As veterinarians, we always fine tune skills and hone strategies to enhance our day-to-day practice. A significant percentage of the primary care case load involves a complaint of the skin, ears, or hair coat. Here are some veterinarian tips from a BOARD CERTIFIED VETERINARY DERMATOLOGIST®.
1. Dermatologic History
Obtaining a detailed history is the most crucial part of a visit intended to address a skin or ear problem. Use of a standard form will increase efficiency in extracting specific information from the pet owner.
Veterinary technicians and assistants may be trained to obtain your dermatology history. You will want to know the primary reason for the visit, the onset of the problem, the age of onset of this problem, any other previous dermatology problem, whether other pets in the home are affected, other skin/ear problems previously encountered, current and previously dispensed medications and responses, and concurrent diseases. What is going on with littermates, where the pet was obtained and when and travel history are useful.
If pruritus is the stand out feature, have the owner rate the severity of itch. Determine duration of itch, course of onset (acute vs. gradual), seasonal trends, and body sites affected. Have owners elaborate if pruritus is reported to be “generalized”. Distribution of itch (or other problem) is critical in fine tuning a ddx list.
Response to previously dispensed medications is also helpful in ruling some differentials in or out. Knowledge of what ectoparasite and heartworm prevention is needed and, a diet history should be recorded. Becoming skilled and efficient at obtaining a useful dermatology history will make working up a dermatology case more efficient and productive.
Determine duration of itch, course of onset (acute vs. gradual), seasonal trends, and body sites affected. Have owners elaborate if pruritus is reported to be “generalized”. Distribution of itch (or other problem) is critical in fine tuning a ddx list. Response to previously dispensed medications is also helpful in ruling some differentials in or out. Knowledge of what ectoparasite and heartworm prevention is needed and, a diet history should be recorded. Becoming skilled and efficient at obtaining a useful dermatology history will make working up a dermatology case more efficient and productive.
2. Dermatologic Examination
A complete examination of the skin, ears, nails, hair coat immediately identifies problems that may or may not be elucidated from the history provided. Consider having extended time allotted to ensure you can complete the examination. Consider charging different fee for dermatology examination. Examine the pet from the nose to tail. Then turn the pet over to examine the ventrum and all surfaces of paws. Oral examination and otoscopic examination complete the exam.
Record observations with descriptions of lesions. Record the type, distribution and severity and extent of lesions. Become skilled in otoscopic examination. To develop this skill, perform otoscopic examinations on all patients presented to the hospital in sickness and in health. Hand held otoscopes are an important tool to have in working condition. Ensure there are enough clean and available otoscopic cones of various sizes. I recommend using disposable cones for high volume clinics, as it is uncommon for cones to be adequately cleaned all of the time. I recommend use of a different cone for each ear to eliminate the risk of transfer of microorganisms. Record observations, trends, response to therapy, medications in medical records and refer to previous observations at reevaluations.
3. Use Veterinary Technicians to Capacity
Technicians are critical in the acquisition of the dermatology history and the successful outcome of prescribed food trials, recommended treatments, and diagnostic tests. Technicians should be utilized as the direct link between the veterinarian and the client. They may be trained to educate clients about all aspects of diagnostic food trials. They become informed about types of prescribed diets, why over the counter diets are not suitable, and other intricacies of starting a food trial such as ensuring non-flavored heartworm prevention options are used, other medications and supplements are addressed etc. They are also the contact that repeats importance of the duration and rationale for the trial, what must be eliminated and following up.
Technicians may become experts in ectoparasite control. They should ensure that a solid flea control plan is maintained in all dermatology patients. Having a technician that is the go-to person for information translates into success of parasite control for all clinic patients. The appointed technician should be aware of available products, basic mechanisms of action, options for both cats and dogs, and how to instruct clients on proper use. Another profit center for veterinary clinics is the use of topical therapy. Technicians may be trained to integrate products into the tx plans prescribed by the vet. They can offer options and review frequency of use, technique, what to expect, etc. Spending a few minutes emphasizing the value of topicals in the tx of dermatology problems will educate the client and increase compliance.
Technicians may also be able to offer additional ideas and products should an owner have questions or concerns throughout the course of tx. Finally, one of the best uses of my technicians is for client communications. While we have to relay medical information and ensure the owner knows that we are intimately involved in the overall care of the medical condition, owners appreciate communications from the clinic staff. Technicians can be charged with follow-up calls, to schedule reevaluations, to call owners if appointments are missed, to refill chronic medications, to communicate with referring clinics, etc. Allowing technicians to assume the helm for client communications increases retention of patients and improves patient care. Involving everyone solidifies the team approach. Finally, technicians can be trained to collect samples, prepare them for the veterinarian to interpret and communicate results to owners. Many technicians are capable of evaluating results of tests for the vet and this will increase the efficiency of the appt. Technicians may be trained to perform cytologies, scrapings, collection of samples for cultures, and preparing a patient for skin punch biopsy. Technicians will appreciate being utilized for medical skills and this increases their inherent value to the clinic.
4. Increase the Frequency of In-Appointment Diagnostics
Performing basic diagnostic tests in dermatology cases allows one to make dx and rule out ddx. Results allow one to more specifically and more confidently make treatment recommendations. Owners appreciate a diagnosis for the problem. They will see the value in paying for tests if they know why they are recommend and understand that results directly lead to tx recommendations. Diagnostics that are essential for dermatology include skin surface cytology, otoscopic cytology, skin scrapings, bacterial cultures and susceptibility testing, and fungal cultures. Skin surface cytology should be performed in almost every case, especially in cases with lesions consistent with folliculitis. Cytology is the best test for the diagnosis of yeast. Cytology can be performed on samples collected from almost any body site and is fast and valuable. Otic cytology should be performed on every patient presented for otitis after otoscopic examination. Results dictate treatment and otic cytology can be used to follow response. Bacterial culture and susceptibility testing is an important test. We will discuss what lesion to culture and when to culture a skin lesion. When indicated, we should be performing more cultures from skin lesions given the increase in methicillin-resistance and the importance of judicial antimicrobial use. Results of bacterial cultures allow us to identify and characterize bacteria causing lesions in difficult cases and to guide antibiotic selection. Fungal cultures are indicated in any folliculitis and if there is suggestion that in-contact animals are affected or in-contact humans have lesions.
5. Increasing the Frequency of Follow-Up Visits
Getting patients in for recheck examinations is challenging, but examining pets after the course of treatment allows one to directly assess response and effect of treatment. Gathering this information (while patient still on medications) also allows one to refine the differential list and propose a follow-up plan or maintenance plan. Recheck visits will decrease the revolving door syndrome. The client will realize you have an interest in long-term care of the problem. Rechecks provide continuity of care. Schedule rechecks before a patient is discharged, confirm visits, and call owners for updates if rechecks are missed. I also recommend twice annual dermatology rechecks for chronic conditions. These may be incorporated in to wellness visits, but additional time should be allotted.
6. Monitoring Laboratory Work
Certain chronic conditions necessitate use of medications that are typically benign but can be associated with undesirable side effects. Discuss the need for monitoring certain medications early. Recommendations will be dependent on drugs used. If a pet is on chronic glucocorticoids for management of atopic dermatitis, at least twice annual CBC, serum biochemistry profile and urine culture is indicated. These appointments also allow owners to communicate observations they are having which may lead to early detection of a problem.
If the patient is on a glucocorticoid for management of autoimmune disease or a sterile inflammatory disease, the frequency of monitoring initially will be every 2-4 weeks. Use of urine culture is a newer recommendation as we now know that a fair percentage of patients on chronic glucocorticoids acquire urinary tract infections without exhibiting typical clinical signs. Clinical signs are absent, because glucocorticoids mask outward signs of inflammation and lower the host’s defense mechanisms against opportunistic infections.
If a pet is on a chronic antifungal agent for the treatment and control of yeast dermatitis (or for treatment of difficult dermatophytosis cases), I recommend serum biochemistry tests to evaluate liver enzymes every 3-4 months depending on duration, dose and frequency of treatment. At dosages used to manage chronic yeast, I rarely identify problems (I most commonly use pulse administration). For dermatophytosis cases, higher dosages and once daily administration of the antifungal is more common, so I recommend once monthly evaluation of liver enzymes.
7. Strategically Use Topicals
Topical therapy products may be incorporated into the treatment and control of almost every dermatology problem. Reevaluate current inventory. Have products that target skin infections, pruritus, scale and crust. Reevaluate what inventory you maintain for treatment of ears. For cleaning ears, have at least one cleaning and drying agent and at least one cerumenolytic agent. Have products with and without a glucocorticoid for treatment for yeast and bacterial infections, not every ear infection needs a steroid containing product. Have products that are solutions and ointments (I rarely use ointments). Have at least one product that chelates the cell wall of gram-negative bacteria, as this can facilitate bacterial kill (triz EDTA containing products). Educate the client how to properly clean ears and know what the client can do at home and tailor recommendations accordingly to ensure compliance. Similarly, tailor skin and coat topicals to owner abilities. Use cytology (skin and ear), to dictate choice of topical therapies. Appropriate use of topical will improve therapy and increase hospital revenue. Additionally, once oral medications are completed and the problem is controlled, use of topical therapy is almost always indicated for continued control.
8. Decrease Usage of Glucocorticoids
While there are many indications for appropriate use of systemic glucocorticoids in dermatology cases, they are often used without consideration of options. It is rewarding and better for the patient if we resolve a problem without them. If you are considering a glucocorticoid, ask whether there is an alternative. Have you considered ectoparasites, have you considered concurrent diseases that the patient has or may be at risk for, have you considered treatment of the secondary infection independent of glucocorticoids as an initial approach, and have you considered what diagnostic test you intend to perform that could be affected by recent use of glucocorticoids. I recommend one also aims to dispense oral glucocorticoids instead of injectable. Most importantly, have a plan for the dose, duration, and follow up. Have a plan for determining the underlying cause of the presenting problem.
9. Have a Flexible Game Plan
As one becomes more confident in the things we have discussed so far, one can develop strategies to improve the approach in cases of recurrent secondary infections (i.e. know when to actively pursue underlying disease), confirmed demodex cases (i.e. know which to treat, what options are recommended for treatment, and how to monitor patients), suspected or confirmed sarcoptic mange cases (i.e. know what is effective in treatment and when to suspect sarcoptic mange), the pruritic patient (i.e. know where to start, what to tackle first, and what to plan for next), and chronic otitis cases (i.e. know when to consider a chronic infection, when to consider otitis media and when to consider surgery) for example.
10. Develop a Relationship with the BOARD CERTIFIED VETERINARY DERMATOLOGIST® in Your Area
As specialists in one aspect of veterinary medicine we are dependent upon solid relationships with referring veterinarians. We value and appreciate the opportunities to treat your patients and work with your clients alongside you.