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The itchy cat challenge

dvm360dvm360 July 2021
Volume 57

Diagnosing and treating cats with pruritus can be difficult. But it is a hurdle veterinarians can overcome. Here's how.

jajam_e / stock.adobe.com

jajam_e / stock.adobe.com

It is a tenet of veterinary medicine that bears repeating: Cats are not small dogs. Veterinary professionals cannot extrapolate methods for diagnosing and treating dogs and attempt to treat cats the same way. “When it comes to cats, make no assumptions,” said Ashley Bourgeois, DVM, DACVD, of the Animal Dermatology Clinic Portland in Portland, Oregon.

This is especially true when it comes to feline dermatology, a subject Bourgeois knows well. “Cats are often forgotten,” she told attendees during her lecture at the Fetch dvm360® virtual conference. “We are limited on the tools we have to treat itchy cats. And cats can be tricky—both getting them into the clinic and even having owners recognize there is a problem.”

Don’t assume psychogenic alopecia is at play

Too often, veterinarians are quick to assume a cat presenting with bald spots or excessive grooming is suffering from a behavioral disorder—particularly, psychogenic alopecia. “Obsessive grooming is much more often from pruritus than OCD or just being stressed,” Bourgeois explained.

She recalled a 2006 study where 21 adult cats with a presumptive diagnosis of psychogenic alopecia were referred.1 After performing complete behavioral and dermatologic examinations, it was found that only 2 cats had psychogenic alopecia. Medical causes of pruritus were identified in 16 (76%) cats and an additional 3 cats had a combination of psychogenic alopecia and a medical cause of pruritus.1

“When I talk to behaviorists, it is much more likely they want over-grooming cats referred to a dermatologist or have an allergic workup performed,” Bourgeois explained. “In order to claim psychogenic alopecia, we have to exclude all hypersensitivity disorders and regular causes of itch. Psychogenic alopecia is going to be a rare diagnosis.”

History taking is the first step

According to Bourgeois, the importance of properly capturing a cat’s medical history cannot be overstated. “A huge portion of how you work up your diagnosis comes back to history and really making sure that you are asking the right questions,” she said.

Crucial questions Bourgeois recommends asking:

  • How old was the cat when clinical signs started?
    • Was this a young cat that was itching, scratching, and having GI issues? Or is this a cat that did not have issues until they were 15?
  • What flea prevention are you using for this cat?
    • Are the other cats and dogs in the home using flea prevention? “Make sure you know exactly when it was given and what the other pets are taking,” she stressed.
  • Is your cat exposed to the outdoors in any way?
    • If they are 100% indoors, is there a dog in the house that goes outdoors?
  • Do you notice a seasonal component? Even if the symptoms are year-round, are there times of the year it seems worse? “It doesn’t have to be all or nothing,” Bourgeois said. “Maybe the cat is always itchy, but in spring and summer it catapults into a much higher itch level.”
  • What therapies have worked? Maybe a therapy worked for a little while but now doesn’t. Or there was a therapy that the client doesn’t wish to continue. “It is important to know what worked in the past,” she added. “Maybe a cat responded well to steroids, but we don’t want to use steroids anymore because of side effects. If they are responsive to steroids though it shows us it is not psychogenic alopecia.”
  • What areas are most affected?
    • Is the patient just a belly licker or does it chew on its paws? “Knowing the areas the owner identifies as a problem is essential because knowing the distribution of lesions is helpful in knowing where to go in your workup,” explained Bourgeois.

Identify what itching really is

Owners may assume an itch simply means that the cat sometimes scratches, but pruritus can present in a variety of ways. “Do not just ask the owner if the cat is itchy,” Bourgeois directed. “We cannot identify what itch is from such a broad term.”

Get more specific by asking the client if the patient:

  • Grooms excessively.
  • Get hairballs. “Since cats are isolated creatures, the owner might not see them itch, but I have had owners notice that their cat only gets hairballs in the summer because they are overgrooming in private. But when we moved into seasons where they weren’t allergic anymore, we did not get hairballs,” she explained.
  • Chews at their limbs or paws?
  • Scratches?
  • Displays head shaking? “Pet owners do not think of this characteristic as itch itself,” Bourgeois said.
  • Always want you to scratch them?

Master the dermatologic exam

Bourgeois suggested attendees consider implementing Fear Free tactics when working with feline dermatology patients. “Dermatology is a chronic disease process most of the time and one that needs frequent veterinary visits to keep under control,” she said.

Little changes that make a big difference:

  • While obtaining the history from the client, open the carrier and let the cat explore.
  • Consider the touch gradient. “All that really means is that you are taking your time and keeping contact with the pet,” she explains. This alleviates the shock of the back and forth of being touched and not touched.
  • Allow the cat to hide. If you have a fearful patient, have pheromone-sprayed towels in the exam room.
  • Leave the more invasive elements until the end, such as the otoscope, facial, and oral exam.
  • Examine the cat within the carrier with the lid removed.
  • Have lots of treats and toys on hand. “There are lots of cats that respond well to that stimulation in a strange environment,” Bourgeois added.

Allergic workup recommendations for the itchy cat

When it comes to diagnostics, one of the most beneficial components is cytology. “I say cytology everything,” Bourgeois declared. “It tells us a lot of information, even if that information is boring. If there was no infection that is still good to know.”

Scraping and parasiticidal trials are important tools, too. “Sometimes you need a few months of having them on good quality flea control to know if flea allergy is a component or if they had some form of lice we couldn’t find through scraping,” she explained.

Dermatophyte culture is advised for a cat that is losing hair. Do not forget to biopsy when you need to and obtain additional staining to rule out that an organism is not causing the issue. “Lastly, lab work monitoring as a systemic check-in is always a good idea,” Bourgeois added.

When to consider adverse food reactions

Bourgeois created a scenario for attendees: Assume the patient is already on strong flea protection and that it is a younger cat who has suddenly started to break out with infections around the head or neck that does not overgroom.

Discussions surrounding a patient’s diet can be sensitive, she warned, but are still important. “There are so many opinions on diets and owners can get very protective of what they are feeding their cats,” she said.

Owners often equate a high price tag with high quality. “Even if it is the best chicken in the world, if your cat is allergic to chicken, they will still react to it. Take a step back and a deep breath when owners get defensive,” Bourgeois advised.

For feline patients with a suspected food allergy, Bourgeois tends to favor hydrolyzed options. “To me, it is one of the gold standards in trying to rule out food allergies in cats.”

Again, cats are not small dogs

Cats tend to display allergies in very peculiar ways, but a veterinarian with a strong sense of the patient’s history and a proper diagnostic workup can effectively pinpoint the causes and prescribe a treatment to provide long-term relief.

There is one way in which canine and feline allergies are very similar, said Bourgeois. “Communication and frequent rechecks are foundational to success. We can manage these cats to have a good quality of life if we get the owners on board and we work them up appropriately.”

Amanda Carrozza is a freelance writer and editor in New Jersey.


  1. Waisglass SE, Landsberg GM, Yager JA, Hall JA. Underlying medical conditions in cats with presumptive psychogenic alopecia. J Am Vet Med Assoc. 2006;228(11):1705-1709.

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