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Diets and the Dermis: Nutritional Considerations in Dermatology Justin Shmalberg, DVM, DACVN, DACVSMR University of Florida College of Veterinary Medicine

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Diets and the Dermis: Nutritional Considerations in Dermatology Justin Shmalberg, DVM, DACVN, DACVSMR University of Florida College of Veterinary Medicine NUTRITION NOTES ACVN NUTRITION NOTES Diets and the Dermis: Nutritional Considerations in Dermatology Justin Shmalberg, DVM, DACVN, DACVSMR University of Florida College of Veterinary Medicine shutterstock.com/Christian Mueller Dermatologic patients are often managed with topical and systemic pharmacologic therapies, The American College of Veterinary Nutrition but nutrition should be evaluated in all animals (acvn.org) and Today’s Veterinary Practice are delighted to bring you the Nutrition Notes column, presenting with skin disease. Nutritional deficiencies which provides the highest-quality, cutting-edge and excesses are rarely the underlying cause of a information on companion animal nutrition, written by patient’s clinical signs, but nutritional modifications the ACVN’s foremost nutrition specialists. often reduce the severity of such signs. The primary objectives of the ACVN are to: • Advance the specialty area of veterinary nutrition NUTRIENTS • Increase the competence of those practicing in this field The influence of nutrition in dermatologic • Establish requirements for certification in veterinary conditions is explained by critical nutrients that nutrition affect keratinization, cellular barriers, and turnover, • Encourage continuing education for both specialists as well as sebum production and composition. and general practitioners • Promote evidence-based research Protein and amino acids provide substrates for • Enhance dissemination of the latest veterinary keratinization, pigmentation, and hair growth. A nutrition knowledge substantial portion of daily protein requirements The ACVN achieves these objectives in many ways, is used for skin and hair production.1 including designating specialists in animal nutrition, providing • Phenylalanine and tyrosine are precursors to continuing education through several media, supporting melanin, and relative deficiencies may induce 2 veterinary nutrition residency reddening of black coats (Figure 1). programs, and offering a wide array of resources related to veterinary • Methionine and cysteine, the primary sulfur- nutrition, such as this column. containing amino acids, are incorporated into hair in large amounts and may be the “limiting” amino MARCH/APRIL 2017 ■ TVPJOURNAL.COM 33 PEER REVIEWED • Vitamin E is the primary antioxidant in the cell membrane and can refer to any of 4 tocopherols and 4 tocotrienols. Alpha- tocopherol is the form with greatest activity in cells, although others may be added to commercial diets as natural preservatives. Experimental deficiency causes alopecia, seborrhea, and increased cutaneous infections.3 • B vitamins participate in many biochemical reactions throughout the body, and experimental deficiencies have caused a variety FIGURE 1. This middle-aged domestic shorthair cat displays reddening of the fur, which may prove of skin lesions. Vitamin B3 (niacin) and B5 responsive to increased dietary protein and/or (pantothenic acid) supplementation above supplementation with tyrosine or phenylalanine. normal recommended allowances has reduced transepidermal water loss in dogs and contributed to the integrity of the stratum corneum.9 acids (ie, those which limit protein synthesis) in some pet diets. Deficiency of these amino acids may Copper serves as a cofactor in enzymatic 3,4 reduce hair growth and increase hair fragility. conversion of tyrosine to melanin. Deficiency can • Proline is a nonessential amino acid critical cause changes in pigmentation. Zinc is critical to collagen formation in the skin. Protein for the transition of nucleated epidermal cells to deficiency would be expected to have a anucleate squamous cells in the stratum corneum, deleterious effect on skin strength.3 and deficiency induces parakeratosis. Zinc also participates in essential fatty acid conversion.3 Polyunsaturated fatty acids provide substrate for the production of sebum, which protects Commercial diets conforming to Association of the dermis and improves coat quality.a American Feed Control Officials recommendations should be replete in all of the nutrients above. • Linoleic acid, an 18-carbon omega-6 fatty acid, However, several factors could increase the appears to be most important for this effect.5–7 relative risk for deficiencies over time: • Omega-3 fatty acids, such as eicosapentaenoic • Malabsorptive disorders, such as exocrine acid (EPA) and docosahexaenoic acid (DHA), pancreatic insufficiency, inflammatory bowel may reduce inflammation secondary to disease, and small intestinal bacterial overgrowth allergic disease in affected dogs and cats.8 • Home-prepared diets without dietary Several vitamins play critical roles in skin health. analysis or supplementation • Vitamin A is a group of fat-soluble retinoids • Diets labeled for intermittent or supplemental critical for epidermal differentiation and normal feeding when fed for an extended time sebum production. Deficiency is rare, but unlike • High dietary phytate concentration, which dogs, cats cannot convert beta-carotene to retinol.3 • Vitamin C is synthesized in dogs and cats from glucose (unlike in humans) and is necessary for collagen synthesis and cross-linking. aFor more information on the roles of polyunsaturated fatty acids, see “Dietary Fatty Acids in Dogs & Cats” by Dr. Catherine Lenox Zinc-responsive dermatosis syndrome 1 in a in the September/October 2016 issue of Today’s Veterinary Practice FIGURE 2. young Siberian husky. Courtesy Dr. Dunbar Gram. on tvpjournal.com. 34 NUTRITION NOTES binds minerals such as zinc, or excesses of some TABLE 1 Concentration of Elemental Zinc minerals that adversely affect absorption of others in Different Oral Supplements* ZINC SUPPLEMENT MG ZN/100 MG POWDER CLINICAL CONDITIONS Zinc gluconate 13 Several common dermatologic signs may prove Zinc methionine 23 nutritionally responsive (Box 1). The primary Zinc sulfate 36 cause may not always be identified, but a skin *A starting dose of 2 to 3 mg Zn/kg is often recommended. biopsy is often prudent to better characterize Many supplements are sold according to the amount of the lesion and to decide how best to modify elemental zinc. a patient’s diet. Knowledge of characteristic or common clinical conditions informs the possible use of nutritional intervention, and a associated with zinc-responsive dermatosis response to a particular nutritional therapy is syndrome I, is advised. Zinc gluconate is well often used to confirm a presumptive diagnosis. tolerated and efficacious, but some clinicians prefer zinc methionine because of increased Zinc-Related Dermatoses availability. The relative amount of elemental zinc for different supplements is found in Table 1. In dogs, zinc-related dermatoses are characterized Vomiting is the most common, and generally dose- by parakeratotic hyperkeratosis of the face dependent, side effect of zinc supplementation, and feet, with resultant crusts and lesions and several forms may need to be tried at (Figure 2).10 These dermatoses include lethal varying doses to assess individual tolerance. acrodermatitis in bull terriers and zinc-responsive dermatosis syndromes I and II. Characteristics of these conditions are presented in Box 2. Serum and hair testing are unreliable measures BOX 2. Characteristics of of zinc status, so supplementation of dogs Zinc-Related Dermatoses with characteristic lesions, especially in breeds Lethal acrodermatitis of bull terriers11 • Complete dysfunction of zinc metabolism • Impaired growth, eating difficulty, crusting and scaling of the feet and pads, and splayed digits • Unresponsiveness to zinc supplementation BOX 1. Dermatologic Signs That May Respond to Nutritional Management • High mortality rate 3,10 • Pruritus Zinc-responsive dermatosis syndrome I • Results from a genetic defect that • Recurrent pyoderma reduces zinc absorption • Dull hair coat • Is more prevalent in Northern breed dogs (huskies, malamutes) • Epidermal scaling Requires lifetime oral zinc supplementation (2 to 10 mg • Urticaria • elemental zinc per kg is empirically recommended)4,10 • Keratinization disorders Zinc-responsive dermatosis syndrome 23,12 • Concurrent gastrointestinal signs • Associated with rapidly growing large-breed • Coat color change dogs or dogs receiving diets high in phytates and other zinc-binding compounds • Chronic otitis • Resolves after a change to a diet with • Miliary dermatitis (in cats) greater zinc concentrations and/or with • Alopecia reduced zinc-binding compounds MARCH/APRIL 2017 ■ TVPJOURNAL.COM 35 PEER REVIEWED Vitamin A–Responsive Dermatosis Hepatocutaneous Syndrome Dermatosis responsive to vitamin A is a rare, This condition, also called migratory necrolytic presumably heritable, condition of dogs. Lesions erythema or superficial necrolytic dermatitis, are characterized by abnormal cornification, is diagnosed infrequently in dogs and, very hyperkeratotic plaques, abnormal sebum, epidermal rarely, cats with liver dysfunction, chronic scaling, alopecia, and secondary pyoderma phenobarbital exposure, diabetes mellitus, or (Figure 3). Biopsy specimens are consistent with pancreatic tumors (such as glucagonomas).4,15,16 orthokeratotic and follicular hyperkeratosis.13 The syndrome has been reported in older Cocker spaniels are the most affected breed, but dogs of many breeds, and evidence exists for a other breeds are also rarely affected.14 Oral retinol possible heritable predisposition in shih tzus.16 (vitamin A) is reported to ameliorate clinical signs, but the optimal dose is unknown (authors have Elevated alkaline phosphatase and microcytosis
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