The Skin Flint Podcast

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.