C09986476 / invoice 10000

Skin flare up again
Person () 
Insurance ()
Reminders ()
Preventatives ()

PRESENTING CONCERN(S):
- Chronic pruritus with constant licking.
- Recent onset of ear flapping (since yesterday, 03/03/2026).
- Malodourous and erythematous ears.

HISTORY:
Lulu has a chronic history of skin issues, suspected to be atopic dermatitis. A referral to a veterinary dermatologist was quoted at $1200, which has been postponed by the owner. The primary concerns are persistent itching, constant licking of her body, and recent ear flapping which started yesterday. The ears were noted to be very red yesterday, with the left ear appearing most affected. Today, there is also some ocular irritation. The pruritus is distressing to the owner. Lulu's appetite and water intake are good, and she walks well daily. She has previously received Cytopoint injections, which provided approximately one month of relief. Apoquel was also used in the past and was effective, but the pruritus returned upon cessation of the medication. The owner uses a mousse prescribed by another veterinarian which provides some temporary relief. She also gets wiped down with colloidal silver wipes or fragrance-free baby wipes after being outside. She is bathed every fortnight with a medicated shampoo. She has a history of receiving steroids. The owner reports that her daughter used to sneak food to Lulu. Lulu's thirst has increased, though the owner clarifies she has always drunk a lot of water.

Diet: One chicken neck in the morning, and a pouch of commercial wet food at night. The owner has switched to a variety of wet food pouches (Lyka).
Current meds: nil reported
Prophylaxis: NexGard Spectra administered on the 15th of every month.
Pre-existing conditions: Chronic atopic dermatitis, possible contact allergy. 
Access to toxins e.g. Rodenticide: nil known

EXAMINATION:
Body Condition Score: 8/9
Hydration status (%): Euhydrated
Cardiovascular: HR 120, cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronous
Respiratory: RR panting, thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal discharge, no coughing or sneezing
Neurological: neurologically no significant findings
Musculoskeletal: ambulating normally x4, no palpable neck, spine, limb or joint pain
Gastrointestinal:
- Oral: NSF, no mouth pain, dental score: 1/4
- Abdominal: comfortable on palpation, no obvious foreign body or mass effect, no significant distension
- Rectal: not performed
Urinary: NSF
Reproductive (incl ext. genitalia): NSF
Integument/Ears: Both ear canals are erythematous and inflamed, particularly the left (worse than right), bilaterally malodorous. The ventral abdomen and paws are also affected by skin changes consistent with atopic dermatitis (diffuse lichenification particularly axilla. ventral abdomen, and inguinal regions with partial alopecia). Periorbital alopecia. Patient is extremely pruritic. 
Lymph Nodes: Peripheral lymph nodes WNL on palpation
Eyes: NSF

PROBLEM LIST:
- Bilateral otitis externa, worse in the left ear.
- Generalised pruritus and persistent licking. 
- Overweight (BCS 8/9).
- Diffuse lichenification.

DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:
- Chronic skin pathology (e.g. Atopic dermatitis, contact allergy, food allergy/intolerance.)

DIAGNOSTIC/MANAGEMENT PLAN:
A multi-modal approach was discussed to manage the current flare-up and investigate underlying triggers. The plan involves addressing the yeast overgrowth, managing pruritus, and initiating a diet trial.

DIAGNOSTICS:
- Tape-preparation cytology from skin and ears: revealed an overgrowth of Malassezia yeast and paired cocci. 
- Biochemistry: 

ASSESSMENT:
Lulu is a 4-year-old Dachshund cross presenting with a flare-up of her chronic skin condition. The primary issues identified are severe pruritus and signs of otitis externa. Cytology confirms an overgrowth of Malassezia yeast on her skin and in her ears. This is possibly in conjunction with underlying atopic dermatitis, which may have food-related and/or environmental triggers. Her current weight of 12.4kg and BCS of 8/9 indicates she is overweight. The plan is to treat the yeast infections, manage the pruritus, and start a strict hypoallergenic food trial to rule out dietary triggers and aid in weight management.

TREATMENT:
- Terbinafine 250 mg PO SID for 2 weeks, recheck skin
- Surolan ear ointment BID for 5-7 days.
- Apoquel 5.4 mg BID for 7 days
- Malasseb shampoo twice weekly initially
- Discussed potential for recommencement of oral steroids, reluctant to do so while started on Terbinafine initially. 

PLAN:
- **Diet:** Commence a strict 8-12 week hypoallergenic diet trial (e.g., Royal Canin Hypoallergenic). All other food sources, including treats and chicken necks, must be eliminated. The daily food ration should be calculated for a target weight of 10kg to facilitate gradual weight loss and can be used for treats. The owner will consider starting this after this weekend.
- **Systemic therapy:** Discussed initiating a 4-6 week course of oral terbinafine, an antifungal medication, to treat the systemic Malassezia infection. This requires a prescription to be filled at a chemist. It was recommended to perform a biochemistry panel to check liver enzymes prior to starting this medication due to its hepatic metabolism. Potential side effects like gastrointestinal upset and periorbital oedema were discussed.
- **Topical therapy:**
    - Continue bathing twice weekly with a medicated shampoo (e.g., Malaseb) to control surface yeast and bacteria.
    - Prescribe a medicated ear cleaner and a topical ear ointment to treat the otitis externa.
- **Pruritus control:** Discussed the option of short-term use of Apoquel to provide immediate relief from itching while the other treatments take effect.
- **Recheck:** Recheck examinations are crucial during the terbinafine treatment course, recommended every two weeks to monitor progress and for side effects.
- **Environmental control:** Advised to continue wiping paws after walks to reduce contact allergen load.

CLIENT COMMUNICATION:
A detailed discussion was had with the owner regarding Lulu's chronic skin condition being an autoimmune journey with likely flare-ups. The diagnosis of Malassezia overgrowth secondary to suspected atopic dermatitis was explained. The multi-modal treatment plan was outlined in detail, including the importance and strict nature of the 8-12 week hypoallergenic food trial. The rationale for systemic antifungal therapy (terbinafine), its potential side effects, and the recommendation for pre-treatment blood testing were discussed. The role of topical therapy (medicated baths, ear medications) and anti-itch medication (Apoquel) was also covered. The costs associated with the diagnostic plan (blood test ~$200) and prescription diet (~$117 for 7kg) were discussed. The owner understands the plan and will consider when to initiate the food trial given an upcoming family event.