Lick Granulomas

One of the most frustrating conditions I treat in dogs is acral lick dermatitis (commonly called a lick granuloma). This condition most commonly occurs on the legs of large breed dogs. The condition starts as a discoloration of the fur. With more licking, the skin thickens and the hair falls out. Eventually the area becomes an ugly mass with a wound in the middle. Sometimes, inflammation will extend all the way to the underlying bone causing a periosteal reaction. These patients often walk with a limp.

Unfortunately, the cause of the condition is not completely understood. It appears to be caused by a combination of factors including the personality of the dog, an inciting cause then escalating damage from the constant licking.  Lick granulomas are most common in anxious dogs who demonstrate obsessive/compulsive behavior. Although I was taught in veterinary college, that the anxiety causes the licking that causes the granuloma, I am not sure this is always true. I have seen calm, well-adjusted dogs become anxious after an injury to their leg. My impression is that they lick to relieve the pain. I have also seen really anxious, obsessive/compulsive dogs who do not develop lick granulomas after an injury.

Lick granulomas are usually located on the wrists and hocks. Possible inciting causes include trauma that causes bone or nerve injury, foreign bodies such as splinters or cactus thorns, allergies and mange. Whatever the initial cause may be, the actual damage comes from the chronic licking. The licking damages the skin and allows secondary bacterial and/or fungal infections to occur. The infections are very itchy making the patient lick even more. 

Successful treatment requires diagnostic tests to determine the cause. My workup depends upon the severity of the granuloma and the patient’s history. I usually start out with blood work and a skin scrape to look for mites. If those tests are normal, I take x-rays of the area to look for an underlying orthopedic problem. Many patients  require a surgical biopsy of the tissue for diagnosis. I combine this with a culture from deep within the granuloma to look for fungus and bacteria. 

Multiple treatments are often required for acral lick dermatitis. Here are my recommendations:
1) Remove the underlying cause if possible. If the dog has a bone plate or pins, remove it. I have watched dogs with hardware inside their legs lick excessively when their legs get cold.  
2) Treat the infection aggressively. Most of these dogs require 2-3 months of antibiotic or antifungal therapy to reach the deep seated infections. 
3) Prevent licking. I personally do not like to bandage these wounds because it prevents the wound from drying out. Under a bandage, the wound stays moist and promotes microbial growth. If the dog will tolerate it, I put an e-collar on them. It is important to make sure the collar is long enough to prevent licking. )
4) Control the itch. This usually involves some sort of anti-inflammatory medication, usually a steroid. The steroid can be sprayed over the surface, injected into the mass or sometimes given orally. There is a new drug on the market called Apoquel that I have used for patients with severe allergies. I am eager to see if this works for granulomas. (More information on this drug can be found on my prior post at
https://drnelsonsveterinaryblog.com/2014/02/20/apoquel-oclacitinib-maleate-for-treating-allergies-in-dogs.aspx
5) Treat nerve pain. I think nerve pain is one of the most overlooked components of lick granulomas. To see if nerve pain is part of the problem, I will numb the area with a local anesthetic. If this works, I often place the dog on Gabapentin. I also give the owners a topical spray (Dermacool) that they can spray on the granuloma. It works great for the middle of the night, when the dog is uncomfortable and can’t sleep. 
6) Use anti anxiety medications as needed. As I said before, I am not sure if anxiety caused the dog to lick or the dog became anxious because of the discomfort from the granuloma. I usually try my other treatments first to see if the dog needs something to calm it down. 
7) There are many more treatments that have been tried for this frustrating problem including laser ablation, surgical removal, acupuncture, herbal therapy and medical laser. 

Unless the cause can be found and removed, acral lick dermatitis usually becomes a chronic condition. Treatment calms it down but never cures it once a large granuloma is formed. 

  

2014 Animal Charity Grant

I am pleased to announce the 2014 Animal Charity Grant.  It is open to animal charities in all 50 states.  The grant is my talk, “Embrace Animals To Improve Your Live, Love & Health”.  I will give the talk for free and cover all of my own expenses. The charity may use the talk to make money by charging for tickets and/or generate donations. This is a great presentation for donors, volunteers and boards of directors. 

Please share this grant with your favorite charity and encourage them to apply.  I should emphasize that all applications should be exceedingly brief.  This is meant to be easy for them to apply.  For further information, please visit;

http://www.veterinarycreative.com/Animal_Charity_Grant_RDE9.html

Congratulations to the 2013 Winner; Companion Animal Association of Arizona, Inc.  http://caaainc.org/

To the charities and those who support you – thank you for the gift you are to animals!

Arthritis Treatment For Cats

    As many of you know, I am alive today because of my cat. Tigre diagnosed cancer in my abdomen by scent, then hissed and tried to paw a sheet over me. Now it is my turn to help Tigs. During the last year, he stopped jumping up on counters and furniture.  At night, he sat by the bed and cried until I picked him up. Eventually, I purchased cat stairs so he could come and go as he pleased. 

    Unfortunately, I diagnosed Tigre with osteoarthritis.  When I flexed his knees, it felt like sandpaper rubbing on wood.  Imagine how much pain he felt. I approached his treatment like I do for all of my patients. I start with the safest, cost effective treatments and then move up. For Tigs, that meant using supplements to reduce inflammation. If Tigs had been overweight, I would have placed him on a diet as well. I tried many different supplements, but always with the same results. Tigs would eat them for a week or two then refuse. For my next course of treatment, I started him on Adequan which is an injectable polysulfated glycosaminoglycan (PSGAG).   

Glycosaminoglycans work by decreasing inflammation. Although the exact mechanism is not known, “experiments conducted in vitro have shown PSGAG to inhibit certain catabolic enzymes which have increased activity in inflamed joints, and to enhance the activity of some anabolic enzymes.”(1) For the first six weeks, I treated him once a week to ‘load’ him up then extended the time between injections until I found his perfect interval. Now he is back to jumping on everything!

Note: Adequan is licensed for use in dogs only. Use in cats is considered ‘off-label’. Please discuss with your veterinarian before using to make sure you understand the risks associated with ‘off-label’ usage. 
 
 

1) Quote from Adequan information sheet including with product.

Call the Pet Poison Helpline for Toxin Information

One of the great resources available to pet owners and veterinarians is petpoisonhelpline.com.  Their number is (800) 213-6680.  For a small fee (around $40) you can receive 24/7 assistance if you have concern that your pet has come in contact with toxins.  Upon receiving your case number, please provide it to your veterinarian who can call and get valuable insight into the proper dosing and treatment best practices for your animal.

The website also contains a great deal of useful information for pets. I really like the comprehensive toxin list that covers plants, chemicals, drugs and even venomous reptiles. The section for pet owners tells people how to make up a poison first aid kit, how to poison proof you home and how to protect your pet during the holidays.  They even have a top ten list of the most common poisons.  I subscribe to the newsletter. My clients and I have experienced tremendous help from Pet Poison Helpline so I wanted to pass this information along.  More info at http://www.petpoisonhelpline.com/.

Pyometra in Dogs

    Pyometra is a life-threatening condition found in intact female dogs. The word pyo means pus and metra means uterus so the translation is a pus-filled uterus. This condition usually occurs in middle age to older females about four to twelve weeks after a heat cycle. During estrus or heat, the cervix opens to give sperm access to the ovulated eggs. Unfortunately, the open cervix allows bacteria to enter as well. After the cycle is over, the cervix closes again as the female’s hormones change from high levels of estrogen during heat (estrus) to high levels of progesterone during the periods between heat cycles (diestrus). Progesterone causes the uterine walls to hypertrophy giving bacteria a perfect place to colonize.  It also inhibits the function of white blood cells in the uterus that fight bacteria. With each heat cycle, the hypertrophy and immunosuppression increase until a pyometra develops.  
  
    Common signs of pyometra in dogs are increased thirst and urination, vomiting, depression and anorexia. Diagnosis is easy in dogs with an open cervix that allows the pus to escape.  Most owners will observe the discharge and bring the dog in for treatment. In patients with a closed cervix, the pus is trapped in the uterus causing it to swell. Diagnosis requires an ultrasound or x-rays to see the fluid-filled loops of the distended uterus.(Pictured below is the rear end of a dog with an open cervix pyometra.)
  

    Treatment is simple, spay the dog immediately.  Unfortunately, that is easier said than done. These girls are really sick. They usually require fluid therapy and sometimes blood or plasma transfusions to get them stable for anesthesia.  In addition, the uterus may rupture contaminating the dog’s abdomen. I have never been able to save a dog after this has happened.  Other complications include septic shock and renal failure. (Pictured below is a pyomentra after surgical removal. I incised the uterus after it was safely removed from the patient for demonstration purposes. The bright green material is pus.)

    To prevent a pyometra from developing, I recommend spaying all non-breeding dogs. A routine spay is much less expensive than an emergency spay with a prolonged hospitalization. It is also safer for the dog. In my opinion, medical management should only be tried in cases of open cervix pyometra. The female is given prostaglandins to cause leuteolysis, thereby decreasing progesterone. The prostaglandins also stimulates uterine contractions to expel the pus and improve uterine immunity. I do not recommend this treatment for cases of pyometra with a closed cervix as the uterus could rupture.  

 

Praise to Na Hoku Jewelers for Refusing to Sell Coral Jewelry

I love to snorkel. I float on the surface of the water, watching all the activity below.  Unfortunately, coral reefs all over the world are in decline. These complex ecosystems are struggling to adapt to the pollution, unregulated harvesting of fish and coral, as well as, climate change. Knowing this, I was surprised to see coral (black, red, gold and pink) jewelry for sale at many shops in Hawai’i. Na Hoku was the only one I visited who does not sell coral. According to a policy posted on the store window as well as online, Na Hoku stopped selling coral jewelry in 2006.  They did so because of the damage it was causing to the beautiful reefs of Hawai’i and commendably did so even though it meant a significant financial loss. Thank you Na Hoku for taking action to protect the coral reefs! 

In addition to refusing to buy coral of any kind, here are some other things we can do to help the coral reefs all over the world.
1) Do not touch the reef. Coral polyps are fragile. Hitting them with a fin or standing on them will kill them. 
2) Buy only farm raised tropical fish for aquariums. Specimens taken from the wild have a high morbidity rate associated with the stress of being netted, transported and then placed in a new environment. According to Snorkel Bob’s, 99% of wild caught fish will die.
3) Use reef safe sunscreen.  Wear a protective T-shirt to decrease the need for sunscreen. A recent study found that sunscreen results in coral bleaching. More information at
http://www.nature.com/news/2008/080129/full/news.2008.537.html.  
4) Keep garbage out of the water. Kauai banned plastic bags because of the damage caused after being ingested by marine animals. 
5) Avoid fertilizers and pesticides which gain access into our oceans through runoff. 
6) Support organizations such as the Coral Reef Alliance (
http://coral.org/ who work to protect our coral reefs.  
 
Sources:
http://www.coralreefinstitute.org/10-ways-to-protect-coral-reefs.htm
http://www.nahoku.com/coral-jewelry 
http://news.nationalgeographic.com/news/pf/82923650.html
http://www.snorkelbob.com/sb_foundation.htm

Health Certificates for Dogs and Cats

Health certificates are sometimes required for pets to travel. The purpose is to allow veterinarians to fulfill our public health role and prevent the spread of contagious disease. In addition, some airlines require a statement of acclimation, which means the pet can tolerate the temperatures it will be exposed to during travel.  Here are my suggestions for navigating this issue.

INTERNATIONAL TRAVEL: Before traveling with your pet, it is important to find out what kind of documentation is required. For international travel, each country sets their own regulations including required vaccinations, parasite control, laboratory tests and the timing of veterinary examinations.  I recommend contacting the country’s embassy for the most current regulations and forms. Do not rely on websites as they often contain outdated information.  Remember that you sometimes may have to begin this process up to six months before travel! 

TRAVEL WITHIN THE UNITED STATES: Health certificates are not required when the owner is personally transporting dogs and cats in their vehicle or on foot within a state or across state lines. Horses, livestock and exotic animals are usually required to have a health certificate for travel between states.  Some states have entry inspection sites to ensure compliance.  When dogs and cats are traveling by air, all of the airlines used to require a health certificate.  Now, some do not if the pet is traveling in the cabin with the owner.  

In America, each state sets their own rules regarding animals. Therefore it is important to check with the state veterinarian’s office to determine what is required.  Most states require proof of rabies vaccination for dogs and cats. I also recommend asking if there are any restrictions which apply to pets.  Some states outlaw keeping certain types of animals as pets. For example, California outlaws ferrets and Hawai’i does not permit snakes.  There may also be city ordinances against specific breeds such as pit bulls.  

Here are my tips to make the process of obtaining a health certificate go as smooth as possible. 

1) Only accredited veterinarians may sign a health certificate. All veterinarians must pass an accreditation exam and fulfill continuing education requirements in order to sign health certificates. When booking your pet’s appointment, verify that the examining veterinarian is accredited as not every veterinarian will be.
2) The pet must be examined within 10 days of signing the certificate.  Clients complain when they must bring their pet in and pay for another examination when the pet had a physical a month prior. Unfortunately, this is the federal rule that all veterinarians must honor.
3) Some airlines ask veterinarians to verify that a pet is acclimated to extremes in temperature. I, personally, will not do this as it is detrimental to the pet. I have read accounts of eight week old puppies freezing to death in cargo holds. I have also read of pets suffering heat stroke when left on the tarmac.
4) Make sure you have the documents to verify your pets vaccinations. If you are going to your regular clinic, then the vaccination record will be part of your pet’s medical record. If you bring your pet to a new clinic, bring copies of the vaccinations to avoid revaccinating your pet. 
5) Bring the address of your travel destination. A health certificate cannot be issued without this information.

Once the veterinary exam is completed and the required information is added to the health certificate, the veterinarian will sign the triplicate form. One copy will accompany the owner while the others will be sent into the state veterinarian’s office.  

Financial Help For Pet Medical Treatments

As a veterinarian, nothing is more frustrating than having to euthanize a beloved pet because of financial constraints. Medical care for both humans and animals is expensive due to the cost of supplies, staff wages and the high cost of veterinary/medical college. Most clinics offer Care Credit which allows a family to make payments over time. But what if the pet guardian does not qualify for this service? Is there anything else available? The answer is maybe.

In the last few years, I have seen some animal charities help financially strapped families pay for their pet’s medical treatments. Most require an extensive application that includes copies of the pet’s medical record as well as verification of the owner’s finances.  Due to the overwhelming number of requests, most charities have specific criteria such as dogs with heart disease, cats with treatable cancer or they may be breed specific. Some charities are regional, requiring proof of residence in a specific geographic area for assistance. The links below provide lists of charitable organizations offering assistance for pet health care. 

http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=3549and http://speakingforspot.com/index.php?p=Financial-Assistance-for-Veterinary-Care.


You Make The Diagnosis: Endangered Seabird

Hawaii is home to a variety of birds, many of which are endangered. The seabirds pictured below only come to shore to reproduce. The birds were hatched in the Princeville area of Kauai, spent three years at sea then returned to find a mate. They won’t produce eggs until eight years of age. This species of bird is known for elaborate courtship displays that involve bowing, chattering and clacking their bills. These birds were hanging out in a quiet neighborhood next to a road. After they heard human voices, they started clacking their bills. Name this bird.
 

Diagnosis: Laysan Albatross

Laysan Albatross spend their entire lives at sea, only coming ashore to reproduce.  They eat fish, crustaceans, squid and flying fish eggs. These amazing birds can actually sleep while flying!  According to Dr. Rattenborg, birds may allow one half of their brain to enter into slow-wave sleep while keeping the other half alert to predators.   

More information at http://www.birds.com/species/k-o/laysan-albatross/ (general facts) and /bcCreatePost.aspx (abstract of Dr. Rattenborg’s research).

Antifreeze and Engine Coolant Poisoning

Antifreeze and engine coolant are poisonous to humans and animals. Unfortunately, the substance is reported to have a sweet taste that attracts both children and animals. Once inside the body, the toxic principle is metabolized into a chemical that destroys the kidneys. I remember seeing the kidneys of a dog who lapped a little spilled antifreeze while out walking with his owner. The kidneys looked horrible, with crystals embedded in the tissue. Besides motor vehicles, many dogs are exposed when they drink from toilets of winterized cabins.  These toxicities are tough to treat because they often ingest a large volume of antifreeze.  If the ingestion is caught early, an antidote can be given. Once the crystals form, dialysis and kidney replacement are the only options left.
 
In 2009, a bill requiring manufacturers to add the bittering agent, denatonium benzoate, was introduced into congress. It was titled, ‘To amend the Federal Hazardous Substances Act to require engine coolant and antifreeze to contain a bittering agent so as to render it unpalatable.’ Even though it had bipartisan support, the bill was never enacted.(www.govtrack.us) Thankfully, the manufacturers voluntarily agreed to add a bittering agent in 2012.  Thank you manufacturers! 

To help prevent further animal and human ingestion, please make sure the antifreeze and engine coolant used in your car or cabin contains a bittering agent to make it less appealing. In addition, purchase antifreeze that replaces ethylene glycol with propylene glycol which is a little less toxic. Store all chemicals in a safe, locked location to prevent accidental exposure. Clean up all antifreeze and engine coolant spills immediately. Last, watch your children and pets carefully to prevent exposure. Wipe your dog’s feet off after walking. More information is available at:
http://www.humanesociety.org/animals/resources/tips/antifreeze.html