The Crucial Role of Topical Therapy
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11/21/2019 The Crucial Role of Options for management of skin Topical Therapy disease in Managing skin disease in dogs Joel Griffies, DVM Diplomate ACVD Animal Dermatology Clinic Marietta, GA www.animaldermatology.com 1 2 Topical Therapy Topical Therapy Disadvantages Advantages ◦ More labor intensive/time consuming ◦ Ease of access ◦ Effect may take longer ◦ Safety ◦ Cost? +/- ◦ Lack of systemic side effects ◦ Useful Adjunctive ◦ Replacement for systemic therapies in some 3 4 Topical therapy MYTH - Bathing is bad Questions/Objectives ◦When & Why is topical therapy a useful Reality tool ◦Bathing has been shown to significantly ◦How do we choose what to prescribe help outcome in a variety of skin disorders ◦How does that differ with the condition ◦IF – we’re using the right products being treated for the right problem… 5 6 1 11/21/2019 Topical therapy Normal epidermal anatomy Questions/Objectives ◦When & Why is topical therapy a useful Formation of stratum corneum & tool cornified cell envelope Extrusion of lamellar granules ◦Allergy (ceramides, cholesterol, ◦Infections free fatty acids) ◦Parasites Lipid production (lamellar granules) ◦Keratinization defects Keratin production Proliferative stem cells ◦Many others Cell layers of the epidermis. From Muller & Kirk’s Small Animal Dermatology. We have access! Modified from Proksch E Folster-Holst R, Brautigam M et al : Role of the epidermal barrier in atopic dermatitis. J Dtsch Dermatol Ges 7:899-910 Fig. 2. p901 7 8 Normal epidermal anatomy Formation of stratum corneum & cornified cell envelope Extrusion of lamellar granules (ceramides, cholesterol, free fatty acids) Lipid production (lamellar granules) Keratin production Proliferative stem cells Cell layers of the epidermis. From Muller & Kirk’s Small Animal Dermatology. Modified from Proksch E Folster-Holst R, Brautigam M et al : Role of the epidermal barrier in atopic dermatitis. J Dtsch Dermatol Ges 7:899-910 Fig. 2. p901 9 10 Epidermal Anatomy Practical Application Stratum corneum ◦ Layers of cornified epithelial cells ◦ Surrounded by a lipid envelope Composed of ◦ Ceramides (sphingosine + fatty acid) ◦ Free fatty acids ◦ Cholesterol 11 12 2 11/21/2019 The Epidermal Barrier Electron Microscopic Observations of Stratum & Corneum Intracelular Lipids in Normal and Atopic Dogs Atopic Dermatitis Inman et al. Vet Pathology 2001 Current Research Atopic dogs Role of epicutaneous allergen exposure ◦ Deposition of lipid into stratum corneum variable ◦ Many areas devoid of epidermal lipids ◦ When present lamellae exhibited abnormal and/or incomplete structure ◦ Both thickness and continuity of stratum corneum lipids were significantly decreased in atopic dogs 13 14 Characterization and quantification of ceramides Electron Microscopic Observations of Stratum in the nonlesional skin of canine patients with atopic Corneum Intracelular Lipids in Normal and Atopic Dogs dermatitis compared with controls Inman et al. Vet Pathology 2001 (Reiter et al. Veterinary Dermatology 2009) Ceramide deficiencies identified in the stratum corneum of Atopic dogs Normal Atopic dogs compared to normal dogs Decreased percentages of ceramide 1 and 9 and increased cholesterol ◦ Ceramide 1 - a vital component of the lipid barrier ◦ Carrier of linoleate – an important Fatty acid in forming the barrier 15 16 Epidermal Barrier: Topical Opportunities? Addition of ceramides, fatty acids (esp linoleic) as replacement and repair ◦ Additives in shampoos ◦ Focal application ◦ Leave-on conditioners Regular bathing to remove ◦ Sources of potential infection ◦ Potential allergens … more to come 17 18 3 11/21/2019 Topical Therapy: Topical Therapy The right products? Therapeutic bathing Our recommendations as veterinarians? ◦First understand what you’re treating ◦Then know what’s available AND proven effective 19 20 Shampoo Categories Shampoo Categories Cleansing Cleansing Soothing/Anti-pruritic ◦ HUGE variety of ingredients, technology and Antimicrobial claims. Some verified, some not Antiseborrheic ◦ Encapsulated moisturizers ◦ Key components for better health of the epidermis ◦ Ceramides ◦ Fatty acids (esp. linoleic) 21 22 Shampoo Categories Bathing as a tool Cleansing for management of skin disease ◦ Selection advice ◦ Use a reputable company ◦ Take advantage of support and advice ◦ Find ones you like that deliver positive results and feedback from clients! ◦ There IS a difference 23 24 4 11/21/2019 Shampoo Categories - Topical Therapy Therapeutic The right products for the right problem Soothing/Anti-pruritic Clinical Approach ◦ Emollients and moisturizers ◦ Ideally ◦ Topical antihistamines & anesthetics ◦ Match product/ingredient with skin disease being treated Antimicrobial ◦ Antibacterial ◦ Shampoos as therapeutic tools ◦ Combination Antibacterial/antifungal ◦ Prescribe based on ingredients and formulation Antiseborrheic (instead of price or marketing) ◦ Mild ◦ Moderate ◦ Aggressive 25 26 Topical Therapy Topical Therapy The right products for the right problem The right products for the right problem Soothing/Anti-pruritic Soothing/Anti-pruritic ◦ Indications ◦ Common ingredients Properties ◦ Mild to moderate pruritus ◦ Emollient Oatmeal - Moisturizing ◦ Allergy (atopy, food allergy, flea allergy) ◦ Fatty acids (linoleic) - Barrier restoration ◦ Xeroderma ◦ Ceramides, phytosphingosine ◦ Without infection ◦ Aloe ◦ Pramoxine ◦ Hydrocortisone - Topical anesthetic - Anti-inflammatory 27 28 Topical Therapy Topical Therapy The right products for the right problem The right products for the right problem Soothing/Anti-pruritic Soothing/Anti-pruritic ◦ Common ingredients ◦ Common ingredients ◦ Emollient Oatmeal ◦ Emollient Oatmeal ◦ Fatty acids (linoleic) ◦ Fatty acids (linoleic) ◦ Ceramides, phytosphingosine ◦ Ceramides, phytosphingosine ◦ Aloe ◦ Aloe ◦ Pramoxine ◦ Pramoxine ◦ Hydrocortisone ◦ Hydrocortisone 29 30 5 11/21/2019 Topical Therapy Topical Therapy The right products for the right problem The right products for the right problem Antimicrobial Antimicrobial ◦ Antibacterial ◦ Indications ◦ Combination antifungal/antibacterial ◦ Treatment AND prevention of… ◦ Bacterial pyoderma/overgrowth superficial and deep ◦ Malassezia dermatitis ◦ Dermatophytosis? 31 32 Impression smear cytology Impression smear cytology 33 34 Topical Therapy Comparative in vitro efficacy of antimicrobial shampoos: a pilot study The right products for the right problem Young, et al. ; VETERINARY DERMATOLOGY Feb 2012 Antimicrobial Compared effects of several shampoos against MSSP, MRSP, Pseudomonas and Malassezia ◦ Antibacterial Chlorhexidine gluconate 2% Ethyl lactate, 10% ◦ Chlorhexidine Do they all work the miconazole nitrate 2% chitosanide ◦ Benzoyl peroxide same? nonionic Spherulites ◦ Acetic acid/Boric Acid Chlorhexidine gluconate 3% ◦ Ethyl lactate Are they monosaccharides Chloroxylenol 2% salicylic acid 2% ◦ Chloroxylenol interchangeable? chitosanide nonionic Spherulites sodium thiosulphate 2%; Chlorhexidine gluconate 4%... Acetic acid, 2% boric acid, 2% Benzoyl peroxide, 2.5% propylene glycol… 35 36 6 11/21/2019 Comparative in vitro efficacy of antimicrobial Activity of chlorhexidine shampoo in vitro against shampoos: a pilot study staphylococcus intermedius, Pseudomonas Young, et al. ; VETERINARY DERMATOLOGY Feb 2012 aeruginosa and Malassezia pachydermatis Results Lloyd et al. Vet Record, 1999 Antimicrobial efficacy of shampoos is highly variable. Compared 2-4% chlorhexidine shampoos Only the chlorhexidine products had consistent broad- Results spectrum activity. 3% and 4% elimlinated Staph intermedius in <1 min at both 1:5 and 1:25 dilutions “Chloroxylenol and acetic acid/boric acid shampoos, in contrast, displayed little to no antibacterial activity” but had 2% elimlinated Staph intermedius at 1:5 and 1:25 dilutions at some effect against Malassezia 8 min 37 38 Activity of chlorhexidine shampoo in vitro against Topical Therapy staphylococcus intermedius, Pseudomonas The right products for the right problem aeruginosa and Malassezia pachydermatis Lloyd et al. Vet Record, 1999 Antimicrobial Results – (continued) ◦ Antibacterial ◦ Chlorhexidine A 2% chlorhexidine shampoo showed faster bactericidal than Antibacterial a 2.5% ◦ Benzoyl peroxide Antifungal ◦ Acetic acid/Boric Acid Antiviral ◦ Ethyl lactate Some effect vs. Malassezia Indicates that formulation also influences efficacy ◦ Chloroxylenol 39 40 Topical Therapy Topical Therapy The right products for the right problem The right products for the right problem Antimicrobial Antimicrobial ◦ Antibacterial ◦ Antibacterial ◦ Chlorhexidine ◦ Chlorhexidine Antibacterial ◦ Benzoyl peroxide ◦ Benzoyl peroxide Degreasing/Keratolytic ◦ Acetic acid/Boric Acid ◦ Acetic acid/Boric Acid Follicular flushing ◦ Ethyl lactate ◦ Ethyl lactate ◦ Chloroxylenol ◦ Chloroxylenol Drying? – caution with >2.5% 41 42 7 11/21/2019 Topical Therapy Topical Therapy The right products for the right problem The right products for the right problem Antimicrobial Antimicrobial ◦ Antibacterial ◦ Antibacterial ◦ Chlorhexidine ◦ Chlorhexidine Mild Antibacterial ◦ Benzoyl peroxide ◦ Benzoyl peroxide Mild Antifungal ◦ Acetic acid/Boric Acid ◦ Acetic acid/Boric Acid ◦ Ethyl lactate ◦ Ethyl lactate ◦ Chloroxylenol ◦ Chloroxylenol 43 44 Topical Therapy Topical Therapy The right products for the right problem The right products for the right problem Antimicrobial Antimicrobial ◦ Antibacterial ◦ Antibacterial ◦ Chlorhexidine ◦ Chlorhexidine ◦ Benzoyl peroxide ◦ Benzoyl peroxide ◦ Acetic acid/Boric Acid ◦ Acetic acid/Boric Acid ◦ Ethyl lactate ◦ Ethyl lactate ◦ Chloroxylenol