Canine atopic dermatitis and the owner

Introduction

Canine atopic dermatitis (CAD) is a multifactorial chronic disease that requires the veterinarian not only to deliver long-term care to the dog but also establish and maintain an excellent relationship with the owner. Unlike some other chronic diseases, there is no true consensus on the best monitoring program for CAD, but maintaining continued contact with these cases is essential to ensure the effectiveness, feasibility, and safety of the various treatment options, and this is only possible if the owner is fully informed and engaged. Optimal communication is therefore the cornerstone of long-term treatment, as CAD can negatively impact the owner’s quality of life as well as that of the patient 12. A recent large-scale survey on dogs with CAD (author’s unpublished data, 2013) demonstrated both that owners frequently lack knowledge of the disease (for example, only 4% understood that CAD is a long-term disease), and that there are often shortcomings in the therapeutic options offered by the clinician (for example, only 15% had tried an elimination diet and only 6% had tried cyclosporine). 

The first, most essential step with CAD is identifying the disease and getting owners to accept its lasting nature before starting on the long journey involved in monitoring a chronic skin condition. However, there are many potential pitfalls; one study suggested there are seven fundamental mistakes to avoid in long-term management of chronic dermatology cases (Table 1) 3. This short paper provides some key measures that can be easily incorporated into daily practice to ensure that the owner of an atopic dog is kept fully engaged and better informed.

First steps: preparation

Atopic dermatitis is a real opportunity for veterinarians, in terms of medical, technical and interpersonal reasons, but it is essential to understand the disease in order to master the various therapeutic options and therefore communicate effectively. This involves the clinician keeping up to date with evidence-based journals and websites (e.g., www.icada.org) 4, and having access to the appropriate equipment for dermatological investigations, including a good microscope and otoscope. Good “tools” to use during the consultation, such as checklists and even metaphorical diagrams 567, may be useful, and additional communication resources, such as informative websites, can also be helpful. Do note however that most canine atopic dermatitis sites are either too technical or very product- or service-oriented, and it can be helpful for the clinic to have its own web page or blog designed specifically for owners of atopic dogs. In addition, follow-up consultations should always be assigned to the same veterinarian, and the clinic should have a trusted specialist for referral of difficult cases.

The consultation process

Certain elements are key to ensuring good client communication, and it is essential that a clinic has an appropriate protocol in place for dermatological cases (Table 2). The first consultation should never be overlong, as this is generally unnecessary and counterproductive. A shorter timeframe is more effective, and should focus on a few vital points. The clinician should first fully understand any existing or previous therapies, and then address the owner's expectations and the limits of their motivation or adherence to treatment. It is also necessary to give an explanation (and if necessary a demonstration) of any medication prescribed, and – essentially – explain what it is intended to achieve. So, for example, if a dog with pre-existing CAD presents with a flare-up of otitis externa and Malassezia pododermatitis, the consultation should focus on the Malassezia, topical ear care, and the feasibility of treatment options. Prolonged explanations about allergies, immune responses or the skin barrier should be avoided, and keeps things simple; an appointment should then be made for a follow-up visit when other aspects can be discussed as necessary.

Subsequent consultations should be equally structured. To maintain a positive relationship with the client, and ensure case continuity, a telephone or video call within 48 hours of the initial consult can allow the clinician to check on treatment efficacy, adherence, and any adverse effects (Figure 1).

A physical check-up 2 or 3 weeks later not only enables a second clinical examination (including aural and cytological checks), it allows further discussion on treatment and logical planning for future management. This can be aided by using a quality-of-life scale 8, whereby identification of the priority factors can greatly assist in making therapeutic choices (Table 3). Information should essentially be provided in stages, with each consultation emphasizing only the necessary points for understanding the treatment.

Outside the consultation 

As noted above, a quality-of-life scale is an essential support tool when carrying out a follow-up 68 and this can be completed online, during a video consultation, or even via a smartphone app. This is in preference to other options such as lesion charts or pruritus scales, which the author finds unhelpful. Keeping in contact is also essential, and for serious cases group meetings with owners may be beneficial. “Care contracts” which assist in monitoring chronic diseases are suitable for dogs with CAD, and financial planning with a monthly breakdown of expenses will keep the owner engaged and facilitate early detection of complications or flare-ups, which can help avoid losing contact with the case.

Conclusion

When dealing with CAD, longer consultations and over-reliance on external resources can be counterproductive, and it is much more effective if the veterinarian can show empathy for the owner’s viewpoint; this must be coupled with a thorough understanding of canine atopic dermatitis and a willingness to offer appropriate treatment options, alongside judicious use of measures that help the owner comprehend the many ramifications of this complex disease.