Join us as we venture into the stables to explore urticaria in horses - those mysterious swellings that appear seemingly out of nowhere and may disappear just as suddenly. Expert guest Dr. Valerie Fadok shares her extensive experience as both a veterinary dermatologist and immunologist to help us understand what causes these puzzling conditions, how to differentiate them from other lumps, and when to investigate further rather than automatically reaching for steroids.

Dr. Valerie Fadok - A dual specialist bringing unique expertise as both a veterinary dermatologist and immunologist. With experience across three veterinary schools, private practice, and as a field specialist with Zoetis, Val brings a wealth of practical knowledge from working with veterinarians and horse owners around the world.

Val discusses how horses are the most commonly affected species with urticaria among the animals veterinarians treat, and how this condition can drive both horses and their owners to distraction. The disease presents unique challenges, with sudden onset cases that sometimes resolve on their own, and chronic cases where horses experience repeated outbreaks over time.

What Urticaria Looks Like:

Papular Urticaria:

The Role of Mast Cells:

Physical Urticaria:

History is Key:

Acute Urticaria Management:

When to Investigate:

Seasonal Cases:

Non-Seasonal Cases:

Environmental Allergens:

Val's Approach:

Customization is Key:

Seasonal Management:

Success with Horses:

Antihistamines:

Corticosteroids:

Off-Label Options:

Realistic Expectations:

Education Needs:

Both Val and Sue emphasize how remarkably compliant and dedicated horse owners are:

In this month's episode, Sue John and Paul invite exotics guru Madonna Livingstone onto the podcast to discuss general and skin issues in ferrets.

Overview of ferrets as pets:

   - Ferrets have been domesticated for over 3,000 years, evolving from the European polecat.

   - They are highly social and prefer to be kept in groups of at least two.

   - Ferrets have high protein and fat dietary requirements, and need a lot of space and environmental enrichment.

Common Skin Conditions in Ferrets:

   - Ectoparasites:

     - Fleas (usually dog and cat fleas) are the most common ectoparasite, causing pruritus and alopecia.

     - Ear mites are very common in ferrets, often asymptomatic.

     - Sarcoptic mange can affect the feet, causing severe pruritus and scabs.

   - Allergies:

     - Skin allergies are rare in ferrets, but environmental contact dermatitis can occur.

     - Food allergies are very uncommon.

   - Hormonal Imbalances:

     - Hyperadrenocorticism (adrenal gland disease) is less common than hyperestrogenism in female ferrets.

     - Hyperestrogenism can lead to alopecia, bone marrow suppression, and even death if untreated.

Treatment Approaches:

   - Ectoparasites: Use of selamectin, fipronil, or moxidectin is recommended.

   - Allergies: Antihistamines, steroids, and omega-3/6 fatty acids can be used.

   - Hormonal Imbalances:

     - Hyperestrogenism is often managed with deslorelin implants or HCG injections.

     - Hyperadrenocorticism may require surgical adrenalectomy or deslorelin implants.

Insights and Takeaways

- Ferrets are unique and fascinating pets, with specific care and medical needs.

- Skin conditions in ferrets can present similarly to dogs and cats, but there are some key differences in diagnosis and treatment.

- Ectoparasites, especially fleas and ear mites, are very common and should be the first consideration when a ferret presents with skin disease.

- Hormonal imbalances, particularly hyperestrogenism in females, are an important cause of skin problems in ferrets and require prompt recognition and management.

- Veterinarians should be familiar with ferret-specific care and be prepared to handle ferret skin cases, as they may be uncommon but can be challenging.

Conclusions and Decisions

- Ferrets are becoming increasingly popular pets, and veterinarians should be equipped to provide appropriate care for their skin conditions.

- Developing a good understanding of ferret biology, common skin diseases, and treatment approaches can help build confidence in managing these cases.

- Consulting resources like the BSAVA Exotic Animal Formulary and seeking advice from experienced exotic animal veterinarians can be invaluable when caring for ferrets with skin problems.

- Promoting proper husbandry and preventive care, such as regular ectoparasite control and monitoring for hormonal imbalances, can help minimize skin issues in ferrets.

Chapter 1 – “Lumps, Not Bugs: Cracking the ‘Sterile’ Case”

03:22 – John welcomes Dr Laura Buckley back for part two on brachycephalic skin disease and tees up two topics: Sterile Granuloma/Pyogranuloma Syndrome (SGPS) and Muzzle Folliculitis/Furunculosis, plus how to manage comorbidities. Laura explains it’s an uncommon, immune‑mediated nodular skin disease of dogs involving histiocytic cells (macrophages). No infectious agent is found and it responds to immunomodulatory therapy.

17:05 – John pivots to Muzzle Folliculitis/Furunculosis: what is it and who gets it? Laura: a bacterial follicular disease confined to the muzzle skin, common in coarse/bristly‑coated brachys—British & French Bulldogs, Pugs, Shar‑Pei, Boxers.

29:52 – Sue asks about juggling comorbidities (e.g., SGPS plus history of demodicosis). Laura: set expectations with owners; if on isoxazoline preventatives, relapse of demodex during immunosuppression is unlikely but monitor closely. Risk is higher during combination immunosuppression (e.g., pred + cyclosporine) and lower on single‑agent maintenance.

Chapter 1 – Intertrigo: Prevention, Work-Up, and When (Not) to Use Antibiotics

(00:11) John introduces the podcast episode and the hosts.

(02:39) John welcomes Dr Laura Buckley (Senior Lecturer, Veterinary Dermatology, University of Liverpool) and asks what “brachycephalic” means and which breeds it covers. Laura explains shortened muzzles and broad, domed heads; the most extreme include French and British Bulldogs, Pugs and Boston Terriers, with Cavaliers, Chihuahuas and Dogue de Bordeaux also affected.

(04:00) Sue notes their huge popularity in UK primary care. Laura adds that around 40% of her clinic can be French Bulldogs, with brachycephalics a very large overall share.

(04:33) Sue asks which skin problems are most common. Laura explains that atopic dermatitis and otitis (externa/media) lead, with interdigital furunculosis also frequent. Cavaliers often show primary secretory otitis media. Skin-fold dermatitis (intertrigo) and muzzle furunculosis are common, and lesions can form over bony prominences where itchy dogs rub.

(06:15) Sue asks what intertrigo is and why brachys get it. Laura explains shortened muzzles leave redundant skin that folds around eyes and muzzle, creating humid, low-airflow pockets that accumulate keratinous/sebaceous debris. Microbial overgrowth follows; bristly coats plus rubbing traumatises follicles and escalates inflammation.

(08:06) Sue asks about prevention. Laura suggests daily fold hygiene from the start: clean away debris; consider antiseptic wipes (e.g., chlorhexidine) once or twice daily, and increase during flare-prone periods.

(09:15) Sue highlights how early routines improve compliance and handling; Laura agrees it gives a “head start,” especially as atopy often appears within the first three years.

(10:08) John asks how early disease presents and how to work it up. Laura explains earliest signs are diffuse erythema in the fold, then partial/complete alopecia, erosion/ulceration, crusting; severe untreated cases may progress to folliculitis and even deep pyoderma.

(11:48) Sue asks about cytology. Laura explains it’s pivotal: expect keratinous debris with cocci (staphylococci) or Malassezia in overgrowth; neutrophils with intracellular bacteria indicate infection and guide therapy.

(12:57) John asks if systemic antibiotics are ever needed. Laura explains they’re rarely indicated: most cases respond to topical antiseptics/antimicrobials plus strong anti-inflammatory control. Consider systemic antibiotics only for genuine deep, painful, draining pyoderma, immunosuppression, poor feasibility for topicals, or proven topical failure - always post culture & susceptibility.

(15:47) John asks how she controls inflammation. Laura uses topical glucocorticoids (often in combination products). For severe inflammation, short anti-inflammatory courses of prednisolone (~0.5–1 mg/kg for a few days before tapering) can calm tissue so topicals can work.

(16:48) Sue asks about long-term routines and when to consider surgery. Laura advises daily fold cleaning (once–twice daily) and twice-weekly topical anti-inflammatories (e.g., hydrocortisone aceponate or mometasone) with minimal systemic absorption; discuss surgery if medical care is impractical, or if maintenance fails with frequent relapses or recurrent infections.

Chapter 2 – Viral Pigmented Plaques (VPP)

(19:33) John moves to VPP and asks which brachy breeds are affected. Laura most often sees Pugs, plus Boston Terriers, Chihuahuas and French Bulldogs.

(20:25) Sue asks what they look like. Laura describes numerous, heavily pigmented, slightly raised plaques that may begin flatter and become scaly, verruciform and hyperkeratotic over time.

(22:00) Sue asks how to differentiate melanoma. Laura says biopsy/histopathology is the diagnostic choice; FNAs from plaques are often low-cellularity keratinocytes, whereas melanoma cytology differs.

(23:43) John asks if plaques regress. Laura explains most persist or increase, likely due to a virus-specific, genetically influenced immunodeficiency in otherwise healthy, often young dogs. For treatment, Laura notes most are cosmetic, but very rarely plaques can transform to SCC, so monitoring matters. Limited numbers can be removed surgically or with laser; for numerous lesions consider systemic/medical options (e.g., azithromycin, interferon, retinoids, vitamin A, topical imiquimod) with variable success.

(25:35) Sue summarises a primary-care approach: monitor unless numerous, pruritic, function-limiting or rapidly changing. Laura agrees; schedule regular reviews.

Chapter 3 – Seasonal Flank Alopecia (SFA)

(26:30) Sue introduces SFA and asks what it is and why it happens. Laura explains it’s a localised cyclic follicular dysplasia linked to photoperiod and melatonin; predisposed breeds include Boxers, Affenpinschers, British Bulldogs, Staffies and Chihuahuas.

(29:40) John asks about geography. Laura notes seasonality is more marked away from the equator where day-length swings are greater. Sue recalls light-box data suggesting equal photoperiod may prevent SFA; both agree the pattern fits a light/melatonin mechanism.

(30:18) Sue contrasts the clinical picture with endocrine alopecia. Laura explains SFA shows sharply demarcated, bilateral flank patches (± hyperpigmentation). Endocrinopathies tend to be diffuse, affect coat quality and other sites (e.g., tail).

(32:27) Sue asks differentials and work-up. Laura highlights hypothyroidism and Cushing’s; use signalment and systemic signs, then haematology/biochemistry ± T4/TSH and targeted endocrine tests as indicated.

(33:03) Sue asks about monitoring. Laura expects regrowth in spring within 1–4 months as day length rises, though a minority become permanently alopecic.

(35:45) John asks about treatment. Laura reassures it’s cosmetic once endocrinopathies are excluded; many owners opt to observe. For those wanting intervention, oral melatonin and increased light exposure are reasonable.

(37:30) John thanks Laura and invites her for episode 2!

Chapter 1: Meet the Microbes

(02:41) John opens the episode, introducing Dr Vanessa Schmidt and inviting her to share her background. Vanessa explains her role at the University of Liverpool, her PhD in antimicrobial resistance in staphylococci, and her leadership in infection control and antimicrobial stewardship.

(03:38) John asks whether staph infections in pets are usually caught or part of their natural skin flora. Vanessa replies that most infections come from an animal's own commensal microbiota, which coexist harmlessly but can cause disease when the immune system or skin barrier is compromised.

(05:07) Sue asks whether humans and animals share the same commensals. Vanessa explains that while many organisms are shared across species, each host also harbours unique flora. Cross-species transfer is possible but not common.

(06:16) Sue asks whether different body sites have different staph species. Vanessa says this is well-mapped in humans, while in pets we know carriage is common in the nose, mouth, and perineum, but site-specific species need more study.

(07:28) John asks about coagulase-positive vs coagulase-negative staph. Vanessa explains that coagulase-positive staph are generally more virulent, while coagulase-negative species can still be important, especially in immunocompromised hosts or in association with implants.

(09:37) Sue asks how to interpret a coagulase-negative result on a lab report. Vanessa advises considering clinical context, immune status, culture growth level, and cytology to judge significance.

(12:34) Sue emphasises the value of cytology. Vanessa agrees, explaining it's routine in dermatology and helps identify intracellular bacteria and neutrophilic inflammation.

Chapter 2: Resistance Training

(14:30) John transitions to methicillin resistance. Vanessa explains MRSP carries the mecA gene, conferring resistance to beta-lactam antibiotics. It spreads clonally and is more stable than resistance in Gram-negatives.

(17:40) Sue asks whether antibiotic use can switch the resistance gene on or off. Vanessa says it's about selection pressure - resistant strains survive when antibiotics are overused.

(19:03) Sue shares her “rucksack” analogy. Vanessa agrees, adding that over time resistant strains adapt, carrying resistance genes more efficiently.

(20:15) John asks about zoonotic risk. Vanessa confirms bacteria like MRSP can pass between pets and owners, though actual infections are rare.

Chapter 3: Less is More: Treating MRS the Smarter Way

(22:33) Sue asks about managing MRSP pyoderma in practice. Vanessa outlines a tiered approach: treat the underlying disease, apply barrier nursing, and use topical therapy like chlorhexidine, aiming to avoid systemic antibiotics.

(27:00) Sue raises chlorhexidine use and guideline updates. Vanessa recommends 2% or above concentrations of chlorhexidine and warns that dilution reduces effectiveness and may lead to treatment failure.

(30:05) Sue mentions suspected resistance. Vanessa confirms resistance is reported and linked to bacterial efflux pumps. She uses hypochlorous acid or bleach as follow-up options in certain MRSP cases.

(33:15) John asks what Vanessa avoids. She avoids systemic antibiotics in superficial MRSP unless absolutely needed, and tailors treatment to the underlying disease. Immunosuppressives are avoided if the infection arose due to immune compromise.

(35:00) Sue asks about treating MRSP otitis. Vanessa explains that lower chlorhexidine concentrations are potentiated by TRIS-EDTA, so she still uses them as first-line ear cleaners.

(36:40) John asks about long-term carriage. Vanessa explains MRSP can persist for months or even years. Decolonisation before high-risk surgery is common, but long-term clearance is difficult and evidence is limited.

(39:42) Sue summarises the discussion: in MRSP, less is more - fewer antibiotics and more topicals. New guidelines offer hope for better resistance control.

ISCAID guidelines

https://onlinelibrary.wiley.com/doi/10.1111/vde.13342?af=R&utm_campaign=Nextmune%20-%20Nextmune%20UK%20Updates&utm_source=hs_email&utm_medium=email&_hsenc=p2ANqtz--e1aa7hsXEupaiUzNH8tbxLSDEH8s4jALF4ScLWjefX83QJvKt5H20n5xE--r0sn9CVwFI

Protect Me guidance from BSAVA

https://www.bsava.com/Resources/Veterinary-resources/PROTECT-ME/

Show Notes

On this month's episode, Sue, John and Paul invite Darragh O'Hanlon (@thetopicalvet)  onto the pod to discuss pollen allergies.

Chapter 1 – How Pollens Affect Animals

(02:32) John introduces the topic of pollen allergies and welcomes guest Darragh O’Hanlon.

(04:09) John asks how pollens cause allergic reactions in animals. Darragh explains that pollens are airborne reproductive grains from grasses, trees, and weeds, and describes their microscopic structure and typical transmission routes.

(06:30) Sue asks whether pollens affect more than just the skin. Darragh explains that:

(08:45) John asks why grass pollens are so problematic over say garden flowers.

(14:20) Sue asks about pollen season overlap and the role of allergy testing. Darragh agrees and describes how pollen calendars can predict seasonal challenges.

(16:20) John asks if pollens cross-react with each other or be linked to food sensitivities.

(19:55) Sue mentions bee foraging and asks about using tape strips to detect pollens on animals. Darragh shares anecdotes and online interest in identifying pollens via tape stripping.

(21:36) Sue asks about ragweed in Ireland. Darragh says it’s rare locally but problematic in the US. He discusses its introduction to Europe and control measures.

(23:20) John asks how pet owners can reduce pollen exposure. Darragh shares advice:

(26:10) John asks about environmental factors like altitude or proximity to the sea.

(29:12) Sue mentions a 2023 study on reactions to grass sap, not just pollen.

(31:14) Sue asks for practical advice on pollen avoidance and resources.

(35:15) John asks about immunotherapy and vaccine formulation.

(38:36) Sue stresses that vaccine components must reflect relevant, local allergens.

(41:05) Sue shares an anecdote about a mismatched allergy vaccine and wraps up with thanks to Darragh.

Useful Links:

Nextmune – Veterinary allergy diagnostics and immunotherapy.

https://nextmunelaboratories.co.uk/

This podcast is based upon the new 'Antimicrobial use guidelines for canine pyoderma by the International Society for Companion Animal Infectious Diseases (ISCAID)' available HERE

(00:00) John introduces the podcast with his co-hosts Sue Paterson & Producer Paul.

Chapter 1 – Understanding Pyoderma and the Need for New Guidelines

(02:56) Sue welcomes Dr. Anette Loeffler, who introduces herself and her background in veterinary dermatology. Originally from Germany, she studied in Munich and has worked in the UK for over 30 years. She is currently a dermatologist at the Royal Veterinary College (RVC) and has a special interest in Staphylococcus and bacterial skin infections and this has led her to work over the last 4 years on the new pyoderma treatment guidelines, aimed at improving antibiotic use and promoting topical therapy.

(04:30) Sue asks Anette to explain antimicrobial stewardship and why it is important. Anette describes antimicrobial resistance as a major global threat. Overuse of antibiotics leads to resistance, so it is crucial to avoid unnecessary prescriptions and focus on appropriate diagnostics.

(06:10) Sue asks how common pyoderma is in domestic species, particularly dogs and cats. Anette explains that staphylococcal pyoderma is very common in dogs due to their unique skin structure, making them more prone to bacterial overgrowth. While cats and other species can develop bacterial skin infections, it is far less frequent and usually not recurrent.

Chapter 2 – Diagnosing and Classifying Pyoderma

(08:00) John discusses evolving perspectives on pyoderma classification and asks if the traditional categories of superficial and deep pyoderma are still relevant. Anette confirms that the new guidelines still use these classifications as they help determine treatment:

(10:19) Sue notes that past treatment approaches lacked strong clinical evidence.

Anette explains that many historical treatment protocols were based on anecdotal evidence rather than research. While deep pyoderma has more robust studies, superficial cases often lacked proper research, leading to overuse of antibiotics.

(13:04) John asks how vets can determine whether a case is surface, superficial, or deep pyoderma. Anette explains that clinical examination alone can often differentiate them:

(16:04) Sue asks how to confirm true bacterial pyoderma and rule out mimicking conditions. Anette stresses the importance of cytology, a simple and cost-effective test that can quickly confirm bacterial involvement. Cytology can also differentiate between bacterial infections, yeast overgrowth, and sterile pustular diseases.

Chapter 3 – Treatment Approaches and Key Takeaways from the New Guidelines

(19:36) John asks about traditional treatment approaches and why they need updating. Anette outlines how older guidelines recommended unnecessarily long courses of antibiotics (e.g., 3-4 weeks for superficial pyoderma, 4-6 weeks for deep pyoderma). While this was logical before antimicrobial resistance became a concern, modern research supports shorter, targeted treatments.

(32:40) Sue asks about helping vets communicate these new approaches to pet owners.

Anette explains that the guidelines include tables, visual aids, and quick-reference guides to support busy practitioners.

(33:28) John asks about when systemic antibiotics are still necessary.

Anette explains that systemic therapy is still essential for deep pyoderma or when topical treatment alone is impractical (e.g., large dogs, owner limitations). In such cases, culture and susceptibility testing should guide antibiotic choice.

(38:15) Sue asks which antibiotics should be the first choice if empirical treatment is necessary. Anette recommends clindamycin, lincomycin, cephalexin, or co-amoxiclav as first-line choices, with fluoroquinolones reserved for resistant infections.

(42:32) Sue asks Anette for her top five takeaways from the guidelines:

(45:45) Sue mentions that the full guidelines will be available online via: WSAVA, ISCAID, and WAVD. Sue also mentioned a  WAVD webinar Anetta hosted, which is a must watch.

The guidelines are currently available HERE

(47:29) Outro – As always, Sue & John wrap up before John asks his co-hosts a light-hearted question to end on

Show Notes

This month, the Skin Flint team welcome RCVS & European Specialist Debbie Gow to the platform to explore Eosinophilic granuloma complex (EGC).

(00:00) John Sue and Paul introduce the podcast.

Chapter 1 – What on Earth Is Eosinophilic Granuloma Complex?

(02:55) Sue welcomes Debbie Gow to the podcast and invites her to introduce herself. Debbie shares that she is a specialist in veterinary dermatology, working at a busy referral hospital outside Edinburgh. She describes her role in setting up the dermatology service, working with a resident and derm nurse, and her continued involvement in CPD and writing.

(04:05) Sue introduces the topic: eosinophilic granuloma complex (EGC) in cats. She jokes that it’s sometimes referred to as “eosinophilic granuloma confusion” due to its complexity and terminology. She asks Debbie to break it down explaining that EGC is an umbrella term for three lesion types:

(07:28) Sue asks about miliary dermatitis. Debbie considers it a separate reaction pattern, not part of EGC, though also common and allergy-associated.

(08:15) John asks about age, breed, or sex predispositions. Debbie explains that while any cat can be affected, young adult cats (6 months to 5 years) are most likely to develop these lesions. Females may be slightly overrepresented, but evidence is limited.

(09:27) John inquires about geographical prevalence. Debbie confirms EGC is seen globally wherever cats are present and exposed to allergy triggers.

Chapter 2 – Lookalikes, Lip Lesions & Licking Cats: Sorting the EGC Puzzle

(10:21) Sue asks whether EGC lesions are pathognomonic or if there are important differentials. Debbie stresses the importance of not assuming a diagnosis without investigation whilst they can have a classical appearance:

Cytology is key to identifying eosinophils.

Differentials include squamous cell carcinoma (particularly for lip ulcers), mycobacteria, fungal infections, and viral diseases.  

(12:37) Sue asks about a minimum diagnostic approach. Debbie advises:

(14:08) Sue asks how to perform cytology. Debbie describes:

(14:59) Sue asks how often infection is present. Debbie says:

(16:52) John asks about allergic patterns in cats. Debbie describes four main reaction patterns:

She notes cats may display multiple patterns and also non-skin signs like conjunctivitis, otitis, or sneezing.

(19:02) John asks if specific allergies present with specific signs. Debbie says it’s inconsistent. While flea allergy is often associated with miliary dermatitis and food allergy with head/neck pruritus, patterns vary and aren’t reliable for diagnosis.

Chapter 3 – Practical Approaches: From Kitchen Floor to Referral Door

(21:23) John asks what owners might notice or try at home. Debbie recommends:

(23:30) Sue asks about food trial myths. Debbie emphasises:

She also recommends:

(28:43) Sue asks how to start a food trial if a cat is self-traumatising. Debbie uses concurrent systemic treatment (usually steroids) to control inflammation during the trial, tapering meds over 4–6 weeks if possible.

(30:05) John asks for the first steps as a guide for primary care vets. Debbie recommends her first steps would be to rule out ectoparasites with full household flea control, possibly whilst beginning topical/systemic treatment as needed for comfort

(32:10) Sue asks what to do when left with suspected environmental allergy. Debbie describes:

(36:50) Sue and Debbie have a healthy debate on the relative benefits of allergy testing when immunotherapy is not being considered as an option. 

(41:08) John wraps up the episode, thanking Debbie for simplifying a complex topic and helping listeners better understand eosinophilic granuloma complex in cats.

John asks Paul and Sue another probing - if not questionable - question.

Show Notes

To celebrate Pet Dental Health Month, the Skin Flints team looked a bit further afield this month, exploring gum health and Canine Chronic Ulcerative Stomatitis with Hannah van Velzen.

Chapter 1 – Understanding the Oral Mucosa and Inflammation

(02:53) John welcomes Hannah, who introduces herself and her journey into veterinary dentistry, from her studies in the Netherlands to her current role leading the dentistry referral service at Fitzpatrick Referrals. She highlights the small but growing number of veterinary dentistry specialists in the UK.

(05:46) Sue asks for a basic overview of the oral mucosa, as it plays a key role in CCUS.

Hannah explains that gingiva surrounds and seals the teeth, preventing bacteria from entering the body, while mucosa covers the rest of the mouth. The mucogingival junction marks the boundary between the two and helps differentiate between gingivitis and mucositis.

She describes the different types of mucosa, including lingual (tongue), palatal (roof of the mouth), alveolar (bone covering), vestibular (cheek and lip folds), buccal (cheeks), and labial (lips). These structures vary in thickness and function, with keratinized areas like the tongue and hard palate providing protection, while thinner, non-keratinized areas aid in saliva flow and bacterial clearance.

(13:24) John then asks Hannah to define common inflammatory conditions affecting the mouth, including:

Hannah emphasises the importance of accurately defining oral lesions to guide diagnosis and treatment. 

Chapter 2 – What is CCUS? How Can It Be Diagnosed?

(18:43) John introduces Canine Chronic Ulcerative Stomatitis (CCUS), asking how it relates to previous terms like CUPS (Canine Ulcerative Paradental Stomatitis) or contact mucositis.

Hannah explains that CCUS was formerly known as CUPS, but the name changed as research showed that 40% of lesions occurred in areas without teeth, making the term "paradental" inaccurate. The condition is chronic, meaning it develops gradually rather than suddenly.

(23:22) Sue asks how a primary care vet should determine whether a dog with oral ulcerations has CCUS or another condition, such as pemphigus vulgaris, lupus, or uremic stomatitis.

Hannah acknowledges that many inflammatory and autoimmune diseases look similar and that no single exam finding confirms CCUS. She advises vets to follow key diagnostic steps:

If the biopsy findings suggest CCUS, referral to a dentistry specialist is recommended. If results are inconclusive, a dermatologist may need to investigate potential autoimmune conditions.

(27:33) Sue asks whether "kissing lesions" (ulcerative lesions where mucosa touches the teeth) strongly indicate CCUS.

Hannah agrees that they are a key sign, but notes that plaque build-up can also cause similar inflammation. A dental clean should be performed first—if inflammation persists despite clean teeth, CCUS is more likely.

(28:31) Sue then asks if certain breeds are predisposed to CCUS.

Hannah confirms that small breeds and terriers are overrepresented, particularly:

Some affected dogs have severe gingivitis and mucosal inflammation despite excellent dental hygiene, making CCUS harder to recognise.

(31:33) John asks how easy biopsies in the mouth are Hannah stresses that biopsies should always be done under general anaesthesia for pain control and a thorough oral exam. She typically uses a punch biopsy, ensuring a portion of normal tissue is included to help distinguish inflammatory from autoimmune causes.

She highlights the importance of sending clear photos and case details to assist pathologists in interpreting results. Additional tests like immunohistochemistry may sometimes be useful.

Chapter 3 – Treating CCUS: What Are the Options?

(35:44) John asks how CCUS is treated and whether treatment varies by severity.

Hannah explains that CCUS treatment is multi-step and includes:

The choice depends on vet preference and patient response.

(45:14) Sue highlights the lack of published research on CCUS and urges vets to seek specialist advice before extracting all teeth.

This month, Skin Flints welcomes a European and Australian boarded veterinary dermatologist, Sonya Bettenay.

Show Notes

(00:00) John introduces this month’s podcast, his co-hosts, and the topic.

(02:21) John invites Sonya to introduce herself, and she discusses her current work in Munich - focusing on skin biopsies, clinical practice, and teaching. Sue highlights Sonya's credentials, noting her Australian and European board certifications. Sonya explains her dermatology training in Australia and California and her involvement with the ECVD as an examiner and tutor.

(03:57) Sue and Sonya discuss the challenges pathologists face in interpreting biopsy samples and the importance of taking quality samples to aid diagnosis. Sonya reflects on improvements in biopsy submissions over the years but notes that obtaining multiple samples often provides a more comprehensive picture.

(05:31) John asks Sonya to explain what a skin biopsy is. Sonya describes it as a microscopic examination of the skin, providing insights beyond surface-level observation. Sonya outlines cases where biopsies are useful, such as unusual presentations that deviate from common conditions, and emphasises the need to tailor biopsy timing based on the patient's condition.

(09:15) Sue asks Sonya whether biopsies should replace basic investigative tests. Sonya emphasises that fundamental diagnostic steps such as skin scrapes, hair plucks, and impression smears should be performed first in most cases. However, she highlights exceptions, particularly for vesicular or severe oral mucosal lesions, where early biopsy is crucial to diagnosing immune-mediated conditions.

Sonya explains the importance of maintaining the integrity of vesicular lesions during biopsy to ensure accurate diagnosis. She stresses the need to take elliptical samples to include surrounding healthy tissue and avoid disrupting the lesion structure.

(11:52) Sue and Sonya discuss the distinction between primary and secondary lesions. Sonya explains that primary lesions, such as pustules and vesicles, provide the most diagnostic value, whereas secondary lesions, like crusts and alopecia due to self-trauma, may offer limited insights.

(15:15) John asks about choosing biopsy techniques. Sonya shares her preference for biopsy punches due to their precision and ease of use, while acknowledging the importance of elliptical excisions for fragile lesions like vesicles. She explains the technical aspects of both methods and how they can impact diagnostic outcomes.

(19:30) Sue raises concerns about the sustainability of single-use biopsy punches. Sonya explains that while some attempts to sterilise and reuse them have been made, they often result in decreased sharpness and reliability. She advises using new punches for best results but acknowledges the need for sustainable alternatives.

Sonya discusses her approach to biopsy sampling, recommending taking multiple samples to ensure comprehensive diagnosis. She suggests including normal tissue alongside affected areas for comparison. Sue and Sonya explore potential innovations for more sustainable biopsy tools, such as reusable handles with replaceable blades.

(23:19) John asks if separate biopsy punches should be used for each sample. Sonya clarifies that one punch can typically be used for multiple samples unless dealing with particularly tough tissues that may dull the instrument.

(23:52) John then asks who can take biopsies and Sonya notes that all vets and also veterinary nurses may be able to take samples depending on local regulations, particularly for alopecia cases.

She highlights the importance of orienting samples correctly by marking the direction of hair growth to aid pathologists in accurate analysis.

(27:25) Sue and Sonya discuss the need for deep biopsies in cases of hair loss or deeper inflammation and introduces the concept of shave biopsies as an alternative for delicate areas like the inner pinna.

(30:50) John asks about the best practices for preparing biopsy sites. Sonya advises against using any antiseptics or alcohol, explaining that preserving surface elements such as bacteria and crusts is crucial for accurate diagnosis. She recommends minimal shaving in the direction of hair growth to retain valuable diagnostic material.

(33:20) John asks about labelling the samples - firstly Sonya provides guidance on handling biopsy samples, emphasising the need for quick placement in formalin to avoid tissue degradation. She recommends gently dabbing samples before immersion to preserve tissue integrity.

Regarding labelling, Sonya highlights the importance of clear sample identification. She discusses techniques such as using coloured dyes or marking sutures to help orient samples and provide context for pathologists.

Sonya also discusses the benefits of using dyes for sample orientation and how different colours can indicate specific sites. Sonya explains how proper labelling ensures better interpretation and helps guide future treatment decisions.

(39:33) John and Sue wrap up the discussion, thanking Sonya for her insights and expressing interest in having her return for further discussions on histopathology.

(41:12) John wraps up the discussion, previewing podcasts to come and asking his co-hosts another odd question.