Set Yourself Up for Success… 20 Minutes Is Not Enough Time for a Derm Case... What to Do?

• Book two time slots. Be creative with billing that extra time is going to allow time for diagnostics, which can be billed for.
• Have the animal dropped off for the day with a detailed history it can be examined, have diagnostics run, and a treatment plan can be formulated by your team throughout the day, then have a discharge appointment to keep things ticking along.

Dermatology cases often have long convoluted histories. Many of them will have recurrent ear or skin infections. If someone’s skin and immune system is working properly, they should not be getting recurrent infections, so be sure to ask yourself why this happening. Don’t just keep treating symptoms. Often the patient will respond, then relapse and continue to cycle over and over, until the owner loses faith in your practice and they move on to a different clinic for help.

An accurate history is of paramount importance! Have a history questionnaire. A good history should include:

• Age of onset (the first time they ever had any issues with their skin, ears or itchiness).
• Seasonality—any time of year that seems better or worse for symptoms.
• Pruritus: itching can look like rubbing, scratching, biting, scooting, licking… sometimes we even have closet lickers and just see evidence of barbering.
• Level of pruritus on a scale of 0–10?
• Other animals in the household affected?
• Humans in the household affected?
• On any medications? Have there been any medications that they feel have made a difference?
• Heartworm/flea/tick preventatives?
• What diet are they on? Supplements? Flavoured toothpaste? Pilling vehicles? Treats?
• How many bowel movements are passed per day? Consistency?
• Any history of adverse gastrointestinal signs? Can include bad breath even though oral health is good, vomiting, burping, borborygmus, flatulence, diarrhea, gland issues, scooting, butt licking.
• How did condition start, and how has it progressed? Any possible trigger? Vaccination, medication, diet change, etc.
• Any body parts the animal really concentrates on?
• Any other symptoms? (respiratory, exercise intolerance, changes in weight, etc.).

That’s a lot to get through, and that’s why a history questionnaire so helpful. We even use history questionnaires for recheck appointments and ask our owners to include those with any update emails that they send us.

Recheck History Questionnaires Should Include

• Any concerns?
• Current diet?
• Current treats? Anything for pilling?
• Any additional supplements? Toothpaste?
• Consistency and number of bowel movements per day?
• Any adverse gastrointestinal signs (same list as above).
• Current medication schedule: medication; concentration; how much and how often.
• Itch level.
• Any lesions on skin? What do they look like and where are they? Are they bothering your 4-legged friend?
• Any adverse reactions noted since starting a new medication (which medication)?
• Any other information you feel is important for us to know?
• Please attach any photos of affected areas on your pet if you feel these are relevant.

Yup! Still a lot of information to go over, which highlights just how useful having a questionnaire is.

When performing your dermatologic examination, always look at your entire patient from stem to stern, including a quick look in the mouth (immune mediated skin diseases often have oral lesions), check eyes for episcleritis, conjunctivitis, corneal opacities, check the nasal planum and dorsal muzzle, check lip margins and lip folds, check ears (canals, pinnae, palpate ear canals), check facial, neck and tail skin folds, examine coat and skin over entire dorsum and ventrum, include nipples, check claws and beds, interdigital spaces between toes and foot pads, genitalia, anus and perianal region, and tail.

Look for any patterns. Many derm conditions have specific distribution patterns. Symmetric lesions suggest an internal disease process or endocrine disorder, while asymmetric lesions suggest infection. Describe any lesions. If you are able to describe lesions, you might find your diagnosis easier! For example, bilateral flank alopecia. If you combine that with a history of seasonal recurrence you have your definitive diagnosis of seasonal flank alopecia. Sometimes, it’s really just that easy.

There are a few general rules of thumb that are helpful to keep in mind:

• Pustules that span more than one hair follicle may indicate immune-mediated skin condition.
• Consider vasculitis if extremities are affected.
• Consider hypothyroidism with any of the following: recurrent infections, hypotrichosis or alopecia over dorsal muzzle, facial or tail base edema, waxy exudate around nipples, corneal lipid deposits.
• Consider food allergies in animals less than a year of age, or in those 6 years and older.
• Food allergies may have little or no response to corticosteroids.
• Environmental allergies in animals 1 to 4 years of age.
• Environmental allergies have a good response to corticosteroids.
• Animals with food allergies often have ears, feet and rears affected (environmental allergies often have ears and feet affected).
• Food allergies often have lesions over the dorsum.
• Environmental allergies have lesions on the ventrum.
• Consider breed predelections.¹
• Treat empirically for ectoparasites.

And the absolute best strategy, bar none, is to perform cytology on every patient you are working up. This can be billed for, to bring in extra income for your clinic. The results are nearly instant, and it is invaluable in guiding treatment for you patients. I can’t tell you how many times we have had an animal referred to our practice for a recurrent pyoderma that is refractory to antibiotics, and it turns out that it is a yeast infection. Don’t waste your patient’s time and your client’s money by guessing. Take 10 minutes to do cytology!

All of the above will get you to a treatment plan.

This plan will have the best chance of working if we have owner compliance. The best way to achieve owner compliance is to take the time to educate your clients, and, have them be part of the decision making when formulating the treatment plan. The best treatment for your patient, is the one that your client will administer faithfully, so help set your clients up for success, starting with treatment selection.

• If bathing is not a realistic option, consider other topicals like sprays, mousse, pipettes, or wipes.
• Review how to actually give a therapeutic bath, or how to apply topical products to ensure your treatment will be delivered.
• If pilling is a challenge, consider injectables, oral liquids, or medications that can be administered once daily to make life easier.
• Do they need appropriate treats, pill pockets, or canned food to be successful?
• If your patient is on a diet trial and treats are important, then help the owner choose a diet that has some associated treats with it or point out what the ingredient list is and have them stay within the confines of that diet.
• Send them home with recipes for acceptable treats, even point out that most dogs love ice cubes! Make sure there aren’t any items sabotaging a diet trial, like flavoured toothpaste, anything in gelatin capsules, animals licking dishes before they go into the dishwasher, caregivers, and so on.

This all seems very basic, but it’s often missed, leaving everyone frustrated and worst of all, leaving our patient uncomfortable.

Put everything in writing so your owner can refer to it, or, share it with the rest of the family.

The final strategy for working with dermatology cases, is to follow up: specific dates to hear back from clients, listed on your visit summary.

• Technician appointments for repeat cytology to ensure infections are clearing.
• Have your clients contact you if anything worsens prior to their scheduled appointment. It may seem crazy, but when wrapping things up with a client, I tell them that things should only get better, not worse. We have all seen clients continue on with treatment for 4 weeks until their scheduled recheck appointment, even though the treatment protocol made their pet more uncomfortable.

Success with derm patients, hinges on owner compliance. The more informed an owner is, the better they understand their role and how they can help their furry friend. Now, more than ever, owners want to be knowledgeable about their pet’s condition, and they will come armed with a lot of questions about information they read online.

It takes time to go through things with your clients. Plain and simple!

The majority of dermatology patients are not cured, but rather are managed. This means a long patient/practice relationship. By training technicians to excel in the recognition of dermatologic diseases, and diagnostics needed, clinicians will be able to get a rapid, and accurate diagnosis to facilitate the early start of an appropriate treatment plan. This is where a technician can truly have an impact on patient care, client service and the reputation of a practice.

References

1. Diagnostic methods (Breed predilections). In: Scott D, Miller W, Griffin C, eds. Muller and Kirk’s Small Animal Dermatology. 6th ed. Philadelphia, PA: Elsevier: 2001;75–82.