The skill to maximize a dermatologic exam would seem very basic, but yet often forgotten. We are always so eager to dive into examining the patient that we forget that a good part of a good dermatologic exam is actually the history of the patient.
A dermatologic exam would constitute the entire dermatology consult. How successful a dermatologic consult would be dependent on how effective the vet identifies the skin condition, prescribes the treatment, communicates that to the owner and if the owner is going to follow up with the treatment.
A good dermatologic exam starts off with a detailed history of the patient. Asking the right questions is very important to obtain correct information of the patient’s skin condition from the owner.
Questions such as:
- Is the patient itchy?
- If so, where is it itchy?
- When is it itchy? Seasonal or non-seasonal?
- Age of onset?
- Acute or chronic?
- Previous treatment and response?
- Previous diet and response?
This information can help categorize the skin condition. Whether it is allergic skin disease, ectoparasite, infectious, hormonal related, or autoimmune.
The next step to a dermatologic exam is examining the patient. Look at the distribution of lesions. Most allergic skin disease in dogs have a predictable distribution pattern. Lesions affecting periocular, perioral, ears, paws, cubital areas, axilla, inguinal, and perianal areas would point towards a possible food adverse reaction or atopic dermatitis. Bilateral flank, lateral thighs, and tail base would indicate a possible flea bite allergy. Ear margin dermatitis and crusting with positive pinna-pedal reflex would be suspicious of sarcoptic mange infestation. Nasal planum, mucocutaneous junction ulceration and crusts would indicate an autoimmune disease and the list goes on. It is important to be familiar with the distribution patterns of different skin diseases.
Once a differential diagnosis of skin conditions has been made, the next step is to take good samples. Missing a skin diagnosis occurs more often from not taking correct samples than actually not knowing about the disease. Hence taking good samples is important to confirming the diagnosis. Sample taking also helps determine what treatment to administer. If antibiotics or anti-fungals need to be prescribed. Vets should be familiar with taking proper samples such as deep skin scrapes, fungal cultures. If vet nurses are tasked to take samples, it is important to ensure that they are well trained to perform those tasks.
No dermatologic consult is complete without providing the client with a treatment plan. If you fail to plan, you will plan to fail. The owner is the one who has to carry out the treatment plan. Whether is it administering medication or performing an elimination diet trial. It is hence important that the clients are clear on the treatment and follow up. Provide a clear schedule so that the owner understands what needs to be done and when they need to come back for a follow up. No diet trial will be successful if the owner does not come back for a rechallenge. Arrange for nurses to call clients and remind them of their follow up.
Key Learning Objectives
- To remember to take a detailed dermatologic history of the patient.
- To be familiar with distribution pattern of different skin diseases.
- To be competent is taking skin samples and to ensure that nursing staff are also well trained to obtain samples.
- Provide the client with a treatment plan and follow up.