Treatment Simplified: A Guide to Comfort for the Itchy Dog Treatment Simplified: A guide to comfort for the itchy dog Atopic dermatitis, a pruritic and inflammatory disease, has no cure. One estimate indicates that one in 10 dogs in the United States has atopic dermatitis, which makes it one of the most common chronic conditions that veterinarians encounter.1 Although practitioners are growing more adept at diagnosing atopic dermatitis, the real challenge comes with providing immediate relief of patients’ clinical signs while addressing their underlying allergic disease. This article illustrates how managing atopic dermatitis in dogs may be simplified and will help you provide comfort for these pruritic canine patients. Treatment Simplified: Start early, address flares, and assess progress Atopic dermatitis can start with acute, seasonal flare-ups and if the underlying disease process is not managed, it progresses, over several months to years, to a nonseasonal, chronic condition.2 Thus, managing the disease earlier should be beneficial. Every dog that suffers from atopic dermatitis has its individual allergic threshold — the point at which the environmental allergen load triggers the dog’s immune system to react. Once the allergic threshold is exceeded, the dog develops inflammation, pruritus, and pain, which usually results in skin damage. Therefore, treatment of the clinical signs and longterm management are always aimed at returning to a point below the dog’s allergic threshold. This, in turn, reduces the number and severity of allergy flareups that the patient experiences. Even in well-managed patients, occasional flare-ups are inevitable and should not be deemed a long-term treatment failure. Jerry Wilson, DVM, owner of Animal Hospital of Collin County in Allen, Texas, says, “Having a plan that will decrease the frequency and severity of these flare-ups is in the best interest of the patient and client. Longterm success is achievable with the correct diagnosis and medication regimen.” Once atopic dermatitis has been diagnosed, this three-month “Treatment Simplified” protocol (Figure 1) may be implemented to help control patients’ clinical signs and monitor their response. Treatment Simplified: Month One — Long-term solution, immediate relief Start long-term therapy early Since atopic dermatitis is progressive, beginning a long-term management plan as early as possible should make it easier to control the disease. In the first month of treatment, ATOPICA® (Cyclosporine capsules, USP) MODIFIED “In many of my earlier cases, atopic patients receiving corticosteroids, shampoos, fatty acid supplements, you name it, were the norm before I prescribed ATOPICA. Now ATOPICA has climbed to the top of my treatment recommendation list.” —Steve Milden, VMD should be initiated at a dose of 5 mg/ kg/day (range 3.3 to 6.7 mg/kg/day). ATOPICA is the first and only approved nonsteroidal prescription medication for the control of atopic dermatitis in dogs. Dr. Wilson agrees, saying, “Having had success with ATOPICA, I now make the recommendation much earlier in the course of therapy.” As with all drugs, side effects may occur. In a field study, the most common side effects were gastrointestinal signs. Gingival hyperplasia and papillomas may also occur during the initial dosing phase. ATOPICA is a systemic immunosuppressant that may increase the susceptibility to infection. ATOPICA is not for use in reproducing dogs or dogs with a history of neoplasia. Please see the included product insert on page 7 for more information. Treat secondary infections Patients with allergic skin disease have alterations to the normal protective Treatment Simplified Figure 1 function of the skin, which increases the likelihood of infection. Secondary bacterial and yeast infections of the skin and ears, caused by Staphylococcus and Malassezia species, commonly exacerbate a dog’s clinical signs, such as pruritus. In dogs with clinical signs of atopic dermatitis, positive cytologic examination results indicate the need for antimicrobial agents.3 Antimicrobial therapy should be continued for four to six weeks and be discontinued only when cytologic examination results are negative. More chronic infections may require prolonged antimicrobial therapy. If fungal infections are present, antifungal treatment (e.g., ketoconazole) may be indicated. Simultaneous administration of ATOPICA and drugs that suppress the P-450 enzyme system, such as ketoconazole, may lead to increased plasma levels of cyclosporine. ATOPICA should be used with caution with drugs that affect the P-450 enzyme system. According to Keith Hnilica, DVM, MS, DACVD, of the Allergy and Dermatology Clinic of the Pet Wellness Center in Louisville, Tenn., “Bacterial and yeast infections and the accompanying pruritus are the most common reasons for apparent failure of most allergy treatments.” It is imperative to resolve any secondary infections to successfully manage patients with atopic dermatitis in the long term. Provide immediate relief Short-term concurrent topical or systemic corticosteroid therapy may be indicated for immediate relief in a dog that is suffering from pruritus and pain. As Steven Milden, VMD, of Delaware Valley Veterinary Hospital in Mullica Hill, N.J., explains, “All atopic pets have some degree of discomfort. While ATOPICA® (Cyclosporine capsules, USP) MODIFIED is the long-term solution to treat the underlying disease to minimize and prevent flare-ups, corticosteroids may be needed in the most severe cases to bring the pet relief.” “With the vast majority of cases, corticosteroids are not needed past 14 to 21 days because most of the patient’s inflammation and itching has subsided and the effects of ATOPICA® (Cyclosporine capsules, USP) MODIFIED are becoming clinically evident.” —Jerry Wilson, DVM Unlike ATOPICA, corticosteroids do not treat the underlying atopic disease and should be used only in the short term to treat the clinical signs. Anti-inflammatory doses of corticosteroids provide quick relief, but also can cause numerous side effects, especially with long-term use. There have been reports of convulsions in human adult and pediatric patients receiving cyclosporine, particularly in combination with high-dose methylprednisolone. (See the Animal Safety section of the product insert — “Methylprednisolone combination: Twenty-four dogs were administered 1 mg/kg/day methylprednisolone alone for 14 days followed by 20 mg/kg/day cyclosporine either alone or in combination with methylprednisolone, or placebo for 14 days. There was no evidence of seizures/ convulsions or neurological signs.”) Treatment Simplified: Month Two — The turning point After four weeks of treating secondary infections, initiating ATOPICA, and managing the patient’s clinical signs, a progress examination should be performed to assess the patient’s response to therapy. If the patient shows a 50% reduction in skin lesions and pruritus, the ATOPICA dose can be tapered to once every other day.4 Conversely, if a dog is only showing slight improvement, the patient’s ATOPICA dose should be evaluated to ensure it falls within the dose range (3.3 to 6.7 mg/kg/day). If the patient’s dose is at the lower end of the range, it may need to be increased or once-daily treatment may need to continue. If no improvement in skin lesions or pruritus has occurred, a thorough re-evaluation of the patient may be warranted, and referral to a veterinary dermatologist should be considered. A cytologic examination should also be included, as failure to adequately address infections may lead practitioners and owners to declare ATOPICA a failure. If the cytologic examination results are negative, antimicrobials can be discontinued. If the secondary infections are chronic, a longer course of antimicrobials may be indicated. By this point in treatment, cortico steroids may no longer be indicated. Dr. Milden offers this perspective based on his clinical experience: “I try to discontinue corticosteroids before the second month A guide to comfort for the itchy dog. MONTH 1* Initial Exam MONTH 2* 30-Day Progress Check MONTH 3* 2 60-Day Progress Check Diagnose atopic dermatitis Treat any infections with antimicrobials. Initiate long-term management with ATOPICA® (Cyclosporine capsules, USP) MODIFIED therapy for long-term relief. YES Significant improvement Consider tapering dose. Continue long-term management with ATOPICA. NO Re-evaluate and consider concurrent disease. A long-term treatment plan will help you achieve success sooner rather than later. NEGATIVE Provide short-term relief with corticosteroids. Cytologic exam Discontinue treatment. POSITIVE Continue treatment until infection is resolved. Discontinue short-term relief. *The timing of progress may vary from case to case. 3 re-evaluation so I can assess the dog’s true level of pruritus. If the dog is still receiving corticosteroids at the end of the first month, veterinarians may prematurely reduce the ATOPICA dose and then see a rapid return of pruritus, leading them (and the owners) to believe (and rightly so) that ATOPICA wasn’t responsible for the decrease in pruritis and that ‘only steroids will help this dog.’” Treatment Simplified: Month Three — Entering the comfort zone The dog’s clinical signs and response to treatment and the results of physical and cytologic examinations should be assessed at this evaluation. ATOPICA® (Cyclosporine capsules, USP) MODIFIED dosage adjustments may be made if needed. By this point, ATOPICA may be indicated as the sole therapeutic “Consistency in our recommendations establishes credibility and confidence in our clients, which helps with compliance and eventually success in treating the clinical signs of this complicated disease.” —Jerry Wilson, DVM agent for long-term management of atopic dermatitis. However, according to many dermatologists, even in the most well-managed patients, practitioners and owners should expect occasional flare-ups, and clients must be prepared to address these. Possible flare factors include an increased allergen load, secondary infections, fleas, and concurrent disease (e.g., food allergy). Some options for managing the shortterm flares include increasing the frequency of ATOPICA administration (e.g., back to once-daily dosing), controlling secondary infections, and adding a topical corticosteroid. Conclusion Once atopic dermatitis is confirmed, practitioners need a reliable, repeatable, and customizable treatment protocol providing both long-term comfort and short-term relief for the atopic patient. Utilizing the “Treatment Simplified” approach may help practitioners achieve success in atopic dermatitis patients sooner rather than later. According to Dr. Milden, “Many clients come to me frustrated. Either the dog has been keeping them awake or they have been dealing with chronic disease. When ATOPICA prevents the return of their dog’s clinical signs, they bring Initiating treatment with ATOPICA as the first-line medication for the primary disease can result in successful, longterm management of atopic patients. me presents!” In addition, Dr. Wilson points out, “Through long-term use of ATOPICA and control of clinical signs and flare-ups, we are able to integrate the pet back into the family — the pet and the people all benefit.” Initiating treatment with ATOPICA as the first-line medication for the primary disease can result in successful, longterm management of atopic patients. The following two case summaries for Prissy and Matty will demonstrate how the “Treatment Simplified” protocol has helped Drs. Jerry Wilson and Steven Milden manage their canine atopic dermatitis patients, describe what they’ve learned along the way, and illustrate how the protocol can help in your practice. REFERENCES 1. Hillier A. Definitively diagnosing atopic dermatitis in dogs. Vet Med 2002;97(3):198-208. 2. Griffin CE, DeBoer DJ. The ACVD task force on canine atopic dermatitis (XIV); clinical manifestations of canine atopic dermatitis. Vet Immunol 2001; 81:255-269. 3. Olivry T, DeBoer DJ, Favrot C, et al. Treatment of canine atopic dermatitis. 2010 clinical practice guidelines from the International Task Force on Canine Atopic Dermatitis. Vet Derm 2010:21(3);233-248. doi: 10.1111/j.13653164.2010.00889.x. 4. ATOPICA Freedom of Information Summary. NADA 141-218, 2003. CLIENT COMMUNICATION SIMPLIFIED Month One 4 Month Two Month Three Long-term solution, immediate relief The turning point Entering the comfort zone 1. Explain the progressive, lifelong nature of atopic dermatitis. 2. Set client expectations. Record the client’s opinion, a pre-treatment pruritus score, from 0 to 10; 0 being normal skin and 10 being severe pruritus. Using a pruritus scale at the baseline examination and at every recheck helps gauge the success of the therapy and monitor the progress of the pet’s condition. 3. Educate the client that ATOPICA® (Cyclosporine capsules, USP) MODIFIED will target the allergic response to provide long-term relief and management of the underlying disease process. 4. Eliminate secondary infections. Discuss with the client that these infections are common with atopic dermatitis and can exacerbate pruritus. 5. Provide short-term relief of clinical signs with corticosteroids. 6. Schedule the next progress examination. 1. Discuss the patient’s progress, including cytologic examination results and pruritus score. 2. Continue ATOPICA® (Cyclosporine capsules, USP) MODIFIED therapy; continue with the daily dose if the patient shows moderate improvement, taper the dose if the patient shows significant improvement. 3. Eliminate corticosteroids. Review with the client that corticosteroids were administered to provide short-term relief of clinical signs and that the targeted therapy of ATOPICA will provide long-term comfort. 4. Celebrate the patient’s improvement with the client. Acknowledge the frustration that comes with atopic dermatitis and talk about a future with a more comfortable, less itchy dog. 5. Schedule the next progress examination. 1. Discuss the patient’s progress and celebrate improvement with the client. 2. Customize the ATOPICA® (Cyclosporine capsules, USP) MODIFIED dosing frequency based on clinical assessment. 3. Educate the client about the likelihood of an occasional flare-up and discuss how it will be handled. To address flares, the frequency of ATOPICA administration can be temporarily increased (in dogs not receiving daily dosing) and other short-term therapies may be used. PRISSY Breed: Maltese-poodle cross Age: 6 years Sex: Spayed female Weight: 12.3 lb (5.6 kg) First Prescribed Atopica® (Cyclosporine capsules, USP) MODIFIED: 5 years of age Veterinarian: Jerry Wilson, DVM “Educating clients about the long-term approach of controlling clinical signs of atopic dermatitis with ATOPICA® (Cyclosporine capsules, USP) MODIFIED is the best solution for most atopic canine patients. By avoiding long-term glucocorticoid use, we reduce a dog’s risk of complications and achieve better results in controlling the signs of atopy.” Before “Treatment Simplified” Patient history and presenting problems to provide immediate relief of the pruritus and treat the yeast dermatitis. • Yeast and bacterial otitis externa two years previously “TREATMENT SIMPLIFIED” • Two-year history of recurring seasonal allergic skin disease, which was treated three times at another clinic • Administer one ATOPICA 25-mg capsule (4.46 mg/kg) once daily for 30 days. • Pruritus involving front limbs and ventral abdomen • Administer an intramuscular dexamethasone sodium phosphate injection (0.66 mg/kg). • Pustules on ventral abdomen and front legs; flaky skin on front legs Month One • Malassezia dermatitis • Prescribe oral ketoconazole (5 mg/kg) once daily. Previous therapies Month Two • Ear flushing with an otic cleansing solution • Antibiotic/antifungal/corticosteroid otic medication • Oral trimeprazine with prednisolone The owner reported that Prissy’s pruritus was greatly improved. Prissy had a few pustules, and cytologic examination revealed that low numbers of yeast were still present. • Oral clindamycin • Continue ATOPICA 25 mg; reduce dosing frequency to every other day. Patient response and treatment plan • Continue ketoconazole; reduce dosing frequency to every other day. Prissy’s otitis resolved with the otic treatments. Her pruritus decreased while she was receiving trimeprazine/prednisolone and clindamycin, but recurred when the medications were discontinued. After two years of unsuccessful treatment of Prissy’s atopic dermatitis at another clinic, Dr. Wilson implemented a treatment simplified plan using ATOPICA® (Cyclosporine capsules, USP) MODIFIED to control the underlying allergic condition. A short-acting corticosteroid and an antifungal were also prescribed Month Three The pruritus was decreased. Prissy exhibited minimal scratching and chewing on the every-other-day ATOPICA dosing schedule. The pustules and yeast dermatitis had resolved. • Continue ATOPICA 25 mg; reduce dosing frequency to every third day. • Discontinue ketoconazole. PATIENT FOLLOW-UP AND OUTCOME • Prissy became mildly pruritic again when ATOPICA was given every three days, but the pruritus rapidly resolved after every-other-day ATOPICA dosing was reinstituted. • Prissy is doing well and the owner is very pleased. • The owner was advised that allergy flares may occur occasionally, and that Prissy’s pruritus can be managed with short-term medications to alleviate the clinical signs at those times. DR. WILSON’S CASE COMMENTARY ”Prissy’s atopic dermatitis is being successfully managed because the owner agreed with implementing a long- and short-term plan to address Prissy’s underlying allergic disease. As the short-term, anti-inflammatory effect of the glucocorticoid diminished, the ATOPICA® (Cyclosporine capsules, USP) MODIFIED targeted suppression of cells that cause the allergic reaction began to help control Prissy’s clinical signs, all while the antifungal helped resolve her secondary yeast infection. Prissy’s owner is aware that atopic dermatitis can be controlled but not cured, that allergy flares will occur occasionally, and that Prissy’s treatment will be lifelong.” Jerry Wilson, dvm In 1982, Jerry W. Wilson, DVM, opened the Animal Hospital of Collin County in Allen, Texas, a suburb of Dallas. He also helps manage the Emergency Animal Hospital of Collin County, an after-hours emergency and specialty practice he helped form in 1985 along with 26 other practitioners in an area north of Dallas. 5 MaTTY Breed: Bichon Frise age: 7 years Sex: Neutered male weight: 14.5 lb (6.6 kg) First Prescribed aToPiCa® (Cyclosporine capsules, USP) ModiFied: 2.5 years of age veterinarian: Steven Milden, VMD “Matty’s case is a reminder that atopic dermatitis should be considered in young dogs with appropriate clinical signs.” BeFoRe “TReaTMenT SiMPLiFied” PATIENT HISTOry AND PrESENTING PrOBlEMS • Presented at 5 months of age for evaluation of pruritus and alopecia • Persistent pruritus, chewing at feet, and discomfort • Alopecia, scaly skin, epidermal collarettes involving the hip regions bilaterally, saliva-staining on feet, possible nail bed infection • Episode of acute moist dermatitis and pyoderma PrEVIOUS THErAPIES • Topical corticosteroid spray • Topical corticosteroid lotion signs indicated nonseasonal allergic dermatitis with secondary self-induced trauma and infection. ATOPICA was prescribed to better control Matty’s underlying allergic condition. “TReaTMenT SiMPLiFied” MONTH ONE • Administer one ATOPICA (Cyclosporine capsules, USP) MODIFIED 25-mg capsule (3.79 mg/kg) once daily for 30 days. ® At this point, Matty was doing great; he exhibited obvious hair regrowth and had no sores or areas of erythema. • Weekly oatmeal/corticosteroid shampoo • Monthly flea preventive MONTH THrEE • Oral diphenhydramine PATIENT rESPONSE AND TrEATMENT PlAN results of a skin scraping and cytologic examination revealed no mites. A complete blood cell count and total T4 concentration revealed no abnormalities. A serum chemistry profile revealed neutrophilia, eosinopenia, and lymphopenia, which were attributed to the corticosteroid treatment. Matty’s pruritus decreased while he was receiving the oral antibiotics and topical treatments but recurred when the medications were discontinued. His history, clinical signs, and response to treatment to alleviate the clinical At this point, Matty was doing well, and the owners reported that they reinstituted a once-daily ATOPICA dosing schedule. • Continue administering one ATOPICA 25-mg capsule once daily for 30 days, then decrease to every other day. PaTienT FoLLow-UP and oUTCoMe • Over the next several months, Matty had one recurrence of pruritus that was associated with reducing the ATOPICA dosing frequency. reinstituting once-daily ATOPICA treatment for 30 days controlled Matty’s pruritus. STeven MiLden, vMd Steven Milden, VMD, opened Delaware Valley Veterinary Hospital in Mullica Hill, N.J., a semirural/suburban area of southern New Jersey in 1994. He works at his small-animal practice with seven veterinarians and a staff of nearly 50 employees. 6 • Three years later, Matty is receiving ATOPICA every other day and has not had any recurrence of pruritus. • The duration of Matty’s relief with ATOPICA treatment alone: 4.5 years. MONTH TWO • Continue administering one ATOPICA 25-mg capsule once daily for two weeks, then every other day. • Oral cefpodoxime proxetil • Two years later, Matty was receiving ATOPICA every third day, but had episodes of pruritus a couple of times a year. When these mild allergy flares occurred, the owner was able to control them by temporarily returning to once-daily therapy. dR. MiLden’S CaSe CoMMenTaRY “Matty was one of my early ATOPICA® (Cyclosporine capsules, USP) MODIFIED treatment cases. In retrospect, his case helped me recognize that I could probably relieve atopic patients’ discomfort sooner by prescribing ATOPICA concurrently with treatment for secondary infections, rather than waiting until the infections resolved to start ATOPICA. Matty’s case also demonstrates that different dogs may require different ATOPICA dosing schedules, and owner communication is key to identifying what schedule works best. We can modify Matty’s ATOPICA dosing schedule to manage his allergy flares — which are likely the result of increased environmental allergen exposure — rather than use multiple medications to relieve the clinical signs. For Matty’s atopic dermatitis, one drug does it all, and his case made me a true believer in ATOPICA’s efficacy for long-term control of atopic dermatitis.” 7 Simplify allergy treatment by starting earlier Keith A. Hnilica, DVM, MS, MBA, DACVD The earlier an allergic patient is started on a management program designed with aggressive allergen avoidance practices and targeted treatment of the underlying disease, the easier the allergic condition will be to control. Patients with chronic allergic disease or recurrent skin or ear infections have immune system changes as well as alteration in normal skin function, which can make it more difficult to treat dermatitis. By starting targeted allergy treatment early in the disease course, simpler, less expensive adjunct therapies are likely to help improve the patient’s condition. The most common allergens in the home environment are house dust mites, molds, and cigarette smoke. These, as well as other allergens (e.g., wool, fleas, certain foods), can often be reduced or avoided with several simple techniques. Bathing the pet with a mild antimicrobial shampoo every three to seven days removes allergens and helps resolve and prevent secondary bacterial or yeast infections. Administering a monthly insect growth regulator and a flea adulticide is the best combination for flea control and prevention. In my experience, feeding a diet without beef or dairy ingredients but with high levels of essential fatty acids is beneficial. Allergic disease changes the normal protective function of the skin, which increases susceptibility to skin infections. These infections can cause severe pruritus and further inflammation. In my clinical experience, up to 80% of allergic patients develop secondary infections, and typically any dog that has a pruritus score above 5 on a scale of 0 to 10 has a secondary bacterial or yeast infection. Additionally, bacterial and yeast infections and the accompanying pruritus are the most common reasons for apparent failure of most allergy treatments. Antibiotic administration is needed for at least 21 days for each pyoderma episode. Yeast infections require topical or systemic antifungal treatment for at least one month. Ear infections usually require ear cleaning every three to seven days and daily administration of a topical antibacterial or antifungal. Often a topical corticosteroid is used to decrease the associated inflammation. Pododermatitis is often treated with topical antimicrobial wipes, shampoos, or rinses used frequently. For patients with atopic dermatitis, the only targeted treatments that modulate the immune system are ATOPICA® (Cyclosporine capsules, USP) MODIFIED and allergy desensitization vaccination. Skin Simplify allergy treatment by addressing flare-ups Ian Brett Spiegel, VMD, MHS, DACVD A multimodal approach is often required when initially treating atopic dermatitis in dogs. Secondary bacterial and yeast (Malassezia species) infections must be identified and managed in order to successfully treat these patients. Preventing flea infestations, ruling out mite infestations, and addressing potential adverse food reactions are important components as well. Corticosteroids are often indicated at some point in allergy management, but ideally they are used infrequently and administered orally and only when necessary. If injectable corticosteroids are used, consider short-acting options such as dexamethasone sodium phosphate. In my opinion, injectable corticosteroids are rarely indicated. The modified formulation of cyclosporine (ATOPICA®) is an excellent option for managing canine atopic dermatitis. This drug lacks the adverse effects frequently associated with corticosteroids. A corticosteroid may be needed in conjunction with ATOPICA when therapy is initiated, and even in a wellmanaged atopic patient, the therapeutic plan will need to be adapted to address occasional flare-ups of clinical signs. Intermittent application of topical treatments may also be effective in helping manage flare-ups of atopic dermatitis. Topical antimicrobials may target the secondary infections, and some topicals may help maintain barrier function. Many topical anti-inflammatory and antipruritic preparations (e.g., corticosteroid sprays or analgesic sprays containing pramoxine) are also available. Keep in mind that every patient is Dr. Hnilica is the author of Small Animal Dermatology: A Color Atlas and Therapeutic Guide, 3rd ed. He is the founder of the Allergy and Dermatology Clinic of the Pet Wellness Center in Louisville, Tenn. or serum allergy testing can be used to identify the offending allergens, and the results can be used to formulate an allergy vaccine that may desensitize the immune system to those allergens. Desensitization therapy has few side effects and various authors have rated response as good to excellent in 60% to 70% of atopic dogs.1,2 ATOPICA is an oral capsule that is administered every day until the patient’s clinical signs markedly improve. Then the dosing frequency can usually be reduced to every other day. In clinical trials, ATOPICA was proven to be effective in 74% of dogs with atopic dermatitis.3 References 1. Griffin CE, Hillier A. The ACVD task force on canine atopic dermatitis (XXIV): Allergen-specific immunotherapy. Vet Immunol Immunopathol 2001;81:363-383. 2. Nuttall TJ, Thoday KI, van den Broek AH, et al. Retrospective survey of allergen immunotherapy in canine atopy. Vet Rec 1998;143(5):139-142. 3. ATOPICA Freedom of Information Summary. NADA 141-218, 2003. Dr. Spiegel is affiliated with the following clinics: Veterinary Specialty and Emergency Center, Levittown, Pa.; Animerge 24/7 Animal Emergency and Specialty Care, Raritan, N.J.; and Garden State Veterinary Specialists, Tinton Falls, N.J. different, and every client’s situation is unique. It is important to remember that, even in the most well-managed cases, flare-ups are inevitable. Flare-ups can be caused by anything from a flea infestation or a change in season to the development of a concurrent disease, such as a food allergy. The art of managing the allergic patient requires good communication with the client as well as patience and perseverance on the part of both the clinician and the client. Sponsored by 8 © 2012 Novartis Animal Health US, Inc.
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