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Allergic Dermatitis

by MKinoshita - September 2, 2009

Steve,
7 year old FS Retr X. Hx allergic dermatitis since approx 6 mos old. Skin scrape, bx done. Responds to abi and pred. (no side effects noted) No response to cyclosporin or allergy injections (serum based on blood testing, not skin testing). 1 bout of Pancreatitis when 4 yrs old.
1st seen Jan - was on Benadryl with no effect. Periobital alopecia/erythema, mild conjunctivitis with mucoid ocular discharge. Alopecia/erythema, lichenification worse on ventral surfaces but also dorsum affected & perianal and perivulvar areas, medial forelimbs. Scratches till bleeds. Papules on dorsal lumbar. Sneezes when skin flares. Tongue pink-red underside and tip, mild white coat. Pulse - deep, soft, rapid. Mu Liv 13. Active BL 20, Liv 13
Does not permit acupuncture (won't settle) - gets very suspicious whenever something is in my hand, otherwise is a very nice dog. On raw diet (skin improved when switched from kibble)
Tried QYT with Nettles, Probiotic. Some fur regrowth. Scratching may have decreased slightly but still bad. Odor to skin, scratches more after being in exam room for a while, scratches till bleeds, prefers cool floor. Tongue - red upper jiao, mild white coat. Pulse rapid, soft, broad, deep.
Continued QYT, added 4 Yellows ("Coptis and Scute") for abi action.
More crusts, large flakes of skin, skin smells more, ears warm but paws cool. Still scratches till bleeds.
Changed formulas to Long Dan Xie Gan Tang with Dan Shen and Ku Shen added (had some from another case).
Got vaccinated. Skin - slight improvement but not much. Less eye discharge. Still lots of crusts on dorsal lumbar, skin still smells. Skin has greasy feel but fur coat feels dry. Large dandruff flakes. Tongue - red, flabby, slightly white coat. Pulse - rapid, forceful, wide. Added Yin Care Herbal wash, Added Hoxsey opposite time of day to LDXGT. Also tried Belladonna 7CH homeopathic.
Off LDXGT by time rechecked, just on Hoxsey. Skin improved - some fur regrowth, less greasy feeling, no bleeding sores, less papules, less smell. Now dorsal scapular area affected - less undercoat. Feet cool, ears warm. Tongue - red (muddy red), dry appearance. Pulse rapid, wiry
Decided to go back to QYT with hoxsey.
Skin worsened so reg vet started abi and pred 1 week prior. No pruritus, alopecia still but minimal erythema. Calmer and less agitated. Large dandruff flakes. Tongue - red, mild white coat, bit flabby. Less agitated but still not allow AP. Pulse- slippery, rapid but slower than prev. Decided to stop Hoxsey, roll in Modified LDXGT with QYT
Got pancreatitis 2 weeks prior- anorexia, vomiting yellow bile - was hospitalized. Stopped pred and "alternative" meds. On zantac and cephalexin. Fur regrowth except undercoat at dorsal scapular area, flanks, axillae. Tongue - pink, mild white coat. Pulse - slippery, slow, superficial to med depth. Restarted Modified LDXGT. Stopped other.
Did really well - more fur regrowth, then past 7 days (this is July) - scratching/chewing, fur loss, pustules, alopecic spot to left of tail base. Diet changed to Wellness canned , orijen dry after pancreatitis. Superficial pyoderma - ventral abd/inguinal area. Dorsal lumbar and thorax crusts and collarettes. Large dandruff flakes. Bleeding lesions of left flak and ventral chest. Tongue pink, mild white coat with spots of pink thru' coat. Pulse slippery, mod speed, deep. Decided to try abi x7 days to calm skin, then restart Mod LDXGT. Skin improved on abi but since off Abi and on Mod LDXGT skin is worse - getting "bumps" acc to owner. Decided to go back to QYT (thought maybe did not use long enough) & added CSWLT to address more of Damp, also restarted 2 week course of abi. Owner reports no side effects to abi, bumps subsiding,scratching less, still smells, still flaky skin.

I really expected the dog to respond to Mod LDXGT and was surprised when she did not. Really think she is Damp Heat. But now wondering if I should be following the Blood Defic route. Or maybe should use QYT with SRT?? or other...

Thanks.
Michelle Kinoshita

by naturevet

September 3, 2009

Hi Michelle,

“Alopecia/erythema, lichenification worse on ventral surfaces but also dorsum affected & perianal and perivulvar areas, medial forelimbs”

Heavy involvement of Yin surfaces generally suggests the present of a Yin pathogen – particularly Damp Heat.

Scratches till bleeds. Papules on dorsal lumbar. Sneezes when skin flares.

“Tongue pink-red underside and tip, mild white coat. Pulse - deep, soft, rapid. Mu Liv 13. Active BL 20, Liv 13”

These points are very common in a Damp Heat skin case. The pulse, however, suggests we need to move blood out toward the skin, rather than in and away from it. This suggests the inflammation is very chronic, with increased perfusion being expected to better combat skin pathogens and flush away inflammatory mediators.

The cool paws supports this ‘take’ on the situation. Many formulas for itch act to move Blood internally. If we need a Damp Heat formula that disperses, San Ren Tang (Three Seeds Decoction) is a better choice. Si Miao San, when used without modification, pulls blood inward to the splanchnic circulation.

“More crusts, large flakes of skin, skin smells more, ears warm but paws cool. Still scratches till bleeds”

Qing Ying Tang is quite moistening, although it moves the Blood outwards. So a Damp animal will show increased Damp Heat signs on the formula. Hoxsey and LDXGT move blood inwards, so with those persistently cool paws, I wouldn’t expect them to work that great for us.

“Got pancreatitis 2 weeks prior- anorexia, vomiting yellow bile - was hospitalized. Stopped pred and "alternative" meds. On zantac and cephalexin”

Even though we can expect it was the pred that caused the pancreatitis, the response of the dog to pred can be viewed as one more of the dog’s symptoms from a TCM perspective. Certainly those signs are directing us to the middle burner and suggesting the role of the Spleen and Stomach. So one of our Damp formulas is still a good call.

Fur regrowth except undercoat at dorsal scapular area, flanks, axillae. Tongue - pink, mild white coat. Pulse - slippery, slow, superficial to med depth. Restarted Modified LDXGT. Stopped other.
Did really well - more fur regrowth, then past 7 days (this is July) - scratching/chewing, fur loss, pustules, alopecic spot to left of tail base. Diet changed to Wellness canned , orijen dry after pancreatitis. Superficial pyoderma - ventral abd/inguinal area. Dorsal lumbar and thorax crusts and collarettes. Large dandruff flakes. Bleeding lesions of left flak and ventral chest. Tongue pink, mild white coat with spots of pink thru' coat. Pulse slippery, mod speed, deep. Decided to try abi x7 days to calm skin, then restart Mod LDXGT.

“Skin improved on abi but since off Abi and on Mod LDXGT skin is worse - getting "bumps" acc to owner.”

Assuming the owner is correct, this supports the notion that the problem is impaired peripheral blood flow and secondary infection.

“Decided to go back to QYT (thought maybe did not use long enough) & added CSWLT to address more of Damp, also restarted 2 week course of abi. Owner reports no side effects to abi, bumps subsiding,scratching less, still smells, still flaky skin.”

CSWLT moves blood peripherally and is non-dampening, so it may explain the beginnings of the improvements you’re seeing. If my theory is correct, if you pull back on the QYT dose a little, the dog should do better still. Let us know how it goes…..

Steve

by MKinoshita

March 15, 2010

Steve,
Help!!
Used QYT with CSWLT with Ku Shen added. No improvement so added abi. Stools softened with abi. (On raw diet). Stopped QYT and continued abi with CSWLT. Worsened off abi.
Decided to try BZYQT with Ku Shen and Albizzia (was getting some anxiety if owner was late returning from work) to support Sp and strengthen Wei Qi.
Skin improved very slightly. (No abi for 3 weeks prior.) Still Perivulvar/perianal alopecia, with perivulvar hyperplasia. Flanks alopeica, erythema, hyperpigmentation. Ventral chest - thin fur. Ventral abd/inguinal alopecia, erythemic papules, hyperplasia and hyperpigmentation. Ventral chin - erythemic papules. Periorbital alopecia with hyperplasia, custs. Lumbosacral - occnal crust, mod dandruff flakes. Pulse deep, wiry, rapid, Tongue - red underside, slight white coat in caudal jiao. Continued BZYQT modified with Ku Shen, He Shou Wu, Bai Ji Li.
After 3 weeks, owner noted more "bumps". Dog did not eat right away (but eventually ate), bit lethargic for 12 hours. Started a western Berberis formula - stools softened after 2weeks of use. Exam - tongue - pink/red - slightly purplish, swollen in Liv/GB area; Pulse slippery, mod to superficial depth, mod speed. Skin exam similar to prev but more crusts/scabs and hyperplasia. Recommended feeding the raw food at room temp, rather than cold. Decided to try Dang Gui Shao Yao San with Bai Ji Li, Ku Shen and a tiny bit of Buthus Martensii (scorpio). Boy, that was a mistake - Skin became way worse - more hyperplastic, more alopecic, pruritic, affecting dorsum and ventrum now, perianal/vulvar area more hyperplastic. Hyperplastic nipples. Had heart murmur (new). Scooting. Also signs of uti - PU/PD, dysuria, hematuria - u/a indicated uti (rbc, bacteria, no crystals) Pulse rapid, superficial to moderate depth, slippery. Tongue pink/red, mild white coat, swollen edges in Liv/GB area.
Changed diet to novel protein raw diet. Debated btn using SMS or CSWLT - decided to go with Dispel Dampness and Nourish the Skin and use Unda # to treat UTI.
Email communication today (2 weeks later) - not doing well (skin and uti)- so I guess I should have gone with SMS.
Questions are - Since the pulse was more superficial, was that an indicator that it was time for SMS or should I have used SMS with Dang Gui? For the UTI, would SMS be adequate, or would I need to add in another formula?
Should I go back to BZYQT to support the Wei Qi as we come into the dog's allergy season again? Can I use it in combo with SMS?
Thanks.
Michelle K.

by naturevet

March 16, 2010

Hi Michelle,

Tough case. You had the idea before of using San Ren Tang. That's probably the best Spleen formula to use when the pulse is not strong and superficial. Since BZYQT was helpful, you can go back to it, but if you're not on it yet, you can give SRT a try. Ku Shen can be added to decrease the dog's itch.

Sometimes (rarely, fortunately) I have to use pred to bail a dog out. I just make sure to examine the dog while it is on the pred, since the drug 'pares the branches to expose the root'. For sure this dog is Damp, and it's a mystery why it hasn't responded better for you. I think some of these dogs have a lot of conventional medical problems layered on top of each other - bacterial infection + fungal/yeast infection + endocrine + allergy, for example - and it's just too much for the herbs to tackle. I saw a patient of mine yesterday that was like that. You may not think the herbs are working, but they work well enough that when you take the dog back off pred and antibiotics (for example), the lesions don't recur. In that sense, the herbs effect a long term cure, but need considerable pharmaceutical help along the way.

So you may want to keep that in mind. It's not the usual circumstance, but it happens.

Meanwhile, I'd try San Ren Tang, as that stone still hasn't been overturned.

Steve

by MKinoshita

March 16, 2010

Steve.
I guess I forgot that I tried SRT. Used it with the QYT. And with Nettles. Can't use pred dt pancreatitis. Ended up using abi again. Then I tried the BZYQT.

However, I have not tried it without QYT, so will see how it goes.
She's starting abi again too.
Thank you.
Michelle

by MKinoshita

May 12, 2010

Steve -
Update and question...
I changed to SRT added Pred at 2.5 mg daily and Reactine at 20 mg daily and cephalexin x 3 weeks (plus ongoing probiotic). Definite improvement but not sure what did it. Skin less erythemic, pruritus decreased, dog less restless.
Decreased changed pred to 5 mg EOD, finished abi, continued SRT and probiotic. Recheck - fur starting to regrow a slight bit(but still pretty naked caudoventrally, perianal/perivulvar area and lateral thighs), perianal/perivulvar hyperplasia lessened slightly. Pruritus worsens close to time when pred is due. Thinning of undercoat dorsally over lumbar and thoracic area with erythemic patches. Has had 2 small perianal skin tag-like growths at 7 and 11 o'clock position that sometimes are smaller in size and sometime slightly bigger in size (but overall are not growing much (3-4 mm)) but found new one (15 mm) adjacent to vulva with a different appearance - firm, raised and slightly nodular, alopecic but not erythemic, attached. FNA - Basal cell tumour.
Pulse is still deep, but slower than previously noted, wiry but wider and softer than usual. Tongue - red/purple underside, mod white coat with small patches of erythema (or no coat) in lateral caudal jiao area mostly (not in centre), edges slightly flabby. (Never get much reaction on palpation of shu or mu pts. Active pts hard to assess dt overall inflammation.)
I continued same tx, but given the growth of this new tumour am not sure SRT is the best formula.
Question: Do you think I should try a stronger Moving and Damp formula? Would SMS modified with Dang Gui to bring to periphery be an appropriate choice? (prevly used modified LDXGT (with no real success) but have never used SMS modified or not).
Thanks.
Michelle

by naturevet

May 13, 2010

I, also, was thinking SMS plus Dang Gui. I think I'd go with that next.

S

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