Multimodal Approach to an Itchy Dog

Ashley Bourgeois, DVM, DACVD: As we move in, we’ve identified something really common, like a secondary infection. We start talking about the importance of multimodal therapy: bathing, mousses, wipes. Those become extremely important. That’s where dermatology can be frustrating for a lot of people, including veterinarians because there are so many things we have to throw at these pets. We’re asking them to do flea control, maybe they’re also changing their diet, and then they’re going on some form of antipruritic because they’re miserable. Plus, we’re treating an infection. We want to think of the long-term solution with something like allergy testing. It’s a lot we throw at them.

But topical therapy can be so important because if we’re trying to minimize the cutaneous absorption of a lot of these pollens, which we know as atopic dermatitis, what these dogs do is they’re essentially absorbing these things cutaneously. Repairing their upper dermal barrier can be crucial. I can ask a client to bathe every day. I can ask them to apply a wipe. I can ask them to mousse. I can write that in the discharge instructions, but they have to be able to do it. From your standpoint, what I want to know is, what are ways I can work with my clients if I need them to bathe twice a week but they don’t know if their pet will feel comfortable with that? They haven’t bathed that frequently before. What are tips and tricks, from your experience, that I can use to increase compliance? Because I do think topical therapy is extremely important.

Christopher Pachel, DVM, DACVB, CABC: As you and I have talked about multiple times, even as we’re consulting on individual cases together, we fully believe that the best therapy is the 1 that’s doable. It’s the 1 that can be implemented. Maybe that won’t be enough, but we’re never going to know unless we can get therapy moving forward. If topical therapy is a big part of that, troubleshooting that right from the get-go allows us to figure out what is doable. For me, the first thing is, even before we get into problem-solving, I need to ask questions. If I’m describing that to the client or the owner, saying, “This is what the best approach is going to be for us in this case. How practical is that for you with your schedule, with your bathroom?” Let’s say we’re talking about bathing. Or maybe they’ve got a little stand-up shower, and they’ve got 140-pound mastiff, and they’re like, “I don’t even have a tub. How would this even happen?” Acknowledging some of that can actually create some vulnerability for clients.

Asking questions and creating a safe space for that dialogue to allow a client to say, “No.” Or “I’ve got a bonkers schedule for the next 3 weeks. Doing a wipe twice a day seems like it would be totally simple, but I’m going to guarantee you that that’s not going to happen.” That’s part of it, making sure that we’ve confirmed that it’s something that can get done. If not, then the follow-up question is, “What’s the obstacle?” Is it a financial obstacle, is it a time obstacle, or if we’re getting into the behavioral stuff, is it a tolerance level? It could be something as simple. I’m thinking of problem-solving. If the owner says, “The dog does great until I go with the mousse, and then the dog is out the door.” Right? Like, nope, I’m out for that.

Would this be an animal who would tolerate a little LikiMat for 30 seconds with some peanut butter—assuming that’s not going to violate a diet trial. We give it a little peanut butter to keep it busy, and I step 2 rooms away and spray the mousse on a little gauze square, and then I can come back and apply it. The solution could be as simple as that. If I’ve asked about it, I can also say, “Is there a way to create a positive association?” It’s not perfect, but can I find a level of therapeutic application that is tolerable, that I can start building a positive association? We might say, “I really need you to get in with that wipe between each of those toes—really get in there.” The owner says, “Nope. Maybe 3 seconds, but that’s it.” Cool. Then let’s start with 2 seconds for the first day or 2. Two seconds, treat. Two seconds, treat. Two seconds, treat. See if we can build an association so we have an animal that, rather than being reserved or resistant, is now positively anticipating that routine. Utilizing those training principles, getting a bit of classical conditioning thrown in to shift that emotional association that the animal has with the procedure. But we’ve got to ask the question and know what problem we’re trying to solve, for sure.

Ashley Bourgeois, DVM, DACVD: I love that. I recently had a client where we were talking about bathing, and I’m asking, “Is it possible? Can you do this?” And you really can’t make assumptions because I have had clients where maybe they’re older, or I’m not sure they’ll be able to do it, and they’re like, “I’m retired, so I’ll go to the groomer once a week. I’m happy to do it.” You never know what they’ll be willing to do if you truly think that it’s important. Which I think topical therapy is. Sometimes bathing is just not an option for that, so we can really lean on other forms of topical therapy in those cases. Using the mousse if it’s easier for them. Using the wipes if it’s easier for them. Using a combination, depending on what lesions are present.

I recently had a client, where we were talking about bathing and they weren’t so sure, based on the tub they had. The dog didn’t like the bathtub. I was like, “The weather is getting better. We’re entering into spring.” We talked about using the hose in the backyard when the weather is nice. He was like, “He wouldn’t care about that at all.” What I told him, because I have my own allergic dog who needs to be bathed all the time and who also hates the bathtub, is I go in the backyard when the weather is nice, and I lather her up, and then we play for 10 minutes in the backyard. She’s going to get some dirt on her paws, and maybe some of it will come off, but there’s nothing magical about locking them in the tub for 10 minutes. It’s just having that contact time. I’ve had owners where they’ve bathed them outside, and then they go for a 10-minute walk. Just something where it’s not this detrimental, “I hate this. I’m not going to do this long term.” Just giving them options. In the end, if they just can’t do it, then you can lean on other forms of topical therapy. Which I think is why it’s so nice we have all these different modes of topical application.

But you really do have to work with them. What’s going to work for 1 owner might not work for another. You’re absolutely right: If I send home a bottle of shampoo and it just sits there, it breaks my heart when clients come back and they’re like, “I just never bathed him.” I wouldn’t have sold you the shampoo when we talked about this, because I know I always do. It’s just giving them those options. People aren’t used to that. They don’t know. This isn’t what they do for a living. To be able to say, “Can you do it outside?” I’ve had people where they have bad arthritis, but their daughter comes over 3 times a week and she loves the dog. She doesn’t mind bathing him. There are options that you can look into, and then in the end, if it’s not going to work, lean on something else. But at least we didn’t give up on something important, like topical therapy, because we didn’t ask the question.

Christopher Pachel, DVM, DACVB, CABC: You mentioned something else in there too that really made me think that when we’re talking about tolerance, for most of the allergy patients, or any chronic dermatitis condition, it’s likely to be chronic. This is not the short game. If we really push just to get it done once or twice, I want to be thinking, “At what cost?” We may have jeopardized the long game by pushing and forcing that animal to stay in the tub. Again, maybe the first time it’s only 2 minutes, and we work our way up. I’d rather get 2 minutes than not at all, or get 10 minutes once, but never again. It’s having that opportunity to troubleshoot the options and really helping clients understand what the ultimate goal is. It makes such a huge difference.

Ashley Bourgeois, DVM, DACVD: Yeah, and I will say, when I’m treating, say a bad pyoderma, that is an important point to make. Because if I set up the expectation that the owner is going to have to bathe 2 to 3 times a week for life, they are frustrated. They are disheartened very quickly. It will last a week. But if they know it is just during this bad infection that we might need to do it that often, if we get through this because we commit to it all of a sudden, we can back off to once a week, every other week. Then all of a sudden, they have a goal and it doesn’t seem so daunting to them. You’re absolutely right. All that stuff is extremely important.

Transcript edited for clarity.