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InFocus

Using topical products as part of a multimodal treatment plan for skin diseases

Topical therapy can be a very helpful aid when managing allergic, infectious and seborrhoeic disorders

Skin disease is one of the most common reasons owners bring their pet to see the vet (Nielsen et al., 2014). These conditions can be frustrating for both owner and vet to get to the bottom of but very rewarding when managed correctly. For management to be successful, accurate diagnosis and client compliance play important parts. Determining the cause of the issue is also important to minimise the risk of recurrence and flare-ups. Veterinary practices are lucky to have an array of parenteral medications to help relieve clinical signs like pruritus and inflammation, but for long-term success it is essential to support and maintain the skin barrier. This is done with topical therapy.

The skin is the largest organ of the body. It regulates temperature, provides a barrier against the environment and it keeps moisture in, keeping the skin hydrated.

It can be divided into three barriers: mechanical, immunological and microbiological. To minimise the risk of skin disease developing or flaring up it is important to maintain the health of these three barriers. This is done by incorporating topical products with restorative properties into the treatment plan. Topical therapy is very important when managing allergic, infectious and seborrhoeic disorders (Banović and Lemo, 2019).

Atopic dermatitis

Atopic dermatitis (AD) is a common disease in dogs. It is an inflammatory and pruritic disease with a variety of clinical presentations that can resemble other disease processes. This can make it a difficult disease to diagnose. Diagnosis is based on meeting the clinical criteria for the disease and ruling out other possible causes with similar clinical signs. It is worth noting that allergy testing is not considered a diagnostic tool for atopic dermatitis but can be done once a diagnosis has been made to identify potential causative allergens for the inclusion in allergen-specific immunotherapy (Hensel et al., 2015).

Dogs with AD have an impaired skin barrier with lower proportions of ceramides and cholesterol in the stratum corneum, widening of inter-corneocyte spaces and abnormal filaggrin production (Lam, 2012) leading to dry and more permeable skin and making it more susceptible to external allergens. They have also been shown to have disturbances in their microbiota. This dysbiosis can lead to bacterial or fungal overgrowth that may favour or enhance atopic flares (Gatellet et al., 2020). It is therefore important to include topical therapies in our AD management plan (Figure 1). Topical products will have a soothing effect on the skin, can help rebuild and maintain the skin barrier and rebalance the microbial flora as well as having the potential to reduce flare-ups. Topical therapies should therefore always be part of the multimodal treatment plan for patients with AD.

FIGURE (1A) Ophytrium-based products can be used to manage atopic dermatitis. Here, a one-year-old Staffordshire Bull Terrier diagnosed with atopy (A) at eight months of age which was not on any immunomodulatory treatment, was shampooed on day one and followed up with mousse applications every 48 hours for 21 days thereafter
FIGURE (1B) Reduced excoriations and erythema were observed on day 21 (B) compared to day 0 (A)

Pyoderma

Pyoderma has been traditionally divided into three types depending on the depth of infection: surface, superficial and deep. In surface pyodermas there is overgrowth of bacteria on the surface of the skin, for example hot spots. In superficial pyodermas the microorganisms have penetrated the skin, but the infection doesn’t extend past the basement membrane, for example folliculitis. Deep pyodermas are those infections that penetrate below the basement membrane, such as furunculosis or cellulitis. Treatment of pyoderma differs depending on the type present.

Diagnosis of pyoderma should always include cytology to determine what type of organisms (bacteria, yeasts, etc) are involved in the infection. This will give you an indication of what you are dealing with and what treatment to use. Oral antibiotics are not always required when treating pyoderma but if indicated, cytology should be followed up with culture and sensitivity testing to determine the most appropriate antibiotic to use.

Surface pyoderma should never be treated with oral antibiotics but can be managed solely with topical treatment containing an antiseptic agent (Figure 2). Most cases of superficial pyoderma can also be managed successfully with just topical treatment, without the need for oral antibiotics (Jasmin, 2003; Müller, 2012; Borio et al., 2015).

FIGURE (2A) An eight-year-old French Bulldog with recurrent pyoderma (A) from eight months of age was suspected of underlying allergies and was not on any long-term immunomodulatory treatment. This was managed with an ophytrium/chlorhexidine 3% shampoo on the first day followed up with mousse applications every 48 to 72 hours for 21 days (B)
FIGURE (2B) An eight-year-old French Bulldog with recurrent pyoderma (A) from eight months of age was suspected of underlying allergies and was not on any long-term immunomodulatory treatment. This was managed with an ophytrium/chlorhexidine 3% shampoo on the first day followed up with mousse applications every 48 to 72 hours for 21 days (B)

For treatment of deep pyoderma, topical therapies play an important role but need to be accompanied by oral antibiotics. This should be based on culture and sensitivity testing. While waiting for culture and sensitivity results to come back, topical therapies can be used. This will avoid the use of an inappropriate antibiotic, save the client money and also soothe the pet’s skin. In cases of recurrent pyoderma, an underlying cause needs to be investigated and treated.

The use of topical therapies can help reduce the occurrence of resistant bacteria. Chlorhexidine digluconate has been shown to be effective against both sensitive and multi-drug resistant Staphylococcus pseudintermedius and it has been suggested that it is at least as effective as amoxicillin-clavulanate against this organism (Borio, 2015). Chlorhexidine digluconate at 2 to 4 percent concentrations have also been shown to provide residual antibacterial activity on canine skin for at least 10 days (Mesman et al., 2016).

Seborrhoea

Seborrhoea can be either primary or secondary in origin. Primary disorders are usually due to a genetic defect that disrupts the normal keratinisation process causing excessive scaling, whereas for secondary seborrhoea the excessive scaling is caused by an underlying disease. Secondary disorders are most common and account for about 80 percent of cases (Barnard, 2015). For treatment to be successful, it is therefore essential to identify and treat, or rule out, any underlying disease (Mauldin, 2013).

Topical therapy is the mainstay of treatment for keratinisation disorders. Treatment goals include scale and crust removal, and oil, pruritus and inflammation reduction. Some topical therapies, such as tar, can be harsh on the skin so try to avoid these and use moisturising therapies to protect the skin barrier. Topical therapies for seborrhoeic disorders include keratolytic (remove scales and reduce adhesion of keratinocytes) or keratoplastic (normalise keratinisation) ingredients as well as moisturisers and emollients to protect the skin barrier, and topical antimicrobials for the management of secondary infections.

Treatment should be tailored to each individual patient and compliance is essential for success (Mauldin, 2013; Barnard, 2015). Therefore, selecting a topical formulation that will suit the owner is of importance. Shampooing the dog or cat is important to get rid of crusts and scales. This can be followed up by mousse applications or using the mousse in between baths. Spot-ons can also be beneficial in restoring the skin barrier function (Figure 3).

FIGURE (3A) Seborrhoea in a cat (A) with underlying diabetes mellitus can be managed with a phytosphingosine-based spot-on once a week for four weeks (B)
FIGURE (3B) Seborrhoea in a cat (A) with underlying diabetes mellitus can be managed with a phytosphingosine-based spot-on once a week for four weeks (B)

Topical therapy and owner compliance

Topical therapies come in different formulations (eg shampoos, mousses, pads or spot-ons) and choosing the right type can help with client compliance. Bathing the dog or cat is important in order to get rid of allergens and crusts from the skin and it should ideally be done at least once at the start of the treatment. Not all dogs or cats like to be bathed or the owner might not be physically able to get their pet into the bath or shower, so in these cases a mousse may be a more appropriate option.

Ophytrium

Ophytrium is a natural ingredient extracted from the root of the Ophiopogon japonicus plant. It has been shown to reduce the intensity and frequency of flare-ups of atopic dermatitis in humans as well as improving quality of life for patients with this condition (Mainzer et al., 2019). Through innovative in vitro human and canine skin models beneficial effects have been demonstrated on the three skin barriers. It has been shown to strengthen the mechanical skin barrier, limit adhesion of S. pseudintermedius to the canine skin and reduce irritation (Ollivier et al., 2019).

References

Nielsen, T. D., Dean, R. S., Robinson, N. J., Massey, A., and Brennan, M. L.

2014

Survey of the UK veterinary profession: common species and conditions nominated by veterinarians in practice. Vet Record, 174

Banović, F. and Lemo, N.

2019

Topical therapy in veterinary dermatology. Veterinarska Stanica 50, 239-245

Hensel, P., Santoro, D., Favrot, C., Hill, P. and Griffin, C.

2015

Canine atopic dermatitis: detailed guidelines for diagnosis and allergen identification. BMC Veterinary Research, 11, 196

Lam, A.

2012

Clinical notes: Skin barrier dysfunction in atopic dermatitis

Gatellet, M., Bruet, V., Cardot, P-M., Laffort, C., Noli C., Ordeix, L., Kesteman R., Ollivier, E. and De-Jaeger, X.

2020

Performance of two protocols combining Chlorhexidine digluconate 3%- and Ophytrium-based shampoo and mousse applications in the management of bacterial overgrowth in dogs. Abstract UNISVET 2020

Borio, S., Colombo, S., La Rosa, G., De Lucia, M., Damborg, P. and Guardabassi, L.

2015

Effectiveness of a combined (4% chlorhexidine digluconate shampoo and solution) protocol in MRS and non-MRS canine superficial pyoderma: a randomized, blinded, antibiotic-controlled study. Veterinary Dermatology, 26, 339-e72

Jasmin, P., Shroeder, H., Briggs, M., Last, R. and Sanquer, A.

2003

Assessment of the efficacy of a 3% chlorhexidine shampoo in the control of elevated cutaneous Malassezia populations and associated clinical signs, in Proceedings, Annual Congress of the European Society of Veterinary Dermatology – European College of Veterinary Dermatology, 170

Müller, R., Bergvall, K., Besignor, E. and Bond, R.

2012

A review of topical therapy for skin infections with bacteria and yeast. Veterinary Dermatology, 23, 330-e62

Mesman, M., Kirby, A., Rosenkrantz W. and Griffin, C.

2016

Residual antibacterial activity of canine hair treated with topical antimicrobial sprays against Staphylococcus pseudintermedius in vitro. Veterinary Dermatology, 27, 261-e61

Barnard, N.

2015

Topical therapy in keratinisation disorders. BSAVA congress proceedings, p. 121

Mauldin, E.

2013

Canine ichthyosis and related disorders of cornification in small animals. Veterinary Clinics of North America: Small Animal Practice, 43, 89-97

Mainzer, C., Le Guillot, M., Vyumvuhore, R., Chadoutaud, B., Bordes, S. and Closs, B.

2019

Clinical efficacy of oligofructans from Ophiopogon japonicus reducing atopic dermatitis flare-ups in caucasian patients. Acta Dermato-Venereologica, 99, 858-864

Ollivier, E., Zemirline, C., Marchand, L. and Closs, B.

2019

Effect of the ingredient A97614A1 on the adhesion and biofilm formation of Staphylococcus pseudintermedius in a model of reconstructed canine epidermis. BSAVA Congress Proceedings 2019, 442-442

Ollivier, E., Zemirline, C., Amalric, N., Rahoul, V., Reymond, N. and Cadiergues, M.

2019

Efficacy of the ingredient A97614A1 in a model of reconstructed human epidermis stressed by cytokines. BSAVA Congress Proceedings 2019, 442-443

Emelie Fogelberg

Emelie Fogelberg, BSc, DVM, MRCVS, graduated as a veterinary surgeon from St. George’s University, Grenada, in 2010. She worked in small animal practice for eight years, including a year and a half for World Animal Protection followed by a stint as a home visit vet for a telemedicine company. She joined Ceva Animal Health as a veterinary advisor in 2018.


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