Case 12

The owners bring Wyatt in one week later for re-evaluation and, on cursory evaluation, Wyatt appears clinically improved. He is bright and alert and bounces into the examination room. While you are taking your history, however, you notice that Wyatt is continually scratching. Wyatt's owners are frustrated because he initially seemed to improve.

Recheck examination findings

• Mild partial alopecia along lateral trunk persists

• Fine papular rash now noted over ventral abdominal area with one to two excoriations, but previous pustular dermatitis in this area has resolved

• Mild interdigital erythema of the front feet (improved from previous visit); hind feet unaffected

• Moderate erythema and scaling noted along both elbows along callus areas

• Otic examination reveals mild erythema of vertical canals and minimal to no ceruminous debris (improved); the horizontal canal and tympanic membrane appear normal. Mild alopecia with scale is noted on pinnal margins.

• Pruritus is marked when skin over ventral trunk is palpated

• Odor resolved

• Cytologic examination of ear and skin samples reveals no significant numbers of bacteria or yeast.

• Superficial skin scrapings taken from current areas of dermatitis (pinnal margins, elbows, ventral trunk) are negative.

The pyoderma and otitis externa have clinically responded well to therapy, but the pruritus persists and concerns you.

QUESTION 5

What is your next best step for Wyatt?

a) Perform a skin biopsy to determine the cause of the pruritus and dermatitis.

b) Refer Wyatt for evaluation by a dermatologist.

c) Rule out occult sarcoptic mange with treatment and response to therapy.

d) Start therapy with modified cyclosporine for refractory atopic dermatitis.

e) Submit a serum allergy test to reassess Wyatt's regional allergies and to rule out food allergy.

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