General practitioners (GPs) typically refer patients to specialists when a patient's medical condition requires expertise beyond the scope of primary care. This referral process is crucial for ensuring that individuals receive specialized diagnostic and treatment interventions. Effective collaboration between GPs and specialists can ensure clear communication for the client and medical team. In dermatology cases, specifically, severely allergic diseases, acute-onset skin disease, chronic otitis externa, and more can be examples in which referral to a dermatologist would benefit both the patient and the owner. However, Julia E. Miller, DVM, DACVD, a dermatologist with Animal Dermatology Group in Louisville, Kentucky, and an assistant clinical professor of dermatology at Cornell University College of Veterinary Medicine in Ithaca, New York, explained to attendees at the Fetch conference in Charlotte, North Carolina that the rate of referral for dermatology cases are less common than other specialties.

One reason for this could be the lack of client education about veterinary dermatologists. Some clients might think their pet’s GP is the only one who can help and without the GP’s recommendation of seeing a dermatologist, they would never know it’s an option. Miller stated, “What [clients] don't realize is that animal dermatologists do it all. We do the bumps on the skin, we also do ear infections, and we also manage allergies, which is very different than how human [medicine] is.”

Miller stressed that GPs could help educate clients about veterinary dermatology and provide information or resources. One of Miller’s suggestions is a website called petsgetallergies.com, and on there, clients can learn more about what veterinary dermatologists do and the diseases and conditions they can treat. Clients can also use this resource to find a dermatologist near them or they can go on the American College of Veterinary Dermatology (ACVD) website to search, as well. “What I really like about this website is it's very much geared towards clients… You could guide them towards this website because it really has some very digestible owner-friendly information.” Miller said.

In 2019, the American College of Veterinary Dermatology (ACVD) conducted a survey of pet owners who have been referred to a dermatology specialist.

 Dermatology was the second to least likely veterinary specialty to receive a referral from a GP, with only behavior being less likely. Oncology, orthopedic, and ophthalmology were some of the highest referrals.

 Only 27% of clients reported that their dogs were successfully treated after their first visit with their GP and 73% of clients visited their GP more than 3 times before they were referred. This highlights the fact that most of these dermatologic cases are complex and chronic.

A survey in the United Kingdom assessed the prevalence, diagnosis, and treatment of dermatological issues in small animals within general practice. Among the 3707 observed consultations, 795 (21.4%) involved a pet with a dermatological problem. In dogs and exotic species, pruritus was the predominant presenting sign, comprising 30% to 40% of dermatological consultations. In cats, cutaneous swellings were the most common presentation (36%).

This case to referral discrepancy is perplexing and Miller said to attendees, “it tells me that we really do need to do more referrals, because we're seeing an awful lot of these cases.”

Another reason for the low number of referrals could be because most dermatology cases are not dire or deadly, but rather chronic conditions that take a lot of effort to treat or manage. However, Miller challenges this idea by stating, “Also remember that pets can be surrendered to shelters because of chronic skin disease. And they're surrendered because dermatology cases have a financial burden, time commitment, and you have a chronic sick dog. that's a big deal, right? So maybe they're not deadly, but they certainly have a lot of negative consequences to our owners.”

GPs might postpone the referral of their patients to specialists because they believe their treatment selection will be effective. However, in that same ACVD study, the diagnosis in 46% of cases made by the GP did not align with that of the dermatologist.

 Miller underscored that referring cases to a dermatology specialist can streamline a patient's treatment and expedite their recovery process.

Open collaboration between the GP and dermatologist is paramount for setting a patient up for success. The synchronicity between both veterinary professionals can create a unified treatment plan and contributes a seamless progression of the therapeutic process. However, it is important to remind the client of the reality that, despite a quick referral, many dermatological cases are chronic and require patience and persistence before there is a noticeable improvement in the pet's condition.

“So get to know if your friendly neighborhood dermatologist, they are happy to talk through cases with you and that can be a really good resource,” Miller said.

Miller JE. Tips and Tricks for Successful Referral and Co-management with your Neighborhood Dermatologist. Presented at: Fetch dvm360 conference; March 15-17, 2024; Charlotte, North Carolina.

Hanna B. Earlier dermatology referral rewards primary care practice (part 1): easing client expenses and enhancing patient care. DVM360 magazine. May 2022: 42-43. 

https://www.dvm360.com/view/earlier-dermatology-referral-rewards-primary-care-practice-part-1-easing-client-expenses-and-enhancing-patient-care

Hill PB, Lo A, Eden CA, et al. Survey of the prevalence, diagnosis and treatment of dermatological conditions in small animals in general practice [published correction appears in Vet Rec. 2006 Jun 3;158(22):763]. 

. 2006;158(16):533-539. doi:10.1136/vr.158.16.533

Articles

Julia E. Miller, DVM, DACVD, explained the importance of dermatology referrals at the 2024 Fetch conference in Charlotte, North Carolina

Combining forces: How general practitioners can work with dermatologists

Officials with the FDA have approved terbinafine and betamethasone acetate otic gel (DuOtic; Dechra) for dogs. This gel is the first animal drug indicated approved by the agency for the treatment of otitis externa associated with susceptible strains of yeast (

According to the FDA, terbinafine and betamethasone acetate otic gel is also the first otic drug intended to treat otitis externa that does not contain an antibiotic. This allows veterinarians to focus treatment and avoid using antibiotics when dogs have diagnosed yeast-only ear infections.

The drug is a fixed combination of the 2 active substances: terbinafine and betamethasone acetate. Terbinafine is an antifungal and is commonly used in human medicine to treat athlete’s foot. Betamethasone acetate is a glucocorticosteroid with anti-inflammatory activity.

The otic gel dissolves in earwax and is slowly eliminated from the ear. It also fights yeast infections for up to 45 days.

Terbinafine and betamethasone acetate otic gel is only available by a prescription from a licensed veterinarian and should be administered by a veterinary professional. Veterinary medicine professionals should clean and dry the external ear canal before administering the initial dose of the product and should administer one dose (1 tube) per affected ear and repeat administration in 7 days. The dog’s ear canal should not be cleaned for 45 days after the initial administration to allow contact of the gel with the ear canal.

The newly approved gel may cause eye injury and irritation in people and dogs. Individuals who administer this drug in the clinic should wear eye protection, and the dog should be restrained to minimize post-application head shaking to help prevent accidental eye exposure in both humans and dogs.

Terbinafine and betamethasone acetate otic gel contains 10 mg terbinafine and 1 mg betamethasone acetate per mL. It is available in a single use tube with a flexible soft tip, supplied in cartons containing 2 or 20 tubes.

FDA approves treatment for yeast ear infections in dogs. News release. FDA. March 15, 2024. Accessed March 15, 2024. 

https://www.fda.gov/animal-veterinary/cvm-updates/fda-approves-treatment-yeast-ear-infections-dogs?utm_medium=email&utm_source=govdelivery

DuOtic by Dechra is the first otic drug intended to treat otitis externa that does not contain an antibiotic

FDA approves drug for treating canine yeast ear infections

Health Benefits of DNA Testing

 How does knowing a dog's genetic background make visits to the clinic easier for both the practitioner and for the pet owner?

 I mean, it's such a great way to really be prepared, right? The whole care team can be prepared. So as a veterinarian, you can be on the lookout for different conditions that you may not otherwise be on the lookout for and make whittling down those lists of differential diagnoses a lot easier. It also prepares your veterinary technicians, your front office staff, the pet owners as well, on things that they could know about their dog to help enrich its life. To help them take better care of their pet is such a great start on really providing great health care from the whole team throughout their life.

 Like a team care approach to genetic counseling, right? Love it. What are some of the health benefits that we could talk about with the DNA testing?

Jenna Dockweiler, MS DVM, DACT, CCRT, CVAT:

 We can test for about 250 health conditions currently, and that covers all body systems. There are skin conditions, there are urinary conditions. You name it, we can test for various conditions that affect the dog. And then kind of the other side of that is knowing the breed actually can be quite helpful for health conditions as well. Breed mix is often very difficult to determine visually. So, for example, many golden retriever mixes are going to be black and they're going to have short hair. They're not going to necessarily look anything like a golden retriever mix. But if you have a patient who comes in, who maybe is, 70% golden retriever but doesn't necessarily look like a golden retriever, I would bet you're going to check those lymph nodes extra close at each of their wellness exams.

 Yes. If you guys ever get a chance to go to the conferences, you'll see their Embark booth that's there. It is so funny because there's so many “aha” moments that the whole crowd gets because they think they know what the dog is made up of and then when they show the results they’re like, “oh my gosh”. They have these “aha” moments. What do you think that means to the veterinarian too when they see those results? Like that's got to be so powerful knowing how they're going to go ahead and practice and take care of that pet.

 Absolutely. And it can, like you say, be very surprising what those results come back as, and that can really help you narrow down some differential lists.

 Yeah, big time. How does genetic testing help strengthen the human animal bond?

 I think it's interesting in veterinary medicine. I think that genetic testing and, you know, the breed part of that is one of the few diagnostic tests we get to do that's fun. I think a lot of times when we do diagnostic tests, it's usually looking for a disease, it's preparing for a surgical procedure. Talking through a CBC chem is nothing like getting to discover what breed your dog is. I’m speaking as a pet owner too, and just how neat that is to find out about your pet. So, I think there's that piece of strengthening the bond, that it's fun. But the second piece of that and having that positive experience is being able to focus on the more serious side of genetics. So regardless of if it's a mixed breed dog or if it's a purebred dog, we all have DNA, right? And that tells a story about that animal's health and some things we can do throughout their life. So, you know, things like making diet recommendations, looking out for different health conditions. And I think that really strengthens the bond in knowing that you're doing all that you can do to take care of your pet and take care of that patient as a veterinarian too.

 It seems to me that pet owners are so much more passionate about DNA tests and then sometimes the veterinarians are, almost as if we don't have enough time to go over those kinds of results or whatnot. So, I'm curious to get your feedback on that. When a pet owner actually is recommending that they want to DNA test their dog and the veterinarian may show some trepidation to that, how do you go about leveraging that conversation?

 I think sometimes veterinarians will say, “well you know the vast majority of the time it's normal. There's nothing there.” I think that as a veterinarian myself, we tend to look for the problems. That's natural. That's our job, but I think a negative test and knowing that it's clear of all the markers that we're testing for is awesome. We need to remember that. That's a positive experience for that client. It’s a way that we can build trust with them. It's a way that they can learn about their pet. And gosh, I mean, all the things that you can find out with genetics that may be rare. I'm thinking about all the things that you would want to know before a surgical procedure—clotting disorders, different sensitivities to the anesthetic drugs, and pre-meds that we use, right? So malignant hyperthermia, not super common. But if you have a sight hound with that mutation, that's a huge deal, right? MDR mutations, sensitivity to acepromazine, butorphanol, things that we use a lot of times with pre-meds. So, when you do find those zebras, so to speak, it's impactful.

Videos

Lindsey Kock, DVM, and Jenna Dockweiler, MS DVM, DACT, CCRT, CVAT dive into the health benefits of DNA testing and how it can strengthen the human animal bond. 

Health benefits of DNA testing

Introduction to DNA Testing

 Hello friends and welcome to VetPerspective. Canine DNA testing has been on the rise for the past four years, becoming more popular in pets than ever. Today, we’re going to discuss the importance of DNA testing, how it works, and provide clients with a unique opportunity of customized care. My Name is Dr. Adam Christman, Chief Veterinary Officer here at DVM360. Thank you so much for joining us. We want to thank our friends from Embark for supporting this great discussion and let’s meet our wonderful colleagues! We have Dr. Lindsey Kock here and Dr. Jenna Dockweiler. How are you, my friends?

Lindsey Kock, DVM, and Jenna Dockweiler, MS DVM, DACT, CCRT, CVAT: 

Thanks for being here! Okay, so a little bit of information about our wonderful friend, Dr. Kock. She is a second-generation veterinarian from Nebraska, began her academic journey at Doane college, earning a degree in biology with a minor in chemistry. Lindsey completed her formal veterinary education as a member of the second class in the professional program in VetMed through the University of Nebraska and Iowa State University. Launching her career as an associate mixed animal veterinarian in Southwest Iowa, Lindsey was awarded the Iowa Veterinary Medical Association’s Rising Star in 2015.

After four years in clinical practice, Lindsey traded in her truck for an office job and had the opportunity to travel around the world leading the companion animal genomics business at Neogen. She was awarded Neogen’s Animal Safety Product and Marketing Manager of the year in 2020.

In 2022, Lindsey founded Deep Dive, DVM Veterinary Consulting, focusing on the adoption of data-driven technologies and animal health. Concurrently, she serves as the head of the Healthcare Product Management Division at Edcetera. Under her guidance, Edcetera’s Veterinary Portfolio, featuring prep, tech prep, etcetera, has flourished, providing essential resources for board exam preparation and professional development. We know how important that is, right?

We also have Dr. Jenna Dockweiler with us. She graduated from Kansas State University’s College of Vet Medicine with honors in 2014 and completed her small animal rotating internship at Wheat Ridge Animal Hospital in 2015. She then completed her comparative theriogenology residency at Cornell University in 2017 and became a diplomat of the American College fo Theriogenologists that year. She practiced small animal theriogenology and general practice for four years prior to becoming a veterinary geneticist with Embark veterinary.

In her spare time, Dr. Dockweiler enjoys photography, hiking, and competing in performance events and conformation with Welsh Springer Spaniels. Those are beautiful!

Jenna Dockweiler, MS DVM, DACT, CCRT, CVAT: 

All right, everybody. We want to chat about the very basics about canine DNA testing. You know, it’s been so popular as you know, Jenna. Let’s kind of take a little bit of a step back and talk about DNA testing in general. Give us a little overview of how Embark DNA testing works and is a blood test necessary?

 Absolutely. It is a simple cheek swab that can be performed at home or in the clinic. It’s a soft swab, so it’s not bristly. It’s very comfortable for the patient. You collect that simple little cheek swab, pop it into the mail with our prepaid USPS mailers, and send it off to the lab. At our lab, what happens is the DNA sample from the patient is amplified. So, many copies are made of that DNA. It is washed over our microarray platform, which just looks like a little microscope slide that has thousands of tiny little beads on it, and those beads are called probes. And each one of those little probes is designed to assess the genome at a predetermined location. Those probes could be relevant to health conditions. They could be relevant to physical traits, breed ancestry, or just be pointed at areas of interest in the canine genome. Once we have our genotype—at all of those over 230,000 predetermined locations—we then can provide a report that gives breed ancestry, health conditions, and physical traits.

 Okay, what’s the turnaround time for that?

 About two to four weeks from when we receive the sample from the lab, we’ll have results back to you.

Meet Lindsey Kock, DVM, and Jenna Dockweiler, MS DVM, DACT, CCRT, CVAT as they prepare to discuss canine DNA testing. 

Introducing Lindsey Kock and Jenna Dockweiler

“How common is allergic disease?” Julia E. Miller, DVM, DACVD, asked attendees at the Fetch conference in Charlotte, North Carolina.

 The answer: fairly common, when comparing to all other reasons pets come into the veterinary clinic. 

Miller, an assistant clinical professor of dermatology at Cornell University College of Veterinary Medicine in Ithaca, New York, shared evidence of this commonality with data conducted by Healthypaws insurance in 2017-2018. The data found 39% of veterinary clinic cases were dermatology related, and specifically allergies. This 39% was comprised of 17% to 22% skin conditions, 12% ear infections, and 5% other allergies.

 Miller also shared with attendees that the word “atopy” comes from the Greek word “atopia” which means uncommonness. This is ironic with how common it is for veterinary medicine.

Allergic dermatitis occurs the pet’s skin develops an allergic reaction, but veterinary professionals need to identify what is causing the dermatologic condition, before diagnosing it properly. To start, a thorough history for each patient should be taken, and it should include the following components:

Atopy is typically seen at ages 1-4 years, however there are exceptions in French bulldogs, bully breeds, German shepherds, Wheatons, and more.

38% of dogs develop a food allergy at less than 6 months of age.

What season was it at onset? (This can point to an environmental allergy vs a food one)

Is the dog taking a flea preventive? What is it? How often is it applied? What is the proper application technique?

Are there any gastrointestinal signs present? (This may point towards a food allergy)

Atopy cases are more common for an allergic disease, affecting 10% to 15% of dogs. Some common signs include scratching behind the elbows, licking and chewing the feet, rubbing at the face, and scooting. Excessive scratching and licking may also contribute to hair loss.

According to Miller, 10% to 25% of atopy dermatitis cases are caused by a food allergy. Food allergy, more formally referred to as 

, is an adverse immunologic reaction to an allergen in the diet. Food allergy is commonly a protein such as chicken, beef, lamb, or fish, however, any carbohydrate or fat may also be an allergen. Diagnosing a food allergy can be quite frustrating since it presents very similarly to environmentally-caused allergies. The same signs of scratching, licking, and scooting can be present. To get an accurate diagnosis, there needs to be a strict, prescription diet trial.

Over the counter diets are not a prescription diet trial but can be called a diet change. Home-cooked is the best practice with strict guidelines from your veterinary dermatologist.

According to Miller, after 3 weeks on a diet trial, more than 50% of dogs will show improvement. After 5 weeks, more than 85% of dogs show improvement, and after 8 weeks, this jumps up to more than 95% of dogs showing improvement. Miller stated, “So the way that I feed diets is I have the client check back in with me at 4 to 6 weeks. If there is zero change in 4 to 6 weeks, I am done. I do not feed that diet for another 2 months. If there is some change in that 4-to-6-week plan, I continue the diet a little bit longer and see how good I can get it.”

However, Miller cautioned attendees to not bother with the diet trial if the client is unwilling or cannot do it right. She emphasized that diet trials are tough because of how strict they are and how consistent clients need to be with them. “If a client is unwilling or unable to do it at trial, just don't do it,” she said.

Miller JE. The itchy and scratchy show: How to confidently diagnose canine allergies (part 1). Presented at: Fetch dvm360 conference; Charlotte, North Carolina; March 15-17, 2024.

Common dog and cat illnesses and accidents. Healthypaws Pet Insurance and Foundation. 2017-2018. Accessed March 15, 2024. 

https://www.healthypawspetinsurance.com/common-pet-illnesses-and-accidents

Collins B. Atopic dermatitis (atopy). Cornell University College of Veterinary Medicine. Accessed March 15, 2024. 

https://www.vet.cornell.edu/departments/riney-canine-health-center/canine-health-information/atopic-dermatitis-atopy

Brush up your knowledge on allergic disease for the itchy dog

Finding the root of the allergy

Caitlin DeWilde, DVM explains why marketing and social media can be important for your veterinary practice

Making client education easier with veterinary marketing

In an interview with Caitlin DeWilde, DVM, founder of The Social DVM, she explained why marketing and social media can be an important part of your business and how it can help clients. From her sessions at the Fetch conference in Charlotte, North Carolina, she hopes attendees take away something practical to start implementing in their clinic.

 I've always been a little bit of a nerd, but what really kind of started my passion was almost a decade ago. As a veterinarian, I was getting really frustrated with clients looking things up in the exam room as I was trying to explain something to them. And I finally asked somebody. I was working with this cat that was blocked, and it was pretty urgent and I needed authorization to move forward with treatment. And the owner was just looking at his phone. I said, 'Sir, do we need to call somebody else? How do we move this forward, I gotta get back to your cat.' And he said, 'Well, I'm trying to find your website to see if you I can find some information about this so I can just send it to my wife so that she will understand because I'm never going to understand all this stuff that you're explaining to me.'

Caitlin DeWilde, DVM, explains why marketing and social media can be important for your veterinary practice