The Skin Flint Podcast

Episode 15 - Knotty ’Nother Sarcoid!

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...
 

Episode 14 - A Scandinavian Success Story

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!

Episode 13 - Summer Itchin’

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!

Episode 12 - The Return of the Wound Queen

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

Episode 11 - The Queen of Wounds

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

Episode 10 - Rabbiting on about rabbit skin

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

Episode 9 - Hypochlorous Acid: The New Old Kid on the Block

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

Episode 8 - Who are the WAVD & what do they do?

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

Episode 7: Come-ply With Me!

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

Episode 6 - Allergy Vaccines: do they work?

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