276. Grab Bag: pesky pyoderma

Welcome to The Dermvet Podcast. I'm Dr. Ashley Bujua, a board certified veterinary dermatologist practicing in Portland, Oregon with animal dermatology clinics. I'm also a mom of two just trying to find the balance like everyone else. Let's learn to ditch the itch, cytology, everything, and make Derm more fun than frustrating. Welcome to another episode of The Dermvet Podcast. I have another fun grabback episode for you guys. I like the grabback episodes because it really shows me the questions that you're wondering about a certain topic. You know, I love doing interviews when I do solo episodes. I don't mind just talking for 15 minutes about something, but I just think it's really nice to see what direct things you guys are curious about and wondering. So I put up a question sticker on my Instagram and came up. I kind of summarized some of the repeating questions to the top seven questions that you guys are asking in the topic that we were doing today is Pyoderma. So first that a question was about cause. So this question is what is a cause and why do we get things like cross-building up with Pyoderma? The cause can really be endless. So there's so many different reasons that dogs and cats can break out with Pyoderma and what's important to recognize is we have to figure out why they're breaking out with Pyoderma. So we can treat the Pyoderma lots of ways to do that. We're going to talk about that, but we always have to figure out the primary cause. If we don't, then the bacteria is just going to come right back and we're going to really frustrated owners. So of course, some of the more typical reasons that we see Pyoderma would be allergies, whether that's atopic dermatitis, food allergy, flea allergy, getting other ectoparasite, so carcoptic, main, demon X, endocrinopathy. So your immune system's not working as well because you have a dog who is hypothyroidism. You have a dog who has cushing's disease. Maybe it's secondary to another medication because they're immunosuppressed. So they have to be on a lot of steroids for another autoimmune disease like IBD or they have neoplasia and they are on chemotherapy and steroids. So things are certainly that effect. The immune system can be impacted. Things that affect the skin barrier, like you're scratching a lot because you're itchy just having an abnormal microbiome, which we know that dogs have, if they have allergies, even if they're not scratching, their microbiome genetically is abnormal. We don't have a lot of diversity of bacteria, which is what we're looking for. So tons of reasons that we can see pyiderma happening. The important thing is you need to figure out why it is happening in that case. Why does crust build up? I like to teach that the crust is kind of like a protective mechanism of the skin. You know, when you have things impacted and there is inflammation and there's excoriations and erosions within the skin, you know, the member of those keratinocytes, they kind of leap frog one another to kind of heal that wound and essentially get things like crusting that kind of develop over that area to protect it while those keratinocytes are filling in. So crusting, depending on the stage that you're seeing that disease process can happen from infection, but remember, crusting can happen from other things too, like autoimmune diseases or dermatophytosis. So just seeing crusts doesn't mean it's a pyiderma, which is why cytology is still super important. Question number two, actually going along those lines, is it necessary to collect cytology if you see pistols or epidermal colorets? So I think what this question is referring to is if you see pistols or epidermal colorets, isn't that pathonomonic? Why do we even need to do cytology? Two fold. One, it's not pathonomonic. So there's other things that can cause pistols. In fact, pimp figures volatious, we always consider a crusting disease, but it actually is a pustular disease. It's just those pistols are really fragile. So they rupture open really easily and it becomes crusted. So we love to find pistols in a suspect pimp figures case as dermatologist. Also, you can have other things that can cause a folliculitis and look like an epidermal coloret. So ringworm, you know, dermatophytosis, doesn't usually look like a beautiful circle that expands out, but obviously you could. You could technically have my second cause that as well. The other thing is it's really important for us to know if with that coloret, is it coccyte? Is it rods? How many are there? Are there other cells we see that can be, you know, give us an indication of why it's happening? And then when we recheck, we're going to be looking for is the quantity a lot better. So if I recheck them, you know, two weeks after starting antibiotics, and there's still some bacteria, but we went from two numerous to count to, you know, occasional one plus, that would be a good sign for me. We just need length, right? So it can be really helpful, not only to identify, yes, we for sure see bacteria, but what type, what shape do we see? And then how much of it do we see? And what is the body doing? Are there neutrophils? Is there nuclear streaming? Is it macrophages that are present? And so we can tell it's been happening chronically. So it's not pathonomonic. It is important for us to still do a cytology on these lesions. Question number three, and I actually got this one quite a bit just with us having Jack inhibitors available. So in the US, in some other countries, but I know it not available in all countries, there are two available options, apaquil, which is oculacinative tablet, and then zinrelia, which is elunicidative tablet. And so with those Jack inhibitors, you will see on the labeling, it says, you know, thoughtful of infections like pyiderma. So the question that was being asked was, Jack inhibitors are not labeled for use with pyiderma is that correct? So what I will tell you is I have lots of patients who break out with secondary infections from their allergies. And if they're not super severe and it's superficial, I need to control their allergies. I don't necessarily think it's the right decision to go to steroids, switching to a monoclonal, like, like, side of point would be awesome. But now every case responds to that. And if they have inflammation present, monoclonal antibodies aren't the best at inflammation just because it's such a targeted therapy, the only one we have available currently being side of point only goes after interleukin 31. So you don't necessarily get direct inflammation control. And they're usually inflamed and uncomfortable. So with Jack inhibitors, I use plenty of them in your basic superficial pyaderma, the where I don't necessarily use them. And I think with the labeling is really getting to more is deep infections. So if you have a really deep pyaderma, then you probably do want to be a bit cautious. A deep pyaderma would be like draining lesions on the skin, fibrosis when you palpate it. It's not just superficial scaling and epidermal colorets on the top of the skin. It's like those really draining nasty lesions that you see. Question number four, if you find cox I onsitology is suffixin your first choice. Let me back up. My first choice is topical therapy, right? So if I can, depending on what the owner is able to do, right? If it's a rip-roying pyaderma, it's pretty diffused, but it's superficial in the owner can bathe, you know, every day, every other day with coaxidine cool, like I would love that to be the case. You know, there are certainly cases where we can't do that based on the owner's ability based on what the pet will allow. So if I need to reach for a systemic antibiotic, and we don't have a history of, you know, recently being on medications like antibiotics, then I do tend to reach for suffixin or a cephalosporin, you know, cephallexin being that first tier antibiotic would be preferred over things like cephalvesin, which is convenia and then cephodoxine. But again, I don't live in the real world. Or I do live in the real world. Oh, my goodness, sometimes I probably don't think I do. I live in the real world. I don't live in a perfect world. And so if there is an issue with the owner being able to administer orally or, you know, twice a day is not going to happen, then I may reach for other options like those in the cephalosporin family, but they are technically their generation. So if we're able to use first generation, it is preferred, but we always have to weigh all of those different things when we're selecting these antibiotics. But yes, if we can use something like cephallexin as a first line treatment, if you have to reach orally, I was asked about topical because it can be really helpful. If we have to reach orally, then cephallexin is definitely a reasonable choice. Next question, I think this is a great one. We're actually going to probably do an episode in the next month or two. There are some new guidelines that came out about treating with the antibiotics in pyaderma. And one big thing from this with length of time. So this particular question was, plum says to use cephallexin for four weeks. Do you always do that? Was a standard length of time for antibiotics? You know, traditionally, we have said, you know, three to four weeks or for a superficial pyaderma, one week beyond clinical resolution for a deep pyaderma, two weeks beyond clinical resolution. But what we're seeing on the human side is actually shorter durations of antibiotics, but making sure you're at appropriate slash higher dosing. So I have really started trying my best to do more. If even if it's like a pretty bad superficial pyaderma, to do more like two weeks, recheck, right? Like, I mean, the hard thing is if owners can actually recheck in two weeks, but I like to really try to see them sooner. I do not treat them like a week past clinical resolution for a superficial pyaderma. If they come in my door, they're doing great. Their psychology is clear. We're done. So I do think we are seeing this shift and length of time. You know, I personally last year, it's the first one I had in a very, very, very long time, but I got bit by one of patients on my arm, a really deep bite, subcutaneous tissue seen in all. And I had to go to urgent care. And sometimes they don't even put dog bites anymore on antibiotics, but since mine was DP did, but I only went on five days of antibiotics. So we are seeing shorter duration, but with that, you have to make sure you have appropriate dosing. You do not want to under dose and do that. And for me, the big thing is the recheck, right? So I used to be more like three to four week re checks. But if it's a pretty standard pyaderma, I'm really trying to see them more like, you know, one to two weeks depending on what I can get from the owner to come in because it may not be that we have to treat them as long. And I do think we'll do a future episode of the podcast where we kind of look at the guidelines that were released because they think it's super important. You know, these things that we got taught previously, we're always getting new literature, new data. And we want to make sure that we're doing best in our antimicrobial usage. And this really is also what we're seeing on the human side is maybe higher dosing, but shorter duration and not necessarily keeping people on several weeks of antibiotics. So no, for a superficial pyaderma, I'm not standardly keeping them on for four weeks. You know, I'm really trying to recheck them one to two weeks if I can. And then try to see if we can come off treatment sooner. Question number six, what is your preferred topical treatment? So as I mentioned, topical is great. And we just have to remember this is a great option for our pyadermas, whether it's sole therapy, which is great when we get away from way with it. I just had a French yesterday in the clinic that had a pretty bad bacterial podidermatitis, but the sonar is very committed. And we are just starting with it's not like swollen fronkylosis. It's just a superficial pyadermin, but we're starting with wipes and bathing first. And we're going to recheck that pet in two weeks and see how things are going. In general three to four percent chlorhexidine for my standard cases is what I reach for. There's several products out there that have that. And with that, you can use bathing. We love bathing because it helps to wash off, you know, debris, pollen. You certainly can use moose and wipes kind of just depending on if it's a focal area, if it's a more diffuse area that you're trying to, you know, treat for the pyaderma. But even if I am having to reach for oral antibiotics, I am almost always, unless the pet will not allow it or the owner can't do it, I'm almost always reaching for some sort of topical therapy concurrently. So if we do need to do say a pretty bad superficial pyadermin, we're doing two weeks of cephalyxin and then we're going to have to recheck them. I am trying to see if the owner could also like bathe, you know, once or twice a week with a three to four percent chlorhexidine or, you know, put some moose on the more difficult lesions because I the benefit about topical therapy is not only, hey, maybe you can treat it not even have to use systemic antibiotics. But if you are having to reach for an oral antibiotic plus you treat them topically, you may be able to shorten that duration. And again, that's really what we're trying to hopefully look for in the new kind of updated guidelines about that. Last question question number seven, when do you decide to perform a bacterial culture? And this is a great question. So right, I'm always doing psychology because I know that it is bacteria and not yeast or something like that. But with that, I mean, honestly, if they don't respond even to my first line antibiotic, and it's financially reasonable for the owner, I would culture after a first failure. And so, you know, I really don't like to reach for more antibiotic sitting need to. If I have a really cost-conscious case, maybe initially we could try, you know, another antibiotic that's not a surplus born like clined amizings that's still a first, you know, kind of tier generation, first tier antibiotic. But man, if we're not responding to like those two, I am really, really pushing for culture or even get strict with topical therapy and like bleaching things like that if they can't. But I really don't like to reach for a third, fourth, fifth antibiotic. The other flip side I will say is if you have a really bad infection in the pets immunosuppressed, I mean, offer culture right off the bat, right? Like it's a really bad cushionoid dog or a dog who's on chemotherapy and really immunosuppressed because it's not an invasive test. So the only downfall is cost, which of course we have to consider. But if I have a case where I just, you know, and worried about how well the pet is even going to help me with their immune system and fight it off, and the owner is able to culture like, why not? Like get that information and just pick up right away. So I'd say the big ones would be failing antibiotics or the come to me and they've had a history of like recurrent pyaderman and going on lots of antibiotics with the primary vet before or I'm worried because they're immunosuppressed and I would just really like to have the information right away. Those are amazing questions that you guys gave me. A really good full scope on some of the deeper, difficult things with pyaderm as I mentioned, I think we'll do an episode where we kind of go over some of those basic guidelines. I think it's really great to see kind of the updated thought process, right, not just what we were taught maybe like 10, 15, 20 years ago. And that includes me. These are things that I were I was taught as well, you know, even in the last probably I'd say five years I've really shifted some of my thoughts on, you know, more topicals using other things like phobia, photo biomodulation when I can, you know, shorter duration of antibiotics if I can, you know, try and get to culture sooner if I can. So I just think it's really important. We understand the serious kind of thought process we have to have with managing pyaderma because it is becoming a big issue with these resistant infections. Hopefully this provided some comfort for you. And we will continue to dive into these different types of cases where there's pyadermat allergies on future episodes of the Durham vet podcast.