AAVD DERM DIALOGUE FALL 2021 by TEAM

DERM DIALOGUE

FALL 2021

Editor: Norma White-Weithers, MS, DVM, DACVD • Veterinary Allergy & Dematology Consultant, Baldwin, NY 11510 Work: 646-329-4719 • Fax: 631-694-3401 • E-mail: nweithers@yahoo.com Assistant Editor: Tim Strauss, DVM • Frederick,CO 80516 | E-mail: drtim@comcast.net

FROM THE PRESIDENT Dear AAVD members Hope everybody is in good health and staying safe in these strange times On behalf of the executive committee I hope everybody enjoyed virtual NAVDF 2021 as much as I did and I hope that people took advantage of the ability to attend lectures for the additional two months after the conference itself is over.

Dr. Klaus Earl Loft, DVM AAVD has been working with the organizing committee and the program committee to secure recordings of this year’s NAVDF lectures. We are in the process of creating a library of lectures from this year’s meeting and potentially future meetings that would be available on the password protected section of our website. These recordings will only be available for paying members of the AAVD at this point, We will likely be making this available starting in the early New Year on the www.AAVD.org. The executive board hopes that the Academy sees this as one more valuable membership benefit and will use this opportunity to review, revisit or see lectures from our fantastic meeting that we were able to have been spite of COVID-19. Please go check out the website to update your membership information on our password protected sections, so we all can use this as a portal to find and contact peers and colleagues. Remember you can also pay your membership fees online, check out bylaws and past meeting minutes and information about how to nominate for the Frank Král award. We hope to have the in person presentation of the 2020, 2021 and 2022 recipients in New Orleans in April 2022. Also remember to check out the AAVD Facebook page, as we are constant working to improve these sites and if you have suggestions, requests or comments or events we all can benefit from. Some of might have noticed that ISVD have generously allowed us to share their fantastic “case of the month” with the academy, please take advantage of this great resource also on the website. This year’s NAVDF virtual meeting went really well and I want to thank the entire organizing committee and the program committee for their hard work putting this meeting together under these difficult circumstances and being very successful. I hope and think this virtual meeting, will serve as the best possible promotion for next year’s meeting in April in New Orleans, where it will be held at the Sheraton from April 27-30, 2022. I think I can speak for everyone; we all hope that this meeting will be in person. Continued on page 2

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FROM THE PRESIDENT

The 9th World Congress broke successfully into the virtual meeting format last fall and had a fantastic record breaking attendance and I think the AAVD can be very happy with the financial support we will gain from this conference. With a large number of AAVD in attendance both in the World Congress and the NAVDF we will get a significant share in the surplus from these conferences, which will allow us to continue and expand our support of the field of veterinary dermatology. The AAVD will do this across multiple traditional areas, as well as novel ways, that the AAVD executive board have been working to bring to our current and future members. The AAVD continues to support that advancement of dermatology in North America traditionally with providing funding for the ACVD/AAVD research grant, scholarships like this year’s registration to the world Congress, which was won by Dr. Claire McCaffrey, as well as our 29 North American Veterinary student awards for 2020. The recipients are given two year free membership to the AAVD as well as $200 and the AAVD reduced registration to the following year NAVDF meeting. The AAVD is working closer with the ADVT and the board are welcoming Chantelle Hanna, CVT to the executive as a non-voting board member and we are looking forward to find new ways where the AAVD and ADVT will be able to help each other. It was great to see the large number of veterinary technicians attending this year’s meeting with 90 technicians in attendance. AAVD is supporting with giving a free registration among the registered AAVD technicians congratulation to Kim Horne for winning. Just like last year the AAVD sponsored 2 lectures and a roundtable session with the invited a speaker at this year’s NAVDF where Dr. Blackwood spoke on self-care in the daily work life and the how stress impacts us physically and mentally. The AAVD have managed to get Justine Lee from https://vetgirlontherun.com/ to speak at the NAVDF 2022 as our 3rd AAVD organized speaker, we all hope that bringing these topics to the front can help the members in ways not considered traditional topics for a dermatology meeting. We are also in the process of creating a NAVDF roundtable event that will be free for AAVD members, more to come on this as well as new initiatives on social media to come this year. The AAVD started a new initiative in the fall and winter of 2020-21 as a way to give some additional member benefits and to generate more excellent for Norma Weithers and Tim Strauss our fantastic Derm dialogue editor team to publish: so far we have held the first three AAVD virtual roundtables/panel discussion. Thank you to Drs. Rose Miller, Karen Trainor and Candace Sousa and guests for their excellent virtual roundtables in September 2020, January and October 2021 respectively all have been great and we hope to get the summaries both in the Derm dialogue and on the website for everyone to use. These roundtables will be a continuous events at likely 2 to 3 times per year and we are looking to identify topics and roundtable moderators for our virtual format for our membership. Please support these events and if you have suggestions for moderators or topics to discuss please reach out to any member of the executive board. I want to take this time to thank all the AAVD executive board members (Drs. Rose Miller Vice President, Verena Affolter Treasurer, and Catherine Outerbridge, Past President) for their continued work in this virtual part of the Academy and your willingness to work and be flexible. I want to Dr. Andrew Millis for his service to the AAVD as he has left clinical practice and is stepping down from the executive board we appreciate his time and effort contribution to the Academy. The board also wants to thank Dr. Jeannie Budgin for all her hard work as the AAVD representative the world Academy. She has accepted to stay on for another four years as the AAVD representative and we appreciate her insight and all the experience she brings to the job. At the recent election the more than 100 members voted electronically to expand the board with additional members and we are so happy to have the following three members at large to the executive board, so please welcome to Drs. Anna Jenstead, Brian Scott and Natalie Theus, and thank them for bringing their time and work to grow the AAVD into the future.

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FROM THE PRESIDENT

All of these and more are why the AAVD continues to be relevant and part of the fantastic field of medicine we all love and we hope that you all see the value in part take and support the AAVD, so we together can support each other and the progress across the pharmaceutical industry, clinical practice from private or cooperate general practice to referral, research, academia, pathology and government wherever our Academy members are. On behalf of the AAVD executive board I am so happy to see the new and old members showing their support and we look forward to see you in April and we will have a small gift to all members in good standing at the NAVDF 2022. Best wishes for a safe and healthy year and looking forward to see you all in 2022

Klaus Earl Loft, DVM

President AAVD Executive Board Co-chair NAVDF Program Committee Co-Chair Sponsorship and Exhibitor of the NAVDF Organizing Committee

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Meeting Planner

ktravitz@pamedsoc.org

Administrative Assistant

Jill Bennish,

Overview of Staff jbennish@pamedsoc.org and Leadership AAVD Executive Board

NAVDF Program Committee

President Dr. Klaus Loft Boston, MA

Members-at-large Dr. Anna Jenstead Chicago, IL

Immediate Past-President Dr. Catherine Outerbridge Davis, CA

Dr. Brian Scott Largo, FL

Program Chair Dr. Sandra Koch Co-Chair Dr. Klaus Loft Dr. Petra Bizikova Dr. Alberto Cordero Dr. Gram Dunbar Dr. Brian Scott

Vice President Dr. Rose Miller Coeur d’Alene, ID

WAVD Representative Dr. Jeanne Budgin New York, NY

Treasurer Dr. Verena Affolter Davis, CA

Editor, Derm Dialogue

Dr. Natalie Theus Columbus, Ohio

Dr. Norma White-Weithers

Baldwin, NY Executive Secretary Michele Boylstein

WAVD Committee

Administration Secretary

AAVD Representative to the WAVD Dr. Jeanne Budgin

NAVDF-OC Committee Positions Term Name Affiliation Email Chair 2021-2023 Dr. Rose Miller AAVD RMillerdvm@gmail.com Co-Chair 2021-2023 Dr. Kristin Holm ACVD Kshdvm@yahoo.com Treasurer 2021-2023 Dr. Allison Kirby ACVD Alliekirby@yahoo.com Social & Sponsorship Chair

2021-2023

Dr. Dana Liska

ACVD

Danaliskadermvet@gmail.com

Social & Sponsorship 2018-2023 Co-Chair OC Mbr AAVD 2019-2023

Dr. Klaus Loft

AAVD

Klausloft@gmail.com

Dr. Norma White Weithers

AAVD

Nweithers@yahoo.com

OC Mbr AAVD

2021-2024

Dr. Anna Jenstead

AAVD A

Jenstead@gmail.com

OC Mbr ACVD

2020-2024

Dr. Lindsay McKay

ACVD

Lindsay.mckay@vca.com

OC Mbr ACVD

2021-2025

Dr. Melissa Eisenschenk

ACVD

melderm@gmail.com

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ROUNDTABLE SUMMARIES Teledermatology Moderator: Rose Miller, DVM, DACVD

Questions on the current use of telemedicine were asked of the participants prior to the roundtable. 12 participants were utilized telemedicine and three were not. Nine of the participants that were utilizing telemedicine started due to the pandemic. One participant had been using telemedicine for numerous years. Another question asked prior to the roundtable, was which platforms were being used for telemedicine. Eleven participants have used Microsoft teams. Seven participants have used Zoom. One participant has used Televet with some glitches in the beginning but resolved with time. Three have used VETNow with some challenges in the beginning. One participant has used Facetime and one has used Intermedia Unit. One participant that has used Zoom felt this was a good resource due to the client’s comfort with this program. This participant was performing telemedicine one specific day of the week when they were out of the office. Scheduling was performed through Calendly app; this is a free resource that integrates with Zoom and sends a link for the meeting. The participant also used a JotForm for intake including images. The clinic would call the client prior to the exam for prepayment. Another participant would bill based on the amount of time needed for the appointment and it was billed in 30-minute increments. They collected payment after the exam. Another participant uses an automated system through their website (GoDaddy) which allowed for booking of exams. The examination was performed through Zoom in the beginning, but the participant was frustrated with the inability to flip the camera direction and switch to Microsoft teams which allowed feature. Microsoft teams also allowed for recording of the examination. If the client was able to send pictures prior to the examination this was very helpful and required by many participants. One participant felt strongly that telemedicine will be part of our future in veterinary dermatology. They also thought it was a good way to capture charges that had been missed in the past for phone conversation with clients. VetNow was discussed as a platform. It was piloted by a location with 3 doctors that were on the roundtable. VetNow is an integrated system which allows for capturing charges. The initial use of this program lead to some challenges with communication of the systems. Due to the challenges this group switched to Zoom with more success, although this led to additional work for billing. It was mention again that images provided by the owner prior to the examination were very helpful to evaluate the patient. A participant was concerned with the overall use of telemedicine due to the difficulty of evaluating ears, paws and inability to perform cytology. Another participant felt like it was important to reframe your goals for the examination when it is performed through telemedicine and allow for a curbside appointment for cytology and otic exams if needed. This participant felt telemedicine allowed for a more focused discussion with the client. Another participant felt like telemedicine was a good source to screen clients that potentially needed to come in for an examination. This is something that was typically unpaid, but now by using telemedicine we are able to capture this charge. It was also mention that some clients that live hours away from the clinic will continue care with the clinician when telemedicine is an option for an examination and discussion. Continued on page 6

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Telemedicine is used at one practice as an adjunctive option but not as a replacement for all dermatologic examination. The participant thought it was very beneficial for some satellite locations that are not visited frequently. This participant has had success with the VetNow platform. There were initially some challenges with VetNow but having all aspect of the program in one place was helpful. The effectiveness of this program paralleled with the clients’ abilities to use this technology. If problems occurred, the client would use Zoom, which was very helpful. This participant thought training the staff on the platform that is being used helped increase the success of the appointment. Another participant mentioned that had success with Rapport through Infinity software which has a telemedicine option through a video conference. Another participant asked about having the clients sign consent forms to allow telemedicine to be performed. It was then discussed that many states have different laws on telemedicine use. One participant in the UK was able to send packets to the clients to perform cytology and send them back to the doctor for evaluation. This allowed for effective samples to determine appropriate diagnosis. Another participants discussed the fear that if cytology cannot be performed thought telemedicine we could have decreased antibiotic stewardship. The group did agree that this could be an issue and antibiotics should be used judiciously. Positives and negatives of telemedicine were asked of the participants prior to the roundtable and are listed below: Positives Six participants: • Felt it was more convenient for clients and the doctors who can potentially work from home. • There was better compliance. • It was more accessible for long distance clients. Five participants: • Thought the doctor was able to get paid in a situation where they would typically have given free advice. Three participants: • Allows more people to access dermatology care. Two participants: • Strengthen the relationship with client and allowed for more efficient, and longer needed discussion with the client. Continued on page 7

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One participant: • Allows more communication with referring vets which strengths that relationship. • It works well for clients if the pet is maintaining well with the current therapy. • Increases the accuracy of the medications and diet because the client is at home during the appointment. • It can be fun to see the pet in the natural habitats. • There is a potentially for more caregivers can be present during the exam Negatives Six participants: • Unable to takes samples/diagnostics which are a tool to aid in diagnosing. Five participants: • Challenging with clients for with technology difficulties Three participants: • Not useful for otitis cases • Challenging to see some lesions through video • Unable to dispense medications directly which could possible lead to less revenue • Can be limited due to state practice laws One participant: • Possible over prescribing of oral antibiotics • Special software sometimes needed • Some clients can be reluctant to schedule • Not as fun

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ROUNDTABLE SUMMARIES A Practical Approach to Self-Care Moderator: Lesley Blackwood, DVM, CCFP Attendees: Dr. Klaus Loft, DVM, Angell Animal Medical Center Dermatology Dr. Julia Miller, DVM, DACVD, Cornell University CVM Dr. Julie Kluxdal, DVM, Dechra Dr. Betsy Jordan, DVM, DACVD retired Both board certified veterinary dermatologists and general practice veterinarians were well represented. The purpose of this roundtable discussion was to evaluate the challenges with implementation of self-care techniques and discover practical solutions to improve physical, mental, emotional, psychological and professional self-care activities in everyday life. All participants were emailed a self-care assessment and self-care plan to complete prior to the discussion. All participants during introductions expressed the need for techniques to manage stress in veterinary practice. As we begin to return to some normal aspects of life one year since the pandemic began, it was mentioned that this a perfect time to reassess our self-care needs and activities. Additionally, participants expressed the need for a worklife balance and guidance to effectively mentor the next generation of veterinarians. Why is it that self-care seems to be the first thing we let go of when times get busy? Our profession historically seems to involve others first (patients and clients) and, unfortunately, this translates to self-sacrifice for veterinarians. In practice, there have been many times I gave up aspects of my personal life for clients and patients. Don’t you think other professions during times of stress also give up on self-care too? Yes, I think there are certain professions that lend to that mindset. But no matter what profession, everyone has demands and stress in their life. In veterinary medicine, the veterinarian is involved in every aspect of practice and there is too much accessibility to the veterinarian. In contrast, in human medicine, a physician would never be involved in billing disputes or be expected to answer emails directly from patients. Because our clients expect it, it’s hard to change the culture. This needs to change especially with regards to establishing healthy boundaries. We need better balance in serving our clients appropriately, and taking care of ourselves as well. Going back to the idea of sacrificing self-care, I think sacrificing self-care does spill over to other professions. It seems that it may be more related to personality type rather than profession. For veterinarians, we spend so much time in school, and so in the early parts of our career, our profession defines who we are as a person. As a result, we commit to long hours at the sacrifice of ourselves. It all goes back to the need to establish healthy boundaries. Can we address the idea of too much accessibility in veterinary medicine? It seems that having text/email accessibility on our phones has negatively impacted us in the realm of self-care. As technology and accessibility evolves, we need to also re-establish our boundaries. Establishing healthy boundaries is one of the most important aspects of psychological self-care. Twenty years ago, I would never have thought I would have been expected to respond to someone within 5 minutes. The accessibility has increased, and expectations are even greater.

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So, who will be the successful veterinarian of the future in the face of changing times and technology? We all are prime members now and that desire to have immediate response with regards to goods and services transfers over to other industries. We need to create a system for establishing expectations for service. We need to find a path where we protect ourselves but also allow for growth with our industry. If I’m hearing the group correctly, it seems the problem is really unrealistic expectations. How do we manage these unrealistic expectations on the front end rather than dealing with the consequences on the backend? Communication is key. We must establish professional boundaries and then communicate these expectations to the client in the initial meeting. We also have to hold ourselves accountable to adhering to established boundaries. Making the decisions and following through on it is important. The one time we deviate from the boundaries, that can become the new expectation. For one participant having two separate phones for personal and business use works because it allows me the opportunity to turn the work phone off at set times and leave home on vacation. That is just one idea and a good decision I made for myself. With clients, if you say yes to unrealistic demands or make an exception, that will set a new pattern and the client will expect that in the future. Communication is so important, but we also need the people to do the communication. Specifically, the technician doctor ratio needs to increase. We also need to train our employees to handle difficult clients. That could help our support staff manage unrealistic demands from clients. We also need to be better with firing clients who don’t respect established boundaries in our practice. The key is finding the balance….having availability but respecting boundaries. In working in the corporate side of animal health, one of the problems veterinarians encounter is the problem of letting go of the business side and hiring someone to do that. This goes back to hiring appropriate number of support staff members, so the veterinarian is not doing everything. What are the obstacles we face in prioritizing self-care activities? Time and money. For one participant, COVID has really put this into context. I’ve worked in dermatology for 20 years and I have never seen as many patients or generated as much money as I did in 2020. The choice might be to pair back expenses and free up time for self-care activities. Something else has to give in order to make time for oneself. I think it is also identifying the value of self-care activities. Sometimes the positive impact isn’t immediate. It can take a while to see the benefits. So, you have to be willing to give yourself the time and understand the potential benefits. For another participant, it’s several factors. “I am so bad at saying no and as a result, I take on a lot of extra work even after hours. It’s hard to identify ones self-worth, versus how others view my worth as a dermatologist. I put too much value on how others value me. It would be good if I could find the worth within myself and learn to say no”. As mentioned by another participant, “having worked until I had children, I felt I couldn’t continue to practice the way I had before, with 100% commitment and also be a good parent. So, participant did step back from the profession to support the family’s needs. I think this topic is interesting from my perspective; I think I could have Continued on page 10

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had better balance as a veterinarian and parent. Dermatology is probably even better suited for work-life balance than other specialties. Student Loan: Some do think it’s hard for veterinarians because they all feel trapped with student loans. Some veterinarians are working a day job and emergency shifts just to pay off the loans. It’s hard to see beyond the financial obligations and that just increases the stress level for practicing veterinarians. This goes back to obstacles in implementing a good self-care routine….time and money. Given the fact that we cannot eliminate the financial obligations and we cannot make more time, what can we do with self-care routines that doesn’t involve time and money? Self-compassion is a good foundation for self-care, and it does not require time or money. It only requires mindfulness and a commitment to how you view yourself. What attitudes do you have towards yourself when you fail to meet other’s expectations? Being negative to oneself was mentioned by a participant. “We have a lot of compassion and empathy for others, but I think we need to tell ourselves that we deserve compassion as well”. Avoiding burnout in high stress positions is also addressing the system. The system will also ask more of you if you’re willing to keep giving it. So, we need to have an attitude of “I’m doing the best I can and I’m giving enough”.

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ROUNDTABLE SUMMARIES Dermatology During a Pandemic: How Covid-19 Has Changed Practice Culture Chantelle Hanna, BS, CVT, VTS (Dermatology, Charter Member) Participants: Dr. Carolyne Hours, Zoetis, Canada; Chantelle, CVT, VTS (Dermatology); Dr. Norma White-Weithers, DACVD; Dr. Lynn Schmeitzel, DAVCD; Dr. Heather Edginton, DACVD; Yolandie DeHanes, CVT; Shilo Anderson, LVT, VTS (Dermatology); Melissa Streicher, AAS, CVT, VTS (Dermatology)(Note-taker); Dr. Lisandro Reynes, Dermatologist. Discussion was centered on how Covid-19 has changed the way we practice, including how we interact with clients, colleagues and staff, from major policy shifts to canceled potlucks, and the logistical issues that accompany those decisions. In March of 2020, our lives changed dramatically in every way. Suddenly we were living life straight from the pages of a fiction novel. We were thrust into an existence of solitude, having to come up with creative ways to stay connected, stay sane, and for those of us in an essential profession, a stay safe while still providing essential services. Introductions Participants went around and introduced themselves. Each gave an overview of how the pandemic has affected them in the daily and practice life. • Many had experienced a dramatic increase in case load, pondering if this related to the fact that people were now home, spending more time with their pets. • Some participants either voluntarily or involuntarily took time off from work. • Clinics that remained open shifted to a “Curbside-Only” practice. Was the dermatology practice kept open or deemed non-essential and closed? One board certified dermatologist discussed her decision to take some time to consider her career path when Dermatology was deemed non-essential at her practice. Within weeks, the practice contacted her to reopen the dermatology service as a telemedicine practice using AirVet. It consisted of consults only with no procedures. In June, the state restrictions were lifted, and the practice decided to open as “Curbside-Only”. The practice worked with Dr. Schmeitzel to develop a hybrid traditional/virtual medical protocol that functioned within the law. The visit was conducted as follows: The ER or Internal Medicine doctors would perform the physical exam. Dr. Schmeitzel would then do an I-phone exam. Her technicians would do the diagnostics they could (cytology, scrape), sending photos of microscope fields to her, if necessary, for review. She would then video chat with owner. After putting the plan in the computer, the technicians would see to it that any additional diagnostics, such as biopsies, are done by either the ER or Internal Medicine Service. Dermatology was also deemed non-essential at the University of Auburn which shut down and sent students home. Technicians were temporarily re-assigned to other departments. Also discussed was how the University addressed the need for students to do rotations when the dermatology service was closed. Once the service was reopened and senior students were no longer virtual, they were split into teams to minimize the number of students on rotation. Underclassmen remained virtual. We discussed the fact that telemedicine was not a possibility in NC so Southeast Veterinary Dermatology in Charlotte was kept open, switching to a curbside-only protocol.

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For those clinics that remained open, what changes were made? • Most clinics transitioned to a curbside-only practice, but a few remained open to clients. • PPE protocols were put in place for staff. • Health protocols were put in place for some, requiring employees to take temperatures. Sentinel testing was implemented at the University of Auburn and they provided each employee with their own thermometer. They are using a self-reporting system where you log in, record your temperature and answer health questions. • For those that remained open to clients, cleaning protocols were increased and the number of clients per pet was limited. The use of exam rooms was rotated to allow for proper disinfection between uses. The length of time spent with the client in the exam room was limited at one practice. Clients are also not allowed to move freely around the clinic and are escorted through the building. • Some clinics instituted phone trees to handle the growing number of calls coming in. • Some clinics doing curbside brought in portable toilets for clients to use while others had a client-only bathroom that was cleaned after each use. • Signs were used to number parking spaces at some clinics. Clients were either asked to bring pets to the door or the technician would go to the client in their numbered space. • All paperwork is being done electronically, including using DocuSign, to minimize client contact at most practices. • Exam rooms were transitioned to kennels where large dogs could be kept. What problems have been encountered in this new paradigm? • Already busy technicians have taken on the role of receptionist now that they are discharging clients over the phone, scheduling follow-up appointments and taking payment. • Infrastructure was insufficient to support having numerous doctors and technicians using phones and computers simultaneously. Some clinics had to upgrade their phone systems, add workspaces, and purchase more computers to handle the workload. • Most participants note a general increase in anxious patients although some owner-protective dogs are easier to handle now that they are being taken away from the owner. • Many clinics have started carrying behavior-modifying medications such as Trazodone, Gabapentin, Melatonin, or Acepromazine to manage the increase in aggressive animals. Masks were discussed as a possible trigger for some dogs as it obscures the face and draws attention to the eyes, making some dogs feel challenged. • Backorders were a big issue last year for a lot of the drugs we use in veterinary dermatology like dexamethasone SP and hydrocortisone products. PPE was also extremely hard to get early on as veterinary medicine was in direct competition with human medicine for gloves and masks. • The length of each appointment was increased for some doctors because there were so many extra responsibilities being done with the same number of staff. • Clients were angry about not being able to come in with their pet and some refused to have their pet seen if they couldn’t be present. • There are safety and liability concerns for some clinics that sit on a busy street in having the staff be responsible for getting the pet from the car to the building safely. Those clinics have put the responsibility on the pet owner to get the pet safely to the door. Continued on page 13

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Was there an upside to having to adapt? • Some doctors feel they are doing are more thorough dermatology exam now that they aren’t trying to examine the pet while simultaneously educating the client in the exam room. • Some doctors have enjoyed transitioning to a virtual working environment. • Technicians have been able to free up time for other tasks by transitioning client education to virtual platforms like YouTube or emailing “How-To” videos for things like allergy injection instruction, shampooing, and ear cleaning. • Most clinics, across the board, have experienced moderate growth. We are busier than ever, seeing more clients and patients every day. The conclusion? No one can say where we’ll be in another 3 months, 6 months, or a year. Hopefully, we will continue to adapt in a way that keeps us healthy as well as our patients. Thank you to all who participated in this round table.

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ROUNDTABLE SUMMARIES Business in Veterinary Dermatology Moderator: Steve Mrha, CEO Animal Dermatology Group, Inc. Secretary: Rusty Muse, DVM, DACVD Introduction The registered attendees embodied a “nice” cross section of the United States as well as an international representation. The round table was designed to discuss the business aspects of veterinary dermatology which encompasses a wide range of topics and issues. An overview of the 2020 veterinary industry statistical trends (revenue and client visits) were discussed which saw a marked drop in business in the months of March and April. These months accurately reflect and correlated with major US shut-downs and restrictions that were put into place due to COVID-19. However, starting in June, the remainder of months throughout the year 2020 marked significant increases in business for the veterinary industry as a whole and this seems to be comparable with the veterinary dermatology specialty business nationwide. There were several suggested topics and proposed areas of discussion which included: recruitment and retention of employees, pharmacy within the practice, marketing of veterinary dermatology services, expansion of services (horizontal and vertical expansion), financial Key Performance Indicators (KPIs), and an open discussion for other topics. Recruitment and retention of employees The question was asked about how dermatology businesses are attracting and retaining employees. There was a substantial discussion around work-life balance issues and attempts to maintain employee’s emotional well-being in this extremely demanding environment, especially while adapting new protocols due to the COVID pandemic. Most clinics and employees are incredibly busy and there was general concern about burnout of these employees. A number of strategies were discussed that have been implemented in various businesses for employees including: making sure that employees have one day off per week (i.e. implementing a 4/10 schedule) when possible, developing an employee cash incentive program when the practice hits their targets, scheduling “mental health” blocks during the day (i.e. appointment cancellation) for employee “catch-up” time, offering doctor’s leadership training on “Emotional Intelligence” and counseling doctors that clinic leaders need to model healthy behaviors as examples for their employees. Specific employee programs have involved developing yoga “quiet” rooms for staff during their breaks, having outside clinic walks during breaks, having a masseuse for chair massages during break times and having counseling available for employees to discuss personal issues that could be impacting their clinical performance. It was generally agreed that it is critical for the success and stability of clinics to develop strategies focused on supporting employee’s emotional well-being. Pharmacy issues affecting dermatology clinics There are numerous business issues that have impacted the pharmacy within veterinary dermatology practices. One topic focused on the influence on-line pharmacies have on the business of veterinary dermatology. It was generally agreed that they do have an impact. There are advantages and disadvantages to working with on-line pharmacies. Many practices and dermatologists spend substantial time reviewing on-line requests, reviewing clinic records to verify drugs, dosages requested and then signing and returning requests. All of this is done as a “free” service for the clients as on-line pharmacies provide no benefits to clinicians. Developing a standardized template for all on-line pharmacy requests with an auto-populate feature of the important information can be used to streamline the process for clinics that have a large number of requests. A major concern experienced by many dermatologists is when an on-line pharmacy makes a mistake in filling the appropriate medication as it then becomes the doctor’s problem to resolve. Continued on page 16

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The larger, more popular on-line pharmacies do offer the client an “experience” that can be rewarding as the ease of the ordering process is enticing to clients. Most of the on-line pharmacies offer discounts over what can be offered by individual practices simply due to lower overhead, volume purchase rebates offered by select manufactures to online pharmacies and on-line pharmacies typically take lower profit margins when setting their prices. As mentioned previously, one drawback to these services is that errors do occur in fulfilment and the end result is that clients and patients can suffer from these errors. There was discussion regarding clinics hosting their own on-line pharmacy by either contracting with a third-party pharmacy or developing and managing their own individual clinic on-line pharmacy (via Shopify). Both provide autoshipment and competitive pricing. One veterinary distributor (Midwest Veterinary Supply) provides veterinary clinics with their own dedicated on-line pharmacy with the benefit of retaining healthy profit margins for the clinic. Other veterinary distributor hosted on-line pharmacies return very small profit margins back to the clinic. The selection of products through hosted third-party pharmacies varies. Also, delayed shipments and timing can be an issue with these services which can look poorly on the clinic. With the recent launch of new, innovative anti-pruritic medications within both the dermatologist’s and general practice pharmacy, there was a discussion whether these medications have had any influence on referrals. The general answer to this was no, but the nature of the referrals tends to be different. Also, during the COVID pandemic referrals have sky-rocketed. Most practices have a waiting list several weeks out for appointments. There was a sentiment that perhaps some of the delayed referral cases may be due to the ability of the new anti-pruritic drugs controlling cases longer until a time that secondary factors become more problematic and the cases are ultimately referred or clients request referral. It was generally agreed that clients are doing their own on-line research, asking for and expecting improved diagnostics and care for their pets which in turn are driving referrals as well. At the end of the discussion, it was agreed that pharmacy sales as a percent of gross revenue should be an everdecreasing component of a good quality dermatology referral practice. Setting appropriate pricing for services and performing those services for our patients will provide the best gross revenue and this is a sustainable market. Marketing The question of how practices are marketing their services and has this changed with COVID. Most dermatologists are not actively marketing their practices with CE lectures to general veterinarians as in the past because of their lengthy wait. Some low-level marketing strategies that are currently being done include marketing to groomers and providing groomers with continuing education. As the pandemic wanes, most expect to resume marketing with CE lectures to veterinarians but the need for this type of direct approach appears to be perhaps less important for dermatologists than in the past. There was discussion regarding the presence of practices on social media. Many practices have Facebook pages but most have had limited experience with on-line presences in the forms of podcasts or other active social media. Expansion of services A question was asked about what types of services are dermatology clinics offering to distinguish themselves from general practices. Various therapies ranging from Cryotherapy, laser therapy, CT/Video otoscopy procedures and HBOT therapy were all discussed and are used at various frequencies by the participants. There was limited discussion that developing expertise in some of these procedures can increase opportunities for financial growth for individual practices. Continued on page 17

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Monitoring Financial Key Performance Indicators (KPIs) There was discussion regarding how individual dermatologists who run their own individual practices monitor their successes and what type of KPIs do they monitor. There was discussion about some of the important KPIs that practice owners should be aware: • Gross Revenue: Money the clinic brought in during a given period before any expenses are subtracted. • E BITDA (Earnings Before Interest, Taxes, Depreciation and Amortization): Snapshot of short-term operational efficiency and a metric that is more accurate reflection of a practice’s operating profitability. There was also a discussion regarding horizontal vs vertical growth of practices’ income: Vertical Growth – Involves expansion into different segments of veterinary dermatology. This might mean expanding into histopathology services, diagnostic imaging services, etc. Horizontal Growth – Expansion of your current business model. This might mean expanding geographically or widening your existing range of products and services. There was discussion regarding these possible means of expanding a practice’s income growth. There was also a discussion regarding individual expenditures that clinics should be reviewing in trying to reduce costs. These include working with individual services that provide benefits, payroll, 401K services etc. as opposed to one group that may provide all services. Working with individual providers may allow for substantial savings for various services. There was recommendation to make sure that practice owners review merchant service fees and discuss with credit card organizations the best cash rebate programs on purchases. Building strong relationships with both manufacture and distributor partners to gain access to best pricing and qualified rebate programs for product supplies. All of these items can decrease expenditure without impacting quality of care.

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ROUNDTABLE SUMMARIES Topical Therapy for skin infections Moderator: Alberto Martin Cordero, DVM. DLACVD. Attendees: 18 Private practice: 13 Companies: 4 University: 1 Moderator welcome everyone and start conversation asking: What is the average number or percentage of your patients that goes with a prescription of systemic antimicrobial therapy? One attendee says that she has decreased the number of prescriptions of systemic antimicrobial therapy in favor of topical therapy Moderator: Have you find any resilience of the clients to apply topical therapy as prescribed? Response was that most of the clients have been under different systemic antimicrobial therapy and several pills, so most of them accept really well the alternative of topical therapy. One Attendee reported that she is culturing most of her pyoderma cases, especially when systemic antimicrobial therapy is involved. She prescribed topical therapy while she awaits the culture results and by the time she gets the results, most of the patients has had an improvement with topical therapy. Another participant mentioned that the increase of antimicrobial resistance compared to 25 years ago is high, around 60% of the cultures are methicillin resistant staph pyoderma, which has changed the approach. Now most of the dogs are sent with a prescription of at least an antimicrobial shampoo, having some clients bathing even every day which has improved their condition. Most of the clients accept it and will do everything they have in order to control the bacterial skin infection. Attendee said that having new additions to topical therapy such as mousses, sprays and bleach increased the efficacy of topical therapy regimens in our patients. By combining these product with the shampoo do prevent recurrences. Another Attendee mentioned that the mousses are a better choice specially in the winter in some locations of the US where clients are more reluctant to bathe. Attendees did agree about the mousses being a good alternative for the clients however attendee feels that nothing replaces bathing. One attendee mentioned that she feels mousses don’t work as good as shampoos and she doesn’t get the same results, however she frequently prescribed them between bathing. She also stated that she believes that mousses or sprays don’t remove as much of the debris from the skin. Continued on page 19

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Another attendee agrees regarding the efficacy of mousse, and prefers bathing, and also mentions that he does not have as much pushback from the clients regarding bathing. Moderator Which are your guidelines and how do you use the bleach? Regarding the use of bleach sprays, one attendee’s prefers bleach bathing in order not to prepare new dilutions daily, and agreed with by another Attendee. Attendee thinks most of the time owner sprays just the hair and not the lesions, and also mentioned that he has witness brown staining with the combination of chlorhexidine and bleach and advice owners not to use these combinations. Question was asked about the dilution of bleach being used. One attendee uses mostly a 1:32 dilution, another uses ¼ of cup per gallon of water to 1:16 dilution. Another uses 1:10 dilution. Question was asked if an after-bathing moisturizing is used to fight the skin dryness from the use of bleach; Response was that it was not normally left on but for 15 minutes and afterwhich a hydrating antimicrobial shampoo is used. One participant mentioned that sometimes daily bleach in applied on some localized areas without having any irritation or dryness and wonders if this may be related to humidity of the geographic region or idiosyncrasy from the patient. The group was asked about what they do with patients that are sensible to the use of chlorhexidine, Answer was given that the attendee believes that most of the time is not the chlorhexidine itself but the formulation and, in some cases, the shampoo is changed to other antimicrobial agents. Attendee further stated that nothing is as effective as chlorhexidine. Moderator mentioned that he prefers the option of acetic acid in case chlorhexidine is not a choice. The group was asked about hair clipping to improve topical therapy. One attendee mentioned that in some cases with really long-haired dogs clipping is advised and better success was observed. Another attendee also stated that clipping is recommended as well Attendees were asked about the most common complains they have received about topical therapy prescription and how do they deal with those problems. One attendee mentioned that the most common complaint is that dogs hate it, while another attendee reported that they don’t see a lot of pushbacks lately regarding topical therapy. Another attendee does ask the owner in the medical chart how often they would be able to bathe their dog and she makes her prescription based on owner response, while another mentioned that he talked to the owner during consultation about the possibility of bathing very often and he normally doesn’t get a lot of pushbacks except for the winter season. Report was mentioned that there is a misconception regarding bathing dogs often by the owners and most owners don’t bathe often due to this. Regarding daily bathing, the moderator asked if most of the attendees are using daily bathing to which they respond that everyone attending has cases on daily bathing. Some attendees reported that the combination of different topicals are used while another was able to achieve at most 3 bathes a week.. Asking the owner how often would you like to bathe if your skin looks or smell like your pets, was mentioned by an attendee. Every other day in most cases is enough to resolve them was also mentioned Continued on page 20

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while some attendees does not have problems asking pet to be bathed daily especially with rescue groups since they have volunteers to help the physically challenged clients to bathe their pets. It was mentioned that we shouldn’t underestimate what clients are willing to do for their pets to improve due to the fact the attendee has witness clients bathing daily even under difficult or physically challenging conditions. Moderator asks the attendees if they think that most owners know how to effectively bathe their dogs stating that sometime the technique is important. Some attendees use handouts for their clients. One participant thinks that most of the shampooing by clients sometimes spare important areas like ventral abdomen and thighs; and advised owners to bathe for the length time of their favorite song. Questions about cats was introduced about what everyone in the group are doing with feline patients and most of the group agrees they don’t have the same problems with cats due to the presentation of difficult pyoderma cases. Last topic discussed is about combinations of different shampoos or products in the same bathing with one attendee responding that sometimes he combines shampoo with essential oils spot on, in order to decrease dryness.

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ROUNDTABLE SUMMARIES OTITIS MEDIA MANAGEMENT Moderator: Dr. Rod Rosychuk Dr. Rosychuk: The topic of our discussion today will be the medical management of otitis media in both dogs and cats. The therapeutic scenarios in dogs that we deal with most commonly would include: Scenario #1 – this is the most common scenario encountered and would be an extension of an otitis externa to an otitis media through a perforated tympanic membrane (TM). This could be due to a foreign body, aggressive bacterial infection (Pseudomonas), severe stenosis of the canals or the presence of a mass occluding the canal, which, in either case results in debris accumulation that eventually perforates the TM. In some cases, the perforated tympanum heals over an active otitis media (so TM then intact). The OM in these scenarios are usually complicated by bacterial infection (Staph. pseud., Pseudomonas, B hemolytic strep, coag. neg. staph, other bacteria; occasionally Malassezia; even more occasionally Aspergillus, Penicillium); +/- neurologic signs of OM (Horner’s syndrome, facial nerve paresis or paralysis); occasionally progression to an otitis interna +/- neurologic signs of this (head tilt, nystagmus, ataxia etc.). Scenario #2 – cholesteatoma Scenario #3 – auditory tube dysfunction – Primary Secretory Otitis Media (otitis media with effusion) in the Cavies, boxers , other brachycephalic breeds Medical Management of Scenario #1 In general, our (CSU) work-up and management of OM in Scenario 1 would include CT, sampling from the middle ear (cytology and culture), thorough flushing of the middle ear, then, for bacterial OM, both topical and systemic antibiotic therapy; often with both a topical and oral glucocorticoid. We note that we are usually treating a concurrent otitis externa. Diagnostics and how they may affect management: CT : almost all of the session attendees did CTs as part of their work up • to support the fact that there was an otitis media. Dr. Outerbridge: if no fluid is seen in the middle ear and there are no bony changes, how often are we missing an otitis media? Moderator: having done several myringotomies in this scenario over the years, unlikely to miss an OM. If CT technique good; experienced “reader” – we rule out OM and move on (not do myringotomy). Suspect we miss only an occasional mild, often more acute otitis media. • Helps differentiate a TM that is pushed in to the bulla by debris (TM cannot be seen well on videootoscopy) vs perforation with OM • Attendee: not only looking at the middle ear, but can use contrast material in the canal, with CT, to evaluate for the presence of TM perforation that may not be visible clinically. If doing MRIs, can just use saline for this purpose. Continued on page 22

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• Attendee: Does the presence / degree of bony lysis warrant preferential surgical vs medical management for OM? Dr. Rosychuk: with mild bulla lysis (even focal, full thickness lysis), patients do appear to do well with medical management. Lysis makes us more conservative with our flushing pressures in the middle ear. In severe cases of bulla lysis/ peri-bulbar inflammation and/or petrous temporal bone lysis/meningeal involvement - we have leaned towards surgical intervention. However, with that said, we have had a few cases that were medically managed because they could not afford to go to surgery – one with meningitis… that still did well with medical management. Culture from the middle ear: • Dr. Rosychuk (Moderator): because we do use systemic antibiotics, we do culture: take samples from deep within the horizontal canal for both cytology and culture, then sample from the middle ear for cytology and culture and combine for culture purposes (would like to know what is in both the canal and middle ear). We use cytology to tell us where the cultured bacteria likely came from. • Attendee: How can we be sure we are culturing from the middle ear? Dr. Rosychuk – using the above rational, probably does not matter? • Attendee – if I see “rods” on cytology and culture Pseudomonas, I use this information to give the client a more guarded prognosis for medical management (treatment may take a longer time and may be challenging). • Attendees: – surgeons tend to like to get their cultures after they have cleaned out the middle ear, ostensibly to sample from the lining of the middle ear /deeper in the middle ear. Using video otoscopy, this option is usually not available to us. Is it indeed any more helpful? • Attendee – I do not culture because I do not use systemic antibiotics in the management of OM. Therapy • Attendee: We use a 5 step approach to diagnostics and therapy: CT, BAER, video otoscopic flush, repeat BAER and CT. They have now managed 30 – 40 cases in this manner. Dr. Shanley is impressed by the fact that, on follow-up CT, there is usually debris still left in the bulla (at times significant amounts). Dr. Rosychuk: it is very common to not remove all the debris from the middle ear with even the most thorough of flushing. This often appears to be primarily epithelial debris, likely adhered to the walls of the middle ear. It does not appear to affect the overall response to therapy. In the few cases where we have followed up with a CT several months later, the debris has disappeared/biodegraded? • Moderator & Attendee:: key part of therapy is flushing large volumes of saline through the middle ear (medium sized dog – 300 to 400 ml). Dr. Rosychuk – can direct a catheter deeper in to the bulla by using a Teflon jugular catheter that you heat with a cerclage wire in the catheter that is bent at its tip/take wire out and curve stays OR check with your cardiologist -they often have curved tip, otherwise disposable catheters that can be used to achieve this end. • Dr. Rosychuk: how many see a dramatically dilated, exudate filled pars flaccida (PF) associated with their OM cases? Only four participants did and it was uncommon. Drs Rosychuk and Outerbridge both felt that the best way to deal with these would be to remove much (1/2 to ¾) with biopsy forceps to keep the redundant PF from re-filling with debris. The PF usually “heals”, but is no longer redundant. Continued on page 23

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• How often do we see what appears to be biofilm with our OM cases overall and how often does this pose a challenge to cleaning the ear? For our discussion group, it appeared to be very uncommon and did not usually pose a challenge. Dr. Mendoza-Kuznetsova noted that its presence may be more common than we realize and that the apparent importance of thorough flushing may, in part be related to the removal of biofilm that could otherwise compromise response to topical antibiotic therapy. • Dr. Rosychuk: to facilitate the break-up of especially waxy debris in the middle ear, we will often inject Cerumene (Vetoquinol) or KlearOtic (Dechra) in to the middle ear. Neither appear to be associated with potential ototoxicity. Question: how can you be sure you have flushed this out of the middle ear? Probably does not matter, but appears to come out readily. • Dr. Rosychuk: following cleaning, we will usually infuse a steroid / antibiotic compounded solution in to the middle ear. It was common for others to do the same. Topical therapy: • Dr. Rosychuk – we generally go to a safer antibiotic-steroid compounded product (enrofloxacin – 22.7 mg/ ml; dexamethasone sodium phosphate – 4 mg/ml; 1:2 ratio) empirically, pending culture results. If we do have to “change up” our therapy, most commonly it is for MRSP or Pseudomonas and we most commonly switch to a topical amikacin solution (amikacin diluted to 10 – 12.5 mg/ml in saline) or amikacin and dexamethasone sodium phosphate (4mg/ml) – ½ ml amikacin (250 mg/ml), plus 6 ml dexSP. and 6 ml saline. In spite of the ototoxicity potentially associated with aminoglycosides, this dilution appears to be well tolerated. Dr. Outerbridge pointed out that in humans, the ototoxicity of gentamicin (and likely other aminoglycosides like amikacin) appears to be concentration dependent. Drs. Mendoza- Kuznetsova and Chin-Yen Wu noted the study by Strain and Merchant (1993) that did not show gentamicin to be ototoxic when placed in the middle ear of dogs. However, Dr. Chin-Yen Wu noted that the authors subsequently realized that the thresholds for interpretation of BAER’s had changed over the years and this data may have to be re-evaluated (i.e. may not be dependable). Dr. Bloom pointed out that the presence of otitis media may actually reduce the potential for drug ototoxicity because of thickening of the epithelial lining covering the oval and round windows that may occur with OM (preventing movement of the drug in to the inner ear). Dr. Rosychuk noted that he has been made aware of a rare case of ototoxicity associated with dilute amikacin use, and wonders if this is more of an idiosyncratic problem. • Dr. Rosychuk – we do send home a “safer” (with respect to ototoxicity) ear flush; for bacterial otitis media, most commonly a TrisEDTA containing product such as Dechra’s Malaket plus; if wax is a considerable part of the problem, Douxo Micellar Solution (Ceva). • Dr. Rosychuk – we do use systemic antibiotic therapy for bacterial otitis media, primarily because we are concerned that our topicals may not have adequate access to all affected areas; antibiotic chosen initially based on cytologic findings, then culture. We note from Dr. Logas’ proceedings for this meeting that she uses a systemic antibiotic for 8 – 12 weeks. We (CSU) tend to use the antibiotic for 6 weeks. We noted that there are no good studies to support these guidelines (essentially driven by experience). Dr. Bloom noted that he does not use systemic antibiotic therapy in his cases (only topicals) and sees what appears to be the same success rates as those that do. In support of this approach, both Drs. Rosychuk and Theus noted that we do see cases of Pseudomonas otitis media wherein there is no good systemic antibiotic alternative and these individuals are then only treated with topical steroids/antibiotics and often an oral steroid and still do well. Dr. Wildermuth noted that, in her practice where CTs are not readily available, she sees chronic proliferative otitis externa wherein she highly suspects the presence of a concurrent otitis media that do very well without the use of a systemic antibiotic. It would appear that this very basic question (systemic antibiotic or not) is crying out for prospective studies to better answer this question. Continued on page 24

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• Dr. Rosychuk: to assess response to therapy, we generally recheck our patients every three weeks initially until we are in remission. Dr. Mendoza-Kuznetsova voiced the consensus that remission is then largely related to normalization of the canals and healing of the TM or living with a TM that does not heal. It would be ideal to repeat CTs on our patients but this is not economically viable. She had worked with ultrasound to assess for the status of otitis media, but found it lacked sensitivity for this purpose. Scenario 2 - Cholesteatoma • Most participants only occasionally saw Cholesteatomas. Dr. Rosychuk noted that historically, this has been considered a surgical disease. There has been a recent report of the successful medical management of several cases (Akihiro I et al Vet Derm; removing as much debris as possible by traction/flushing and suction from the middle ear, then tube flushing on awake dogs once weekly for 2-4 weeks, then q 2 weeks for 4 weeks, then once monthly; Topical mometasone daily and an “at home” flush). • Dr. Botelho (from Brazil) noted that she actually sees a very large number of patients with this problem (as many as 1-2 per week on occasion). They are primarily Pugs and French bulldogs. Many have characteristic “cyst” like structures visible within their middle ears. Some have neurologic signs on presentation. This is a specific area of interest/research for Dr. Botelho. She employs medical management for the majority of these individuals (thorough middle ear cleaning; topical and systemic steroids; at 6 months she repeats the CT and middle ear flush). Those with severe proliferative/lytic changes on initial CT are sent to surgery. Feline Otitis Media: 3 Scenarios Extension through a perforated TM (so an extension of problems related to otitis externa): CT, culture middle ear, flush, post flushing infuse antibiotic / steroid in middle ear, systemic antibiotic (Clavamox or Pradofloxacin) then based on culture – 6 – 8 weeks; oral steroid (anti-inflammatory dosages); Topical antimicrobial /steroid and flush. Auditory tube dysfunction: suspected to be the most common cause of OM in the cat. Often produced with acute neurologic signs of OM and/or otitis interna. Often a history or active rhinitis/pharyngitis (viral?). CSU approach: CT, myringotomy (cytology and culture), flush middle ear, post procedure infuse antibiotic/ steroid, systemic antibiotic 6 - 8 weeks; oral steroid (decreasing dose over 6 weeks; similar to dosages used for polyps), topical antimicrobial/steroid and flush. • Recent report of cats with similar changes only treated with an oral antibiotic, +/- NSAID with reasonably good success – but small numbers. Need prospective studies to see what approach is best. • Dr. Bloom – doesn’t use the systemic antibiotic unless sees bacteria (only steroid). Dr. Rosychuk agreed. Dr. Bloom – has anyone used only anti-viral therapy for these cases – none had. Aural Polyps: Dr. Miller had mentioned earlier in the discussion that she has some frustration dealing with these cases. Dr. Rosychuk noted the high degree of success (i.e. resolution/ lack of regrowth) as reported by Bachtel et al in the proceedings of the recent 9th Congress of the WAVD with traction/avulsion to remove polyp material to just within the TM, treatment of the common concurrent bacterial otitis media and very importantly followup treatment with an oral steroid (Prednisolone at 2-3 mg/kg/day for 2 weeks, then 1 – 1.5 mg/kg/day for 2 weeks, then 0.5 – 0.75mg/kg/day for 2 weeks, then 0.5-0.75 mg/kg once every other day for 2 weeks; Continued on page 25

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total of 8 weeks of therapy). This was used with a safer topical steroid/antibiotic compounded solution (e.g. enrofloxacin : dexamethasone). The oral steroid regimen is what appears to “shrink” the residual polyp material and reduces the tendency towards recurrence.

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ROUNDTABLE SUMMARIES Equine Round table summary: Moderator: Annette Petersen Dr. Med. Vet., DACVD The round table had 9 participants, 7 dermatologist, one dermatology resident and one participant from industry. The discussion began with Apoquel: only 2 participants had used it in a few horses and at the dose presented at the ACVIM forum 2020 of 0.25 mg/kg with approx. 30-50% success but the cost prohibited long term use since no dramatic response was seen. Withdrawal times of steroids prior to skin testing varied between participants (1-2 weeks off oral dexamethasone) but some Urticaria horses were successfully tested on every 48 h dexamethasone on the dexamethasone off day Nobody appeared to have problems with skin testing in the off season/winter, as we all agreed that horses have stronger reaction than most dogs and cats. The time of reading the skin test varied, everybody agreed to read 20-30 min, several people would read at one and four hours for late phase reaction and relied on photos from the owner/trainer for 24 h (+/48h). Participants agreed that the 24 h and 48 h results rarely changing anything for the formulation of the immunotherapy. One participants is working on prick testing with a multi test devise for efficiency. The Greer prick test devise was found to be more irritating. The participant uses Unitest by Lincoln Diagnostics with multiple wells for glycerinated allergens which speeds up the test to about 30 seconds per horse and the horses do not require sedation. The study will be presented in New Orleans 2022 and published in AJVR soon. Several participants are skin testing horses mostly for equine asthma cases and only the occ. pruritic or urticarial horse. Success rate of immunotherapy appears to be higher in horses than in small animals. Immunotherapy was called “educated WooDoo” that works by one participant. Two participants are using ELISA testing (both use Heska), one of them uses it for extended Mold testing. Most of the participants are skin testing for Grain smut but at less than 250 PNU to avoid false positive reactions. Several participants are seeing lots of positive reaction to dust mites and storage mites, with one participant wondering if there was possibly a pan reactivity as he sees a lot of horses’ reaction to dust mites, cockroaches, moth, ants and other insects all together. Sublingual immunotherapy was briefly discussed. The publication in VetDerm 2016 from Australia was mentioned about a horse with angioedema as an adverse reaction to SLIT. The problem in horses is that it is not clear where to put the “sublingual” dose. One participant from Florida sees a lot of vasculitis cases in allergic horses and uses Pentoxifylline for those. One other participant has good success with Doxycycline for vasculitis cases. Continued on page 27

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Pastern dermatitis vasculitis cases were briefly discussed; one participant uses Sunscreen (Human sunscreen Neutrogena face sunscreen with Helioplex ) and Pentoxifylline at 15 mg /kg and “soxforhorses.com” . Apoquel was also mentioned for these cases.

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ROUNDTABLE SUMMARIES Apoquel in Cats Moderator: Amanda Young Participants in the round table had extensive to very limited experience with Apoquel use in cats. All experience is very subjective. 1. What diseases are people using in cats with Apoquel in practice? a. Feline atopic syndrome – by far the most common – variable success b. Eosinophilic granuloma complex – some have had moderate success to very successful response in these cats; uncertain pathomechanism of how JAK/STAT is involved in these lesions c. Idiopathic ulcerative dermatitis – no response to very effective d. Pemphigus foliaceous – one participant use it in combination with steroids which allowed steroid to be reduced. e. Have been asked about using in asthmatic cats – never have used f. Palliative care for cats with cancer in a shelter setting (controversial) 2. Doses that are being used in cats? a. 0.6-1.2 mg/kg PO BID b. 1 mg/kg PO BID 3. Which type of cases should we be considering Apoquel as an option; should this be offered as first line? a . Many are using in cats that are difficult to control with or have severe intolerance to other conventional therapies such as steroids, cyclosporine or ASIT b. Typically, it is used as a second or third line option. c. Used as a steroid sparing medication – may not be able to completely eliminate steroid us but able to reduce to very low doses d. Diabetic cats e. Cats with other comorbidities where steroids may be contraindicated (CKD) f. Difficult cats for owners to medicate with Atopica – in general cats take it well crushed in canned food g. Always discuss extra-label use with owners h. In the UK they need to follow the cascade (prescribing unauthorized medicine) – they will use steroids or cyclosporine first before Apoquel i. Some only use it alone to stay away from combination immune suppressive medications and/or to see how much Apoquel is really helping. 4. Speed of onset/how long for a trial? a. Some feel onset takes longer to see improvement in cats compared to dogs but not sure exactly how long that is. b. If after 5 days no improvement will make dose adjustments c. Trial for 2 weeks d. Trial for 2 months (if some improvement is seen in the first month) Continued on page 29

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5. Do you try to taper the medication at any time? a. Most cats seem to require BID b. Some cases do go to SID for cost c. More rare cases do well on SID 6. Adverse side effects? a. Neutropenia – that did slowly improve after discontinuing, was seen at 5 month blood monitoring b. Rarely vomiting – may have been associated with higher dose c. Dr. Loft has seen 5 cases of feline demodicosis, 2 also were also asthmatic with atopy – 1 had facial demodicosis with the cat chamber pattern (not checked prior to Apoquel use). Responded to demodex treatment. d. One cat developed multifocal pleomorphic giant cell sarcoma 3 months after Apoquel was started for a steroid sparing agent. Prior to Apoquel use the cat had bilateral entropion due to keratomalacia. Strange case – of course it was own by a veterinary technician. May or may not have been associated with Apoquel. e. Upper respiratory signs (infections/herpes virus flares) – low occurrence f. Please report adverse event to Zoetis, In US call 1-888-ZOETIS-1 – even if using extra label, even if not sure about association/causation. 7. What laboratory monitoring are people doing? a. Pre-treatment, baseline CBC/Chem, FeLV/FIV neg status. b. CBC/Chem – 1 month, then 3 months later c. CBC/Chem -2 months, 5 months, and then every 6 months – until comfortable with that labwork – then annual d. Depends on the case and what else is going on e. CBC/chem - early on did 1 month, every 3 months, but that frequency has decreased after being used more frequently. Now check 7-10yr cats BW q 6 months, annually if younger f. Urinalysis – Not routinely checked. 8. Have you seen referring veterinarians using Apoquel? a. A few have seen – usually the same dose labeled for dogs, the cats were not well controlled. b. Recommend rDVMs to refer to board certified dermatologist for Apoquel use at this point. 9. What mg pills are being used a. 3.6 or 5.4 mg– whole or half tablets always – never quarter tablets as medication may not be distributed evenly. b. ¼ of 16mg tablets always (we split in the clinic for owners and charge a slightly higher fee for this)– still have good success in cats overall. c. Michele from Zoetis – reminded us they are not recommended to be quartered. Stability studies have shown Apoquel is stable after being halved for up to 14 days, but no studies have been conducted beyond that time frame and there have not been any stability studies on quarter tablets. The tablets tend to crush easily when quartered. Continued on page 30

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10. Compounding a. 16mg tablets can be used – multiple clinicians supply Apoquel to local compounding pharmacies to make into a liquid - works well in cats b. I s there any worry about humans handling this drug? We don’t know 11. Comments from Michelle from Zoetis a. Zoetis is interested in developing new treatments for cats b. They tell practitioners it is extra label use but there are publications about use in cats that are available for them to research. c. They don’t promote using, give a dose recommendation or monitoring recommendations. d. In US there are rewards for Zoetis rebates to help with cost – not available for cats however since it is off label use. e. Any follow up from early studies in cats with mastocytosis? – No further information than what was previously published 12. Tips for medicating cats – discussion was more about getting cats to take Atopica a. Mixing medications into oily substances – vegetable oil, fish cooking oil b. Non-dairy coffee creamer c. Melting vanilla ice cream d. Vanilla extract e. Almond milk f. Canned rabbit food g. UK – tubes of beef/yogurt

DERM DIALOGUE

World Association for Veterinary Dermatology Report to AAVD The World Association for Veterinary Dermatology, in addition to overseeing the World Congress of Veterinary Dermatology (WCVD) every four years, guides and encourages the development of national and international organizations devoted to the discipline, fosters education globally, and provides funding to working groups and committees active in veterinary dermatology. The WAVD organizes and funds scholarships for veterinarians to attend the WCVD, established the Peter Ihrke scholarship that provides externship opportunities in veterinary dermatology at UC Davis for veterinarians from underserved areas of the world, and more recently developed a Foundation Course in Veterinary Dermatology available for all to access on the wavd.org website. The WAVD also publishes Advances in Veterinary Dermatology and the Clinical Consensus Guidelines. The AAVD is a member organization of the WAVD and as your representative, I have attended quarterly zoom calls during 2021 in lieu of in person meetings given the global pandemic.

WCVD 9 and 10 updates

The 9th World Congress of Veterinary Dermatology was transitioned to a virtual meeting while maintaining an Australian theme. Drs. Mandy Burrows, Rusty Muse, David Lloyd, Richard Halliwell, and Craig Harrison put forth a tremendous amount of work that resulted in a very successful meeting. Income for the Webinar Vet hosted virtual event exceeded expectations with a total of 3,238 paying registrants, including 336 registered through the Shanghai server (ESAVS) and 233 registrants for the pathology stream. The 10th WCVD will be held in July of 2024 in Boston, MA. The Executive Organizing Committee has been established with Dr. Catherine Outerbridge serving as president and Emily Rothstein as secretary. Six major themes have been proposed as follows: Innovations in Dermatology, Immunodermatology, Otology, Dermatology and One Health, Atopic disease and Allergy, and Skin Biology in Health and Disease. Please visit www.vetdermboston to learn more!

Clinical Consensus Guidelines (CCG) updates

The WAVD has established a process to have expert committees develop and publish clinical consensus guidelines (CCGs). The first two CCGs were published—dermatophytosis and methicillin-resistant staphylococcal infections in Veterinary Dermatology in May of 2017. Demodicosis and Malassezia dermatitis followed with publication in February of 2020. Current CCGs, equine hypersensitivities (Dr. Rosanna Marsella, chair) and best practices in otology (Dr. James Noxon, chair) were presented at the North American Veterinary Dermatology Forum and European Veterinary Dermatology Congress in 2021 and are under review. Comments may be submitted on the wavd.org site. Prepared by Jeanne Budgin, AAVD representative to WAVD, December 2021

DERM DIALOGUE

North American Veterinary Dermatological Forum