Michele Rosenbaum, VMD, DACVD
Helping Pet Owners Stay off the Emotional Rollercoaster of Itch: Flares are a normal part of life for an allergic dog; don’t give up on what has been working.
Even when you have provided your allergic patient relief from their itch with highly effective targeted treatments, this frustrating cycle of itch can start all over again if an allergic trigger causes a flare of their disease. Owners can become anxious and stressed when flares occur, especially if their pet is on a medication that “seems to have stopped working.”
It is important to communicate to owners that periodic flares are normal and expected for dogs who have allergic skin disease when re-exposed to their allergic triggers that send them over their itch threshold. It is important to set realistic expectations with pet owners. The “80-80 rule” is achievable in most dogs: We can control about 80 percent of the clinical signs for about 80 percent of the time.To achieve that goal, we need to develop a long-term sustainable treatment plan for the individual pet and their caregiver that minimizes allergic flares.
Examples of flare factors:
- Flea allergy dermatitis is a life-long condition that excellent year-round parasite control and anti-itch medication can control well most of the time. But if flea control lapses, or dogs are exposed to fleas, they may flare.
- The same can be said about a dog with a food allergy. What if a toddler drops food, the trash tips over, bread is left on the counter, a spill happens, or the dog licks plates in the dishwasher. These small exposures may lead to an allergic flare.
- Bacterial or yeast infection can trigger cytokines that worsen itch and inflammation in the skin, break down the skin barrier, and act as an allergen. It is vital that infections be treated quickly to avoid a major itch flare.
- Another unpredictable cause of allergic flare is the seasonal increase in pollen count. It is virtually impossible to hide from the tree pollens that rain down each spring leaving a dust of yellow-green on every surface outside.
Tips to Reduce Flares of Itch When on Medication
When an owner calls to say that their targeted anti-itch medication is just not working anymore, make sure to have them come back for a re-examination to check for flare factors. They should not be given a “phone fix” or be told to stop the current medication. Often, these dogs will have an obvious reason for the flare, with the most common being a bacterial or yeast infection. Look for other flare factors such as fleas, scabies mites, infection, and diet changes. Return to the streamlined diagnostic approach to rule these out (see part 4 in this series).
Once these flare factors are corrected, the medication often goes back to working well again. The “Prepare for the Flare” sheet is a helpful resource from http://www.scienceofstrongerbonds.com under Resources that you can give pet owners to help them prepare when their pet has a flare of allergic itch. They can rate their dog’s itch level using the scale shown and there is guidance on the next steps when they notice a flare. There is also an area to write notes to bring to their appointment.
In cases where these are ruled out and the flare is due to seasonal pollen spikes, combining medications*1,2 may get your patient back on track. CYTOPOINT can be given in case of flares, where a dog was previously controlled by APOQUEL alone – and vice versa. One can be layered on top of the other to provide more control of itch and inflammation during seasonal flares.
*In the CYTOPOINT safety study 53/162 (32 percent) of dogs receiving CYTOPOINT also received APOQUEL during that study and the study concluded that “there were no clinically apparent adverse interactions between lokivetmab and any of the concomitantly administered medications.”
Consider CYTOPOINT when recurrence of previously controlled itch occurs, for example when a diagnosed flea or food allergic dog “falls off the wagon” and needs sustained itch control while returning to a restricted diet or regular flea control.
Example of a long-term sustainable treatment plan for dogs with atopic dermatitis:3
- Anchor treatment with targeted therapy to control itch and inflammation (APOQUEL, CYTOPOINT, cyclosporine)*
- Year-round flea control with an oral isoxazoline product*
- Weekly bathing with an antibacterial, antifungal, or hypoallergenic moisturizing shampoo*
- Using a mousse, wipe, or spray 2-3 times weekly over known problem areas
- Weekly ear cleaning and maintenance ear medication
- Feeding a high fatty acid, barrier repair diet, or hypoallergenic diet if food allergic
- Allergen Immunotherapy injections or oral drops
*Recommended for most allergic dogs
An anchor treatment is a single, sustainable therapy that provides satisfactory control. Most dogs will not need all these treatments, and many will do well on a targeted anchor therapy and flea control alone, helping to reduce caregiver burden, anxiety, and stress. Dogs with recurrent skin infections often benefit from regular bathing and topical therapy. AquaPaw and other brands provide suction-based adhesive “plates” to apply to the wall of the tub to provide food-based restraint. Smeared with peanut butter or squeeze cheese, they help the dog keep still while licking the wall as the owner bathes the patient. Long-lasting commercial otopacks or thermal-activated ear hydrogels can help reduce the FAS of frequently applying ear medications.
Other more severe non-seasonal, progressive cases require more intensive multi-modal therapy for long-term control and are best managed by a boarded-certified dermatologist. A study showed that owners of well-controlled canine dermatology patients had the same caregiver burden as those with a healthy dog, and this measure correlated well with owner quality of life.4
By communicating realistic expectations on the life-long nature of atopic dermatitis and minimizing the stress of flares with a tailored, sustainable treatment plan, most atopic dogs can lead healthy and comfortable lives. See scienceofstrongerbonds.com for helpful resources for your team under Resources.
Important Safety Information: APOQUEL. Do not use APOQUEL in dogs less than 12 months of age or those with serious infections. APOQUEL may increase the chances of developing serious infections and may cause existing parasitic skin infestations or pre-existing cancers to get worse. APOQUEL has not been tested in dogs receiving some medications including some commonly used to treat skin conditions such as corticosteroids and cyclosporines. Do not use in breeding, pregnant, or lactating dogs. Most common side effects are vomiting and diarrhea. APOQUEL has been used safely with many common medications including parasiticides, antibiotics and vaccines.
See full Prescribing Information at https://www.APOQUELdogs.com/APOQUEL_pi.pdf
CYTOPOINT has been shown to be effective for the treatment of dogs against allergic dermatitis and atopic dermatitis.
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
- 1. Michels GM, et al. A blinded, randomized, placebo-controlled trial of the safety of lokivetmab (ZTS-00103289), a caninized anti-canine IL-31 monoclonal antibody in client-owned dogs with atopic dermatitis. Vet Dermatol. 2016 Dec;27(6):505-e13.
- 2. Souza CP, et al. A retrospective analysis of the use of lokivetmab in the management of allergic pruritus in a referral population of 135 dogs in the western USA. Vet Dermatol. 2018;29:489-e164.
- 3. Olivry T, et al. International Committee on Allergic Diseases of Animals. Treatment of canine atopic dermatitis: 2015 updated guidelines from the International Committee on Allergic Diseases of Animals (ICADA). BMC Vet Res. 2015 Aug 16; 11:210.
- 4. Spitznagel MB et al. Caregiver burden in the veterinary dermatology client: comparison to healthy controls and relationship to quality of life. Vet Dermatol 2019;30:3-e2.