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April 2024
Gems from the Guidelines: Management of Allergic Diseases
Julia Miller, DVM, DACVD, co-chair of the task force behind the 2023 AAHA Management of Allergic Diseases for Dogs and Cats Guidelines, offers some recommendations on how to make it easier to get itchy pets (and the people who live with them) the care they need.
A Conversation with Julia Miller, DVM, DACVD
If you work in small animal general practice, managing allergic disease is a part of everyday life—and a constant challenge for vet teams with too many patients and not enough time. Julia Miller, DVM, DACVD, co-chair of the task force behind the 2023 AAHA Management of Allergic Diseases for Dogs and Cats Guidelines, understands why the demands of primary care practice mean sometimes diagnostics don’t get done every time, some pets will never see the inside of a dermatologist’s office, and some days just don’t allow for as much client communication as we’d all like—but she’s got some recommendations to make it easier to get itchy pets (and the people who live with them) the care they need.
Katie Berlin: I am here with one of the co-chairs of the very first AAHA Management of Allergic Diseases for Dogs and Cats Guidelines, Dr. Julia Miller. Julia, would you give us a little bit of an intro to yourself—besides that you can sing really well—and what it is you’re passionate about now?
Julia Miller: Yeah. So, I love singing, and I did that for a long time, but I also grew up a horse girl. I’ve ridden since I was a little kid. So when I did go to vet school, I actually went to farrier school right before vet school because I wanted to be an equine podiatrist. That was my initial goal. Spoiler alert, I firmly believe that changing your career can be very good for you, and you should be open and flexible to how your interests may change.
After Cornell, I did a large animal rotating internship at the University of Georgia. After my internship, I didn’t want to pursue specialty work because I was burned out from doing the internship. So I wanted to go into general practice, also because I really saw the value during my internship, being a specialist that people referred to, I saw the value in having a really solid general practitioner who knew what they were doing, knew how to work up cases, and then could refer appropriately.
So I went into general practice after my internship and I did mixed animal practice, which was a surprise to me. I was absolutely one of the first people in vet school that when I finished my small animal medicine rotation, I was like, “Done. Never doing that again. Cat diabetes, see you later.” And then I became a mixed animal practitioner and promptly ate all of those words and definitely treated a lot of cat diabetes throughout the years. So I really enjoyed the large animal aspect of practice tremendously, but I found myself gravitating towards the small animal side of things more than I thought I would have, and I gravitated towards dermatology more than I thought I would have.
As I moved forward in practice, I started to develop a love for specialization again. And I decided, did I want to do more surgery or more dermatology? And as it turned out, derm won. So I ended up coming back to Cornell and doing a derm residency, and then I stayed on at Cornell after my residency as faculty for a couple years, which was wonderful. I had a great experience teaching vet students, but now I’m in private practice in Kentucky working with Animal Dermatology Clinic in Louisville. And I love it. I love derm. Give me the grossest stuff, the smelliest things, the chronic diseases that you can’t cure, I’m all about it.
KB: What about in your free time now? You obviously have tried a lot of different aspects of vet med and have found your place, at least for now. Do you have a third space where you can just be Julia and you don’t have to be a specialist or doctor or anything?
JM: Yeah. Weirdly enough it’s at karaoke. I adore karaoke. It’s so fun. I love going there. There’s actually a real dive bar here called Mr. Jeans, and I go there on Thursday nights and have a blast just doing karaoke and hanging out with strangers, making friends. The beautiful thing about living in the south or in Kentucky is that you never meet a stranger here. So I enjoy doing that, and it gives me a little break from being Dr. Miller.
KB: Oh, love it. Do you know Alyssa Mages? Because she is a karaoke fan. And so some vet conference, I have a feeling there’s going to be a karaoke night with you there.
JM: Heck, yeah. Sign me up.
KB: Okay. Alyssa, if you’re listening, you got a victim. So, okay, back to the guidelines. This is the first time that AAHA has published guidelines for the management of allergic disease in dogs and cats. And I think that’s really cool, and I’m really excited to see how the guidelines are received. What was it like co-chairing that task force?
JM: It was such a unique experience for me. I have never been a part of anything consensus-related and I really enjoyed it. I really enjoyed the breadth of knowledge that was brought into the group, and I found it fascinating. I always say dermatology is the gray area. There’s not one way to fix every case, which is why I love it and many people hate it or find it frustrating.
We really were able to come together on a lot of things and work through the minute details and come to a consensus, honestly, fairly easily. I really enjoyed working with everybody and seeing what their different lived experiences. It was a very rewarding experience for me.
KB: There are a lot of resources out there for management of allergic disease, and it seems like new ones are popping up all the time. What makes the guidelines different from what’s available already?
JM: What I love about our guidelines is that they are concise, they’re digestible, they give you bullet points, flowcharts, and charts of things to do. It’s all very compact, and we did that on purpose. We wanted it to be very practical, approachable, and condensed.
You can sit down, read it, get a good idea of how to work through things, and then you can reread it and reference it later. You can go back and look at a flowchart and say, “Hey, I’ve got a food-allergic dog. I don’t remember how long I’m supposed to feed this diet, let me turn to this page and go through the flowchart that’s there and remind myself very quickly, very easily on how to work through that.” I think approachability is really one of the benefits of these particular guidelines.
“The value of the technician in a dermatology workup is incredible. We can’t overstate their value, truthfully, because the way I look at it, they are an integral part of just about every piece of our workup.”
Julia Miller, DVM, DACVD
KB: So important. It doesn’t matter what kind of great resources you have, if you need them in a pinch and they’re not accessible, or it takes you 12 clicks to find them, you’re not going to use them. I also love what you said about how it’s geared towards not just the general practitioner, but their team as well, and to vet students who are entering the profession. Having something that is like a CliffsNotes for when you’re overwhelmed is very, very helpful.
Having technicians involved is something that I definitely want to talk about. Amanda Friedeck, who is a VTS in dermatology, was on the task force as well. Did you find that having a technician on the task force changed how you saw some of the things that you would otherwise have wanted to say or changed your point of view in any way?
JM: It was so lovely having her there because I always like to see things from another side. And to a doctor, seeing things from the technician side, is such an important perspective to have. So having her being able to chime in was great. She definitely had some direct influence on what we said and how we can utilize technicians and where we should put that in.
The value of the technician in a dermatology workup is incredible. We can’t overstate their value, truthfully, because the way I look at it, they are an integral part of just about every piece of our workup. In dermatology, history-taking is critical. It’s a big part of what we need, a big part of what we do.
When did the itch start? What is the level of the itch? What treatments have you used? Right off the bat, your technician is your first line of defense. They’re the ones that you can train to get that excellent history, and that’s going to set you in the correct direction on the case.
If you have a savvy technician, you can also teach them how to take your skin cytologies for you, so that by the time you’re walking in the room, you’ve already got all that behind you. And your technician can really help you be more efficient, but also more accurate, which I love.
And then once you make your diagnostics, you figure everything out you’re doing, you’re going to talk with the client, it’s going to go half over their head, they’re a deer in the headlights, we just talked about a chronic long-term disease that we’re not going to cure, and then you leave the room. But then you got to remember that, again, that line of defense you have is your technician. And they can go back in, they’re the ones who can reiterate everything, say, “Did you understand what she said? Let me show you how to put the ear medication in. Let me show you how to use the mousse. Here’s your Apoquel. This is twice a day,” and that sort of a thing.
KB: That’s so true. I don’t know what I would have done in my last practice. We had a lot of credentialed technicians who read all the cytologies and in many cases took the samples, skin scrapings, and whatnot. We wouldn’t have gotten through the day otherwise.
One of the things that I love about hearing you talk about working with Amanda on the task force is that that process, really, the task force process and the creation of these guidelines is a model for how we should be working with technicians in practice—as members of the team. They’re educated. They have their own experience and their own opinions about how we should be doing things, and we should listen. There’s no reason why veterinarians should think they have all the answers when the technicians are right there on the floor with them, and in many cases, for a lot longer while we’re typing up charts.
So let’s talk about something else that you mentioned briefly before, which was spectrum of care. You said that you were working with people who were actually teaching and talking about spectrum of care in dermatology cases. Can you elaborate a little bit more on that, what that means and why you think it’s so important?
“To me, spectrum of care means that there is more than one way to fry an egg, there’s a lot of different ways to approach a case, and we need to look at what people can do, what people can afford, and how to help our patients in the best way possible.”
Julia Miller, DVM, DACVD
JM: I think spectrum of care is something we’re talking a lot more about in veterinary medicine and also talking more about teaching it to the vet students. Because the way I look at life, there’s the gold standard, the ivory tower, the best of the best, and then there’s a lot of stuff beneath that that’s still really good veterinary medicine and really good care towards a patient. When I was in general practice, I was in rural North Carolina for my first job, the gold standard, best-of-the-best just was not economically, emotionally, or physically feasible for many of my clients.
The important thing to do is to look at the whole case and decide how we can provide the best medicine with everything that we’re given. To me, spectrum of care means that there is more than one way to fry an egg, there’s a lot of different ways to approach a case, and we need to look at what people can do, what people can afford, and how to help our patients in the best way possible.
We thought about that a lot in these guidelines. Of course, I might say every single case needs these 10 things every single time, but you can absolutely still treat cases and work cases up without doing every single thing, every single time. So we tried to take into consideration what you can do, how to work with what you have effectively, and still get really good care for our patients.
KB: That is so refreshing to hear. I know a lot of people will have mixed opinions about that, because I think a lot of people think of the AAHA guidelines as best medicine or gold standard or whatever those phrases mean. But I think over the last, at least the last couple of years, when I’ve been at AAHA, I’ve seen the definition of best medicine change dramatically from the ivory tower like, “This is what you learn in school, in the textbooks, and you get tested on kind of thing,” to, “Best medicine is what’s best for that pet and that client in that room at that moment.” And that often does not look like the textbook solution. And what’s worse? Doing something less than “gold standard,” or sending that pet home without care?
Do you feel like spectrum of care approaches will help to improve compliance with clients and trust in the veterinary team?
JM: Yeah. I really do think they will. And I think, especially in dermatology, it can get really expensive really fast. Taking the stigma off of things and saying, “Hey, if this is what you can do for your pet to be comfortable, I’m working with you. I’m with you to try to help your dog. If you can’t afford this very expensive skin culture, guess what’s cheap? Bleach. Bleach is cheap. This topical mousse, this shampoo that we have is pretty cheap.”
These are all the things that I think we try to take into consideration with spectrum of care. And I’m very happy that the guidelines were able to address some of that and take away a little bit of the shame. We all practice vet med, we’re all here for the clients and the patients. It’s just important that in the end we try to do what we can do to make the pet feel better and also to make the client feel better.
“The big thing I would say with referral is if you think that you’ve got a client who might be interested, start the conversation early . . . I can’t tell you how many of my clients come and tell me, ‘I had no idea you existed. I’ve been going to my vet for 10 years with this itchy dog and I didn’t know a veterinary dermatologist existed.’”
Julia Miller, DVM, DACVD
KB: What about referral? One of the things that I struggled with and sometimes struggled with with colleagues was when to refer derm cases. Because when clients get differing messages from different doctors in the practice or different team members in the practice, it’s sometimes hard to convince them that referral is warranted or is in the best interest of that pet, even if they have the money, because they’re like, “Well, so and so will just treat it.”
But there’s a big difference between throwing cephalexin at the problem over and over again and actually getting a diagnosis and trying to figure out what’s going to work best for the pet. What would you like general practitioners to know about referring derm case?
JM: The big thing I would say with referral is if you think that you’ve got a client who might be interested, start the conversation early. And they don’t have to refer early, but you can just drop the fact that a dermatologist does exist into the conversation early-ish. Because I can’t tell you how many of my clients come and tell me, “I had no idea you existed. I’ve been going to my vet for 10 years with this itchy dog and I didn’t know a veterinary dermatologist existed.”
Now maybe they’d been told about me a hundred times and they just forgot, but I also do think it’s important for us to mention that. Because also I remember in practice some clients will surprise you. Clients you would never think would’ve referred will be like, “Oh, yeah. I’ll go. Yeah, I’ll go tomorrow.”
So send them to me early if you can, because that’s going to give the patient and the client the best chance at achieving success, or at least start having the conversation early. I recognize that a lot of clients won’t come right away, but if you drop the hints and say, “A dermatologist does exist. You’ve been here for bacterial infection four times this summer, maybe we should start thinking about seeking some extra help.” I think that can be really important.
KB: Okay. Last question that I have for you. These guidelines are packed. They’re so meaty, just absolutely packed with information. If you had a pearl of wisdom from them that you’re like, “Okay. If you take one thing away from these guidelines, I want it to be this,” what would it be?
JM: It is very hard to have one pearl of wisdom. I think that there’s a couple of mantras in derm that these guidelines really bring up. And one of those is, if at first you don’t succeed—you missed something, do more diagnostics. If you are using Cytopoint for itch control and it’s going great, and then all of a sudden it’s not going great, the dog is itching all over the place, see if there’s a bacterial infection with your cytology. Is there now Malassezia dermatitis? Does the dog have scabies or fleas because they stopped their flea preventative? So if something that worked stopped working, do more diagnostics. Just don’t switch that dog to Apoquel and say, “Oh, I guess Cytopoint isn’t working anymore, we need to move it.”
Another thing that we talk a lot about in the guidelines is—as frustrating as it is—there is no one-size-fits-all that works for every patient. So it is really important to have lots of communication with your client about how they’re doing things, do we need to pivot? And if one drug doesn’t work, try another drug. Don’t just keep trying the same drug over and over again and expect different results. You may need to pivot or you may need to change, because all of these patients are very unique in the way they present and all of them are very unique in the way they respond to our treatments.
And then last but not least for me, history taking matters so much. In dermatology, it really does matter because when you’re talking about environmental allergy versus food allergy, it’s all in the history. It’s not in your physical. They look the same. They’re identical dogs. It’s all in the history taking. So utilize your technicians, train your technicians, to ask more than just vomiting, diarrhea, how you’re doing at home. Make sure you’re getting that thorough history, because that is a huge part of your workup.
KB: That’s another thing that I had meant to come back to—what you said about how some people, by the time they see you, don’t even like the pet anymore. And I have seen that so often and it’s so sad and I don’t blame them at all. Your average bulldog is gross. And it’s not their fault, but they smell weird and there’s discharge everywhere and the wrinkles and they’re licking everything, if they can reach it even. And if they’re not licking it, they’re scooting and I don’t blame owners at all for being like, “Oh my God. What am I going to do?” And like, “I don’t want to even have people over to my house because it smells like this dog,” and at the same time you know they really love those dogs. So that, if nothing else, is motivation to try to get these under control sooner, and if not, send them to you. It’s not a write off, it’s a leveling up of that dog’s care to somebody who has a lot more time to spend on it.
JM: My dad always used to say, “Derm cases don’t die, they just smell like it.” And he’s correct, he’s 100% correct. But I think it is important that we take our derm cases seriously. A lot of people are ready to refer eyeballs because it’s like, “Man, if I mess up, the dog loses an eye.” Well, think about that same way for your derm cases. If you mess up, they might send the pet to a shelter, and then that’s lost. So the consequences can be negative if we don’t manage our derm cases appropriately, and I think it’s important that people take that and think about it, that it’s not just about a little Proin or a little cephalexin, it does go a little bit deeper there.
I hope everybody reads the guidelines. Have a drink of coffee in the morning, read the guidelines, make sure you’re up to date.
Central Line: The AAHA Podcast is generously sponsored by CareCredit.
Catch the full episode, and every other episode of Central Line: The AAHA Podcast, on major podcast platforms, YouTube, and at aaha.org/podcast.
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Julia Miller, DVM, DACVD, is co-chair of the task force behind the 2023 AAHA Management of Allergic Skin Diseases Guidelines. She works at the Animal Dermatology Clinic in Louisville, Kentucky. |
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Katie Berlin, DVM, is the host of Central Line: The AAHA Podcast. |
Photo credits: Fetrinka/iStock via Getty Images Plus, vitapix/iStock via Getty Images Plus, ThamKC/iStock via Getty Images Plus, Wirestock/iStock via Getty Images Plus