The art of veterinary dermatology can be both a rewarding and challenging vocation for the veterinary surgeon.

As well as gaining great job satisfaction from getting patients to look and feel better, an equally disheartening aspect exists to not being able to cure a proportion of patients with chronic disease. The latter can leave clients feeling confused and dismayed regarding their pet’s skin condition – and with the competitive nature of the veterinary market, they will be more likely to quickly “jump ship” and go elsewhere, rather than wait for a reply to any complaints or queries raised with the practice.

One commonality of complaints is communication, be it verbal or non-verbal. It may be a lack of clarity, appropriateness or detail (Moore, 2008). Coupled with the findings from one study that showed owners to have a poor quality of life in the presence of various dermatological diseases affecting their pet, it would be of no surprise that, in the event of any miscommunication with a client, further frustration can ensue.

Complaints may be due to clinical and/or non-clinical matters. The former may have three separate foundations in dermatology from which a client may raise a concern:

1. The clinical signs of a diagnosed condition persist for several weeks to months, despite having trialled various treatment modalities. Examples include canine atopic dermatitis (CAD) and alopecic disorders such as colour dilution alopecia and alopecia X.
2. The clinical signs of a disorder are recurrent over a period of time, despite having initially been given appropriate treatment. Examples will include canine recurrent pyoderma and Malassezia dermatitis, and feline eosinophilic granuloma complex.
3. The recurrence/persistence of clinical signs that have been treated with trial symptomatic therapy without a formal diagnosis. This can be typical of those cases of undiagnosed demodicosis or sarcoptic mange that present with erythema and pruritus, and have been given trial treatment with corticosteroids and antibiotics.

As it can be appreciated with the aforementioned scenarios, dermatology can no doubt present a conundrum to the clinician relative to those straightforward conditions that can be managed in first opinion practice (gastrointestinal endoparasites, bacterial conjunctivitis and cat bite abscesses, to mention a few).

As practitioners focus on the plethora of diagnostic and treatment algorithms available to them, consideration of the human-animal bond to the overall case management may go innocently unnoticed. This bond is, essentially, a positive emotional attachment between owner and pet – a relationship in which the vet will play a crucial role in maintaining.

Dermatological diseases will have a negative impact on the quality of life of pets and their owners. Sarcoptic mange, pododermatitis and atopic dermatitis were the highest contributors towards a poor quality of life among dog owners in one study (Noli et al, 2011), whereas eosinophilic granuloma, pemphigus foliaceus and otoacariasis were ranked the highest causes among cat owners (Noli et al, 2016).

Fragmentation of the human-animal bond may lead the client to feel angry, helpless and/or guilty, and this can provide the impetus for complaints raised with the practice. Furthermore, this may cause veterinary staff to perceive clients of pets with dermatology problems as “difficult” and “intense”. It is advised clinicians be mindful of this fractured relationship when managing dermatology cases as this may, ultimately, help to improve communication, animal welfare and client relations.

The following scenarios serve to highlight some client concerns the practitioner may stumble on when managing skin cases in general practice. With any dermatological scenario, it is imperative the salient features of the case are effectively communicated at the outset (see meteor model, Panel 1). This not only aims to give the owner an overview of what is to come, but also helps to set his or her expectations to a realistic level.

A powerful indicator of client satisfaction is meeting his or her expectations (Poot, 2009), with making a diagnosis and explaining the prognosis accounting for 94% and 82% of client expectations, respectively, in one study (Sanchez-Menegay and Stalder, 1994). More specifically, in dermatology – and perhaps more relevant from a communication of point of view – the British Journal of Dermatology reported patient satisfaction depended on the clinician’s ability to provide explanations and show empathy (Renzi et al, 2001).

Scenario examples include:

• “I can hear her nibbling all night, and it is distressing her and keeping us all up. You have got to do something… can you not take a blood test or something to see what she is allergic to?”
• “He is chewing his paws again until they are bleeding and I can’t see it any more.”
• “That new medication you gave sorted it completely for a while, but it’s come back again. I spent £50 on those tablets and they have done absolutely nothing. I would expect spending that much money would have sorted it. I am not happy. I want a refund or I will take this further.”

Pruritus is a common presenting sign in dogs, representing up to 40% of all the dermatology consultations in general practice, with CAD being a common diagnosis in dogs (Hill et al, 2006).

CAD is defined as a genetically predisposed inflammatory and pruritic skin disease, with characteristic clinical features associated with IgE most commonly directed against environmental allergens (Halliwell, 2006). It is a multifactorial disease characterised by immune dysregulation, microbial colonisation, skin barrier defects and environmental factors (Nuttall et al, 2013). Some of the breeds predisposed are the German shepherd dog, boxer, West Highland white terrier and border terrier. It may be seasonal or non-seasonal in nature and the pruritus can be exacerbated by various flare factors, such as ectoparasites, infections (bacterial and yeast) and food allergens.

The current diagnostic criteria for CAD have been published by Favrot et al (2010). A further discussion of this and the diagnostic work-up for CAD is mentioned in an article by Hensel et al (2015).

In the author’s experience, most client concerns raised will be based on the frustration his or her pet is scratching on a recurrent or persistent basis, with the accompanying primary lesions progressing from erythema and papules to conspicuous secondary lesions, such as excoriations, self-induced alopecia, hyperpigmentation and lichenification (signs most commonly distributed on the ventral abdomen, paws, muzzle, periorbital and aural regions).

Clients may also complain at this stage their pet smells and shampooing has not seemed to have helped. Coupled with the economic implications of numerous repeat consultations, investigations and trial treatments, it is understandable queries may be raised by clients.

Potential pitfalls

From a diagnostic perspective, a full and clear medical history should be taken: the signalment (age, breed, neuter status), general health, nature of the dermatological problem (for example, pruritus, alopecia, draining tracts and skin masses to mention a few), the duration and progression of the presenting signs, and response to treatment. Evidence of skin lesions on in-contact pets and humans are also key questions to ask in the history. The latter points are important, as this may help to narrow the differential diagnosis from the beginning to include contagions, such as Sarcoptes scabiei, Cheyletiella species and dermatophyte infection.

It is not uncommon to have a scenario where chronically pruritic dogs would have been given a presumptive diagnosis of CAD over many months, but will actually be found – after having been examined by another colleague or practice – to have fleas, sarcoptic and/or demodectic mange that is contributing to their ongoing clinical signs.

Some owners may be content, as they will acknowledge their pet’s condition will improve after receiving a revised diagnosis. Others, however, may, understandably, be upset as they would have committed their pet to receiving costly immunosuppressive therapy, with welfare implications from potentially deleterious side effects.

With society in general being more litigiously aware, owners have reportedly raised concerns over the financial implications of misdiagnoses – both from a self-funding and pet insurance perspective.

One common misconception among clients is they will expect the signs of CAD to be cured after a course of antipruritic drug therapy. To date, no such cure for CAD exists, but the clinical signs can be managed with various treatment modalities (Miller et al, 2012; Saridomichelakis and Olivry, 2016) – such as glucocorticoids, ciclosporin A, oclacitinib, antihistamines, essential fatty acids, allergen-specific immunotherapy, shampoo/topical therapy and allergen avoidance, and with the recent introduction of monoclonal antibody therapy, such as lokivetmab.

Time should be taken to discuss the relative efficacy, adverse effects and costs involved, so the client may make an informed decision. It is useful to note on the clinical records this discussion has taken place.

Furthermore, the owner’s expectations should be reset to a realistic level. Over a year, it is likely his or her pet’s clinical signs may be perceived to be controlled very well on occasions and instances of mild to severe flare-ups of pruritus may occur.

The manifestation of the disease in dogs can differ depending on its breed (Wilhem et al, 2011), geographic location (Jaeger et al, 2010), dietary habits (Pucheu-Haston et al, 2015) and its environment (Bizikova et al, 2015). This is by no means an exhaustive list and the owner should be prepared to expect variations in the clinical picture over a period of time.

One potential pitfall to avoid is underestimating to a client the time it will take to investigate his or her pet’s pruritus before a diagnosis of CAD. An investigation for pruritus with CAD in mind can potentially take several weeks. As other pruritic diseases have to be ruled out, sufficient time should be given for an ectoparasitic treatment trial, to treat skin and ear infections (bacterial and yeast), and to complete a food trial to investigate cutaneous adverse food reactions (CAFR).

Not every client will commit to a food trial (using a home-made or commercial diet) due to time, expense, palatability and fear of changing the dog’s dietary routine.

In these cases, although the owner’s wishes should be respected, it is wise to mention – in the event of starting therapy for a working diagnosis of CAD – flare-ups of pruritus may occur that may be related to CAFR and the possibility of a diet trial may need to be revisited in the future.

• “I paid a lot of money to see what she was allergic to and you are now telling me all the tests are negative. Why is she still scratching? You said we would be able to find out what she was allergic to and confirm the diagnosis.”

This scenario is not uncommon in clinical practice as owners may request serum testing to aid in the diagnosis of CAFR and CAD. Clients will often complain out of frustration, as they would have agreed to lengthy investigations, and “the lack of an answer” from a blood test can be disheartening as their pet would potentially still be pruritic and distressed. Further details of the pros and cons of serological testing can be found in text by Miller et al (2012).

With respect to CAFR, the author would briefly like to mention that although a blood test may seem a rapid method towards a diagnosis, evidence exists to suggest serology, at this moment in time, has limited value in clinical practice.

A study investigating food allergen-specific IgE in dogs revealed dogs with food allergy to beef – confirmed with an elimination-provocation trial – tested negative to allergen-specific IgE to beef, whereas control dogs with dermatophytosis and atopy tested positive (Mueller and Tsohalis, 1998). This was further demonstrated by Foster et al (2003), which demonstrated the presence of IgE against chicken and lamb in control dogs with no clinical signs of CAFR.

Similar frustrations will be encountered with serum allergen-specific IgE testing for CAD. This test is not to be used as a shortcut towards a final diagnosis of CAD as it is, essentially, a diagnosis of exclusion after having ruled out various other causes of pruritus. Furthermore, in the presence of various confounding variables, the test can report false positive and/or negative results, and the report should always be interpreted with this in mind. Nevertheless, the value of allergen-specific IgE serology testing will be it allows the practitioner to select allergens to be incorporated within allergen-specific immunotherapy.

The advantages and disadvantages of immunotherapy, along with the aforementioned points, should be made clear to the owner at the outset to prevent any misconceptions and the potentially awkward scenario described previously.

Some clients may become so attached to any positive result from these tests in the belief avoiding the allergen may cure their pet from its discomfort.

The author would like to reiterate that any results should be interpreted within the context of the patient and other confounding factors. It is recommended to gain advice from your regional veterinary dermatologist or diagnostic laboratory.

Client compliance is a major determinant of successful case management and owners should be informed of the need for long-term commitment when deciding on appropriate treatments. In a dermatological case series discussion by Goodman (2014), it was shown poor compliance can lead to a disruption in the human-animal bond, with clients becoming frustrated, angry and guilty as their pet continues to suffer. The clinician should equally be obliged to ensuring success in this regard, as he or she will be responsible for prescribing the appropriate treatment that will help minimise distress between the client and pet.

Most of the therapeutic options in dogs and cats with CAD will include oral formulations (tablets, capsules, liquid), and topicals such as ear drop preparations, shampoos, gels, sprays and foams. Some owners may not admit to struggling with the administration of medications due to fear of embarrassment or being judged. Open-ended questioning, such as “how do you feel about giving tablets or shampooing?”, may help to determine whether compliance will be an issue.

Numerous treatment options exist for CAD authorised for use in the UK veterinary market that can improve client compliance, and make treating CAD a positive experience for both pet and owner.

The implications of the latter are you are likely to retain clients at the practice and happier owners will, hopefully, equate to fewer complaints regarding the management of their pet’s condition.