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 allergic triggers that send them over their itch threshold. It is also 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 individual pets and their caregivers 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 dusting 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, 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 Zoetis that you can give pet owners to help them prepare when their pet has a flare of allergic itch.

In cases where these are ruled out and the flare is due to seasonal pollen spikes, provide individualized therapy as needed (see example of treatment plan below).

Example of a long-term sustainable treatment plan for dogs with atopic dermatitis:¹

• Anchor treatment with targeted therapy to control itch and inflammation [Apoquel^® (oclacitinib tablet) or Cytopoint^® or  cyclosporine] ^2-4*
• 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 to 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. When these are smeared with peanut butter or squeeze cheese, the dog can be kept occupied by licking the wall as the owner bathes them. 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 multimodal therapy for long-term control and are best managed by a board-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.⁵

By communicating realistic expectations to clients on the lifelong 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.

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. Consider the risks and benefits of treatment in dogs with a history of recurrence of these conditions. New neoplastic conditions (benign and malignant) were observed in clinical studies and post-approval. 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. For more information, see full Prescribing Information at Apoquel.com/pi.

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.

References

¹ 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.

² Cosgrove SB, Wren JA, Cleaver DM, et al. A blinded,randomized, placebo-controlled trial of the efficacy and safety of the Janus kinase inhibitor oclacitinib (APOQUEL®) in client-owned dogs with atopic dermatitis. Vet Dermatol. 2013;24(6):587-e142.

³ Marsella R, Ahrens K, Wilkes R et al. Comparison of various treatment options for canine atopic dermatitis: a blinded, randomized, controlled study in a colony of research beagle dogs. Vet Dermatol 2020; 31: 284-e69.

⁴ Moyaert, H., Van Brussel, L., Borowski, S., Escalada, M., Mahabir, S. P., Walters, R. R. and Stegemann, M. R. A blinded,  randomized clinical trial evaluating the efficacy and safety of lokivetmab compared to ciclosporin in client-owned dogs with atopic dermatitis. Vet Dermatol 2017; 28: 593–e145

⁵ 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