The Skin Flint Podcast

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!
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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...

Episode 5 - Call The Vet Nurse!

In the fifth episode of the Skin Flint Podcast, we invited Sara Kendall RVN to join us for a discussion on how veterinary nurses can improve dermatology cases by close interaction with the vets. Sara is also the Group Manager of the VNDG (Veterinary Nursing Dermatology Group).
 
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Chapter 1 - Call The VN!
(00:00) John introduces Sara to the podcast and Sara lets us now about her role as a nurse working in busy first opinion practice, who is involved in dermatology
(01:31) Sue asks why Sara why she became an RVN.  Sara shares her journey as a VN from the age of 17.
(02:09) Sue asks if nurses are being used more in practice now and Sara feels like it has changed massively, from nurses being glorified kennel maids to becoming much more involved, starting for Sara with a graduate diploma changing her approach and showed her practice owner that she was capable of doing more.
(03:35) John shared his approach from becoming involved in lab work taking him into dermatology and asked how Sara came to this field. Sara shares that It was the Vetruus/NextmuneUK rep coming round and showing their products which helped her to realise how much she could help first with ear management and then following that through courses into learning more and more about skin management.
(04:48) John asks Sara what Schedule 3 is - and Sara clarifies this as the guidance for what nurses can do - in order to avoid blurring the lines between case support and actual diagnosis of conditions 
(05:35) Sue further clarifies this as nurses not doing surgery or diagnosing but helping with investigation and communication, exercising patience with clients in order to prevent them misusing treatments and therapies.
(06:40) Sara echoes this by telling of how her clients will often reach out to her than the vet for this reason and are more likely to be honest about the management of their pets skin issue and ask questions they might feel are silly questions.
 
Chapter 2: Why The VN?
(07:45) Sue mentions the NHS and their utilisation of nurses and asks if this something we could benefit from and Sara shares how she has been blown away by the size of the role in the human sector in the UK before John mentions his Aunt is a consultant nurse in dermatology - being the ‘go to’ for skin management.
(09:22) Sara says how she feels the shortage of vets in practice in the UK can be really helped by utilising the nurse in this way and Sue echoes this, affirming this as needing to be a partnership in order to ensure the nurse feels capable and trained in order to manage this work.
(10:35) Sue then asks Sara about the training she completed to work in dermatology and Sara talks of competing the Vet Nurse Merit award and using other bits of various CPD.
(11:18) John then talks about how the VNDG (Veterinary Nursing Dermatology Group) and how it looks to bring all this together under one body, before then asking what the VNDGs objectives are - Sara then talks of the development of nurses to help more in dermatology for the benefit of practice, patient and owner.
(12:10) So John asks if you are an owner with an itchy pet, at what stage would a nurse be involved and Sara demonstrates how the owner will come in to see the nurse for an hour long consults in order to facilitate a history of the case and diagnostic tests and to help educate the owners on the nature of skin disease.
 
Chapter 3: How The VN?!
(13:18) Sue asks how the nurse makes the step to running that consult from doing skin tests and things in the background and Sara shares how she took a while to get to grips with the diagnostics, and so the consultation started more as an informational consultation about the challenges of lifelong skin management before then, as her confidence grew and she had educational support, going into more diagnostic support. Which John says is the opposite from his approach and this shows each individual nurse and practice setting will be different in how the nurse becomes more involved, but the all encompassing skills of a vet nurse can be gown and applied across this discipline of dermatology. Sara shares how this then produces a service which is valued and appreciated. 
(16:05) Sue asks if this also improves the income for the practice as well as improving the management of the case and Sara agrees, saying all her services are charged for and clients are satisfied and grateful for the service and s have never queried these fees.
All three reflect on how nurses can really help to manage owners through this, and Sara and Sue share how ear disease if the most common reason for owners going elsewhere because it is never approached and managed as a skin issue. 
(18:19) Sue reflects on the different elements of skin disease and how nurses are incredibly valuable in monitoring these and John says how dermatologists like Sue, having that approach to the use of the veterinary nurse, demonstrates the how important the role of the veterinary nurse in dermatology is.
(19:56)  Sue asks how someone would contact the VNDG to be more involved and John directs them to www.vetnursedermgroup.co.uk
Outro - Summary
(24:50) John, Sue and Paul reflect on how much the nursing role has developed in years and what the future could look like.

Episode 4 - Food For Thought

In Episode 4 of the Skin Flint Podcast, we invite specialist Hilary Jackson to join us to discuss a large and very important topic - diet. Hilary was on the faculty at North Carolina State University, before returning to Scotland where she works as a clinical director at the Dermatology Referral Service in Glasgow. She has clinical and research interests in canine atopic dermatitis and immune mediated skin disease and has published and lectured widely on these subjects and other aspects of veterinary dermatology.
 
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Intro
John Redbond introduces producer Paul Heasman and specialist Sue Paterson for this podcast focusing on diet in relation to pet skin. Sue introduces today’s interviewee as Hilary Jackson, the leading dermatologist on food allergy who has worked in the US and UK and recently finished editing the BSAVA dermatology manual.
Chapter 1: A Balanced Diet
02:21   Sue welcomes Hilary, who introduces herself as in clinical practice in Glasgow with a specialist interest in allergic skin disease in dogs and cats; Sue clarifies her as a world authority on the subject having published a lot of research in the area before
 
03:20 Sue asks why it is important to feed a dog a balanced diet - Hilary clarifies this goes beyond simply considering food allergy, with the skin requiring a quarter of the protein in a dog or cat’s diet. The balance of minerals and fatty acids are also important for skin health. Hilary says any owner should consult a veterinary nutritionist to feed any diet, particularly if home preparing and issues arrive when people go ‘off piste’
04:16 Sue then enquires about what sort of problems Hilary sees as a dermatologist related to insufficient diets or foods the individual pets are allergic to. Hilary replies saying dull hair or poor growth can be a sign of an insufficient balance in the diet and generally itching (or ‘pruritus’ as it is technically known) is the indicator for allergic response to food.
 
Chapter 2: Food Allergies
05:37 Sue asks when a food allergy could start in pets and Hilary suggests they can start at any age; however dermatologists see a lot of young dogs with this. They can go on to develop other allergies to things in the environment but generally if allergy is seen under 12 months it is a food allergic response.
 
06:35 John then asks what sort of foods owners should look out for with allergies, and Hilary says it is very much dependent on what the dog has been fed, so the vet needs to take a careful diet history of what they have eaten, then this will be one or a combination of those foods (likely protein). This will have developed over time, not be from a sudden change as is often thought.
 
07:35 John then asks what signs should be looked for with food allergy and Hilary says unfortunately no signs point between either food or environmental allergy, but the signs for both are itchy ears, itchy faces, paw licking, leg nibbling, tummy rubbing or sometimes scooting and rubbing the back end. With a food allergy occasionally intermittent vomiting, loose stools or diarrhoea could be a sign as this is an internal problem.
 
08:44 Sue asks if this is a pedigree problem related to specific breeds and Hilary says she sees it in all dog but some studies have suggested Boxers, West Highland White Terriers and Labradors can be more prone, but it is often dependent on the area you live.
 
09:49  Sue and Hilary together clarify any dog can get a food allergy and this isn’t related to the quality of the protein at all.
 
Chapter 3: The Right Diet for Allergies
11:05 John asks if there is an easy way of finding the protein they are allergic to, perhaps a blood test, but Hilary says blood tests have been shown to be unreliable so the only way is to feed an elimination diet for 6-8 weeks, consisting of something they haven’t eaten before, before going back to the original foods to find what was causing the reaction.
 
12:41. Hilary clarifies what a novel protein is: anything which is novel to that patient. This can be difficult to find as lots of different protein find their way into the diets, plus cross reactivity means you couldn’t feed (e.g.) turkey to a patient who had eaten chicken previously.
 
13:42 John asks about a vegetarian or vegan diet as an option and Hilary says this can be used as an option for elimination foods; also something called hydrolysed food, where the molecules of the protein are broken down so small that the patient does not react.
 
14:40 Sue clarifies a vegetarian diet should be a pre-made proprietary diet, rather than a home-made mix of vegetables, to ensure the nutritional content is adequate, before then asking about hydrolysed diets (could you feed a chicken allergic dog a hydrolysed chicken diet?). Hilary suggests this isn’t always the case depending on the degree of hydrolysis, so the ultra-hydrolysed foods should be used in these instances.
 
17:00 Sue asks if ‘undeclared proteins’ (proteins not on the labels but which are present in the food) are something avoided with a hydrolysed food and Hilary suggests the hydrolysed diets do well on this.
 
18:07 Sue asks whether an owner with a beef allergic dog should avoid all ruminants in case of cross reaction; Hilary agrees that to be safe this would be the best option - and there can also be less logical cross reactions such as fish and chicken!
 
18:53 John asks if an owner should really be asking their vet which diet to use, given all the variables and Hilary suggests there is a lot of misinformation in pet shops on food, stating the word hypoallergenic actually means very little, as it is so dependent to on what the individual pet is allergic to.
 
19:42 Sue asks how long a pet should be fed a diet before you would expect to see a change with Hilary recommending a minimum period of 6 weeks as the skin takes a lot longer to settle down from this, than say diarrhoea would.
 
20:30 Sue then asks how to cope with a dog itching excessively whilst waiting 6 weeks for the skin to settle and Hilary agrees that its welfare is most important - so some anti itch medication may be used in the short term whilst waiting for the skin to settle down from the diet change.
 
21:23 John asks if you would stay on the new food long term, if it works and Hilary shows how this can be very complicated based on other variables (e.g. the seasons changing and a different environment) so the only way to know for sure is to go back and feed the original food and see if the problem returns - which she indicates could take a week.
 
Chapter 4, the Skin and Gut Microbiome
23:38 Sue asks about the gut and the skin microbiome, whether feeding yoghurt (for example) could improve these symptoms. Hilary says we’re still uncertain - but in people it has been recommended. Hilary and Sue both talk around some of the studies on how these could be related, but stress the research is in its early stages so people shouldn’t jump to feeding a raw diet, for example, based on this.
 
26:14 John asks if this is suggesting a healthy microbiome in the gut means a healthy microbiome on the skin, but Hilary says we do not have evidence for this yet; we do however know more about how the balance of the microbiome on the skin is very important to the health of the skin now, and its response to allergy.
 
27:16 John enquires as to whether supplementation would be a good way of improving the coat and response to allergy, and Hilary says the skin barrier (which keeps the bad out and good in) can be improved with supplementation in theory, with a skin barrier fortifying diet or essential fatty acid supplementation.
 
29:00 Sue summarises that we must be aware of what we are feeding our pets, especially if we have a pet with a food allergy and Hilary suggests more premium diets would be better for consistency on this. Sue wraps up by reiterating the vets are the best place to go to find out more on a potential allergy in their pet.
 
Outro
31:20 John bids farewell to Sue and Paul, who all wrap up the conversation before John puts them on the spot with another silly question.

Episode 3 - Westies And Besties

In Episode 3 of the Skin Flint Podcast, we invite dermatology specialist Janet Littlewood to join us to discuss a very popular breed of dog - West Highland White Terriers (Westies). Janet has over 30 years' experience in referral dermatology, holds the RCVS Dilpoma, and is an RCVS Recognised Specialist in Veterinary Dermatology. 
 
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SHOW NOTES
Intro (00:00) - Westies And Besties
John introduces Sue & Paul, before briefly addressing the topic to be discussed and who is joining us on episode 3.
Chapter 1 (03:08) - Why Westies?
Sue introduces Westie skin disease and Janet talks about whether this breed is more likely to suffer from skin issues. John then asks if there is a link between the white coated nature of the breed and the skin disease and Janet points out there is not any evidence of a link and there are also other white coated breeds which aren't as prone to skin problems.
John then poses the question as to whether there is anything potential owners can do to reduce the risk of getting a Westie puppy likely to have skin disease. Janet talks about seeing the mum and dad of the puppy, especially the mum, and looking for saliva staining on the hair coat (rusty/reddish-brown) as a suggestion of allergy being in the genes of the puppy. But she also points out this isn't a guarantee and some severely affected puppies come from mildly affected parents.
Sue brings up Lucy's Law, which regulates people buying puppies from breeders and not bad sources. Janet also urges caution in having a rescue Westie, as they are often rehomed because of skin disease, but may well look fine at the point of rehoming as the rescue centre they are in is a low allergen environment. Janet shares a story of rehoming a dog herself, but it very quickly became symptomatic when she arrived home.
Chapter 2 (10:35) - Westie Skin Disease
John asks if it is only allergy we are talking about with ‘Westie skin disease’, which Janet clarifies: it is generally an environmental allergy with secondary issues from something like bacterial infection. It is sometimes, but not often, a food rather than environmental allergy.
Sue talks about the horrible black thickened skin Westies can get and Janet talks about this being a result of a long-term secondary infection, referring to it as a dysbiosis (see next question), often caused by a yeast infection called Malassezia dermatitis. She mentions these are even more itchy and hard to control with anti itch therapy such as Oclacitinib (Apoquel), Lokivetmab (Cytopoint) or glucocorticoids (steroids) than the allergy itself. As such the vet should find out what micro organism is overgrowing on the skin.
Sue then clarifies the word dysbiosis, and Janet talks about this being the imbalance of micro organisms on the surface of the skin, micro organisms which are naturally on the skin already. This imbalance causes an overgrowth of one organism, bacteria or yeast, which is what she says is often called infection.
Chapter 3 (14:14) - Diet
Sue summarises the way allergy unsettles the skin and brings the conversation back to Westies; she asks what can Westie owners do? Janet suggests a diet high in essential fatty acids - this can normalise the skin barrier, and she clarifies she's not referring to hypoallergenic foods but diets with these specific oils added. Sue clarifies what these oils are found in.
Sue then asks if Malassezia (Yeast) infections can be solved with a no-yeast diet. Janet clarifies the skin yeast isn't like brewers yeast in bread but a skin surface yeast, and diet would not contribute to this yeast overgrowth. These yeasts are normally in the skin in certain areas naturally, but they get out of control when the skin becomes upset.
John again summarises how we get to this point and that owners can use a combination of things to help manage this. John then asks Janet whether a raw food would solve the problem. Janet suggests first of all, the importance of bathing with a medicated shampoo as well as her previous recommendation of a diet with fatty acid in, as washing the coat can look after the skin and also wash off the particles they are allergic to. She then goes on to talk about the question of raw food, and puts forward that cooked meat is less likely to cause an allergic reaction than raw meat, so there is no science to suggest raw feed would work and no veterinary bodies recommend this at this time.
Sue talks about studies showing the essential fatty acid benefits on the skin, and further points out these are not in raw food.
Chapter 4 (23:02) - Shampoos & Foam
John raises the question of how an owner even begins to work out what to use to treat the skin. Janet says as a dermatologist she takes an evidence-based approach, so talking to a vet or vet nurse is the best thing for an owner to do.
Sue asks what an owner should look for in a shampoo for good anti-bacterial and anti-yeast activity.
Janet mentions chlorhexidine-based shampoos (Clorexyderm 4% shampoo, Peptivet Shampoo) and for shampoos with Chloroxylenol as well. For confirmed yeast issues they need anti-fungal elements and Janet suggests shampoos with Miconazole (Malaaseb) and other ‘..azoles’ as she calls them. Also shampoos with acids, such as lactic or acetic acid and points out there is an evidence base for using all these ingredients.
Sue asks about moisturises for the skin barrier as mentioned earlier, in the form of foams and sprays and Janet reflects on success she has seen in cases using the anti bacterial and/or anti-fungal shampoo alongside a moisturising shampoo or foam/spray. She also mentions how a chlorhexidine-based spray or Foam daily (Clorexyderm 4% Foam and Spray) has been shown to be as effective as a shampoo and with a better residual effect.
Janet point out that different recipes work for different dogs.
Chapter 5 (27:09) - When To Go To The Vet
John brings the conversation to a close asking about a disease being a sign of skin disease and also what flashcards Westie owners should have in their minds for deciding when to visit the vet. Janet explains redness, rubbing, head shaking and scratching of the ears are all signs of a disease and concurs this is a sign of skin disease. Also sore feet, and rashes or what to look out for with general Westie skin disease and all of these should direct an owner to visit the vet. Janet says any time these things occur for a second time it is a warning sign of energy and so an owner should push the vet for more investigations if they are not doing this. She mentions the possibility of a vaccination against an allergy and suggests these investigations could help to treat your skin condition long-term, rather than always treating the symptoms in the short term.
John then asks when an owner should in Janet's opinion push for a specialist. Janet again says the second time you see the signs in a Westie, as this is the best way to get better management long-term if this is not happening in the owner's practice.
Sue clarified that the specialists as well as having more training also have more practice and Janet echoes these sentiments, saying even if your dog responds well to the first dose of treatment, to push when the problem returns to investigate the cause and not just keep repeating the same treatment over and over.
Outro (33:14)
John, Sue and Paul conclude the conversation and say how much they enjoyed speaking to Janet. John asks another tricky question to end the episode.

Episode 2 - Return of Mr Flea

John, Sue and Paul welcome back 'Mr Flea' (parasitology expert Ian Wright) for a second episode of The Skin Flint Podcast focusing on treatments, pet health schemes, media coverage and finally drawing some conclusions to the discussion.
 
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SHOW NOTES
Intro (00:00)
John, Sue and Paul look forward to another chat with Ian Wright the parasitology expert and welcome your thoughts and questions through the social media channels at Elearning.Vet, including any more wacky questions for Sue! Find us on Facebook, Instagram, Twitter and LinkedIn.
 
Chapter 1, Treatments and The Environment (02:22)
John starts by asking Ian about Fipronil and Ian suggests this product still has its place and cast doubt over the idea of drug resistance of fleas to this component. He points out it is easily shampooed off however and not as good for dogs that swim in rivers etc. This brings the conversation to the consideration of the environment with the product washing off when they swim; with Ian stating that there just isn’t the data to suggest that this or any other component is contaminating the environment, however with a product like this which is easily washed off it is better to choose another route for pets that swim. He feels there is more research needed into the environmental aspects. John then asked if the manufacturers have guidelines on the environmental impact and Ian expresses his concerns about the lack of information given to clients about this both by the manufacturers and those selling the products as few owners read datasheets and need all the information to make the best choice for them and their pets.
 
Chapter 2 Pet Health Plans (08:47)
Sue raises the question of how appropriate pets health plans are and Ian agrees that they can restrict choice depending on the degree of clinical freedom a vet has when choosing treatments for patients on a plan. He suggests however that many plans have either a leading product which can be changed or in some cases a completely bespoke plan and feels that this is the best option to give flexibility, pointing out health plans are good for encouraging affordable regular flea control when used appropriately.
Sue points out this is where the vet nurse can be vital in helping to choose appropriate treatment with the owner by gathering all the information and John agrees, whilst expressing concern about the degree of choice involved and whether environmental aspects should be considered based on the conversation. Ian suggests approaching the environmental aspect with care given the lack of data, but suggests that indeed speaking to the owners about their specific preferences and lifestyle factors will help in the future to add the environmental aspect into the conversation and selection of treatment.
 
Chapter 3, Media Scrutiny (15:21)
Sue continues the conversation on the environment pointing out the media awareness, including the stat that a teaspoon of Imidaclorpid can kill 1.25 million bees, Ian agrees it is an emotive subject, and statistics like that one can be unhelpful but in time considering the environment when selecting appropriate treatment can be part of that conversation between practice and owner. John asks if the obvious idea of oral flea treatments such as the Isoxazolines being a solution to the environment aspect holds true and Ian points out there is no evidence to suggest they don’t contaminate the environment anymore then there is evidence to suggest environmental contamination seen is caused by spot-on treatment. The best option is to look at each pet an owner and make a decision appropriately.
Sue asks if it is appropriate that we should be recommending routine treatment all year round and Ian says that it is based on a risk based approach for all pets and parasites, with the level and prevalence of fleas judged to be high enough to justify treatment for all pets, all year round.
 
Chapter 4, Integral Flea Control (22:25)
The conversation turns to integrated flea control and the use of multiple methods to control fleas, not just on the individual pet but also in the environment. Ian discusses a number of methods including insecticide sprays, hot washing, vacuuming, growth regulators and flea sterilising products – stating that the adult flea on the pet it’s just the tip of the iceberg.
 
Chapter 5, Juvenoids and Conclusion (28:32)
Sue asks about the use of juvenoids such as Lufenuron and Permethrin and their consideration with the environment and Ian reiterates that there is a lack of evidence here, but points out they are unlikely to be necessarily better or worse than any other products both for the environment and also the control of fleas. He states that it is better to prevent fleas rather than fight them once they are established which will always require more insecticide in the long run. Sue and Ian point out environmental consideration with other things such as ant killer and agricultural insect control is just as in need of consideration and research before they both conclude the conversation with the importance of a bespoke approach
 
Outro (34:50)
John, Sue and Paul conclude the conversation and Sue tackles another challenging question to end on.

Episode 1 - ”Mr Flea”

In Episode One, Sue and John interview Mr Flea - the brilliant Ian Wright. Ian is a practising Veterinary surgeon and co-owner of the Mount Veterinary Practice in Fleetwood. He has a Master’s degree in Veterinary Parasitology, is head of the European Scientific Counsel of Companion Animal Parasites (ESCCAP) UK & Ireland and guideline director for ESCCAP Europe.
 
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SHOW NOTES
Intro - Mr Flea (00:00)
In the very first skinflint podcast we look at fleas, with the help of Ian Wright BVMS BSc MSc MRCVS expert in parasitology and who the team dub ‘Mr Flea’.
First up we meet the team, european specialist dermatologist Sue Paterson MA VetMB DVD DipECVD FRCVS, Manager of the veterinary nursing dermatology group John Redbond RVN and Paul Heasman the producer of the podcast and director of CPD platform e-Learning.vet
 
Chapter 1, ESCCAP (03:50)
We meet Ian and kick off the conversation learning about the work Ian does with ESCCAP (European Scientific Council Companion Animal Parasites). We hear about how they are a body of parasitologists around the UK and Europe who advise Vets, nurses and owners on parasites.  https://www.esccap.org/
 
Chapter 2, Cat Flea (07:53)
We then start by talking about the cat flea, the most common flea seen on cats and dogs learning about how they love central heated homes. Then we look at how fleas affect different animals differently and even affect people. Ian shows us the ways they can be affected including allergy, disease transmission and general irritation and even fatal anaemia in extreme cases with kittens and puppies. Sue points out that sometimes fleas get forgotten when looking at skin disease and Ian shows how there is still education needed around fleas, especially as there is still a stigma amongst pet owners around the idea of their pets being dirty if they have fleas.
We move on to look at the many different options available to Vets and owners for flea treatments. Ian shows the best treatment is the one suited for an individual owner and pet, with such considerations as swimming and shampooing.
 
Chapter 3 – Vet practices (18:32)
Sue asks if we should, given the variety and need to choose free control around the individuals needs, always be buying these from the veterinary practice and Ian agrees. He shows how this is necessary for the best advice and the reduction of environmental contamination *More on this in SkinFlint epiode 2!
Ian stresses that trained advice is key in selection of appropriate flea treatment.
We then touch on those products which are more natural/herbal alternatives and Iain shows the lack of evidence behind these can be very dangerous and so they can’t be recommended.
 
Chapter 4 – Speed Of Kill (23:37)
We wrap up by talking about speed of kill and Iain shows how important this is, demonstrating that 16 to 24 hours is very important as this is when fleas start laying eggs; demonstrating  speed of care is paramount when selecting treatment, with mode of action (type of flea treatment) the other important factor to be considered as well.
 
Outro – What flea would you be? (26:24)
We close the podcast, taking the time to ask you are pressing dermatology, flea related question.