guidelines are designed to simplify the path to diagnosis and management of canine and feline allergic skin diseases, while emphasizing a multimodal approach for the patient and effective client communication to ensure the best possible outcome. To that end, the guidelines are organized in eight sections, as summarized in the following. Each of the eight sections begins with three key takeaways. Because of space constraints, the key takeaways are not transcribed here. This is just one example of the guidelines’ usefulness and why it is necessary to read them in their entirety.
Section 1 describes the steps in diagnosing the canine patient with allergic skin disease. Each step in the process is discussed in some detail.
Step 1 is taking the clinical history and conducting the dermatologic physical examination. The guidelines offer a list of key questions to ask when taking the history and several photos of pruritic canine patients as a reference to aid in the physical examination (Figure 1). Step 2 is collecting the minimum dermatologic database; the minimum database is described.
Clients should be informed that there are likely no quick fixes or cures, only lifetime management strategies.
Step 3 involves treating pruritus and step 4 is treatment for secondary infections and ectoparasites. The latter is supported by several images of the cytology of secondary bacterial and yeast infections (Figure 2). Step 5 is to recheck, verify medication, and assess response to treatment, with discussion of treatment options depending on the dog’s response to initial treatment. Step 6 is the diet trial, which is important to making a diagnosis because no historical or physical examination findings can differentiate atopy from food allergy. Figure 3 is a decision tree for assessing diet trial results.
Step 7 addresses seasonal atopy or nonseasonal atopy with seasonal fluctuation.
At a Glance |
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Visual aids provide essential support for diagnosis, treatment, and management of the allergic pet and a guide to the varied contributions of technicians to effective, efficient care. Table 1: Antipruritic and anti-inflammatory medications for dogs Table 2: Acute flare and long-term management therapies in dogs Table 3: Oral antihistamine doses for dogs Table 4: Antimicrobials for skin infections in dogs (organized by appropriate use and with reference to the 2022 AAFP/AAHA Antimicrobial Stewardship Guidelines) Table 5: Oral antifungal medication doses for dogs Table 6: Antipruritic and anti-inflammatory medications for cats Table 7: Acute flare and long-term management therapies in cats Table 8: Oral antihistamine doses for cats Table 9: Oral antifungal medication doses for cats Figure 1: Clinical presentation of the pruritic canine patient Figure 2: Cytology of secondary bacterial and yeast infections Figure 3: Assessing diet trial results Figure 4: Diagnosing allergic skin disease in the canine patient Figure 5: Clinical presentation of the pruritic feline patient Figure 6: Diagnosing allergic skin disease in the feline patient Figure 7: Flowchart of technician utilization for allergic skin diseases: One veterinarian and two technicians Figure 8: Client communication flow chart for treatment plans |
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Section 2 addresses treating the allergic canine patient, with subsections devoted to flea allergy, food allergy, and atopy. The discussion of atopy addresses initial management as well as long-term management and acute flares.
This stage can be frustrating as there is no one-size-fits-all treatment. Besides the need to manage secondary infections, inflammatory flares, and individual patient responses, veterinary teams must consider client compliance and finances.
Atopic patients need lifelong medical care requiring routine veterinary visits and an active working relationship with the client.
If adequate control of clinical signs cannot be achieved by the third veterinary visit, referral to a veterinary dermatologist should be presented as an option to provide more effective treatment and less cost in the long run.
Atopic patients need lifelong medical care requiring routine veterinary visits and an active working relationship with the client.
Section 3 shifts focus to the feline patient, focusing on diagnosis. This section discusses clinical presentations of allergic dermatitis in cats and key differences between cats and dogs. Compared with dogs, the pathogenesis of allergic skin diseases in cats is not as well understood.
Feline atopic syndrome has been proposed as the umbrella nomenclature describing allergic dermatitis involving environmental allergens, food allergy (gastrointestinal manifestation), and allergic asthmas (respiratory disease) often associated with immunoglobulin E antibodies.
Feline atopic skin syndrome (FASS) refers to the entity associated with inflammatory and pruritic allergic skin disease from environmental allergens. The guidelines note that FASS can only be diagnosed based on compatible history and clinical signs and by ruling out all other similar-looking diseases.
None of the feline cutaneous reaction patterns are pathognomonic for any particular pruritic disease, emphasizing the need to perform a thorough diagnostic workup, including an accurate clinical history and dermatologic physical examination (step 1) and a minimum dermatologic database (step 2). The minimum dermatologic database should be collected based on reaction patterns (Figure 6).
Figure 5 presents photographs of the four distinct clinical patterns of feline allergic dermatitis: miliary dermatitis, head and neck pruritus, self-induced alopecia, and eosinophilic granuloma complex (including eosinophilic plaques, granulomas, and indolent ulcers).
Step 3 is to treat pruritus during the diagnostic period, and step 4 is to treat ectoparasites and secondary infections (a photograph shows superficial skin infection due to Staphylococcus spp.). Although topical antimicrobial therapies are ideal to reduce the overall exposure to systemic antibiotics, the grooming behavior of cats and their decreased tolerance for topical applications often limits their use.
Step 5 involves rechecking and assessing the cat’s response to antiparasitic/antipruritic therapies. Step 6 is the diet trial, referencing the algorithm in Figure 3 for assessing the trial.
Follow the Icon! |
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Throughout the guidelines you will find icons that highlight tips related to spectrum of care (see Section 6), technician utilization (Section 7), and referrals: Spectrum of care recommendation Use of over-the-counter (OTC) diets should not be recommended when conducting a diet trial. Ingredients not declared on the label have been detected in OTC diets, possibly negating the results of the trial. However, the guidelines task force agrees that an OTC novel protein diet can be used if financial constraints make other diets impossible. The client should be warned that an OTC diet may not provide optimal results and should be considered a diet change, not a true diet trial.
Having technicians take the history is an excellent way for them to build client trust and relationships that can carry through treatment follow-ups, client education, and ongoing control measures.
A diagnosis of feline atopic skin syndrome is an excellent juncture in treatment to consider referral to a veterinary dermatologist if this has not occurred already. |
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Section 4 describes managing feline chronic allergic conditions, including initial and long-term management of feline allergic skin diseases and acute flares. This section addresses flea allergy, food allergy, and FASS.
Before launching into a discussion of treatment and management options, pause for a moment to congratulate the client for seeing the diagnosis process through. Doing so speaks volumes about a practice’s compassion and desire to cultivate long-lasting relationships.
The guidelines stress that ectoparasites and infections need to be ruled in or out before treating allergic skin disease. They also point out that FASS has different management considerations compared with canine atopic dermatitis; partnership with a veterinary dermatologist can be beneficial.
Section 5 provides an overview of diagnosis and treatment of allergic otitis externa (AOE) in dogs and cats, including clinical presentation, diagnosis, treatment, and short-term and long-term management. The guidelines note that AOE is an inflammatory condition and should not be confused with infection, though infection often occurs secondary to AOE.
Section 6 presents spectrum of care (SOC) considerations for allergic pets. Spectrum of care means providing a continuum of acceptable care that considers evidence-based medicine while remaining responsive to client expectations and financial limitations.
This section discusses SOC considerations relevant to the clinical history, physical examination, treatment, referral, and telehealth.
Section 7 discusses the vital role of veterinary technicians and how to optimize their involvement, as illustrated in Figure 7. A veterinarian working with two technicians can see two appointments in the time it would otherwise take to see one.
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Being aware of state regulations is the responsibility of the credentialed technician and the management team, and all actions taken must fall within the scope of their license. The entire veterinary team should become familiar with the scope of practice for credentialed technicians in their state. |
The only limiting factors are state regulations and a veterinarian’s willingness to train technicians to take over specific duties within defined parameters.
Many technicians want more responsibility commensurate with their training and allowing them to assume additional job duties is a wise investment of time for veterinarians.
Section 8 addresses client communication, with special emphasis on preparing clients for the long road ahead. This includes openly discussing factors like work schedules, household environment, and financial concerns that may affect patient care plans. It is especially important to manage client expectations, including that diagnosing and finding the right combination of treatments may take some time, that managing allergies is a lifelong commitment, and that flares occur even in well-managed cases. Ten key messaging points are offered.
The 2023 AAHA Management of Allergic Skin Diseases in Dogs and Cats Guidelines are a rich resource of information, tips, and recommendations written by a task force of experts. Owing to space considerations, this executive summary can provide only a high-level overview of the guidelines’ content. As mentioned previously, there is no substitute for reading the guidelines in their entirety. Access the full guidelines and additional resources at aaha.org/allergic-diseases.
The 2023 AAHA Management of Allergic Skin Diseases Guidelines are generously supported by Hill’s Pet Nutrition Inc., Merck, and Zoetis.
Constance Hardesty is a freelance writer living in Colorado. She is former editor-in-chief of AAHA. |
Photo credits: Aleksandr Zotov/iStock via Getty Images Plus, sdominick/iStock via Getty Images Plus, Solovyova/iStock via Getty Images Plus