The Skin Flint Podcast
Whether you simply have a pet with skin issues, or are a vet / vet nurse looking to bolster your CPD record with free, easy to listen to, on the go discussion on and around pet skin disease - this is the podcast for you! Join European leading dermatologist Dr Sue Paterson, Dermatology Veterinary Nurse John Redbond and Elearning.Vet content provider Paul Heasman as they pick their way through the scabby surface of pet skin disease. Expect interviews with some of the smartest minds in animal dermatology to get beneath the surface of the latest thinking on all things fur and skin, keeping their gloved fingers on the pulse of current topics itching to be discussed. This podcast is brought to you by Nextmune UK (formerly Vetruus), specialist in veterinary dermatology and immunotherapy. Nextmune bring you products such as Otodine and CLX Wipes – market leading products in the management of skin and ear cases. In association with Elearning.Vet - providing the highest quality veterinary content free of charge.
Episodes
Wednesday Mar 20, 2024
Episode 21 - Sustainability? It's (eco)-logical!
Wednesday Mar 20, 2024
Wednesday Mar 20, 2024
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.
Tuesday Jan 09, 2024
Episode 20 - We’ve Been Expecting You, Malassezia
Tuesday Jan 09, 2024
Tuesday Jan 09, 2024
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.
Thursday Oct 19, 2023
Episode.19 - Mr. Bump’s Guide to Navigating Skin Tumours
Thursday Oct 19, 2023
Thursday Oct 19, 2023
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.
Wednesday Sep 13, 2023
Episode 18 - ’Ear All About It!
Wednesday Sep 13, 2023
Wednesday Sep 13, 2023
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!
Tuesday Aug 01, 2023
Episode 17 - Skin Flint vs The Derm Vet; a Podcast Collaboration Special
Tuesday Aug 01, 2023
Tuesday Aug 01, 2023
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
Wednesday Mar 22, 2023
Episode 16: The Great Protein Debate - Beef or Beans?
Wednesday Mar 22, 2023
Wednesday Mar 22, 2023
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?!
Tuesday Jan 10, 2023
Episode 15 - Knotty ’Nother Sarcoid!
Tuesday Jan 10, 2023
Tuesday Jan 10, 2023
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).
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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...
Friday Sep 09, 2022
Episode 14 - A Scandinavian Success Story
Friday Sep 09, 2022
Friday Sep 09, 2022
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.
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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!
Tuesday Jul 19, 2022
Episode 13 - Summer Itchin’
Tuesday Jul 19, 2022
Tuesday Jul 19, 2022
For this episode Sue, John & Paul invite the wonderful Victoria (Tori) Robinson onto the podcast - a dermatology specialist based in referral practice in Glasgow.
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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!
Friday Jun 10, 2022
Episode 12 - The Return of the Wound Queen
Friday Jun 10, 2022
Friday Jun 10, 2022
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.
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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