As a slightly different approach to this episode, John Redbonds heads to BVNA Congress to hear nurse's thoughts on the current lay of the land, and invites a few special guests to share their thoughts as well.

(00:00) John introduces the podcast and his co host – eLearning.vets head of education, Amelia Sherwood, looking into Veterinary Nursing in Dermatology, with conversations with Veterinary Nurses and industry people. Starting with some conversations from the British Veterinary Nursing Association Congress.

Chapter 1: VN Dermatology at BVNA congress – the challenges and the opportunities.

(02:12) John has a conversation with a couple of nurses working for a small group of practices that are involved in dermatology, without specialising. They reflect on some of the ways they have found to work more on dermatology, along with some of the challenges.

(05:49) John then speaks to two nurses working in a charity based PDSA practice, where they do the majority of dermatology work, and the cases are worked up thoroughly and fully – they reflect on why this is the case and why nurses do this more and how this shows that this is the most sensible and correct model.

(08:26) John speaks to Paris, a nurse who is interested and trained in dermatology – and sees the cases, but is unable to put her skills to use because the practice she is working at doesn’t utilise those skills.

(10:25) John speaks to someone working for a company called VN Recruitment – to discuss options which exist for nurses with an interest in dermatology to find a practice where they can use their skills.

Chapter 2: VN Dermatology Nursing in a corporate industry.

(12:45) John then speaks to representatives for the corporate groups to see if there were opportunities are present for nurses in CVS, VetPartners and IVC to progress in dermatology – and specialist centres and training programmes to exist, if a nurse pursues that route.

(17:50) John has a conversation with a nurse who had been heavily involved in dermatology work, but been made redundant by the group she worked for – with no options as a result locally to work as a vet nurse due to competition for places. Demonstrating the challenges that exist in the current landscape.

Chapter 3: VN Dermatology on the move.

(20:55) John spoke to Claire, a nurse who uses a more district nursing model to deliver her nursing skill set – showing there are ways for nurses to diversify within this landscape – and whilst she has some involvement in dermatology in partnership with her local practice, she recognised there could be more opportunity and potential for this.

(27:00) John speaks to Nicola Swales, the dermatology nurse at paragon referrals, who moved 4 hours across country to work as a dermatology nurse having worked at Langford referrals previously. Nicola shares how heavily she is involved in this process, showing just how involved nurses can be.

(34:12) John wraps the podcast by speaking to Amelia Sherwood, a veterinary nurse who has worked in wound management and the advancement in the nurse role in a large group; she shares her thoughts on where the veterinary nurse industry is currently and reflects on the challenges and opportunities there are for nurses.

Pododermatitis Paw-dcast Part 2 – A Surgeon's Perspective

(00:00) Intro - this month, Sue, John and Paul invite EBVS Specialist in Small Animal Surgery, Jakub Kaczmarek onto the platform to discuss the other side of pododermatitis - from the surgeon's perspective.

(03:12) John introduces Jakub, highlighting Ursula's recommendation following their fruitful discussion on pododermatitis. He invites Jakub to share his background. Jakub expresses gratitude for the invitation and mentions Ursula as a mentor during his residency in Germany. He discusses their collaboration on pododermatitis, combining dermatology and surgery. Jakub shares his educational journey from Poland, a semester in Vienna, and his internship in Germany, which focused on surgery and dermatology. He currently works in Cologne.

(04:55) John acknowledges Jakub's expertise in dermatology and asks how a surgeon fits into managing pododermatitis in dogs. Jakub emphasises teamwork between dermatologists and orthopaedic specialists, noting the complexity of pododermatitis. He explains that it can arise from both skin-related and conformational issues, necessitating collaboration for optimal care.

(06:16) John enquires about the types of lesions found on dogs' feet. Jakub explains that abnormal weight distribution from orthopaedic conditions, like developmental elbow disease, can cause pressure on specific paw digits, leading to abrasions, inflammation, and even local pyoderma. He describes hypertrophy on the paw's plantar surface, potentially forming "pseudoballs." Chronic irritation can result in excessive licking, leading to severe inflammation, which requires both orthopaedic and dermatologic management.

Chapter 2 - Toes: Lesions and Lameness

(09:25) Sue comments on the dog's paw pad structure, noting that abnormal weight-bearing can lead to skin issues. She asks if this is the pathomechanism for pododermatitis. Jakub agrees and adds that while there are many potential causes, mechanical issues may also contribute. He supports Sue's idea that malalignment and weight distribution lead to abnormal weight-bearing and related problems. Sue clarifies that some cases of pododermatitis have dermatological causes, while others stem from orthopaedic issues. Jakub agrees but points out that breeds like Labrador Retrievers and Bulldogs often have both conditions, complicating the determination of the primary issue. Sue P recalls a study revealing Bulldogs walk on their toes, which could contribute to multiple health issues. She emphasises the need for a multidisciplinary approach. Jakub references a study by Tim Nuttall involving over 160 dogs, noting that factors like body condition and hair type are significant in causing pododermatitis and interdigital cysts. Sue P agrees, linking higher body condition scores to more weight on the front limbs, thus making pododermatitis more common there. Jakub clarifies that while pododermatitis is typically seen more in front limbs, conditions like hip dysplasia can also affect hind limbs. He explains that primary dermatological issues may affect both front limbs, while orthopaedic problems often involve a single limb. Sue P sums up that multiple limb involvement likely relates to skin conditions, while single limb issues could indicate orthopaedic problems. Jakub agrees, adding that orthopaedic conditions like OCD or FCP typically show changes in the affected limb.

(14:53) John revisits Jakub's "top-down or bottom-up" approach, asking how it relates to recognising orthopaedic diseases as triggers for pododermatitis. Jakub explains that common orthopaedic triggers include developmental elbow diseases like OCD and FCP, as well as shoulder OCD, which causes dogs to alter their walking to reduce pain. He notes that patellar luxation often results from underlying angular limb deformities that shift the weight-bearing axis, exacerbating dermatological issues.

Chapter 3 - Surgical Solutions: From Lasers to Collaboration for Better Outcomes

(17:30) Sue asks Jakub to elaborate on triggers, noting that predisposed breeds and age of onset play a role, citing Labradors as an example. Jakub confirms that Labrador Retrievers exhibit these issues, with signs of orthopaedic problems appearing as early as five to six months, and severe cases at four months. He mentions common large breeds prone to orthopaedic problems.

(18:59) Sue asks about the timing of pododermatitis relative to orthopaedic diseases, questioning if lameness in young dogs could precede pododermatitis. Jakub notes that pododermatitis and orthopaedic diseases usually present in older dogs, around two years of age. He hasn't observed significant changes in younger dogs, suggesting it takes time for pododermatitis to develop due to malalignment and weight redistribution. Sue P agrees, noting that in her practice, older dogs often present with pododermatitis alongside a history of earlier orthopaedic problems. She suggests a compensatory mechanism may lead to conditions like interdigital cysts. Jakub agrees, highlighting that dermatological conditions like pododermatitis are painful due to inflammation, which can lead to chronic discomfort. He asks Sue if Labrador owners ever report lameness when presenting dermatological issues. Sue P mentions that owners usually don’t report pain, necessitating probing for details. She reflects on referring a three-year-old Labrador with recurrent interdigital lesions to an orthopaedic surgeon to assess joints. If swelling or crepitus is present, she recommends CT scans and emphasises early intervention. Jakub recalls Sue's 2012 publication linking interdigital lesions with elbow issues. He has observed that treating elbow conditions often leads to improvement in lesions, suggesting that combining orthopaedic corrections with topical treatments could yield better outcomes.

(25:18) John asks Jakub to elaborate on surgical approaches for pododermatitis, including techniques like webectomy and podoplasty. Jakub notes he has not performed podoplasty but has seen it used successfully in severe cases. He prefers laser ablation, as it is quicker and effective when collaborating with a dermatologist who has tried conservative treatments. He recounts streamlining procedures significantly, reducing time from 1.5 hours to 30-35 minutes. Sue adds context, explaining webectomy and podoplasty. She contrasts her cold steel surgery experience with the benefits of laser surgery. Jakub explains that CO2 lasers are more precise and cause less collateral damage than diode lasers. He emphasises the advantages of laser treatment in sealing vessels, which minimises bleeding and post-op pain. He mentions a colleague who leaves wounds open post-surgery, but he prefers using honey treatments for healing.

(34:06) John concludes by praising the collaboration between Jakub and dermatologists like Ursula, highlighting the importance of a multidisciplinary approach in managing complex cases like pododermatitis.

Outro

(37:07) Final thoughts John puts another bizarre question to Sue and Paul.

Chapter 1 – Companionship for Life on the Streets

(02:58) John asks Jade to introduce herself and her background as a vet and how she came to setup Streetvet. Jade shares her story of experiencing homelessness in London with a man called Dave and his dog brick, and using her past research on homelessness and dog owners coupled with her own experience in mental health challenges and how having a dog helped her, to drive her to want to help these dogs and their owners. She shares how she started going round with someone who who cut hair for homeless people, and used this as a launching pad for doing the same as a vet seeing the dogs of homeless people.

(10:05) Sue talks about the data showing the importance of companionship for homeless people with their pets, and Jade shares how there are papers and research showing that lots of factors from loyalty through to body heat show that they are vital, and her own experience maps onto that.

Chapter 2 – Building StreetVet: A Backpack and a Big Heart

(13:37) John asks Jade about how Streetvet started and what id does, and jade share how she and co-founder Sam Joseph set it up going out just the two of them, and calling themselves Streetvet – but they realised the size of the task and in 2019 set it up as a registered charity ad looked to grow it. She talks about how it picked up traction in the media through both the need for it – but also how the professional of vets needed it – with Vets and Nurses remaining in the profession providing this service reconnected them with their work. This was a completely unexpected thing for Jade.

(17:30) John asks how the service works and Jade shares that they go out with a backpack and do all the things they would in a consultation – so taking blood samples and urine samples etc. They look to empower the owner on feeling involved by doing this on the street – before then if they need to go into a practice and Streetvet have a network of practices that help provide inpatient services. Streetvet also started an accredited hostel scheme as less than 10% of hostels in the UK accept pets, to prevent owners from having to hose to remain on the street if they have one. She also mentions they offer boarding for times where the owner need to go into hospital for healthcare themselves and can’t take their pet with them.

(21:10) Sue asks about the management of chronic, long term illnesses in the Streetvet work, Jade shares that they have set times and set locations rather than approaching the owners on the street – so the owners come to them in those times. But this allows them to come back again, and jade has been surprised that they have been able to treat long term diseases like cushings and diabetes, in cases where the client is committed to the process – as they do keep coming back.

Chapter 5 – Tackling Skin Woes: Managing Dermatology in the StreetVet World

(27:00) John asks about specifically the management of skin disease in the Streetvet environment and Jade shares that they do treat these, but the challenges are very real. They have even had cases of clients performing a diet trial and long term management of skin disease. The challenges in the life of these people can make it very difficult for the owners to have consistency, but the clients are very good at coming for regular flea treatment and prophylactic skin care, in some way because of the social benefits to coming and sharing in the the streetvet community and this makes managing these cases easier than one may think.  Jade discussed the types of medications they have food they can help with, topical treatment and some antibiotics to help with these cases as well as steroids if needed. Then they do have access to other medications if needed which they wont carry in the backpack.

(32:35) Sue asks how this is funded and Jade again emphasises how great and supportive the veterinary profession has been – with companies supporting with pro bono products and vets and nurses fundraising.

(34:19) Sue asks about the size of Streetvet and Jade says they are on 24 locations in total, and over 400 volunteer vets and nurses. And Sue asks how people can be involved – Jade mentions the website where you can get involved in volunteering, whether a vet, vet nurse or someone wanting to help in some other way – or fundraising as well. Or follow on Facebook and Instagram.

www.streetvet.org.uk

https://www.facebook.com/streetvet

https://www.instagram.com/streetvetuk_/

(37:02) – John, Sue and Paul wrap up the podcast.

Pododermatitis Paw-dcast Show Notes

(02:21) John invites Ursula to introduce herself. Ursula discusses her background and passion for pododermatitis, its prevalence, and its impact on dogs' quality of life.

(03:33) When asked to define pododermatitis, Ursula explains that it's inflammation of the paw skin, with a particular emphasis on chronic cases, known as C-PIF. She discusses the various signs to look out for, such as excessive licking, lameness, and specific changes in paw appearance as the condition progresses.

(05:31) Sue talks about the complexity of pododermatitis, and Ursula draws parallels with chronic otitis in terms of the multifaceted factors involved. She emphasises the importance of considering predisposing factors, primary causes including orthopaedic issues, secondary influences, and perpetuating factors in diagnosing and managing the condition effectively.

(06:57) Sue asks Ursula to explain how orthopaedic diseases can contribute to pododermatitis in dogs. Ursula explains that pain from orthopaedic conditions alters weight bearing, causing dogs to adjust their stance and potentially rub their paws together, leading to inflammation and abnormal walking patterns. She goes on to discuss specific orthopaedic diseases, including elbow dysplasia, hip dysplasia, and arthritis affecting joints such as toes, carpus, tarsus, elbows, hips, and the back. These conditions can disrupt normal weight distribution and contribute to the development of pododermatitis.

(08:35) Sue further illustrates with an example and Ursula emphasizes the importance of referring chronic cases to orthopaedic specialists for thorough examinations and imaging. She acknowledges the complexity of diagnosing older dogs with multiple affected areas, stressing the need for integrated care across disciplines to effectively manage pododermatitis.

(09:56) John asks if this is just dogs and Ursula confirms that while cats can also suffer from pododermatitis, the chronic form discussed, known as C-PIF, predominantly affects dogs and not cats. John then asks about breed predispositions, particularly in relation to posture-related issues in Labradors. Ursula elaborates that certain breeds, notably larger and heavier ones like bulldogs, French bulldogs, and pugs, are commonly affected. Labradors and Golden Retrievers also constitute a significant portion of cases. The characteristics such as short, bristly coats and broad, flat paws, may contribute to their susceptibility to the condition. Ursula notes that even without orthopaedic diseases, these breeds' anatomical traits appear to play a role in the development of pododermatitis.

(12:20) Sue reflects on a study involving bulldogs walking on pressure plates, noting that those without interdigital lesions tended to walk more upright. She emphasises that dogs with flatter feet and heavier builds are more prone to issues due to their posture, suggesting a correlation between anatomical features and pododermatitis. She further discusses how these factors influence investigation and treatment approaches. Ursula agrees, highlighting the significant role of allergies alongside orthopaedic diseases in pododermatitis cases. She notes the complexity in distinguishing between underlying orthopaedic conditions and inherent anatomical predispositions in certain breeds. Ursula shares a case involving a dog initially treated for allergies, later developing orthopaedic issues that exacerbated pododermatitis, illustrating the interplay between these factors.

(14:47) Sue outlines the investigative process, starting with a comprehensive history and dermatological examination, incorporating orthopaedic evaluations based on findings. Ursula explains her approach, emphasising the importance of ruling out issues, particularly Demodex, through rigorous testing methods. She discusses predisposing factors such as weight and breed characteristics, and systematically examines for primary diseases like allergies, orthopaedic issues, and endocrine disorders. Ursula stresses the need to assess secondary infections and carefully inspect paw conditions, especially ventrally, to identify specific dermatological and orthopaedic indicators.

(18:24) Sue asks about infection management in pododermatitis cases. Ursula explains that for superficial cases of pododermatitis, she primarily employs topical treatments. However, in chronic cases where deep pyoderma is present, systemic antibiotics are often necessary. She emphasises the importance of not relying solely on antibiotics without addressing underlying factors, as this can lead to recurring infections and antibiotic resistance. In deciding whether to use systemic antibiotics, Ursula considers the overall treatment plan. If surgery such as laser therapy is planned, she may opt against systemic antibiotics. For cases where medical therapy alone may suffice, she stresses the need for culture and sensitivity testing to target treatment effectively and minimise antibiotic use.

(20:17) John questions Ursula about the approach to treating infections and determining underlying causes simultaneously. Ursula explains her concurrent approach, emphasising the urgency in addressing both infections and underlying conditions early on to improve the dog's quality of life.

(22:17) Sue asks about anti-inflammatory therapy options in pododermatitis and the efficacy of non-steroidal anti-inflammatories (NSAIDs) versus steroids, cyclosporine, tacrolimus, and anti-pruritic drugs like oclacitinib and lokivetmab.. Ursula details her approach, highlighting the need for potent anti-inflammatory agents in severe cases of pododermatitis. She explains that while drugs like oclacitinib can alleviate itching, they may not sufficiently address inflammation. For cases requiring robust anti-inflammatory action, Ursula often starts with systemic steroids and cyclosporine simultaneously, gradually tapering off steroids once cyclosporine takes full effect. She stresses the challenges and side effects associated with long-term steroid use, advocating for cyclosporine as a viable long-term treatment despite its delayed onset of action. Ursula discusses transitioning to topical therapies like tacrolimus or non-thinning glucocorticoids as conditions improve, aiming to minimise reliance on systemic medications over time.

(25:16) Sue asks about the complexities faced by Ursula when treating animals with multiple conditions. Ursula acknowledges the multifaceted nature of these cases, stressing the importance of weight management as a foundational step due to its lack of side effects. She emphasises the need for collaboration with orthopaedic specialists to address underlying orthopaedic diseases like elbow dysplasia early on. For pain relief and inflammation management in the feet, Ursula initially uses systemic steroids and cyclosporine, with a cautious approach to long-term steroid use.

(27:05) Sue asks about prioritising orthopaedic surgery to correct primary causes like ununited coronoid process before addressing pododermatitis. Ursula acknowledges this strategy, noting that while surgery can eliminate chronic factors perpetuating pododermatitis, the outcomes vary depending on the case's severity and the owner's preferences. She explains that surgical intervention in the paws may provide faster relief, especially when orthopaedic conditions are severe. However, she also highlights the challenge of reversing long-standing paw conditions even after correcting the primary cause. Ursula emphasises the importance of timing and individualised treatment plans tailored to each patient's specific needs and responses.

(29:14) John enquires about the feasibility of surgical procedures for pododermatitis in general practice versus referral settings. Ursula explains that surgical suitability depends on the general practitioner's expertise in dermatology, orthopaedics, and surgical techniques. For interdigital web surgery using traditional methods, like cold steel, she mentions the challenge of post-operative management due to necessary rigid bandaging. She contrasts this with CO2 laser surgery, highlighting its advantages such as reduced bleeding, pain, and swelling post-surgery due to sealed lymphatic and blood vessels and nerve endings. Ursula notes that CO2 lasers offer precise, fine-tuned tissue removal while preserving healthy dorsal skin, promoting healing by second intention without sutures. This approach aims to restore normal paw anatomy, crucial for long-term health. Ursula cautions against using diode lasers due to their higher collateral heat damage potential, unsuitable for delicate pododermatitis cases requiring precise tissue control.

(33:49) Sue summarises the distinctions between podoplasty and CO2 laser techniques: podoplasty involves excising interdigital tissue and suturing toes, whereas CO2 laser surgery delicately removes scar tissue and abnormal follicles, crucial for preventing recurrent infections. Ursula elaborates on using CO2 lasers in both painting and cutting modes depending on tissue conditions, emphasising its efficacy in restoring paw health through precise, controlled tissue removal.

(35:03) John concludes the discussion and Ursula emphasises the significance of regular examination of paw pads, especially in predisposed breeds or suspected allergic patients, urging veterinary professionals to involve owners in observing early signs like erythema. She stresses the value of early referral when cases become challenging, highlighting proactive management as key.

(37:52) Sue and John wrap up with their thoughts on this month’s guest, before John asks the team a question that’s been bugging him all episode…

Unleashed: The Dawn of the Leishmania

Intro

Chapter 1: The Attack of the Sandfly

3.17 Sue introduces the topic of leishmaniasis, and Christian describes leishmaniasis as a multisystemic disease affecting humans and animals, primarily dogs. He notes its prevalence in regions like the Mediterranean and its expansion due to climate change and imported infected dogs.

5.19 Sue questions whether leishmaniasis occurs naturally in the UK or is solely imported. Christian mentions reported cases in the UK, suggesting transmission via infected phlebotomine flies brought back by travelers from endemic regions. The conversation shifts to the sandfly vector responsible for transmitting leishmaniasis. Christian describes the sandfly as small, silent, and potentially painless, emphasizing its absence in the UK but the possibility of migration due to global warming. Christian advises against using repellents on dogs in the UK due to environmental concerns but stresses the importance of monitoring the situation, given he acknowledges the likelihood of sandflies reaching the UK in the future.

7.27 John queries if leishmaniasis can be transmitted by other vectors like fleas. Christian affirms that sandflies are the primary vector for the disease, although other potential vectors are suspected but not proven. John then asks if humans can contract the disease from infected dogs. Christian explains that with the vector absent in the UK, human transmission from dogs is unlikely. However, he emphasizes the importance of isolating positive dogs to prevent transmission through blood transfusion.

Chapter 2: The Haunting Symptoms and Diagnosis

9.11 The conversation then transitions to the clinical signs of leishmaniasis. Christian describes typical systemic symptoms such as anorexia, weight loss, lethargy, and mucous membrane pallor, along with some less common signs like polyuria and polydipsia. Christian also discusses characteristic skin lesions, including non-pruritic exfoliative dermatitis and erosive lesions. Sue adds her observations about the scaly appearance of affected dogs without itchiness, contrasting it with parasitic skin conditions. Christian concludes by stressing the importance of diagnostic assistance in accurately identifying the disease, especially considering its varied clinical presentations.

12.09 Sue brings up how leishmaniasis can affect nails, prompting Christian to elaborate on what clinicians might observe. He describes nails that grow unusually long and fast, resembling talons rather than being deformed. Christian notes that this sign is relatively rare in his experience, with scaly dermatitis or ulcerative dermatitis being more common presentations.

13.11 Sue then queries whether certain clinical presentations carry a better prognosis than others. Christian explains that prognosis depends on the severity of internal organ involvement, particularly kidney disease. The disease originates from the skin but can affect various body parts due to the immune system's reaction.

14.12 John asks how general clinicians diagnose it. Christian outlines that diagnosis relies on compatible clinical signs and specific clinical pathologies, notably anemia and changes in protein levels. While general practitioners can conduct serological tests, more specialized examinations may require referral to a laboratory. Christian emphasizes the importance of considering travel history and ruling out other conditions before treatment initiation.

16.40 Sue raises the issue of screening for leishmaniasis in dogs rescued from abroad, inquiring about the incubation period and when to start screening. Christian explains that the incubation period varies greatly, suggesting performing a quantitative serological test six months after returning from an endemic area. If positive, measures like using repellent and excluding the dog from blood transfusion banks are advised. Sue seeks more detail on the blood tests, and Christian elaborates on measuring the amount of Leishmania-specific antibodies using quantitative serological tests. These tests help detect high antibody levels, indicative of infection.

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Chapter 3: Eternal Vigilance Against the Parasite

18.55 John then asks about therapy options for positive cases. Christian emphasizes the goal of controlling clinical signs and pathological abnormalities, as complete parasite elimination is rare. Therapy typically involves a combination of leishmanicidal drugs, which aim to kill the parasite, and leishmaniostatic drugs, which maintain a low parasitic level, together aiming to reduce the parasitic load and prevent relapses. He notes the need for topical treatments alongside systemic therapy to manage symptoms like scaly skin.

22.00 John asks about drug availability and Christian mentions challenges in drug availability and potential side effects, particularly with drugs like allopurinol, which can cause adverse urinary effects. He recommends monitoring for crystal formation in the urine and considering alternative treatments if needed, highlighting emerging immunomodulatory drugs as promising options. However, his leishmanicidal drugs of choice would be allopurinol and meglumine antimonate.

23.55 Sue then asks about the expected response time to treatment and the monitoring process. Christian explains that clinical improvement can be seen in about four weeks with meglumine antimonate and two months with Miltefosine, an oral drug. Monitoring every three to four months is crucial, although antibody titres may take longer to decrease.

24.55 John asks about the lifelong management of the disease. Christian confirms that the drugs can be expensive and may need to be imported, emphasizing the importance of compliance and regular check-ups to improve prognosis.

25.51 Sue concludes by highlighting the role of primary care vets and dermatologists in managing the disease. She also enquires about alternative treatments like turmeric and herbal concoctions. Christian stresses the importance of evidence-based treatments and mentions dietary nucleotides and active hexose correlated compounds as effective alternatives.

27.29 Sue thanks Christian and expresses concern about the potential spread of leishmaniasis in the UK due to warmer summers and increased animal movements across borders.

Welcome to a new episode of the Skinflint Podcast, celebrating our impressive milestone of 10,000 downloads. This episode is a deep dive into the crucial role of sustainability in veterinary dermatology, presented to you by Nextmune UK and Elearning.Vetand featuring Monika Linek.

Chapter 1: Setting the Sustainability Stage 

(03:10) Sue introduces Monika to the podcast, who shares her experience as a German dermatologist and diplomat of the ECVD. Monika discusses her work in a referral practice in Germany and her involvement in "Parents for Future," advocating for climate justice and sustainability.

(05:20) Monika defines sustainability as meeting present needs without compromising future generations' ability to meet their own. It involves maintaining a balance to prevent depletion of natural resources and harm to ecosystems.

Sue emphasizes the importance of sustainability in preserving the Earth for future generations. Sustainable practices ensure a lasting and enduring system for future generations.

(06:40) Sue raises the issue of sustainability in veterinary dermatology practices and asks Monika about potential improvements. Monika highlights several areas for improvement, including reducing carbon footprint from energy use, transportation, and waste management.

(07:39) Monika acknowledges the challenges of telemedicine in veterinary dermatology due to the necessity of physical examinations. However, she sees potential in remote consultations for follow-ups or initial assessments, particularly for referring practices. Finding a balance between technology and quality care is crucial. Monika also notes telemedicine's ability to reduce clients' carbon footprint by minimizing travel, a point Sue agrees with, emphasizing its role in complementing traditional consultations and promoting sustainability.

Chapter 2: Navigating Sustainable Solutions

(10:19)  John asks about areas in veterinary dermatology that could reduce carbon footprint. Monika underscores the importance of considering the environmental impact of drugs, particularly antibiotics and anti-parasitics. She notes the shift towards antibiotic stewardship and the need to rethink the use of topical anti-parasitics like chlorhexidine. Monika emphasizes the necessity of rethinking and changing practices regarding drug usage to minimize environmental impact.

(12:32) John appreciates Monika's insights and finds them encouraging, as these considerations align with responsible veterinary practices. He delves into the choice between systemic and topical treatments in dermatology, seeking Monika's opinion on their sustainability. Monika discusses the need for susceptibility testing before antibiotic use and emphasizes the benefits of combining topical treatments with antibiotics to reduce treatment duration. She advocates for avoiding systemic antibiotics when possible, relying on topical treatments alone for superficial pyoderma.

Regarding alternatives to chlorhexidine, Monika suggests hypochlorous acid as a more environmentally friendly option. Sue agrees, highlighting the importance of effective yet eco-friendly alternatives that do not compromise animal health.

(16:28) The conversation shifts to the development of technologies like photonic therapy as potential replacements for topical treatments. However, Sue acknowledges the challenge of balancing efficacy, cost, and environmental impact in private veterinary practice. Monika points out the need to address the pricing of eco-friendly products, highlighting the broader systemic issues surrounding their accessibility and affordability.

Chapter 3: Practical Sustainability

(18:36) John raises a practical question about the disposal of unused medications and antiseptics. Monika mentions new guidelines in the UK for returning unused or expired antibiotics and medicines to clinics for proper disposal. She highlights the importance of implementing better waste disposal systems for medicines in the future.

Sue adds that the UK has an "antibiotic amnesty" campaign encouraging people to return unwanted antibiotics to designated drop-off points instead of disposing of them improperly. These drop-off points include pharmacies and veterinary clinics, which have appropriate methods for disposing of clinical waste.

(21:36) John raises the idea of reusing items in veterinary practice, such as scalpels and biopsy devices, instead of relying solely on single-use plastics. Monika suggests that while it may be challenging to revert to using glass syringes, there are still opportunities to explore reusable alternatives for certain items, such as surgical gowns and towels. Sue emphasizes the importance of putting pressure on manufacturers to produce more recyclable and sustainable products, even if it means paying a bit more.

When discussing sterilization methods, Sue acknowledges that there are various factors to consider, such as the environmental impact of disposing of sterilizing solutions. Monika suggests that methods like autoclaving could be more sustainable if powered by renewable energy sources like solar or wind power, reducing their carbon footprint.

(26:53) John reflects on the complexity of sustainability discussions within veterinary practice, noting that while there may not always be clear answers, the important thing is that people are actively engaging in conversations and considering sustainable practices. Monika raises concerns about greenwashing and emphasizes the need for genuine action rather than just slogans. Sue adds that changing habits can be challenging but underscores the importance of prioritizing sustainability in everyday actions, even those seemingly small, like shutting down computers.

(29:00) Shifting the conversation to dietary choices for animals, Sue asks about sustainable options for food trials, particularly considering allergies. Monika discusses the challenges of finding novel protein sources and suggests that home-cooked diets may be more sustainable, though caution is needed, especially with cats. She also highlights the need for transparency from pet food manufacturers regarding the carbon footprint of their products, echoing the call for informed decision-making and accountability in veterinary practice.

(34:35) Monika highlights three key tips for sustainable veterinary dermatology practice: rethinking antibiotic and antiparasitic use, addressing waste management through the waste hierarchy, and reducing paper consumption by embracing digital solutions. Sue acknowledges the importance of these tips, emphasizing their relevance for all veterinarians. John expresses gratitude to Monika for her insights and contribution to the discussion on sustainability in veterinary dermatology.

Chapter 1: "The Dermatological Agent: Ross's Malassezia Mission"

02.42 - John begins by welcoming Ross to the Skinflint podcast and acknowledges Ross's expertise in "Malassezia." He asks Ross to share his background and explain what Malassezia is.

Ross introduces himself as a professor of veterinary dermatology, detailing his experience in farm practice and later transitioning to small animal practice. He pursued further studies and a Ph.D. specifically focusing on Malassezia, and so has been interested in them for more than 30 years.

03.44 - John asks Ross to elaborate on Malassezia, describing it for listeners who might not be familiar with the term.

Ross explains that Malassezia is a group of yeast found naturally on the skin of various mammals and birds, thriving in lipid-rich environments. It typically exists as a commensal organism on the skin but can become an opportunistic pathogen, leading to dermatitis and otitis in dogs and occasionally in cats and horses.

05:27 - Sue asks if Malassezia is the same across different species or if there are variations.

Ross explains that there are 18 known species of Malassezia, each potentially adapted to a specific host. He discusses examples like M. cunicui in rabbits, M. caprae in goats, and M. equina in horses. He notes M. pachydermatitis as the dominant species in dogs, which is unique as it can grow on routine culture media, unlike other species requiring lipid supplementation. In contrast, cats may have different species like M. nana and M. slooffiae, among others, leading to variations in yeast colonisation. There's a discrepancy between what's identified molecularly and what's observed in cultures, particularly in dogs, highlighting an unexplained scientific disparity.

Chapter 2: "Species Confidential: Malassezia's Breed of Intrigue"

8.44 - John asks Ross about the location of Malassezia on animals.

Ross mentions that, in dogs, Malassezia is predominantly found in web spaces (75-80%), lip fold regions (similar proportion), and ear canals (about one-third). Lower levels are detected on the trunk, axilla, groin, and dorsum due to their warm, moist nature.

10.00 - John inquires about identifying Malassezia in cytology with dermatology tests like tape strips or impression smears.

07:35.54 - Ross confirms that Malassezia has a characteristic peanut-shaped morphology, identifiable under microscopy, usually abundant in specimens obtained from areas like a friendly basset hound's ear wax or neck fold wax, which are good teaching examples.

08:17.63 - Sue asks Ross about determining the relevance of Malassezia presence in ears or skin.

Ross explains breed-specific variations in normal yeast population, how certain breeds might have high yeast counts without causing issues, and that the anatomical site also influences yeast populations. He notes that there's no clear clinical cut-off for relevance; treatment response often helps assess its significance, as excessive yeast might not always correlate with clinical symptoms.

14.39 - John asks Ross about the clinical signs indicating an overgrowth of Malassezia.

Ross explains that signs like inflamed or greasy skin, particularly in folded areas, ears, neck, or groin, are indicative of a potential Malassezia issue, especially in predisposed breeds (he names some).

16.48 - Sue asks Ross about Malassezia as a primary or secondary disease and its relation to underlying issues.

Ross mentions that Malassezia is a commensal yeast and when it causes disease, it's often secondary to an underlying problem, involving immune system imbalances or hypersensitivity responses. Ross confirms that even in breeds prone to Malassezia, like Basset Hounds, there's usually an underlying cause for yeast proliferation. He mentions high Malassezia colonisation in mucosal populations of Basset Hounds, indicating more than just skin folds contributing to the issue.

Chapter 3: "Fungal Intrigue and Secret Signs: Unravelling Malassezia's Plot"

20.33 - John discusses the common misconception regarding skin folds and Malassezia issues in certain dog breeds with Ross. They touch upon the possibility of Malassezia hypersensitivity, its occurrence in certain dogs, and its association with atopic dermatitis.

Ross explains that while Malassezia hypersensitivity exists, its clinical presentation might not always correlate with immediate hypersensitivity reactions. He discusses intradermal testing in Bassett Hounds and the presence of IGE reactivity in some dogs, especially those with atopic tendencies.

25.19 - Sue asks Ross about primary care veterinary surgeons' preferred methods for diagnosing Malassezia dermatitis. Ross recommends simple techniques like ear swabs, tape strips, and microscopic examination for diagnosing Malassezia in primary care settings.

26.21 – John asks about whether this can be transferred between pets and humans.  Ross discusses the potential for Malassezia transfer between pets but emphasises that transferring Malassezia Pachydermatitis from pets to healthy owners is quite unlikely. He mentions instances in neonatal care units where Malassezia-related infections traced back to pet dogs have been observed, emphasising the importance of handwashing in preventing transmission.

28.18 - John inquires about treatment recommendations for Malassezia infections. Ross emphasises the accessibility of Malassezia yeasts for topical treatment and discusses the practical challenges in applying topical therapy to dogs with dense hair coats. He highlights the efficacy of 2% miconazole/2% chlorhexidine and 3% chlorhexidine shampoos based on consensus guidelines, alongside systemic treatments like itraconazole and ketoconazole.

34.29 - Sue asks Ross about the role of steroids in managing chronic Malassezia otitis and skin infections. Ross explains the importance of oral prednisolone for reversing stenosis in the ear canal and discusses the use of steroids in chronic Malassezia dermatitis, particularly in cases with allergic components, thickened skin, and hyperpigmentation.

39.44 - Ross provides a summary of the approach to Malassezia otitis externa and skin infections, suggesting a varied approach depending on the severity of the condition. He highlights situations where combining prednisolone with antifungal treatment may be necessary.

Sue and John express their gratitude to Ross for his expertise and wealth of information on Malassezia. They acknowledge the complexity of the subject and appreciate the insights shared during the discussion.

John introduces the podcast and the co-hosts for this conversation; the guest on this episode is RCVS Specialist in Veterinary Oncology, David Killick.

Chapter 1 – Little Miss Diagnosis

David's Background:

2.14 - David began in general practice in 2003 and later specialized in medical oncology at the University of Liverpool, earning a PhD at the RVC in London. He is now the professor of veterinary oncology at the University of Liverpool.

Malignant vs. Benign:

3.19 - Benign growths stay localized, mostly causing no problems during a pet's lifetime, while malignant growths can invade nearby tissues and spread.

4.49 - Approximately 40-50% of skin growths in dogs are malignant.

Investigate All Lumps

5.30 - Investigate All Lumps: Investigating all skin lumps is essential, even if no immediate action is taken. Initial investigation involves history-taking and examination, looking for signs like attachment to underlying structures or enlarged lymph nodes.

Biopsy Importance

8.05 - Diagnostic biopsy samples, including fine needle aspiration (FNA), are invaluable in veterinary medicine. FNA is minimally invasive, providing initial insights in 80-90% of cases. It may not offer a precise diagnosis but guides further steps.

David suggests fine needle aspiration as a cost-effective initial diagnostic tool, emphasizing its utility in informed decision-making. Other options include incisional and excisional biopsies, each with its own considerations regarding risks and benefits.

By prioritizing fine needle aspiration, veterinarians can efficiently navigate the path toward accurate diagnoses and appropriate treatment plans.

Factors Influencing Animal Skin Tumours

11.05 - Sue inquires about factors influencing susceptibility to skin tumours in animals, such as age, breed, and sex. David discusses breed-related associations with specific diseases in veterinary oncology, citing mast cell tumours in bulldogs, boxers, and retrievers. He mentions melanomas more common in Scotties and Schnauzers and highlights characteristics like rapid growth and tissue attachment raising malignancy concerns.

Identifying Common Benign Lumps Visually

13.18 - John seeks insights into visually identifying common benign lumps. David notes some, like skin tags, papillomas, and sebaceous adenomas, can be recognized by appearance. Skin tags are outgrowths, papillomas breed-specific, and sebaceous adenomas common in aging Cocker Spaniels. David advises monitoring, measuring, and fine needle aspiration for accurate identification.

Understanding Pigmented Tumours in Dogs, Especially Melanomas

16.33 - Sue asks about pigmented tumours in dogs, melanomas specifically. David explains not all pigmented tumours are melanomas. Dark or black lesions suggest melanomas, including malignant melanoma and benign melanocytoma. Skin melanomas may require removal if melanocytes are detected, with digital and oral melanomas requiring active management.

Identifying Melanocytes in Fine Needle Aspirations

18.00 - Sue questions melanocyte identification in fine needle aspirations. David notes pigmented tumours are usually melanomas, with characteristic black granules in cells. He mentions amelanotic melanomas' rare occurrence, especially in oral cases.

Chapter 2 – Introducing Mr Mast Cell

Insight into Mast Cell Tumours

18.52 - John seeks insight into mast cell tumours (MCTs). David explains their origin from mast cells, which release histamine and cause itchiness and redness. MCTs may periodically change size upon palpation. They are common in dogs, especially specific breeds, potentially requiring multiple management due to recurrence.

Using Fine Needle Aspirations (FNAs) for Diagnosis and the Role of Veterinary Nurses

22.10 - John inquires about using fine needle aspirations (FNAs) for diagnosis and the role of veterinary nurses in interpreting samples. He wonders if preliminary assessments in practice are acceptable due to budget constraints and potential risks. David encourages practitioners, including vets and nurses, to develop cytology skills, which are enjoyable and relatively easy to learn. He suggests self-examining slides in their lab, writing reports, and seeking feedback for skill improvement. David notes that mast cell tumours are an excellent starting point for cytology learning as they often feature distinctive "fried egg-like" cells with blue to purplish granules. However, expert consultation is crucial for tumours with unusual characteristics or more aggressive features.

The Necessity of Biopsies for Tumour Grading After FNAs

25.15 - Sue questions the necessity of biopsies after fine needle aspirates (FNAs) for tumour grading. David notes FNA's value in general practice and good correlation with histological grade. He emphasizes combining clinical tools and considering staging, especially for higher-grade tumours. For less aggressive cases, FNA of the draining lymph node may rule out lymph node involvement before surgery. David discusses grading schemes, including the pattern grading scheme and Kiupel system.

Chapter 3 – Mr and Mrs Outcome

Treatment Options for Mast Cell Tumours

29.55 - John inquires about mast cell tumour treatments and whether they're managed in primary vet settings or by specialists. David explains treatment involves addressing the local tumour through surgery or radiation therapy, with staging for potential metastasis. Medical therapies like chemotherapy or growth factor inhibitors are considered if metastasis is found. Emerging therapies like Tigilanol tiglate and Electro Chemotherapy are mentioned, particularly for challenging cases.

Prognosis of Mast Cell Tumours

35.52 - John inquires about mast cell tumour prognosis. David explains that low and intermediate-grade tumours have a generally favourable prognosis with surgery, even if some cells remain at the margins. However, high-grade tumours, especially if they've spread, often require ongoing medical therapy and monitoring, with potential recurrence.

Key Points on Dealing with Dog Lumps and Seeking Specialist Guidance

37.54 - Sue summarizes key points: Urges not to ignore lumps on dogs, as up to 50% can be malignant. Recommends consulting specialists like David instead of relying on online sources for accurate guidance and evolving treatment options. David appreciates the summary, emphasizing the dynamic nature of oncology and the limitations of online information.

https://www.liverpool.ac.uk/sath/about-us/

43.44: John wraps the pod with another daft questions.

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(00:00) John introduces the podcast and welcomes our guest for this episode - the founder of the Dermatology Referral Service in Glasgow, Peter Forsythe.

Chapter 1 – The Ears

(02:58) John welcomes Peter Forsythe, who talks about how he got involved in dermatology and how ear disease makes up half the caseload in the referral practice he works at.

(04:41) John asks why it is important dogs have clean ears and Peter discusses the long tube made up of the auricular and annular cartilages which are lines with glandular skin which produces wax - which combines with skin cells to make up what we know as wax. He says a build-up can alter the environment on the ear canal, increasing humidity and increasing the number of microbes such as bacteria and yeast, which - whilst normally present - can develop into an overgrowth or even infection. He also talks about the concretions, or balls of ear wax which can form adjacent to the tympanic membrane or ear drum, and they are called ceruminoliths and can sit on the ear drum and damage and even perforate it. So it is important to manage this ear wax and keep the ear clean.

(07:55) Sue asks about the ‘self cleaning’ mechanism the ear called epithelial migration and Peter describes this as similar to the shedding of cells we have on our continuously growing skin cells, but in the ear these have a sliding, upward motion to them as they do this, and this slowly carries cells and wax up and out the ear like a slow moving escalator – at the speed our nails grow at.

(09:49) Sue asks if this changes with age and Peter says there isn’t information on age changes, but in cases of inflammation or disease this is affected, slowing it down and then leading to increased build up of wax. Peter says the human ear produces 2 kilos of wax in a lifetime!

(11:32) Sue asks what Peter recommends to clients in terms of ear cleaning with puppies and he doesn’t recommend routine ear cleaning in puppies if they are healthy, as the mechanism is working well; however, he does think in those breeds where they are prone to ear disease, that it is good to get them used to you handling their ears at a young age.

Chapter 2 – The Cleaning

(13:34) Sue asks about hairy ear canals or plucking ears and Peter says in his view plucking hairy ear canals in poodles and bichons for example, where the hair can trap the wax, can irritate and inflame the ear and begin ear disease, so he wouldn’t pluck them. If the dog has got ear disease (otitis) then some plucking maybe necessary – but ear phobia – where a dog has had bad experiences and they won’t let people go near their ears, is more of an issue and plucking can lead to this. He would prefer then to begin cleaning if you can see wax building up. This is the same with a dog with a pendulous (flappy outer) ear (which can also contribute to ear disease) – but he does point out too much cleaning can overly wet the ear and cause more problems – so each case must be considered carefully.

(17:15) Sue asks as a pet owner who can see so many different ear cleaners, what can help you decide and what to look for and Peter divides these into two. Firstly softening or dissolving ear wax products called cerumenolytics, containing things like propylene glycol, mineral oils, glycerine; through to secondly salicylic acid or even stronger sodium docusate (DOSS) or carbamide peroxide (which is only recommended in anaesthetised dogs) which dissolves. Sue clarifies then this depends on how waxy the ear is as to which you reach for and Peter says it is recommended to talk to the vet about it rather than purchasing straight from the internet.

(21:10) John points out it is important then for any nurse or vet to have a good understanding of the ear cleaners on their shelves and Peter wholeheartedly agrees, saying for example a more water based ear cleaner being used to dissolve and remove wax doesn’t make sense and also cleaning isn’t comfortable for the dog; so it is important to demonstrate the use of a product to an owner, and give them tips such as warming the ear cleaner a little to make it more comfortable.

Chapter 3 – The Cleaners

(24:20) John asks about powders and Peter remembers when they were used more frequently, but he does not recommend them at all as they mix with the wax and make it stickier and dryer. John goes on to ask what changes in the ear once disease starts to set in; Peter says if a dog has had ear disease once, it is very likely to happen again and can happen repeatedly. Over time this changes detrimentally the ear canal; the lining becomes thicker and the tissues become swollen and oedematous, the glands become enlarged and even massive over time; all this narrows the ear canal and impairs the epithelial migration and so you have an increased build up or wax in a smaller canal and this favours the further build up of bacteria and/or yeast in the ear. He also says the ear drum can then weaken and even perforate, so a hole can appear and then infection can get into the middle ear which is both more serious and hard to treat. He points out if the ear disease being allowed to continue year on year this can then result in long term changes where the ear cartilage becomes calcified, so effectively into bone – at this point often only surgery can help.

(29:38) Sue mentions these dogs all have underlying issues which cause these ear problems, and flags this for a further podcast. Sue then asks about the cases where we have these changes and the presence of yeast and bacteria and asks if there should be cleaning in all of these cases; Peter replies that there is strong evidence to say that due to the increase in discharge they should all be having regular cleaning – as the normal treatment for these cases - antibiotic and or antifungal ear drops - need to be able to get to the lining of the ear through this discharge in order to work. So, they need cleaning prior to the drops going in. Sue asks if these are the antiseptic cleaners we would use and Peter agrees, saying you want the cleaner to both remove the wax build up but also have an antiseptic effect, he mentions isopropyl alcohol, para-chloro-meta-xylenol (PCMX) and in particular chlorhexidine with Tris EDTA as a common effective combination for these cases – which in some cases can resolve the disease when used as a sole treatment. Sue reflects that as in Scandinavia as heard on a previous SkinFlint, more thought is going into using these to avoid antibiotic use.

(32:47) Sue asks Peter what a practice would have as three key ear cleaners for stocking their pharmacy, Peter says three is a good number and they would want a soothing, wax softening cleaner for the low symptom waxy ears – such as a glycerine, propylene glycol or mineral oil with camomile for example. Then a more potent, cerumenolytic ear cleaner, possibly with a detergent such as DOSS or chlorhexidine or alcohol. Then the third would be an aqueous ear cleaner for use in the purulent, pus based discharge in severe cases such as a pseudomonas infection, and this would be the chlorhexidine and Tris EDTA combination as discussed.

(36:34) John wraps up and summarises the conversation.

(41:35) John asks his co-hosts the usual daft questions so we don’t take ourselves too seriously!

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(00:00) John introduces today’s guest - host of another veterinary dermatology podcast The Derm Vet, Ashely Bourgeois.

Chapter 1: UK vs US Dermatology

(02:50) Sue asks Ashley how she started out in podcasts and Ashley shares her story, wanting to stay involved in dermatology whilst also raising children and not wanting to lose that knowledge base, and helping  others in that kind of position.

(04:33) John asks Ashely and Sue what the difference between the UK and US in approach to dermatology. Sue says the approach is the same, but the system is slightly different and there isn’t so much of a referral process in the US as here in the UK. Ashley agrees, saying often people will come direct, but that they have good relationships with first opinion practices in order that clients are aware dermatologists exist.

(06:45) Sue says the board certified dermatologists exist in both regions, but in the UK we have an intermediate tier of advanced practitioners which doesn’t exist in the states; therefore asking Ashley if there are any areas in the US which aren’t covered well geographically with specialists. Ashley says there are areas without specialists, and there is work to see if they can develop better coverage; including the possibility of telemedicine in for example a state that doesn’t have dermatologists.

(08:58) Sue asks if the rules around dermatology prescribing through telemedicine differs state to state and Ashley confirms this, saying in her state for example, they must see a client at least once a year whereas in other states this is possible long term remotely.

Chapter 2: UK vs US Antibiotic Use

(11:30) Ashley then asks Sue if it differs in relation to staphylococcus infections in the UK and US and Sue says it really does, and also across Europe from the UK. She points out in Scandinavia they hardly use antibiotics at all and use antiseptics much more, and this seems to really correlate to having less resistance. Sue asks for example if Ashely would use vancomycin and Ashely says whilst she hasn’t for this one she has had to use rifampin and chloramphenicol. She reflects there is a shift in the mindset with the use of antibiotics because of the number of times they will only have one or two choices left due to resistance.

(14:45) Sue asks if it is right you can buy neomycin, polymyxin, bacitracin over the counter and Ashely says you can for topicals, and said she even had a client who had fish antibiotics they were giving to their dog whenever they felt there was an infection. Sue reflects what would be available by comparison in the UK.

Chapter 3: UK vs US In Practice

(17:17) John asks whether a clients expectation would differ in terms of approach to a skin case in the states than in the UK and Ashley says there is much the same issue in terms of clients not understanding the long term nature of skin management, particularly in allergy and also the multimodal approach; where often more than one therapy is going to manage the patients skin. She is always quick to point out to owners these cases will change and even when well managed, this will change and they will flare up.

(20:14) John reflects that in the US the Vet nurses or Vet Techs as they are called there are still as important to case management as here in the UK and Ashely passionately agrees, saying they are critical to the solidification of a case management – instilling confidence in the owners to the treatment plan long term. They also catch mistakes and understand the cases very well.

(23:05) John asks Ashely about the education side in terms of the difference with logging CPD and education. Ashley says the regulations are quite strict in terms of whether she can talk off label at lectures and online and her and Paul reflect on some of these aspects.

Chapter 3: UK vs US Dermatology Top Trumps

(26:27) Sue asks Ashley for most common presentations and Ashley and Sue spend some time reflecting on the differing cases and presentations seen both in the US and UK. Where Ashely is in the US the climate is similar but Sue reflects it is interesting how the diseases are so different.

(33:50) John wraps the podcast by asking Sue and Ashley what their favourite and least favourite disease it. Pemphigus comes out well whilst sterile nodular panniculitis and bald Pomeranians/alopecia X and lick granulomas really don’t!

Visit Ashley’s Website HERE

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