Whether you simply have a pet with skin issues, or are a vet / vet nurse looking to bolster your CPD record with free, easy to listen to, on the go discussion on and around pet skin disease - this is the podcast for you!
Join European leading dermatologist Dr Sue Paterson, Dermatology Veterinary Nurse John Redbond and Elearning.Vet content provider Paul Heasman as they pick their way through the scabby surface of pet skin disease.
Expect interviews with some of the smartest minds in animal dermatology to get beneath the surface of the latest thinking on all things fur and skin, keeping their gloved fingers on the pulse of current topics itching to be discussed.
This podcast is brought to you by Nextmune UK (formerly Vetruus), specialist in veterinary dermatology and immunotherapy. Nextmune bring you products such as Otodine and CLX Wipes – market leading products in the management of skin and ear cases. In association with Elearning.Vet - providing the highest quality veterinary content free of charge.
Site
RSS
Apple
Recent rankings
Latest chart positions across Apple Podcasts and Spotify rankings.
Shared links between episodes and podcasts
Links found in episode descriptions and other podcasts that share them.
Discover shows related to The Skin Flint Podcast, based on actual content similarities. Explore podcasts with similar topics, themes, and formats, backed by real data.
To celebrate Pet Dental Health Month, the Skin Flints team looked a bit further afield this month, exploring gum health and Canine Chronic Ulcerative Stomatitis with Hannah van Velzen.
Chapter 1 – Understanding the Oral Mucosa and Inflammation
(02:53) John welcomes Hannah, who introduces herself and her journey into veterinary dentistry, from her studies in the Netherlands to her current role leading the dentistry referral service at Fitzpatrick Referrals. She highlights the small but growing number of veterinary dentistry specialists in the UK.
(05:46) Sue asks for a basic overview of the oral mucosa, as it plays a key role in CCUS.
Hannah explains that gingiva surrounds and seals the teeth, preventing bacteria from entering the body, while mucosa covers the rest of the mouth. The mucogingival junction marks the boundary between the two and helps differentiate between gingivitis and mucositis.
She describes the different types of mucosa, including lingual (tongue), palatal (roof of the mouth), alveolar (bone covering), vestibular (cheek and lip folds), buccal (cheeks), and labial (lips). These structures vary in thickness and function, with keratinized areas like the tongue and hard palate providing protection, while thinner, non-keratinized areas aid in saliva flow and bacterial clearance.
(13:24) John then asks Hannah to define common inflammatory conditions affecting the mouth, including:
Gingivitis – Inflammation limited to the gingiva, without mucosal involvement.
Mucositis (stomatitis) – Inflammation affecting the mucosa, which is central to CCUS.
Periodontitis – Inflammation of the structures supporting the tooth, which can lead to tooth loss.
Hannah emphasises the importance of accurately defining oral lesions to guide diagnosis and treatment.
Chapter 2 – What is CCUS? How Can It Be Diagnosed?
(18:43) John introduces Canine Chronic Ulcerative Stomatitis (CCUS), asking how it relates to previous terms like CUPS (Canine Ulcerative Paradental Stomatitis) or contact mucositis.
Hannah explains that CCUS was formerly known as CUPS, but the name changed as research showed that 40% of lesions occurred in areas without teeth, making the term "paradental" inaccurate. The condition is chronic, meaning it develops gradually rather than suddenly.
(23:22) Sue asks how a primary care vet should determine whether a dog with oral ulcerations has CCUS or another condition, such as pemphigus vulgaris, lupus, or uremic stomatitis.
Hannah acknowledges that many inflammatory and autoimmune diseases look similar and that no single exam finding confirms CCUS. She advises vets to follow key diagnostic steps:
Perform a thorough dental cleaning and radiographs to rule out periodontal disease.
Differentiate gingivitis (gum inflammation) from mucositis (mucosal inflammation).
Take a biopsy if mucosal inflammation is present, as periodontal disease should not cause mucositis.
Look for "lymphoplasmacytic infiltrates" on biopsy, which strongly suggest CCUS.
If the biopsy findings suggest CCUS, referral to a dentistry specialist is recommended. If results are inconclusive, a dermatologist may need to investigate potential autoimmune conditions.
(27:33) Sue asks whether "kissing lesions" (ulcerative lesions where mucosa touches the teeth) strongly indicate CCUS.
Hannah agrees that they are a key sign, but notes that plaque build-up can also cause similar inflammation. A dental clean should be performed first—if inflammation persists despite clean teeth, CCUS is more likely.
(28:31) Sue then asks if certain breeds are predisposed to CCUS.
Hannah confirms that small breeds and terriers are overrepresented, particularly:
Cavaliers, Labradors, Maltese, and Greyhounds.
Greyhounds are prone due to poor dental health and periodontal disease.
Spaniels may also be affected, though this is not yet confirmed in literature.
Some affected dogs have severe gingivitis and mucosal inflammation despite excellent dental hygiene, making CCUS harder to recognise.
(31:33) John asks how easy biopsies in the mouth are Hannah stresses that biopsies should always be done under general anaesthesia for pain control and a thorough oral exam. She typically uses a punch biopsy, ensuring a portion of normal tissue is included to help distinguish inflammatory from autoimmune causes.
She highlights the importance of sending clear photos and case details to assist pathologists in interpreting results. Additional tests like immunohistochemistry may sometimes be useful.
Chapter 3 – Treating CCUS: What Are the Options?
(35:44) John asks how CCUS is treated and whether treatment varies by severity.
Hannah explains that CCUS treatment is multi-step and includes:
Dental Cleaning & Plaque Management:
Full dental cleaning is the first step.
Extractions are considered only for teeth that contribute to inflammation.
In mild cases, cleaning + home care (brushing, antiseptics) may suffice.
Home Management & Pain Control:
Some owners can maintain oral hygiene, others cannot.
The choice depends on vet preference and patient response.
Long-Term Management & Research Gaps:
Some dogs may eventually stop medication once inflammation is controlled.
More research is needed to determine which cases respond best to which treatments.
Avoiding full-mouth tooth extractions remains a key goal.
(45:14) Sue highlights the lack of published research on CCUS and urges vets to seek specialist advice before extracting all teeth.
Episode 27 - Packing The Perfect Punch in Skin Biopsies
Episode 27
Friday, January 24, 2025 • Duration 45:46
This month, Skin Flints welcomes a European and Australian boarded veterinary dermatologist, Sonya Bettenay.
Show Notes
(00:00) John introduces this month’s podcast, his co-hosts, and the topic.
Chapter 1 – First Cut: Introducing Skin Biopsies
(02:21) John invites Sonya to introduce herself, and she discusses her current work in Munich - focusing on skin biopsies, clinical practice, and teaching. Sue highlights Sonya's credentials, noting her Australian and European board certifications. Sonya explains her dermatology training in Australia and California and her involvement with the ECVD as an examiner and tutor.
(03:57) Sue and Sonya discuss the challenges pathologists face in interpreting biopsy samples and the importance of taking quality samples to aid diagnosis. Sonya reflects on improvements in biopsy submissions over the years but notes that obtaining multiple samples often provides a more comprehensive picture.
(05:31) John asks Sonya to explain what a skin biopsy is. Sonya describes it as a microscopic examination of the skin, providing insights beyond surface-level observation. Sonya outlines cases where biopsies are useful, such as unusual presentations that deviate from common conditions, and emphasises the need to tailor biopsy timing based on the patient's condition.
Chapter 2 – Going Deeper - Steps Before Biopsy
(09:15) Sue asks Sonya whether biopsies should replace basic investigative tests. Sonya emphasises that fundamental diagnostic steps such as skin scrapes, hair plucks, and impression smears should be performed first in most cases. However, she highlights exceptions, particularly for vesicular or severe oral mucosal lesions, where early biopsy is crucial to diagnosing immune-mediated conditions.
(00:00) John introduces the podcast and welcomes our guest for this episode - the founder of the Dermatology Referral Service in Glasgow, Peter Forsythe.
Chapter 1 – The Ears
(02:58) John welcomes Peter Forsythe, who talks about how he got involved in dermatology and how ear disease makes up half the caseload in the referral practice he works at.
(04:41) John asks why it is important dogs have clean ears and Peter discusses the long tube made up of the auricular and annular cartilages which are lines with glandular skin which produces wax - which combines with skin cells to make up what we know as wax. He says a build-up can alter the environment on the ear canal, increasing humidity and increasing the number of microbes such as bacteria and yeast, which - whilst normally present - can develop into an overgrowth or even infection. He also talks about the concretions, or balls of ear wax which can form adjacent to the tympanic membrane or ear drum, and they are called ceruminoliths and can sit on the ear drum and damage and even perforate it. So it is important to manage this ear wax and keep the ear clean.
(07:55) Sue asks about the ‘self cleaning’ mechanism the ear called epithelial migration and Peter describes this as similar to the shedding of cells we have on our continuously growing skin cells, but in the ear these have a sliding, upward motion to them as they do this, and this slowly carries cells and wax up and out the ear like a slow moving escalator – at the speed our nails grow at.
Episode 17 - Skin Flint vs The Derm Vet; a Podcast Collaboration Special
(00:00) John introduces today’s guest - host of another veterinary dermatology podcast The Derm Vet, Ashely Bourgeois.
Chapter 1: UK vs US Dermatology
(02:50) Sue asks Ashley how she started out in podcasts and Ashley shares her story, wanting to stay involved in dermatology whilst also raising children and not wanting to lose that knowledge base, and helping others in that kind of position.
(04:33) John asks Ashely and Sue what the difference between the UK and US in approach to dermatology. Sue says the approach is the same, but the system is slightly different and there isn’t so much of a referral process in the US as here in the UK. Ashley agrees, saying often people will come direct, but that they have good relationships with first opinion practices in order that clients are aware dermatologists exist.
(06:45) Sue says the board certified dermatologists exist in both regions, but in the UK we have an intermediate tier of advanced practitioners which doesn’t exist in the states; therefore asking Ashley if there are any areas in the US which aren’t covered well geographically with specialists. Ashley says there are areas without specialists, and there is work to see if they can develop better coverage; including the possibility of telemedicine in for example a state that doesn’t have dermatologists.
(08:58) Sue asks if the rules around dermatology prescribing through telemedicine differs state to state and Ashley confirms this, saying in her state for example, they must see a client at least once a year whereas in other states this is possible long term remotely.
Chapter 2: UK vs US Antibiotic Use
Episode 16: The Great Protein Debate - Beef or Beans?
Episode 16
Wednesday, March 22, 2023 • Duration 37:34
Ep.16 Show Notes
In this Skin Flints episode, Sue, John and Paul welcomed Dr Arielle Griffiths to the platform to discuss a very topical subject - sustainable pet food.
(00:00) Introduction
Chapter 1: “Understanding the Urgency: Why Sustainable Food is Necessary for Our Pets”
(03:44) John welcomes Arielle to the pod, who talks about her work in the industry and in setting up the Sustainable Pet Food Association. As a GP vet she became involved in nutrition and did extensive research before also becoming environmentally and sustainably focused as a result of seeing a change in the world.
(07:31) Sue asks Arielle to clarify what is meant by obesity-based diets and Arielle says this is where owners are (through love) overfeeding their pets and potentially causing arthritis, heart disease and a number of conditions relating to the excess weight. This tipped her to realise the use of plants as a base in food can really help, which was a big factor in her becoming vegan herself.
(09:08) Sue clarifies we are talking about people feeding too much or an imbalanced diet and the carbon footprint of that diet – and that we are discussing dogs here and not cats. Arielle says that the need for palatability in foods has resulted in an excess of protein in the diet and more meat being used than needed, affecting the sustainability. She shared that wet, meat-based diets have the largest carbon footprint, including raw lean diets – with one study in Brazil demonstrating a dog on this diet matched that of a human in that country.
Chapter 2: "Exploring the Landscape: What Constitutes Sustainable Food?"
Episode 15 - Knotty ’Nother Sarcoid!
Episode 15
Tuesday, January 10, 2023 • Duration 50:22
Ep.15 Show Notes
In this Skin Flints episode, the team were delighted to host one of the giants of the equine world - the brilliant Derek Knottenbelt (or Knotty, as he is also known).
(03:49) Sue introduces Derek Knottenbelt who gives his background in the industry and his practical emphasis.
(05:09) Sue asks Derek "what is a sarcoid?". He describes it as a reactive skin tumour – so skin cancer is the best way to think about it and not viral as it has been before which has resulting in an incorrect approach; a multi-morphology skin tumour affecting all equid species and continuing to puzzle the scientific world.
(07:00) Sue asks whether it can be contagious given it is a tumour and Derek says that it is his contention that it is transmissible with circumstantial evidence to suggest this, but the mechanism for this is very little understood – it has some relationship with the bovine papilloma virus.
(08:06) Sue asks flies are spreading this and Derek says it is – where sarcoids occur tend to be where the skin is thin – where flies can feed with impunity – where it sweats and there is less hair and therefore where flies feed. Derek doesn’t believe it is the biting fly that transmits it – but a surface feeding fly which feeds on a sarcoid and then transfers the sarcoid element into the site of skin trauma on another horse – which could include where a biting fly had caused tissue damage.
Episode 14 - A Scandinavian Success Story
Episode 14
Friday, September 9, 2022 • Duration 44:55
In this episode of the Skin Flint podcast, Sue, John and Paul welcome Katarina Varjonen to the platform to discuss the Scandinavian approach to responsible veterinary antibiotic usage.
(02:46) Katarina introduces herself and her experience as a dermatologist; Sue clarifies she is also the incoming president of the European Society of Veterinary Dermatology.
(04:00) Sue talks Katarina's career, working in Scandinavia, the UK and the USA, commenting on how good Scandinavia is on managing antibiotic usage. Sue then asks why responsible antibiotic use is important and Katarina says the one health consideration ties in and is really important across the profession in order to avoid using them longer than needed to prevent resistance. She feels most countries have put a lot of work into eliminating unnecessary use.
(06:39) Sue asks Katarina to outline the advanced approach Scandinavia has to this and Katarina says antibiotics are not completely off limits, but the guidelines are strict for recommendations – as well as limitations to what is available on the market. So for a number of years now fluroquinolones and 3rd generation cephalosporins are limited to life threatening situations, requiring culture tests as proof. Sue clarifies these are classed as critically important antibiotics in humans.
Episode 13 - Summer Itchin’
Episode 13
Tuesday, July 19, 2022 • Duration 35:25
For this episode Sue, John & Paul invite the wonderful Victoria (Tori) Robinson onto the podcast - a dermatology specialist based in referral practice in Glasgow.
(00:00) - The Skin Flint team open the episode and introduce the guest for this itchy episode.
Chapter 1 – Summer itchin’, had me aghast...
(02:30) Sue welcomes Tori, who briefly introduces herself and her background.
(03:15) Sue asks what would we mean by 'summer itch' and Tori says this can mean a higher level of pollen, but also possibly parasites as there is more agricultural activity happening.
(04:25) John asks whether it is something that all dogs do - itch more as it gets hot? Tori replies that not all dogs should scratch, they may do occasionally but it is about noticing when it manifests into more of a problem with frequency and intensity (e.g. with patches of hair on the carpet or your dog not being able to be distracted from it). Then hair loss or reddened skin can be the next indicators of a problem and an owner should see a vet.
(05:44) Sue asks about brown staining on the coat and how this isn’t necessarily dirt – Tori shares how this is discolouration from excessive licking and can be a marker for a secondary infection such as a yeast overgrowth or bacterial overgrowth which in of themselves are very itchy, and so this discolouration can be an indication there is a problem.
(06:37) Sue asks whether quality of life is affected even if a pet doesn’t get sore from the itching. Tori says how for us it can be really bothersome to have an itch and so it is the same for animals. She says how sometimes it is not until an owner has begun to treat the itch, that they realise how much it has been affecting their pets health; with them becoming less irritable, sleeping and eating better and generally more comfortable. Sue clarifies that without even soreness, the increased saliva staining and scratching would be enough to need to investigate further and Tori echoes this, saying vigilance with your pet is important as this may be more obvious in some breeds than others.
Episode 12 - The Return of the Wound Queen
Episode 12
Friday, June 10, 2022 • Duration 31:47
In this episode John, Sue and Paul welcome Georgie Hollis back to the platform for the second half of their discussion of all things wound-related.
(00:14) John re-introduces the ‘Queen of Wounds’ conversation from last episode’s part one.
Chapter 1 – Debridement or indeed 'debridement' in French
(01:00) Sue asks about biofilms and how she would suggest dealing with this slime over the wound. Georgie touches on diabetic foot ulcers and uses a pepper analogy for bacteria, saying a sprinkling of bacteria like pepper on the chips is where you can shake the chips and the pepper comes off. Colonisation is where the pepper is sticking to the chips and isn’t going to move, and biofilm is where the pepper has now forming its own protein coat around it and the vinegar is not going to penetrate it.
So, biofilm formation is an important consideration as the body can’t remove them – it is hard to see them and know when you have them and so it is hard to know if you have removed them. You can use some antiseptic solutions to help remove these such as hypochlorous or PHMVs.
(03:35) Sue asks about honey and whether this is helpful. Georgie says honey is useful for wounds with yellow debris, as this has some properties to remove dead tissue and so is a debriding agent as well as an antiseptic. So using the yellow stuff on the yellow wounds, which gets rid of the bioburden and then the antiseptic gets rid of the contamination.
Episode 11 - The Queen of Wounds
Episode 11
Thursday, May 26, 2022 • Duration 35:37
This week Sue, John and Paul welcome a very friendly face (voice?!) to the podcast - one Georgie Hollis. Georgie is a wound specialist who built her career in the human healthcare industry but moved over to veterinary and created The Vet Wound Library as an incredibly useful resource for vets and nurses.
(00:00) John introduces the podcast team and Georgie Hollis
Chapter 1 – The queen of wound management and her wound angels
(02:16) Sue asks Georgie to introduce herself and Georgie explains her origins were in podiatry and human patients with wounds and dressings; now she has taken that understanding to the veterinary world, as there has been a lack of understanding in this area of the veterinary profession.
(04:00) Sue introduces the Veterinary Wound Library and Georgie explains how she identified that she could either become a distributor for product or independently set up a platform for vets and nurses to come and get help on choosing dressings and with cases; she then set up the library for this, with a team of specialists to help answer questions on wound surgery and dressings. Georgie talks about the ‘bandaging angels’ who go in and help practices in dealing with bandaging issues and improve their wound management.
(06:48) John asks what a wound is, and Georgie describes this as any break in the skin, caused by a surgical instrument or by accident – she goes on to say that surgical wounds are kept as clean as possible and accidental wounds are from injury and involve more damage and contamination, as well as potentially including bruises and contusions where you may have an impact.
Sonya explains the importance of maintaining the integrity of vesicular lesions during biopsy to ensure accurate diagnosis. She stresses the need to take elliptical samples to include surrounding healthy tissue and avoid disrupting the lesion structure.
(11:52) Sue and Sonya discuss the distinction between primary and secondary lesions. Sonya explains that primary lesions, such as pustules and vesicles, provide the most diagnostic value, whereas secondary lesions, like crusts and alopecia due to self-trauma, may offer limited insights.
(15:15) John asks about choosing biopsy techniques. Sonya shares her preference for biopsy punches due to their precision and ease of use, while acknowledging the importance of elliptical excisions for fragile lesions like vesicles. She explains the technical aspects of both methods and how they can impact diagnostic outcomes.
Chapter 3 – Preservation - Sustainability and Practical Considerations
(19:30) Sue raises concerns about the sustainability of single-use biopsy punches. Sonya explains that while some attempts to sterilise and reuse them have been made, they often result in decreased sharpness and reliability. She advises using new punches for best results but acknowledges the need for sustainable alternatives.
Sonya discusses her approach to biopsy sampling, recommending taking multiple samples to ensure comprehensive diagnosis. She suggests including normal tissue alongside affected areas for comparison. Sue and Sonya explore potential innovations for more sustainable biopsy tools, such as reusable handles with replaceable blades.
(23:19) John asks if separate biopsy punches should be used for each sample. Sonya clarifies that one punch can typically be used for multiple samples unless dealing with particularly tough tissues that may dull the instrument.
(23:52) John then asks who can take biopsies and Sonya notes that all vets and also veterinary nurses may be able to take samples depending on local regulations, particularly for alopecia cases.
She highlights the importance of orienting samples correctly by marking the direction of hair growth to aid pathologists in accurate analysis.
(27:25) Sue and Sonya discuss the need for deep biopsies in cases of hair loss or deeper inflammation and introduces the concept of shave biopsies as an alternative for delicate areas like the inner pinna.
Chapter 4 – Packing a Punch - Sample Handling and Labelling
(30:50) John asks about the best practices for preparing biopsy sites. Sonya advises against using any antiseptics or alcohol, explaining that preserving surface elements such as bacteria and crusts is crucial for accurate diagnosis. She recommends minimal shaving in the direction of hair growth to retain valuable diagnostic material.
(33:20) John asks about labelling the samples - firstly Sonya provides guidance on handling biopsy samples, emphasising the need for quick placement in formalin to avoid tissue degradation. She recommends gently dabbing samples before immersion to preserve tissue integrity.
Regarding labelling, Sonya highlights the importance of clear sample identification. She discusses techniques such as using coloured dyes or marking sutures to help orient samples and provide context for pathologists.
Sonya also discusses the benefits of using dyes for sample orientation and how different colours can indicate specific sites. Sonya explains how proper labelling ensures better interpretation and helps guide future treatment decisions.
(39:33) John and Sue wrap up the discussion, thanking Sonya for her insights and expressing interest in having her return for further discussions on histopathology.
(41:12) John wraps up the discussion, previewing podcasts to come and asking his co-hosts another odd question.
(09:49) Sue asks if this changes with age and Peter says there isn’t information on age changes, but in cases of inflammation or disease this is affected, slowing it down and then leading to increased build up of wax. Peter says the human ear produces 2 kilos of wax in a lifetime!
(11:32) Sue asks what Peter recommends to clients in terms of ear cleaning with puppies and he doesn’t recommend routine ear cleaning in puppies if they are healthy, as the mechanism is working well; however, he does think in those breeds where they are prone to ear disease, that it is good to get them used to you handling their ears at a young age.
Chapter 2 – The Cleaning
(13:34) Sue asks about hairy ear canals or plucking ears and Peter says in his view plucking hairy ear canals in poodles and bichons for example, where the hair can trap the wax, can irritate and inflame the ear and begin ear disease, so he wouldn’t pluck them. If the dog has got ear disease (otitis) then some plucking maybe necessary – but ear phobia – where a dog has had bad experiences and they won’t let people go near their ears, is more of an issue and plucking can lead to this. He would prefer then to begin cleaning if you can see wax building up. This is the same with a dog with a pendulous (flappy outer) ear (which can also contribute to ear disease) – but he does point out too much cleaning can overly wet the ear and cause more problems – so each case must be considered carefully.
(17:15) Sue asks as a pet owner who can see so many different ear cleaners, what can help you decide and what to look for and Peter divides these into two. Firstly softening or dissolving ear wax products called cerumenolytics, containing things like propylene glycol, mineral oils, glycerine; through to secondly salicylic acid or even stronger sodium docusate (DOSS) or carbamide peroxide (which is only recommended in anaesthetised dogs) which dissolves. Sue clarifies then this depends on how waxy the ear is as to which you reach for and Peter says it is recommended to talk to the vet about it rather than purchasing straight from the internet.
(21:10) John points out it is important then for any nurse or vet to have a good understanding of the ear cleaners on their shelves and Peter wholeheartedly agrees, saying for example a more water based ear cleaner being used to dissolve and remove wax doesn’t make sense and also cleaning isn’t comfortable for the dog; so it is important to demonstrate the use of a product to an owner, and give them tips such as warming the ear cleaner a little to make it more comfortable.
Chapter 3 – The Cleaners
(24:20) John asks about powders and Peter remembers when they were used more frequently, but he does not recommend them at all as they mix with the wax and make it stickier and dryer. John goes on to ask what changes in the ear once disease starts to set in; Peter says if a dog has had ear disease once, it is very likely to happen again and can happen repeatedly. Over time this changes detrimentally the ear canal; the lining becomes thicker and the tissues become swollen and oedematous, the glands become enlarged and even massive over time; all this narrows the ear canal and impairs the epithelial migration and so you have an increased build up or wax in a smaller canal and this favours the further build up of bacteria and/or yeast in the ear. He also says the ear drum can then weaken and even perforate, so a hole can appear and then infection can get into the middle ear which is both more serious and hard to treat. He points out if the ear disease being allowed to continue year on year this can then result in long term changes where the ear cartilage becomes calcified, so effectively into bone – at this point often only surgery can help.
(29:38) Sue mentions these dogs all have underlying issues which cause these ear problems, and flags this for a further podcast. Sue then asks about the cases where we have these changes and the presence of yeast and bacteria and asks if there should be cleaning in all of these cases; Peter replies that there is strong evidence to say that due to the increase in discharge they should all be having regular cleaning – as the normal treatment for these cases - antibiotic and or antifungal ear drops - need to be able to get to the lining of the ear through this discharge in order to work. So, they need cleaning prior to the drops going in. Sue asks if these are the antiseptic cleaners we would use and Peter agrees, saying you want the cleaner to both remove the wax build up but also have an antiseptic effect, he mentions isopropyl alcohol, para-chloro-meta-xylenol (PCMX) and in particular chlorhexidine with Tris EDTA as a common effective combination for these cases – which in some cases can resolve the disease when used as a sole treatment. Sue reflects that as in Scandinavia as heard on a previous SkinFlint, more thought is going into using these to avoid antibiotic use.
(32:47) Sue asks Peter what a practice would have as three key ear cleaners for stocking their pharmacy, Peter says three is a good number and they would want a soothing, wax softening cleaner for the low symptom waxy ears – such as a glycerine, propylene glycol or mineral oil with camomile for example. Then a more potent, cerumenolytic ear cleaner, possibly with a detergent such as DOSS or chlorhexidine or alcohol. Then the third would be an aqueous ear cleaner for use in the purulent, pus based discharge in severe cases such as a pseudomonas infection, and this would be the chlorhexidine and Tris EDTA combination as discussed.
(36:34) John wraps up and summarises the conversation.
(41:35) John asks his co-hosts the usual daft questions so we don’t take ourselves too seriously!
(11:30) Ashley then asks Sue if it differs in relation to staphylococcus infections in the UK and US and Sue says it really does, and also across Europe from the UK. She points out in Scandinavia they hardly use antibiotics at all and use antiseptics much more, and this seems to really correlate to having less resistance. Sue asks for example if Ashely would use vancomycin and Ashely says whilst she hasn’t for this one she has had to use rifampin and chloramphenicol. She reflects there is a shift in the mindset with the use of antibiotics because of the number of times they will only have one or two choices left due to resistance.
(14:45) Sue asks if it is right you can buy neomycin, polymyxin, bacitracin over the counter and Ashely says you can for topicals, and said she even had a client who had fish antibiotics they were giving to their dog whenever they felt there was an infection. Sue reflects what would be available by comparison in the UK.
Chapter 3: UK vs US In Practice
(17:17) John asks whether a clients expectation would differ in terms of approach to a skin case in the states than in the UK and Ashley says there is much the same issue in terms of clients not understanding the long term nature of skin management, particularly in allergy and also the multimodal approach; where often more than one therapy is going to manage the patients skin. She is always quick to point out to owners these cases will change and even when well managed, this will change and they will flare up.
(20:14) John reflects that in the US the Vet nurses or Vet Techs as they are called there are still as important to case management as here in the UK and Ashely passionately agrees, saying they are critical to the solidification of a case management – instilling confidence in the owners to the treatment plan long term. They also catch mistakes and understand the cases very well.
(23:05) John asks Ashely about the education side in terms of the difference with logging CPD and education. Ashley says the regulations are quite strict in terms of whether she can talk off label at lectures and online and her and Paul reflect on some of these aspects.
Chapter 3: UK vs US Dermatology Top Trumps
(26:27) Sue asks Ashley for most common presentations and Ashley and Sue spend some time reflecting on the differing cases and presentations seen both in the US and UK. Where Ashely is in the US the climate is similar but Sue reflects it is interesting how the diseases are so different.
(33:50) John wraps the podcast by asking Sue and Ashley what their favourite and least favourite disease it. Pemphigus comes out well whilst sterile nodular panniculitis and bald Pomeranians/alopecia X and lick granulomas really don’t!
Search The Derm Vet Podcast on your podcast platform, or follow the link HERE
(11:49) John asks why vegetarian or vegan food is a more sustainable option and Arielle says it is proven that animal agriculture for the use in pet food accounts for 2.5 - 3% of the entire carbon footprint of the world. This comes from deforestation to provide this food and the by-products of the food as a result of the market.
(13:40) Sue clarifies this as methane production from the animals used increasing the carbon emissions along with the deforestations. Livestock accounts for over 70% of global farming land use but only produces 18% of the world’s calories and 37% of total protein - with dog and cat food being equivalent to an entire country’s worth of production. But Arielle says the health benefits are what turned her more to vegetable based foods.
(15:29) Sue comments on the information on the human side for the health benefits, with more GPs suggesting it – she asks if there is evidence to support this on the pet side. Arielle says there is and comments on how in the 27,000 years of domestic evolution dogs have developed to require 52% of their diet to be carbohydrate due to the change in their genes over that time compared to the wolf they descended from, which only needs 1.2% carbohydrate. She also says dogs 3,000 years ago were primarily plant based.
(17:09) John asks if the theory of raw feeding being more natural for dogs is therefore unmerited and Arielle agrees, explaining that dogs obviously love eating food like this which is the success of the industry – but in terms of the environment there is significant evidence that resistant bacteria has been shown to be happening as a result of raw feeding, as well as it not being healthy for the dog. And she reiterates - a dog is not a wolf!
(19:18) John goes on to clarify Arielle is advocating a formulated dog food which is vegetable based and asks if it could be insect based. Arielle says it could and there are a number of companies for this, but she focuses on vegetable based and insects are just using another way of recycling protein and therefore whilst they are more substantiable – they are not as much so as the vegetable equivalents. She mentions how she was one of three vets speaking on the subject at London Vet Show along with Professor Andrew Knight and Dr Mike Davies - talking about animal nutrition and the evidence for vegetable based diets, which previously had looked to have a vegan diet, but a new independent study from Australia and Mexico reviewing all the papers indicated the evidence is sound. She argues now we know they are healthier for our pets and our planet there is an urgency.
Chapter 3: "Making Informed Choices: Considerations for a Sustainable Diet"
(24:40) Sue asks what we do about different life stages and different conditions and Arielle says there is a puppy plant based food and a senior plant based food – and in fact any plant based food is good for senior dog.
(26:12) Sue asks about particular conditions as well (e.g.) skin conditions and Arielle says she’s getting 2 or 3 people a day asking her to transition their dogs from meat diets because of an intolerance to it, and much has been shown to evidence the gut microbiome health being linked to that of the sin and therefore the skin health.
(28:19) Sue asks if you can transition to a plant based diet overnight. Arielle advises that the cases where they are really uncontrolled and unhappy on the food can transition overnight with a care to not over feed. But for the majority of dogs - as with any dietary change - a slow transition over 2-3 weeks is better; 4-5 weeks for raw fed dogs, in order to allow the gut to adapt to the change.
(29:29) Sue asks about the evidence suggesting grain free diets can lead to heart disease and Arielle says this came about in 2018 with increased instances of dilated cardio myopathy in breeds you wouldn’t normally see. She explains this is a result of substitute ingredients and is resolved with the addition of taurine to diets – which is an important reason to use a formulated diet. The number of cases has now dropped as a result of these changes.
(32:45) John wraps the conversation and asks Arielle if there are any resources to highlight and Arielle again recommends the Sustainable Pet Food Association as a great resource to find out more, and find the right food.
(36:18) Outro – Sue raps up as an ever-wise voice of reason.
(40:57) John asks Sue and Paul - Beef or beans?!
(10:12) Sue says this would fit with periocular sarcoids as flies tend to feed there and Derek again agrees, saying wherever sarcoids occur rarely, they are always associated with wounds which further demonstrates this.
Derek uses the analogy of surface feeding flies being like teenagers going to MacDonalds, where the food is greasy, warm and available at almost no cost – whereas biting flies are like Richard Branson who wouldn’t dream of going to MacDonalds but a 5 star Michelin star restaurant – before then saying sometimes the biting flies go there after and have a pub drink and transfer the sarcoid.
This all fits the epidemiology of the disease – but the process of exactly how this happens and the link to bovine papilloma virus is not yet fully understood.
(12:36) John summarises the conversation so far and Derek goes on to show how in 1985 in a survey 2.5% of British horses had sarcoids, with an average of 2.5 sarcoids each. In 2018 this had risen to 8% of British horses with an average of 24 sarcoids each - so this disease is steadily increasing.
Chapter 2: Sarcoidy
(15:06) John asks if there are any breeds, ages or predispositions which are more susceptible and Derek says that whilst some studies have demonstrated this he does not think it is so simple having seen sarcoids in just about every breed that is available – he says there are genes which impart susceptibility as there have been outbreaks within families of horses. So it is very difficult to isolate. He also studied age of onset within a study of close to 30,000 horses and the numbers merely mimicked the population – so no definitive evidence, and he has seen 40 year old and 17 day old horses with sarcoids. He is more convinced of conditional, situation and environmental factors over any of age, breed, gender and colour.
(19:05) Sue asks about sarcoids themselves – what do they look like? Derek says it is often misdiagnosed as something else because of how multiformal it is. Because it is a tumour of fibroblasts and not epithelial cells often what you see bears no relation to what you would perceive as a fibroblastic tumour. This is because of the effect of the viral component on the disease and the impact this has on the surround tissues.
So firstly the occult form of sarcoid is not the occult tumour – but may contain the tumour – and this must be kept in mind. He goes on to say the circular nature of this form is in effect a result of the mediators diffusing out from the centre. Then the centre begins to develop and become more dermal / epidermal and morphs into something more like a wart, but is not a wart but a ‘vericosal, wart like tumour’, the next from of sarcoid.
Then the next stage/form is either a hard mass-like nodule of fibroblasts called a type A nodule and is completely subcutaneous, or a type B nodule which is attached to the skin dermis. These are easy to identify and are very easily characterised.
Then there is a fleshy form which is very aggressive, vascularised and ulcerated (usually infected) tumour which appears like granulation tissue.
Derek says each of these types has its own potential differential diagnosis which makes them very open to misdiagnosis.
(27:07) Sue asks what causes the transition of one for, to another and if that should point to biopsy. Derek says that with the age of the tumour there is a constant progression, and traumatising the lesion will only accelerate this process (such as with a harness or a buckle, or the movement of the skin in mobile areas). This means biopsy, whilst definitely useful, is only worth doing if you have a plan of what to do when you find it is a sarcoid - as it will otherwise just exacerbate the problem.
Chapter 3: Treatmenty
(30:53) John asks then what the treatments are for a sarcoid and Derek says superficial lesions require less interventions and a 5% or 10% floriorisol and if this does not work a imiquimod – but it is important to bear in mind they are still dangerous because they don’t like being treated, so if you aren’t successful they worsen and a real determination is needed with the disease to keep progressing to the next step. A surgical or laser excision could be considered but it is critical these are sent for pathology for margins to know if you have removed it all – as not doing so require further action.
(35:04) Sue asks what the prognosis is, with good margins and without; Derek says a successful, safe margin of removal is a good base for a start – however there can be tumour cells seeded during surgery and indeed after on the scar from fly attack -so this must still be treated cautiously. If you haven’t got a successful margin you will get deep root recurrence – so by the time you see the tumour it will be twice as big. In this instance Derek likes multimodal therapy, using immunologic methods such as immunosiden, BSG or radiation, or local chemotherapy. Derek goes on to discuss types of localised chemotherapy – also pointing out you can add other therapy such as cryosurgery on top as well. Each time you are adding on a little prognosis – but Derek points out the only thing predictable about a sarcoid is that it is unpredictable and there are over 40 treatments to consider in managing these with new therapies coming out all the time and he lists some of these, but warns against the nonsense brigade – with poor evidence based treatments on the market such as marmite or toothpaste – successes in these instances are coincidental to spontaneous resolution.
(44:55) John wraps up the conversation and summarises, while sue mentions Equine Medical Solutions (Derek’s app).
Outro
(46:58) John brings the podcast to a close by putting Sue and Paul on the spot was another probing question...
(08:23) John says this sounds quite extreme in comparison to what we do in the UK and asks if this would be considered a few years ahead of the UK and what is happening in the US. Katarina comments on it more as a cultural difference, feeling that the smaller industry in Scandinavia has helped to spread the message from within, along with the government and health sector working hard to spread the message to the public. As a result they don’t get pressure so much from clients to use the antibiotics in the first place.
(10:19) Sue asks if it is easier to treat a disease in Scandinavia because there is less resistance to antibiotics, or whether it is harder because you have less access to antibiotics. Katarina says that actually they still have the same access, but the big difference in the case management is that in Scandinavia they are far more keyed into preventative approach to a disease, meaning the cases are better managed in the first place and therefore cases are less severe from the outset.
(12:10) John asks if this comes at all from the owners side, with them being more in-tune with identifying issues early and Katarina doesn’t believe so – she feels this comes entirely from the veterinary side.
Chapter 2 – The Prologue to a Case
(13:52) John asks Katarina to share what things would help with that early identification and Katarina says scratching and head shaking is the early sign, and whilst the approach to these first symptoms will be the same for treatment, the conversation about underlying causes is begun at this stage, which is almost always allergy. Katarina herself describes this to owners as the dog equivalent of allergic eczema but in the ear.
(16:20) Sue asks Katarina to talk through her approach to a case. Katarina says she would start by feeling the ear canal on the outside, is it firm or soft to suggest issues – it also helps the dog to get used to being handled. Then she has a look with an otoscope down the ear if the dog tolerates - or she may sedate at this stage if not – in order to examine and perform cytology. If the canal is inflamed she will go to cleaners and anti-inflammatories to open up the canal, even before thinking about treatment of the infection.
(18:07) Sue asks Katarina to clarify what is meant by Cytology and Katarina describes this as the basic and easy to perform diagnostic tool for these cases, using a Q-Tip (cotton bud) to gather material from the upper ear canal and roll onto a microscope slide before staining with Diff Quick (or similar) to look for bacteria, round or rod shaped, yeasts or inflammatory cells. As well as assessing the level of the load.
(19:43) John says this sounds quite straightforward, asking if this is something a specialist needs to do or whether a non-specialist / nurse could perform this; Katarina says that actually even in referral practice it is mostly the veterinary nurse who will do this, taking the sample, staining and even examining under the microscope. It is not specialist cytology and only takes a couple of minutes. Katarina shares that for fractious dogs a clean finger rather than a cotton bud, into the entry to the canal and rolled onto a slide will also work.
(23:18) John asks if the cytology is something that is done just initially, or whether this would be done in follow-ups and Katarina shares that she performed cytology all the time at every visit as standard. This is because as she is using anti-inflammatories and other treatments she will see an improvement visually so cytology is the only way to know whether she is resolving the actual infection.
(23:57) Sue clarifies then the switch from treatment to maintenance would be made once she observes the levels of microbes dropping to what would be considered normal rather than symptoms.
Chapter 3 – Chapter and Verse on Treatment
(25:21) Sue asks what kind of actives (stuff in the products) Katarina would use in terms of anti-inflammatories and cleaners having done cytology and found microbes present. Katarina says the texture of the discharge from the ear, whether this is fatty/lipid or ceruminous/waxy in which case she would reach for a squalene based cleaner or if it is a liquid based discharge with pus forming she would use a chlorhexidine/tris EDTA based cleaner. If she suspects a biofilm in the ear as well from slimy discharge she would add in an an-acetal cysteine flush to the cleaner.
(26:59) Sue asks what anti-inflammatories she would use and Katarina clarifies this would depend on thickening of the skin in the ear – so if the ear is stenosed/narrow she would use oral steroids in addition to topical steroid in the ear, but if it was more minor she would only use a topical. This also reduces pus formation. Sue asks how you would use a topical steroid without using the other antibiotic and antimycotic treatments that are in licensed, steroid containing topical products. Katarina says she would use a steroid on its own without the others even though the licensed products are next on the cascade, because the antibiotic stewardship wins over the grey zone element of the cascade in these instances. John summarises this and Katarina clarifies that the preparation of the ear and selection for antibiotics is critical to making sure that when she does then reach for it, it is effective as it can possibly be.
(32:33) John asks what ear cleaners when used in preparation of the ear also have some effect on the microbes we are seeing in the ear at the same time and Katarina says that actually even just cleaning out the ear gives the body and immune system a chance to start helping in fighting the infection – so begins the process. Then the likes of chlorhexidine and Tris EDTA combined, and an acetal cysteine help further to fight this if they are present in the cleaners, hypochlorous acid as well.
(35:30) Sue asks if Katarina feels that maybe in the UK we are tempted to reach for antibiotics too soon and Katarina says often we feel safer doing this because we want to manage these cases, and it is a big step to understand there are steps we can take first before assessing to see how well they have worked, in order to manage the cases which don't need antibiotics and identify the ones which do. She would try for two weeks generally first before reaching for antibiotics if there hasn’t been a reduction in the number of microbes in the ear.
Sue and Katarina summarise the importance of the use of topicals to try and push forward the appropriate use of antibiotics.
(37:40) John asks one final question to Sue and Katarina on how important this is, whether people need to really take this seriously and whether there should be any pressure from the authorities on this. Katarina says we do need to take it seriously, perhaps less to with topical antibiotics than systemic (oral/injectable), but this is still very important to strive for this. Sue says that the use of cytology is critical and underperformed in terms of understanding whether there is infection present in the first place, and whether we have completely eliminated the infection at the end of treatment. We need these drugs and we turn on the resistance when we feed the bugs these drugs, and we are moving in the right direction together. Katarina echoes this, showing a lot has happened even in the last few years.
Outro
(43:55) John and Sue wrap up before John asks his usual silly question (ask your own sensible or silly question by emailing hello@elearning.vet ) – Sue and Paul are asked what frustration they would most like a drug to rid their lives of, walking into a put down by Paul!
(08:18) John asks what the most common causes of itching would be and Tori mentions this could be related to area or lifestyle, but could also be related to parasite infestation such as fleas, or harvest mites (which are geographically restricted) – or pollens and moulds. So there are lots of geographical things which can be a factor in summer itch.
Chapter 2 - Summer itchin’ happened so fast...
(09:38) John asks if there is anything a pet owner could do at home prior to going to the vet, to which Tori highlights how good parasite control can go a long way to helping the 10-40% of pets who present for routine treatment and have some form of parasite infestation. She also points out not all the parasite products are as good as each other and so it is still worth speaking to the vet to make sure you have the most appropriate treatment. She also points out how bathing the pet can really help to manage summer itch before it starts to wash of pollens and prevent secondary infections.
(10:54) Sue asks what Tori would means with a shampoo – what sort of active ingredients should an owner look for. Tori starts with soothing shampoos – saying they will have things like colloidal oatmeal in which can help with moisturising and phytosphingosine to help with skin barrier function; and all of these types of moisturising agents are designed to help build up the protective barrier the skin forms against things that the pet is allergic to. Tori then talks about the antiseptic shampoos, saying most will contain chlorhexidine when purchased from the vets; she warned against just buying something over the counter, particularly with human shampoos as he’s had a different pH which is not suitable for a pet.
(12:43) Sue asks about antihistamines and oil supplements which she may also buy over the counter and Tori discusses how antihistamines can be very effective if given preventatively, before the start of symptoms. She talks about how us humans take an antihistamine at the very first signs if we have an allergy, but it is not possible for a pet to tell the owner about the signs and so antihistamines in a pet are being used once the symptoms have been going on for a long time; and as histamine release is only one component of the itch, by this point it is too late.
(13:53) John asks why a vet would do tests rather than see a patient with an itch and prescribe something for the problem there and then. Tori says that as there are so many different potential causes of it, it is very important that the vet does the tests in order to ascertain the true cause and put forward an appropriate treatment. She uses the example of a bacterial or yeast infection needing something to treat it or a parasite infestation needing something totally different; so just putting up something to stop the itch will not be dealing necessarily with the appropriate cause.
(15:20) Sue clarifies this as treating a disease as opposed to treating a symptom and Tori fully agrees. Sue then goes on to ask what sort of tests a vet may do to find out the cause, to which Tori talks about the history being a really important part of this, and that a vet isn’t being nosy, but needs to get a blanket of information to understand the disease. This will mean questions like where are they walked and what do they sleep on etc. Then for tests she talks about Sellotape strips from areas that are red, slides pressed against oozing areas, hair plucks from affected places and skin scrapes to look for parasites. All of this helps to rule out what isn’t causing the itch or find out what is.
(17:35) Sue asked what the next steps may be if no underlying allergy has been found from all of these tests or a potential food trial. Tori says this can depend on the time of year – and so if it is the summer months they react it is more likely to be a pollen allergy than say a food allergy, which would be all year round. She says some of the level of work up may depend on whether you see your first opinion (GP) vet or whether you then go on to see a referral specialist dermatologist.
(18:43) John asks Tori to clarify the difference between a GP vet and a referral vet and Tori likens it to the difference between seeing your GP and a consultant when going to the doctors. She says a specialist would have done a residency on dermatology for anything between three and nine years as well as taken exams, they would also be doing extra learning to keep up to date. Sue and Tori then expand this saying a dermatologist will be more experienced in dealing with the more weird and wonderful diseases.
(20:43) John asks then if there are some things which are easier to treat than others and Tori says absolutely, a parasite burden for example is much easier to treat with an anti-parasitic then something like an allergy to a pollen, which could be difficult to exactly ascertain a lifelong to treat.
Chapter 3 – Tell me more tell me more...
(22:05) Sue mentions that previous podcasts for skinflint have discussed immunotherapy vaccines, as well as shampoos, so what else would or could a vet reach for if these have been unsuccessful or something else is required? Tori mentions drugs which can supress the itch such as glucocorticoids (often just called steroids) as well as Oclacitinib and Cyclosporin which modify the part of the immune system causing the itch. She goes on to mention biological therapies called monoclonal antibodies which are proteins which bind to the response which causes the itch to stop it – called Lokivetmab, and says these can be used alongside any other treatments which treat the cause of the itch.
(23:23) Sue asks whether these are safe and Tori says that of course - everything has a safety profile and glucoroticoids for example have a lot of side effects; however some of them can have great success in treating the itch and so this can still be necessary. Sue then clarifies that the monoclonal antibodies are newer and more specific action and Tori agrees, saying these have a much higher safety profile as they are not metabolised by the body anywhere near as much and in fact, human allergists are quite envious of these products the veterinary market has.
(26:04) John says these sound quite expensive and asks whether it is a straight choice between using one of these drugs if you have the finances, or using shampoo if you are looking for a cheaper alternative and Tori clarifies how it isn’t as simple as that. It goes back to how we have discussed the different causes of the itch and how different treatments may be needed, even to be used alongside one another in order to treat the disease. She says this can be challenging for owners to begin with, and with regards to cost she encourages owners to have an honest conversation with the vet, so the vet can select the different therapies needed around the budget.
(27:43) Sue summarises by saying there are lots of different treatments, and each case will need those treatments tailored around the specific needs for that patient symptoms, and potentially also for the owners financial situation and Tori completely agrees; she says how 80% of the cases she sees a referral practice are allergic skin disease and all of these go home with completely different treatment plans. She also adds that any given patient may need different treatment options over time as the disease evolves and develops, this isn’t necessarily that the patient is building up an immunity to the treatment, but more the disease itself changes over time.
(29:25) Sue also highlights the importance of the animals comfort in terms of welfare, and asks Tori what she would reach for if she wanted to make the pet comfortable quickly. Tori says this is where the speed of action of glucocorticoids, oclacitinib and lokivetmab mentioned previously are very useful working within a few days where appropriate – with cyclosporin being a few weeks and immunotherapy a few months
(30:50) Sue uses the analogy of these drugs being the fire extinguisher on the disease, to put out the initial problem, before then the other therapies being the smoke alarm on preventing the problem for returning.
(33:46) John says thankyou and farewell to Tori.
Outro
(34:43) John wraps up the podcast with another trademark silly question, this time asking Paul and Sue where they would choose to have an itch to scratch if they had to!
(05:27) John asks about debridement and when you would do this. Georgie says debridement gets rid of non viable tissue, where it had been damaged and the blood supply has been cut off – this is protein rich material and the bacteria will eat this and therefore you don’t want it in the wound. Manual removal of as much as possible using a scalpel under anaesthetic or with products such as honey, called autolytic debridement which uses osmosis by using sugar to draw out the dead stuff much like a poultice
(07:24) Sue asks about medical maggots and Georgie says these rather than autolytic debridement magots use enzymatic debridement where you use enzymes to break down dead tissue. So the maggots vomit the enzyme protease into the wound and this makes a protein soup which they then eat and then they poo into the wound which has been shown to have beneficial effects on granulation tissue.
(08:41) John asks then whether this pushes the owners again to go to the vet to make the decision as to whether debridement is necessary. Georgie agrees and says this goes further, where there may be different times when this is necessary, talking about a process of demarcation; so it may not be that you can tell which part of the wound is going to die and need debridement straight away.
This is an important consideration, because you don’t want to cut off skin which may still be viable, meaning that it still has a blood supply and could play an important role in reducing the size of the wound.
Chapter 2 - Dressings
(10:03) Sue asks about what considerations there are with selection of wound dressings and Georgie says you need three boxes in the cupboard.
1) dressings that help you debride, and clean the wound up and help it granulate.
2) dressings that donate moisture, to stop the wound drying out – citing a study from 1962 be George Winter which showed from pigs with wounds left open to the air that they healed 30-50% slower that wounds kept moist and covered. All of our modern selection of dressings is based upon this principle of keeping the wound moist as a result of this understanding, and it is important that these dressings are left in place long enough for the wound to heal, as changing the dressing too regularly can remove cells regenerated on the wound.
3) dressings that absorb moisture absorb exudate and hold moisture to the wound as long as possible to aid healing, such as super absorbent foam dressings for large wounds. So, this is a balancing act and an art, selecting the dressing according to the type of wound and what any given wound is doing at any given time. For example, in the inflammatory, early stage there is a lot of exudate as the white blood cells work on the wound and then as the wound begins to granulate it starts to dry and a different dressing would be needed. There are many factors which will affect when and how a wound will be at each stage and Georgie lists some of these in context of areas and breeds and species.
(15:07) John asks if there are any tips on bandaging difficult areas and Georgie says there are and cites an example, a good product is a fingertip gauze you can tape on to protect the tail and John mentioned dog ends as a product on the veterinary market for this. Georgie stresses the important of anchoring this to the tail and describes this.
Chapter 3 – Georgie’s 10 Top Tips
(17:44) John asks for Georgie’s top ten hints for caring for wounds.
Nominate a wound nurse, to look after dressings and help people in the practice.
Be sure to lavage a wound and as soon as possible.
Don’t use toxic antimicrobials in wounds as discussed.
Organise the dressing cupboard in ways as discussed.
Chuck out sudocreme! Georgie feels there are better products out there.
Review bandaging techniques as this might not be the best.
Don’t use honey out of a jar, medical grade honey should be used, as there could be contamination in a jar of honey for food.
First aid kit, having a salt solution in a water bottle and hypochlorous and get your pet to the vet as soon as possible.
Puncture wounds can be serious.
Sue says if it isn’t working ask for help, whether an owner, nurse or vet. As muddling on isn’t on the animal’s best interest, and Georgie wholeheartedly agrees.
(24:51) Sue asks about sustainability and how sustainable wound care is and Georgie has been thinking about this recently. Wound dressing manufacture for example is a factor, citing that manuka honey being derived from New Zealand, shipped to the UK for manufacture and then shipped back to New Zealand. She also talks about the repeat use of a Robert Jones bandaging as a huge use of recourses and sustainability gives a good reason to use a cast for this bandage type.
Outro
(29:39) John wraps up the conversation with a final-off-the-wall question and Georgie plugs a friend’s company which sustainably repairs surgical equipment Fix Your Kit
Chapter 2 – Wounds At Home
(08:27) John then asks about whether healing is different between the two types of wound – Georgie uses an example of a cut from glass being a laceration vs a scrape along the ground which would be an abrasion, stressing all of these all need cleansing and preparing in order to allow them to heal – and this healing may not be necessarily in the way the owner would expect.
(09:30) John asks what would lead you to decide whether a wound would need stitching / leaving open / or more drastic action such as a skin graft. Georgie says one of the biggest considerations is how old the wound is, the time between when the wound happens and when it is cleaned is critical. She mentions a study where they looked at wounds in goats and saw a marked reduction in bacterial growth when the wound was new, and the research shows that for every hour earlier a wound is washed, the bacteria present was reduced by half. The multiplication of bacteria in a wound reaches a point where it overcomes the hosts response – so the earlier the wound is washed the greater chance to prevent this from happening – therefore the wounds cleaned the earliest are the most likely to heal successfully.
(11:26) Sue asks how an owner would clean a wound. And Georgie advocates the use of saline – saying this balances with the body’s own cells and citing the example of the skin becoming wrinkly in the bath. This happens because the bath water is less salty than the skin and the skin cells swell – which causes some damage. So, this is preferable to normal water and can be made with a teaspoon a salt in a pint of previously boiled water.
(13:25) Sue clarifies what is meant by an isotonic solution. Georgie does say a bottle of water to flush the wound is preferable to not flushing the wound however.
(14:08) Sue asks how the owner would then use this saline solution on a wound and Georgie speaks of the water bottles with the type of end to suck or squirt the water from, as ideal as this creates a bit more of a flush – even a clean garden sprayer. The ideal pressure is 8-15 pounds per square inch - this is a like a high pressure jet of water.
(16:20) John asks whether a pet should be allowed to lick a wound and Georgie says alpha amylase in saliva is a good thing for cleaning wounds, as this is cleaning and removing all the dead stuff from the wound, which they refer to as wound bed preparation – however the tongue is very abrasive and the mouth can be contaminated, and so they don’t suggest that licking is allowed. Georgie does also point out a patient continually trying to interfere with a wound may be a sign that things aren’t great.
(19:50) Sue clarifies that Georgie is saying she would advise that a vet or nurse flushes as the client would, with an isotonic solution and not immediately use a disinfectant such as chlorhexidine. Georgie says it is always best to flush again with this isotonic solution again anyway, and uses the analogy of poo in a toilet, and how you would flush the chain to get rid of it rather than just spraying it with disinfectant.
(21:20) Sue asks what antiseptic Georgie would then recommend going onto and Georgie says there is controversy and confusion around this, which drives people to use toxic substances such as chlorhexidine in wounds. This is known to damage cells which are involved in the regeneration of wounds, meaning the use of this in a wound which is healing will actually slow this process; this is the same for iodine when too concentrated. They will kill bacteria as they are intended to, but they will also damage cells and delay wound healing and so must be used carefully, if at all. Georgie goes on to say there are antiseptics which are much more wound friendly, including hypochlorous acid (see previous podcast episode)
(25:55) Sue asks about how different species react and whether as a horse owner, knowing that horses have a lot of granulation tissue, she would suggest hypochlorous over chlorhexidine or any other products for equine wounds. Georgie says all mammals heal in the same way with some subtle differences, which in horses does means more granulation tissue, but highlights what is most important, going onto list some of the important factors which will cause wounds to fail or be inhibited.
3 Movement – a key one where movement in the wound constantly traumatises the cells and delays healing.
4 Proud flesh – but this is often a consequence of the above
5 infection – which again is a result of the above or contamination, and the growth of bacteria will then prevent the wound from healing properly.
Georgie says it doesn’t matter what species you are dealing with, the mammalian response is the same to wound healing across species; which is first for the body to stop any bleeding, then inflammation where the body digest any bugs or dead tissue around the wound, then granulation where it remodels and regrows new granulation tissue and blood cells, which acts as a carpet underlay for the epithelial cells of the skin to then re-migrate across and close over the wound. The wound will at this point also contract by 30-50% of its original size at this time, so that a scar is never the same size as the original wound. So thorough lavage with a non toxic substance during this process is best and hypochlorous or saline would support this.
(29:41) Sue clarifies then that something like hypochlorous would be better in a wound first aid box than something like hibiscrub (a soap scrub containing chlorhexidine used in veterinary practice). Georgie in response to this stresses that there is no place for hibiscrub in the management of wounds – as this is a ‘scrub’ and has soap elements and is used for the cleaning of the surface of the skin for example in a skin prep for surgery and has no place for use with broken skin – so hypochlorous would be far preferable.
(30:36) John asks if there are any top tips to approach managing wounds. Georgie talks about prepare, promote and protect as a way of summarising the steps for managing wounds, and suggests a vet nurse in a practice as the perfect person to establish a trolly in the practice and divide it into those three sections. So you can’t go to the promote and protect drawers before you have done the prepare.
Prepare: Clipping, cleaning and getting rid of dead stuff – which she clarifies is debriding the wound and prepares the wound bed for healing.
Promote: Is about dressing selection to encouraging a healthy granulation wound bed to help the wound through the healing phases, so granulation tissue at 4 days, start to fill in 7-10 days and wound contraction occurs around that time. If there is a lot of granulation tissue at this time a decision needs to be made as to whether to now close this surgically or allow to heal by granulation alone. She says that at the veterinary wound library they have seen many cases where the wrong decision has been made here and the wind has been left to heal for too long.
Protect: Is looking at the inhibitors of healing as discussed previously plus interference, cell transformation such history of tumours meaning the wound wouldn’t heal as you would expect, client compliance (owners being able to follow the right treatment plan correctly), correct products used as discussed before. Applying this logic to the wound to make sure it is encouraged to heal as sympathetically as possible.
OUTRO
(34:14) John wraps up part one and says to look out for the next episode where we continue the conversation with Georgie.
(35:00) HIDDEN OUTTAKE: distribution of contamination secret 'easter egg'...
