Basic Comprehensive Protocol INTRODUCTION PSYCHOGENIC Festations

allergies Basic comprehensive protocol INTRODUCTION PSYCHOGENIC festations. procally, thus increasing the intensity of the allergy mani- interact andmaythese factors feedback themselves reci- cause, because primary whichisthe is difficult toascertain mation andtheitching have (Figure beendescribed 1).It inflam- impliedintheonset of theskin Multiple factors infections. dary scratch and/orlickitself, causinglesionsandeven secon- processesand inflammatory that causetheanimal to allergiesMost incats anddogsshow upwithpruriginous gies, atopic dermatitis, fleaallergy allergy. and contact processes are clinicalpractice food intheveterinary aller tions to oneormore allergens. The mostcommon allergic Allergic diseasesincludearange ofhypersensitivity reac Aetiology andpathogenesis tient and to of its owner. the situation and the expectations can behandled, always adapted to theneedsofeachpa- treatment, establishingmeasures that againstthefactors the diseaseiskeyfor applyingalong-term comprehensive matic treatment. causesof Understandingtheunderlying sympto of goingpasttheimplementation ofashort-term dermatitis. With thiswe want to highlight theimportance relatedof thefactors to thedevelopment ofanallergic tremendously. thisbulletin,we In willmakeaquickreview on the pathogenesis and treatment of allergies has evolved tations insmallanimalclinics. thelast10years, In research Allergic diseases represent a high percentage oftheconsul- to food allergies Comprehensive therapeutic approach mation anditching. Adapted &Olivry, from 2016. Saridomichelakis Figure inflam- impliedinthedevelopment pathogenic factors 1.Main of skin ENVIRONMENTAL ALLERGENS ALLERGY FLEA ALLERGENS INFLAMMATION FOOD ITCHING CONCOMITANT INFECTIONS Malassezia /PyodermaMalassezia BACKGROUND GENETIC EPIDERMAL BARRIER INFLAMMATORY CELLS FUNCTION AND MEDIATORS - - - and theimmunesystem response againstitisactivated. ofthefood assomethingstrange,body considers apart pharmacological (caffeine intolerance) factors, etc. mediated by metabolic(e.g. orgluten intolerance), lactose foods that donotinvolve theimmunesystem. They are Key concepts • • • • • • • • the therapeutic treatment. tial for diagnosis acorrect oftheallergy andthechoice of A thorough clinicalexamination andanamnesisare essen- or ifitwillonlyprovide information. evaluate iftheresult may helpinthetreatment oftheallergy ofallergy canbediagnosed withatest. kinds Some We must • • • Keys for diagnosis allergens. IgE antibodies mainlydirected againstenvironmental involves clinicalmanifestations characteristic related to condition withageneticpredisposition component that ge, fleabite allergy, etc. to ruleoutotherdiseasesthat causeitching: man- cessary Before considering afood orenvironmental allergy itisne Vaccines? Changes?... Skin barrierfunction Skin Atopic andpruriginous dermatitis: itisaninflammatory Previous andcurrent treatments Diet Features oftheitching: intensity, pattern ofthelesions... Seasonality Age ofonset Coincidence withaspecificsituation: Presence offleasorotherparasites Habitat: Are otheranimals/owners affected? Food adverse reaction. allergy: immune-mediated The Food intolerance: adverse againstcertain reactions Concomitant skin Environmental Food allergens Psychogenic Flea allergy FACTOR infections allergens Clinical history Clinical examination. their droppings offleasor Detection Clinical examination. Cytology Clinical examination. Trans-epidermal water loss Food restriction-reintroduction allergen-specific IgE test or Intradermal Clinical examination TESTS - Intestinal permeability as a background in allergy cases

Skin manifestations of food allergy are indistinguishable gestive disorders, such as pancreatitis, cirrhosis, etc. may from those of atopic dermatitis. Up to 40% of the dogs with cause problems at the gut level. The arrival of inadequately atopic dermatitis symptoms show sensitisation to food digested proteins to the colon allows them to be digested allergens. In case of showing atopic dermatitis symptoms, by bacteria, that produce residues that damage the gut mi- especially if it has a non-seasonal pattern, we should analy- crobiota and the mucosa. se if the animal has developed a food allergy. 5. Consumption of poor-quality diets. 6. Nutritional deficiencies: the intestinal permeability

A damaged intestinal wall may allow partially digested and the associated inflammatory process also feedback the INTESTINAL PERMEABILITY molecules with a high molecular weight to pass through nutritional deficiencies. it, which would have never happened with a healthy gut 7. Food allergy. mucosa. This is why the immune system considers them as 8. Autoimmune diseases (rare). something exogenous and starts a reaction against them, causing an allergic response. Therefore, there is inflam- State-of-the-art hypoallergenic food contains hydrolysed mation, recruitment of more immune cells…, and a posi- proteins, so amino acids, and not whole protein molecules, tive feedback mechanism is triggered that perpetuates the pass through the intestinal barrier. This controls the allergy mucosal damage, that is seen at a systemic level: itching, symptoms significantly, because allergic reactions are re- inflammation, dry skin, alopecia, etc. duced.

But it is necessary to underline that the primary cause of Causes of intestinal permeability the problem are not proteins, but intestinal permeability: 1. Previous use of drugs: NSAIDs, corticoids, antibiotics... an epithelial barrier that is damaged and that cannot exert 2. Intestinal dysbiosis: gut microbiota imbalance to the its protection role against exogenous molecules: antigens, detriment of beneficial bacteria. Candidiasis is normally pathogens, toxins, poorly digested food, etc. Due to this, present in many cases and it must be treated with antifun- we must search for the cause of this damage on the gut gal drugs. mucosa and try to repair it as soon as possible. It is only 3. Chemical sensitivity and secondary inflammatory in this way that the entrance of these high molecular wei- processes against synthetic additives or other irritants. ght proteins (that on many occasions would not come into 4. Enzyme insufficiency and malabsorption: extra-di- contact with the immune system) will be avoided, and so the immune response will not be triggered.

Figure 2. When the integrity of the gut mucosa is compromised, an intestinal permeability problem appears: the epithelial barrier is unable to control the entrance of exo- genic substances, that enter the bloodstream and can cause a series of reactions at a systemic level. Comprehensive therapeutic options for allergy Restoration of gut health Repairing of the skin This is the key for the comprehensive therapeutic approach The restructuration of the epithelial barrier by means of fa- of food allergy, because it is to be found in the origin of tty acids or shampoo therapy are deemed as key steps for many of the cases. The gastrointestinal tract is considered the long-term treatment of atopic dermatitis (Saridomiche- as an ecosystem that is based on three pillars: the epithe- lakis & Olivry, 2016). lial cells, the immune system and the gut microbiota, and all of them must be taken care of. Dermovital Omega 3-6-9 is a supplement suitable for repairing and maintaining the integrity of the skin barrier. It The epithelial barrier is the first defence mechanism against contains essential fatty acids, as well as MSM, biotin, zinc the entrance all kind of allergens, pathogens and poorly and selenium, and it is a great nutritional support for skin digested glycoproteins. In the case of allergies, there are metabolism. many factors that compromise the integrity of the gut epi- thelium: inflammatory processes, diarrhoea, gut dysbio- Therapy with dermatological shampoos helps to control sis… GlutaVet can facilitate the regeneration of the intes- skin infections (Malassezia, pyoderma…), as well as exer- tinal mucosa, because it contains a precursor of glutamine, ting a moisturising and soothing action. COMPREHENSIVE THERAPEUTIC COMPREHENSIVE OPTIONS a conditionally essential amino acid that exerts a protective and regenerative effect on the intestinal mucosa. It also The normalisation of the skin barrier through these supple- acts as an energy source for enterocytes, lymphocytes and ments allows to: macrophages, so the immune system is supported at the • Prevent the entrance of allergens through the reduction gut level. of the allergenic load settled on the coat and the skin, and reinforce the physical barrier represented by the skin. The consumption of prebiotics and probiotics, such as Flo- • Reduce the itching and the inflammation. ravet Complex, help the microbiota to develop harmoni- • Moisturise and soothe the skin, avoiding the excessive cally, exerting positive effects on the gut health, among trans-epidermal water loss. which we must underline: • Reduce the secondary infections. • The strengthening of the immune system: e.g. the regulation of the Th2/Th1 balance. • The decrease in the pathogenic agents such as bacteria, parasites, Candida… • The drop in the food intolerance symptoms. • The prevention and treatment of diarrhoea.

COAT AND SKIN HEALTH • Dermovital Omega 3-6-9 Essential fatty acids • Dermosel shampoo Seborrhoea • Dermovital shampoo Atopic dermatitis + itching • M-Derm shampoo Pyoderma and Malassezia

ALLERGIC REACTIONS • Histamín Control Natural regulator of the allergic and anti-inflammatory response • KrillVet Omega-3 fatty acids, anti-inflammatory

REGENERATION OF THE GUT WALL • GlutaVet Glutamin for the regeneration of the mucosa • Floravet Complex Symbiotic (prebiotic and probiotic), plants and medicinal mushrooms • EnziVet Digestive enzymes • Restriction diet Management of the allergic reactions We must not forget… The entrance of the allergen causes a response of the T and The communication with the owner B cells, that produce IgE antibodies that pre-activate the One of the greatest challenges in the treatment of allergies mast cells. The contact with the allergen causes the degra- is achieving a good relationship with the owner; a rela- nulation of the mast cells, and molecules such as histamine, tionship based on trust and commitment. When the cau- leukotrienes and interleukins (which have a direct responsi- se of the allergy is unknown or it cannot be avoided, the bility in the activation of allergic processes related to inflam- allergy becomes an incurable chronic disease, and thus it mation and itching) are released. Therefore, the damage to can be very frustrating for the owner and the veterinarian. the skin barrier is worsened, and the entrance of new allergens is facilitated, and this feedbacks the allergic process. There is not a single, effective and well-defined therapy for the treatment of allergies. Each case is different and implies There are nutritional supplements, such as Histamín Con- a comprehensive customised therapy. Therefore, the esta- trol, that help to modulate the response of the immune sys- blishment of a good relationship with the owner is key so tem: a key step for normalising the allergic reactions. These the veterinarian can handle their expectations, financial si- supplements can act at different levels in the chain reac- tuation and degree of commitment. The most appropriate tions, being conducive to the following: rebalancing the treatment for allergies is the one that implements measu- Th1/Th2 populations, inhibiting the mast cell’s degranula- res that are adapted to the clinical needs of the animal and tion, reducing the pruriginous processes… This effect may the owner’s situation. be increased with the concomitant use of KrillVet, thanks to the anti-inflammatory effects of its omega-3 fatty acids.

ACTION THERAPEUTIC OPTIONS Reduce the allergic reactions • Histamín Control • KrillVet • Immunosuppressants, anti-inflammatory drugs Improve the gut health • GlutaVet • Floravet Complex • EnziVet • Restriction diet • Dermovital Omega 3-6-9 Avoid the release of mediators of inflammation • Histamín Control • KrillVet • Glucocorticoids, cyclosporine, oclacitinib Reinforce the skin barrier • Dermovital Omega 3-6-9 • Topical treatments Treat the concomitant skin infections • M-Derm Shampoo (Malassezia and Pyoderma) • Dermosel Shampoo (seborrhoea) • Dermovital Shampoo (pruritus) • Topical antiseptics Control the ectoparasites • Natural repellents: Stanvet® Life , Pulvex • Environmental insecticides: Pulfin Handle psychogenic factors • Measures to reduce stress • KrillVet • Anxiolytics BASIC COMPREHENSIVE PROTOCOL (e.g. potato) 2weeks, after avoid cereals. between meals may eat allthefruitthat It itwants orlikes chicken,fish.20g/kgof weight, in2meals. Vicent’s book(2016)may befollowed. -Natural elimination diet:therecommendations in food. -Hypoallergenic • Changethedietfor oneoftheseoptions: times/day. • For 1month: newly-affected animals Therapeutic protocol in • • • • • • Characteristics: Newly-affected animal comprehensive control Food allergies basic theevolution). (amount ofcereals, quality synthetic additives, etc.). diarrhoea. sporadic short-lived Histamín Control + GlutaVet: •Control infections, ifpresent. thesecondary •Promote therepairing ofthegutwall. •Promote thehealingofskin. •Reduce itching andinflammation. • Objectives Optional: food allergy tests (we canwait andsee Check vaccines andparasites. Check thecurrent andthepastmonths diet andits Generally, onlyitching, withoutlesions. Sometimes, Young oradultanimal. shows thesymptomsIt for thefirsttime. ted towards theclinicalpractice amore natural andlessaggressive medicine. Germany. thelast15years, In questioningtheconventional after medicalmethodologypartially, hehasdirec since Center trainingcal practice them,after intheAnimalMedical ofNew York andinseveral private clinicsin Graduated in Veterinary from Medicine theUniversity ofCordoba in1975.Hehasworked insmallanimalclini- applying her expertise in physiology toapplying herexpertise improve thehealthofpets. Barcelona, together withstays at theCECAD, inGermany. Shecurrently works asProduct at Stangest, Manager Graduated in Biology from the University of Barcelona in 2011. She took PhD studies at the Bellvitge Campus, in SHORT TERM: Dogs: reintroduce. Dogs: carbohydrates gradually orsteamed. Boiled vegetables may beadded. . Asingleprotein source: beef, turkey, rabbit, 1 pill/10kgofweight, 2 •Reinforcement oftheepithelialbarriers. ofexposure. periods oftheallergic •Management the during reactions to avoid it. •Identifycauseandtry theunderlying • llergenic food orthenatural dietpermanently. dually. thesymptoms appearagain,return If to thehypoa - for 2months at least. Try to return to food thenormal gra- not producing confusing results. and to inhibitthesymptomsreactions oftheinflammatory not hibitors of the allergic with the aim of trying reactions of allergy. So, ideally, notto useNSAIDsnorin- we willtry repair thetrigger to theintestinal detect mucosa andto try isatransitional, butnotacompleteIt diet. The goalisto • • days later: D Evolution which theanimalhasbeentreated intensely withNSAIDs. problembility intensely, except inmore complex casesin to improvesary thegutmicrobiota nortreat- thepermea this case(newly-affected notnecesIn animal)itisnormally - ofmeat, offaland ginraw to addanother kind bones. LONG TERM: epending on the chosen diet, check the evolution 30-45 PhD in Biomedicine - [email protected] PhD in Biomedicine Hypoallergenic food:Hypoallergenic ifthere isanimprovement, keepit Natural elimination diet:ifthere is an improvement, be Veterinarian - [email protected] Cristina Moncunill Werner Ulrich Ulrich Werner - - Chronic patient - Antifungal medication: Dermovital Omega 3-6-9 and Biotin B Complex contain biotin, that acts by inhibiting Characteristics: the growth of Candida from its yeast to its pathogenic mould form. Intense itching. Hives. Bad-looking skin and coat (it alre- • - Repopulation of the gut microbiota: such as Floravet ady denotes nutritional deficiencies). On many occasions, Complex, at high doses. different lesions are seen. • It has been treated several times with conventional symptomatic therapy, and it improves with it, but the ani- Therapeutic protocol mal relapses after suspending it, sometimes immediately in chronic patients and sometimes after some months. • There can be digestive disorders with flatulence and with For 45 days: or without diarrhoea. • Histamín Control + GlutaVet: 1 pill / 10 kg of weight, 2 • Several hypoallergenic foods have been tried. When the- times per day. If the itching is very intense, the dose of His- re is a relapse, there is a tendency to change the food brand. tamín Control can be doubled during the first 10 days and • The therapy has been changed (prednisone, cyclospo- then reduce it to the maintenance dose. rine, oclacitinib, etc.), and frequently the patient has been • Natural elimination diet exclusively. The possibilities of treated by many veterinarians. providing commercial diets have already come to an end. • Floravet Complex, a symbiotic based on prebiotics and probiotics. 1 envelope per day. Supporting diagnostic tests: • Try to remove, progressively the previous therapy (immunosuppressants, anti-inflammatory drugs) that does not If they have not been carried out yet, we can resort to • work fully or that the client does not wish to keep using due a blood antibodies test. In some cases, desensitising vac- to the side effects that it causes and the cost that they entail. cines have been used after identifying some allergens, but - If the itching is intense, return, temporarily, to predniso- the therapy has been discontinued due too several reasons ne at the minimum effective dose (start with 0.25 mg/kg of (cost, adverse reactions that have needed a therapy with weight, 1-2 times per day −test out−) for 1 week or 10 days corticoids, etc.). while the animal starts to eat the natural diet. It is better Thyroid gland test. • if we can administer the dose every other day. After 10-20 Biopsies. • days discontinue it gradually. • If flatulence or short-lived sporadic diarrhoea are seen, Tests for Candida make an exocrine pancreatic function test and start a the- The intestinal permeability is a problem that appears in a rapy with pancreatic enzymes (EnziVet), mixed with food. severe form in chronic patients, and it is generally accompa- nied by an important alteration of the gut microbiota. The treatment of chronically allergic animals causes intestinal Evolution dysbiosis, that can facilitate the proliferation of Candida. Therefore, it is recommendable to make a stool test to as- Once an improvement is seen, if it persists, the administering certain the presence of this pathogenic mould. of the aforementioned supplements can be discontinued gradually, based on the veterinarian’s opinion, and start the: Pathological consequences of the presence of Candida • Supplementation with fatty acids, such as Dermovital • Production of histamine --> they favour allergy. Omega 3-6-9 or KrillVet, krill oil that is very rich in omega-3 • Consumption of vitamin B6 --> they cause a deficit. fatty acids. They can be administered from the beginning, but • Secretion of neurotoxic substances --> tiredness and their absorption will be optimal when the intestinal villi have anxiety. been repaired. In the case of cats or of small animals, fatty • Zinc deficit -- > drop in the activity of the macrophages acids can be administered in liquid form: Dermovital gotas. against Candida. • Imbalance of the gut microbiota. Keep the natural diet and then add offal and raw bones of the same animal species before changing to another How to fight Candida? species. If there is a relapse, repeat the tests for Candida - Diet: avoid the nutrients that may be used by Candida for and the treatment against it: Dermovital Omega 3-6-9 or its proliferation: carbohydrates, fermented products, sulfur Biotin B Complex. amino acids, etc.

References - Day, M. et al., 2013a. Expert Views from a Roundtable on Canine Allergic Disease. - Day, M. et al., 2013b. Expert Views from a Roundtable on Canine Allergic Disease Itchy Dogs − Part 2 Building a Clinical Toolbox for Treating Allergic Patients. - Hensel, P. et al., 2015. Canine atopic dermatitis: detailed guidelines for diagnosis and allergen identification. BMC Veterinary Research, 11, p.196. - Marsella, R. et al., 2012. Current understanding of the pathophysiologic mechanisms of canine atopic dermatitis. Journal of the American Veterinary Medical Association, 241(2), pp.194–207. - Saridomichelakis, M.N. & Olivry, T., 2016. An update on the treatment of canine atopic dermatitis. The Veterinary Journal, 207, pp.29–37. - Vicent, Verónica, 2016. Dieta BARF para perros. CreateSpace Independent Publishing Platform. DIGESTIVE COAT AND SKIN ALLERGIES Floravet Complex / Dermovital Omega 3-6-9 / Histamín Control / GlutaVet / EnziVet Dermatological shampoos KrillVet

To obtain more information

Video http://bit.ly/2uqAQ1h

Experiences http://bit.ly/2twJ7UL

STANGEST, S.L. l Ctra. del Pla de Santa Maria nº 285 nave 37 l 43800 Valls (Tarragona) Tel. +34 977 604 651 l [email protected] l www.stangest.com