The mother said: "My daughter in KL asked me to consult you. My dog had skin diseases for so many years except for one year 3 years ago. I feed salmon and other good food. Every time, the itchiness would recur after some time after my vet had given a steroid injection. I hear steroids are not good for my dog."
"I don't know why your vet has not or will not give the anti-demodectic injection," I said. "Did you ask him why? Did he do a blood test to screen the health of this old dog, esp. the liver and kidney functions? If these organs are not normal, he might not want to risk giving the injection. You can ask him to fax to me the blood test results."
"Do you vets get along well with one another?" the mother had not asked her regular vet why he did not give the anti-demodectic injection. She also did not want to upset her regular vet by asking for clinical records for me to peruse and get a bigger picture of the dog's health.
"All vets do fax or email copies of our client reports to the 2nd-opinion vets when requested by the owner to do so. There is no problem for any vet in Singapore to do that as every vet will have owners who want a 2nd or 3rd opinion for his pet that does not respond to treatment by the first vet." As the mother was not comfortable to making the request, I did not insist and took her history of what happened to her dog from the beginning. She had brought some medication given by her previous vet. These included antibiotics, anti-mite cream and fatty acid oil supplements.
"Some skin diseases are not easy to cure unless the cause is known," I checked that this slim Shih Tzu did not have hair loss, little scales, four black paws with big skin warts, clean ears, teeth with little tartar despite no dental check up, a broken tail end with grey skin as if it had partial gangrene and very swollen anal sacs.
"Now the paws are not so itchy," the mother showed me a "poisonous" white cream that her regular vet had given her maid who must wear gloves to apply to the paws. "After applying the cream, the mites die and so the dog does not bite his paws so much. He also does not have that red flush of the skin in the evening causing him to cry and whine now."
The cream was formulated by her vet and so I would not be able to tell whether it included a steroid, hence accounting for the cessation of inflammation.
"Listen carefully to the client," I said to my intern from 4th year the Vet University in Kuala Lumpur. "What she wanted was to get an anti-demodectic injection." The mother had said that her vet had done skin scrapings and showed her "cigar-shaped" mites under the microscope. "These are demodectic mites," I referred to a chart drawing of demodex and her daughter took an image with her hand phone.
The consultation was nearly one hour long as the mother wavered on whether to get another blood test done or get her vet to give me his results and thereby offending this good vet. "I have a bottle of 100 tablets of Eltroxin tablets," she showed me and I have given half of the bottle. My vet said my dog has low thyroid hormones." She was reluctant to get a thyroxin blood level test done.
"A thyroxin test will show whether the medication is effective or not and on the status of the low thyroxin level," I said. "In fact, a repeat blood test is always advised to monitor the disease some 4 weeks after the first and the first blood test was 3 weeks ago." It was hard knowing what was the situation since the mother did not want to upset her regular vet.
So, this back and forth conversation took nearly an hour. "How to cure the demodectic infection?" the mum asked again and again.
"Demodectic mites are normally present in the dog's skin," I said. "When its immune system is below normal or low as in puppies and old dogs like yours, the mites multiply and cause skin itchiness and disease. So, increasing the immune system would have helped considerably."
"How about giving my dog the anti-mite injection?" she asked me. "A blood test is necessary to screen the health of your dog before I give the injection," I am not surprised that Singapore dog owners nowadays are sophisticated to know that some vets give regular anti-mite injections to kill the demodectic mites. However, this was a very old dog and the injection might kill him.
"If the owner wants the injection, the vet ought to give it," I said. "But educating the owner is difficult. The best way is to boost the immune system of your dog. Why does your dog lick all four paws till they are black?" I had explained that the large skin warts on and above the paws irritate the dog as he tried to lick them off. "Continuous licking to get rid of the paw warts, cause the skin to break, become inflamed, infected and ulcerated. After some weeks, the melatonin skin pigments get inside the skin, causing blackness of the skin of the paws. Excising the warts would remove a stress for this old dog and hopefully the demodectic mites will not cause disease."
"But my dog is so old and will die under the general anaesthesia," she replied.
"A blood test will show whether this dog is fit for anaesthesia," I said. "The electro-surgery to excise
the skin warts off the paws takes less than 5 minutes and I can say that the dog has a very high rate of survival since anaesthesia is so short."
The daughter seemed to know what I was talking about. The mother was pre-occupied with the possibility of recurrence of the red skin flush and loud whining in the evening, probably stressing her so much. So we were at different ends of the world. The dog was much better now due to the variety of medications, the skin cream and the fatty acid oil supplements but this skin flush and whining might recur. Her daughter would be going home to Australia in a few days' time.
It needed a lot of patience. What the mother wanted was a treatment to cure the disease once and for all as she had spent a lot of money with so many treatments by her regular vet.
What I proposed was to remove the stress factors as treatment involved steroids and anti-mite cream and/or injections which could harm this old dog.
"I will pay for the blood tests," the daughter suddenly volunteered. Chronic skin diseases are costly to treat and in this case, it was not only the recurrence of itchiness and whining but also money matters. Unless the cause can be identified and can be easily treated, skin diseases are hard to cure in some dogs. In this dog, the ventral groin area is no long black, due to previous steroid jabs. But the paws were still black. On detailed examination, I would say the big skin warts on the four paws would be due to the spread of these viral warts by the dog licking as the body seemed free of the warts unlike other old dogs. The dog's anal sac was voluminous with dark brown thick viscous oil. I asked my intern to express the glands and she managed to get 5% out. I showed her how to do it and expressed over 3 ml of the oil while another intern videoed the procedure. The broken tail needed to be amputated. This was another advice I gave and the mother said: "Earlier the tail was black. I massaged it till the colour returned." That meant the tail had become gangrenous and is now half alive. The hairless tip and broken angle of the tip would be an irritant to this dog, decreasing the immune system and encouraging the demodectic mites to overwhelm his body causing red flush and pain of whining. If only dogs can talk.
So, the first advice would be to remove the warts and in most cases, the dog would become much happier and no longer need to get rid of these "dangling" tumours. Simple solution if the dog was young and not an anaesthetic risk. "Warts seldom appear in young dogs," I said to the mother. "I had an old pug in which I removed 50 skin warts."
"Is the pug OK?" the mother asked.
"Yes," I said. Skin warts do irritate the older dog but many owners are oblivious to this discomfort of the old companion.
UPDATE ON FEB 6, 2013
A blood test to screen the dog's health and thyroxin levels were permitted by the owner. The test revealed a high level of liver enzymes. As there is a high risk of death on the operating table, the owner did not want any anaesthesia to remove the paw warts and the broken tail. The anal sacs were expressed (videoed by an intern) and its voluminous greyish oil disposed. As for the anti-demodectic mite injection, this dog would best not take this injection. What the mother had sought in visiting me would best not be given by the vet.
Case 2. Itchy Dogs. Generalised ringworm