Expert Q&A: What veterinarians revealed about treating canine atopic dermatitis

Canine atopic dermatitis (CAD) is one of the most common and complex conditions veterinary teams face. According to claims data from a multinational pet insurance company, allergies are the leading cause of veterinary visits, and the average allergic dog accumulates 16 allergy-related appointments over its lifetime. Yet despite its prevalence, little research had examined how real-world factors, especially client financial constraints, shape the diagnostic and treatment decisions veterinarians make every day.

That gap is what motivated a recent survey study published in the Journal of the American Veterinary Medical Association (JAVMA). Led by Christina M. Gentry, DVM, DACVD, of the Texas A&M University College of Veterinary Medicine and Biomedical Sciences, and co-authored by Lori Teller, DVM, DABVP, the study surveyed 718 North American veterinarians about their opinions, diagnostic processes, and prescribing behaviors for CAD—with a particular focus on how financial constraints and existing knowledge gaps influence clinical decision-making.

Gentry and Teller sat down with dvm360 to discuss what they found, what it means for general practitioners, and what veterinary teams can do today to improve outcomes for their atopic patients and the clients who love them.

Why is canine atopic dermatitis such a challenging condition to manage?

Gentry: CAD is kind of an umbrella term for dogs that have allergic skin disease—basically skin itching, rubbing, rolling, licking, chewing that is caused by things in the environment, like aero allergens, pollens, dust mites, as well as those triggered by their diet. This is a really frustrating condition because it tends to start in young adulthood; the average age is somewhere between 1 and 3. They're outliers in some breeds where it's as early as 3 to 4 months of age, and sometimes it doesn't happen until middle age or after a move to a new location. And because it starts so young, these patients are going to have this condition for their entire lives—so it's a condition that has to be managed for a decade or more, potentially in an owner that wasn't prepared to have a patient with a long-term health issue in the best years of their life.

It's also frustrating because it's often progressive. They may start with having just a little bit of skin lesions over the summer, and then as the years go on, it's now a year-round thing requiring multiple different types of care—topical things, oral things, injectable things—all together to keep the pet happy. And I think from a doctor perspective, it's hard for us sometimes to judge when these patients are going to get worse. Which is the dog that we may be more proactive with? Because this animal is going to be more of a problem later. And that can be really frustrating for clients, too. They finally get a handle on it after a year working on something, and then three years later it changes again and it's worse.

Teller: I agree. When the patient first comes in, you wonder is this just a flare-up? Dr. Gentry and I are in Texas and we're allergy central, especially near the Gulf Coast, so it's just constant. Owners don't always grasp that at the beginning. Even when we have that conversation, many of them have their own allergies—but there are a lot more options for them. It's a lot different for them to take a shower with a special shampoo and moisturize than it is for us to tell them they need to bathe their large, very hairy dog twice a week for the rest of the dog's life. Insurance, all of those things play a role, and having those conversations about a long-term disease and what it takes to manage it successfully—sometimes it's hard to grasp, especially early on.

What prompted this study, and what were the key findings?

Teller: The Stanton Foundation was looking for ways in which spectrum of care could be applied to various problems in the dog population. We know canine atopic dermatitis is such a major problem. Our original goal had been to do a literature review and then apply that to spectrum of care and help veterinarians manage it along different ways—but it became readily apparent that there's really just not a lot of literature out there. So Dr. Gentry had the great idea of: let's do a study, find out what people know, what they think they know, and what they don't know, so that we can do further studies from that point on.

Gentry: Our frustrating thing was when we said, 'Okay, let's do this literature search.' Spectrum of care encompasses a lot of things—some information on owner compliance, owner feeling about what therapies are hard, what affects their quality of life, sprinkling a little bit on what financial constraints affect how people practice. But taking all those things together and asking: if there is limited funds, how do we treat a patient? Or if there are time limits? We actually realized that no one had really asked anyone that, and so the idea was: let's make some of the literature if it's not already there.

For the top-line findings, I think what I'm hearing from a lot of veterinarians is we really are seeing a lot more financially constrained clients than maybe we are assuming. In our study, we gave a definition: that the client would have difficulty with routine, emergency, or illness care—that those things would potentially be a problem to their budget. And we had about half of respondents saying that at least 25% of their clients fit into that mold. That's hard for any veterinarian to deal with for an acute problem, where okay, could we scrape the funds for this one bout of diarrhea—but that becomes a lot harder when you have a disease that is forever.

How do we meet clients where they are, provide reasonable expectations? And those were a lot of the areas I found really interesting—how veterinarians decided on drug selection. The veterinarians in our study are already showing they're practicing across a spectrum of care, because they are choosing lower-cost drugs more often for flares in financially constrained cases versus just assuming that you pick the same drug every time. But there were some areas that perhaps we could still improve upon—particularly in the area of antibiotics—because we were still finding sometimes that veterinarians were prescribing antibiotics that we really shouldn't for first-line infections, and some of the more expensive antibiotics at that, regardless of financial constraints.

The study found that 58% of respondents said at least 25% of their clients had substantial financial constraints. Was that surprising?

Teller: I'm not surprised, but I come from a primary care background, so it's something we're fighting across the board, right—dealing with financial constraints and practicing spectrum of care, whatever the problem is. And then we get to atopic dermatitis, and being in primary care, we do what we can do—but we do often offer a referral to dermatology, and the instant pushback is, 'No, that's too expensive, I don't want to do that.' And yes, that initial consult may be expensive, but even other studies have shown that if we can get them in early to get that referral, sometimes they just understand the disease better. Sometimes, because a specialist is telling them, they're more likely to listen. So I can say, 'You need to bathe the dog every week, every two weeks'—and they're like, uh huh, whatever you say, Dr. Teller. But if I send them to Dr. Gentry and she says the same exact thing, they're like, okay. Sometimes it's just having that reinforced by somebody else. And if they have an understanding of why we're making all these recommendations, and they're willing to stay on top of it before they get a bad flare, ultimately over the long run, that becomes a bigger cost savings to them.

Gentry: For me it was more of a surprise, because as Dr. Teller mentioned, I see the patients whose owners have the finances, the time, and the emotional ability to handle having an extra appointment with a new person. And I think as a specialist now in academia—we're in College Station, sitting between cities—I do see a true spectrum. It's a really good reinforcement to me to be reminded of reality: not that I'm a specialist in an academic institution who only gets to see the special things, because I'm teaching veterinary students who are going to go out there day in and day out and practice across the United States in many different communities. I need to know what they are going to be facing to be able to educate them in a way that they can be successful.

The study also found that most veterinarians rarely provide clients with an estimate of the annual cost of managing CAD. Why does that matter?

Gentry: When I see a patient on referral, they've often been through multiple different allergy drugs, multiple antibiotics—they come in with a whole bucket of shampoos and ear flushes. And often what I hear is, 'I just spent $170 on this injectable allergy medication, and it wore off in three weeks,' or 'two months ago I spent $9 on this pill.' The reason I asked about whether we give clients estimates is that when they get to me, I'm pretty upfront. I'll say, 'If the injection worked for four weeks, that's the expectation—would you be okay if we spent $107 on this injection for the next year?' And some clients are like, 'That's all I need to do to make it better? Amazing.' But some are like, 'Oh no, I can only afford that once a quarter.' So I think if we're upfront with clients—assuming they're willing to listen, we have the time, and they're engaged—we can say, 'We're going to try this drug, but know that if it works, I'm going to tell you to do it about every month. How would you feel about that?' If they immediately say that's not doable, then we can explore other options.

The whole goal is to keep their pet comfortable long-term, so they're not in the office every month for a flare—which ends up being more and more expensive over time. What's also important to know for those of us in a primary care setting is that when we see a dog for the first or second time presenting with atopic signs, we don't know if this is going to be just seasonal, or chronic from the get-go. We can have that initial conversation that this is a long-term disease, but we may not be able to give them that annual estimate until we have more history behind us.

What did the study reveal about antibiotic selection, and where are the gaps?

Gentry: One of the most important issues we face as dermatologists is an increased prevalence of resistant bacterial skin infections. It's very common—either when you first see a dog with allergies, when their GP first sees them, when they're having a flare—that there's a skin infection. What we've learned over time is that when we were routinely providing antibiotics for this all the time, we were seeing more resistant bacterial populations. And now we have so much prevalence of a few strains of resistant bacteria that are endemic in the United States. Dogs can develop resistant skin infections very rapidly.

Our goal is to start limiting systemic antibiotic use. And the question was, if we limit systemic antibiotic use, are we going to be able to successfully treat bacterial infections with topical therapies? The answer is yes—topical therapy works just as well as oral antibiotics for superficial pyoderma. But when oral antibiotics are necessary, we have guidelines: first-line therapies are first-generation cephalosporins, amoxicillin-clavulanic acid, and clindamycin.

What we found is that most veterinarians were doing really well—choosing cephalexin for financially constrained cases, which is a common, low-cost, effective antibiotic. In non-financially constrained cases, there was more of a shift toward cefpodoxime, which is a third-generation cephalosporin. I think veterinarians are choosing it because it's once-daily—so it's a convenience and compliance decision. But literature suggests that using more third-generation cephalosporins is more likely to contribute to increased bacterial resistance. And then we were still seeing some recommendations for fluoroquinolones without culture, and for amoxicillin alone—which most staph are naturally resistant to at this point. So I think there are some areas where those of us in educational roles can really lean in to help.

Teller: I completely agree with Dr. Gentry. We have to recognize that amoxicillin is great for first-line UTIs in a female dog—not good as the first-line antibiotic in skin infections. Part of our ongoing research and educational efforts from this study will be to help educate veterinarians and clients on judicious use of antimicrobials and why your veterinarian is recommending these particular antibiotics.

How should primary care veterinarians approach the referral conversation?

Teller: Some of it's going to be case by case—how frustrated the client is, how compliant they are, how well the patient is responding. But in general, if I'm seeing a patient for the third time within a year and it's just not working, or the owner is struggling, I'm going to recommend a referral. And especially if I get pushback, I'll say, 'Many times if you get a referral early in this process, we can do a lot more for the long-term management, and it will ultimately make it easier for you to manage fluffy.' I'll say, 'Just go one time, hear what the dermatologist has to say.' And the dermatologist and I will work together—so if going back on a repeated basis isn't doable, whether that's money or distance, I can manage the pieces I can manage here, and you may just need to go back every so often for a follow-up with the specialist. If I can frame it as 'this is what's going to help fluffy get better faster and be easier for you to manage over her lifetime,' they're more readily open to taking that referral.

Gentry: Allergies are now something like 10% to 20% of the dog population, right? It's clearly not physically possible, even if every dermatologist in the United States was seeing cases seven days a week for 12 hours a day, for us to see the amount of pets that have allergies. We rely on the fact that the majority of allergic dogs are being treated by their primary care veterinarians successfully—we're just seeing the ones that are not responding as expected, or who are particularly difficult because of the dog's size, the severity of the disease, or limitations the client has.

And I think just starting with: as a dermatologist, my goal is I can't cure your dog's condition—no one can—but I want to give you strategies to make it less severe. If we see these patients when they're 2, 3, and 4, and we can talk about multimodal drug therapy before there are things like ear canal scarring and interdigital scarring where the disease has gotten so bad over time, or before they're open to immunotherapy to reduce drug requirements—that's the time. It's much harder when I get the 9-year-old dog whose ears are now end-stage and needs expensive surgeries. We love it when our primary care partners are saying, 'Hey, these patients seem to be on the harder end of the spectrum—send them in early.'

What role does client communication play in long-term success?

Teller: Communication is so much of what we try to do—being open and honest while being empathetic about it. I have dogs; there's no way I could bathe my dogs twice a week. And if I had to go see Dr. Gentry, I'd just say I cannot bathe my dogs twice a week—they're two giant labs, it's not happening. So what are our alternatives? When a client can be open and honest about what they can manage given time constraints and their lifestyle environment, that's huge. And it also becomes a conversation about managing expectations: if this is what you can do, this is what you can expect—versus if you can do this and this, then our expectations may change. I need them to be honest about what they can and cannot do so that I can manage those expectations.

Gentry: Literally the same thing. The more open clients are about what they can and cannot do—and sometimes why they can't—the more we can actually fix. I had a client in my residency in Denver who couldn't bathe her dog inside in the winter because her shower had just a regular head. And I said, 'You know, like at Walmart, for about $20, you can buy those cool drop-down ones.' And she was like, that was revolutionary. I know that seems silly, but if you've just never gone to that one aisle at Walmart to look for that particular drop-down showerhead and didn't realize they're relatively cost-effective—that was life-changing for her. So it's not only asking about the limitations—sometimes if you ask why, you'll find things that are completely outside your control, or that have a simple solution.

We also asked whether veterinarians felt their clients knew that CAD is a lifelong condition, and it was an overwhelming 'yes, I think my clients understand.' So I feel like our veterinary population is doing a good job messaging this.

What's the top takeaway for primary care veterinarians?

Teller: Recognizing the communication piece—and that could be hard in a busy schedule when you're going from room to room. Have your team members be a part of that. I have some amazing technicians who know the canine atopic dermatitis conversation backwards and forwards. I can outline the plan to the client, and then turn that conversation over to a team member to go into the details—how to use the shampoo, leaving the lather on for 10 minutes before rinsing it off, things like that. Get your team involved in those conversations so you can go do your doctor things, and your team can really play a role in that client education piece. I have clients who come back and want to see my technician. They're like, 'Okay, great, Dr. Teller,' and I say, 'Oh, Fluffy is looking great, glad it's working. Go on—I want you to talk to the tech.' Which is perfect. That's what I want to hear.

Gentry: I would say that's literally my realm as well—if we can just talk about what we need to do, things generally go better. And our Durham technicians—we have one in particular, Anna, who has been a technician in dermatology longer than I have been a doctor—and she's fabulous. We really should continue to encourage our technicians to be that piece of the communication puzzle.

But my other takeaway is: don't forget corticosteroids. Now that we have so many other drugs that are not steroids, which have—in a good way—fewer adverse events for long-term use, we've kind of forgotten a little bit that steroids are useful for allergies to calm flares, particularly at the beginning of diet trials. And I think when we are approaching cases where finances are a concern, we need to be more open to saying, 'Because steroids cost 50 cents a pill, I would rather do that for a couple of weeks while I calm your infections before I reach for the non-steroid drugs that I'm going to use long-term that cost more money.'

Any final thoughts you'd like to leave veterinarians with?

Teller: It's important to remind clients that since this is a lifelong condition, there are other things that may complicate it in that lifetime as well. Certainly young dogs are susceptible to mange—make sure that's not complicating the case. There are so many medications we use for flea and tick prevention that also control mites. Recognizing that fleas are a trigger, that animals can develop new allergies. So it's not just, 'You have this lifetime problem and here are the drugs to treat it'—we need to recognize that the next skin problem may not be related to allergies. It could be an endocrine problem or something else, and clients need to understand that other things, as their animal ages, can also impact what they are seeing.

Gentry: I am so thankful for all the people that took the time to take our survey, because it was a long one. But our study shows that in general, veterinarians are rocking it. They are doing the best they can across the spectrum of care. And what we, as those of us that work in educational roles, can do is continue to provide more information and more guidance to help people make decisions across the spectrum of care. It's easy to say, if you have endless funds, always do A, B, then C, then D—but what do we do when that's not the case? There's no perfect system, but I think those of us in the education space can really lean into that to help students and our veterinary partners.