Skin...like peeling an onion looking for the causes. And like a lot of pathology...you find out what it isn't but not what it is sometimes. I have been in the veterinary field since 1972, and have learned more about skin issues in the past 7 years I have worked with cats exclusively than I ever though possible. But getting to the bottom of causes is not easy, or inexpensive.

My two personal experiences are as follows:

Five year old cat, seasonal obsessive licking, making sores on skin. Did not want to use steroids on her as she was a breeding queen, so occassionally put on a soft e-collar and she'd heal up and be fine for a few months. She did not have excessive Malassezia overgrowth like many Cornish Rex (and many allergic cats and dogs). When I 'retired' her and found a home for her, I wanted to try and find out what the cause for her skin issues were and ran the Heska Environmental Allergen test and lo and behold, she was very allergic to Storage Mites (which live in grains--think dry cat food. In her new home, she was put on a canned only diet and she has now rarely breaks out. One other option for pets sensitive like her is to put the dry food in the freezer and meal time feed it so it isn't out to harbor the mites.

Three year old cat with excessive Malassezia-ears, toes, chin, perineum. His allergy tests came back within normal limits pretty much, but I put him on a grain free diet and he improved. Enough for me to continue feeding him separately from everyone else? Not really but at least with doing the testing, I knew what were and what wasn't his sensitivities.

Or, I could have skipped all the testing and bathed and cleaned and collared them as needed and saved a bunch of money, but I like to know what I am dealing with and therefore be able to give them the best lifetime care I can...that's just me.

Teri and the cats of Furrydance September 3rd, 2009 11:06:38 AM

I use these blogs to become and educated client. I understand what is going on during an exam. I can ask intelligent questions.  I can even do some preventative maintenance.  Plus I think all the vet talk is cool....

Betsy September 3rd, 2009 11:44:38 AM

Dr. K,

Skin problems are really diffuclt to diagnose and treat. My cat Crosby was diagnosed with chin acne, but he loses fur on the legs sometimes and the vet never gave us any med that stopped or controlled the problem. We're taking our cat to another vet very soon. My Crosby aslo has asthma, so it all might allergy-related. Here you can see CRosby and read about our awful emergency experience. http://www.thedailytail.com/?p=541

Asthma, as you know well, can be deadly in cats.

Daniela Caride

www.TheDailyTail.com

Daniela Caride September 3rd, 2009 11:45:34 AM

Oh, Dr. Khuly, I was *irritated*.  You'd just talked about how many different causes itching can have, and they're all so different.  I had a dog that was incredibly difficult to diagnose and treat for allergies.  I tried various things I could myself (food elimination diet, etc), but in conjunction with a LOT of vet visits, trying to figure out just what was wrong with the little guy.  If I had tried to handle it entirely on my own, my poor dog would have suffered for a lot longer before we found the solution to his misery.

And someone wanted you to just hand them the all the answers online without them having to lift a finger?  No testing, no diagnosis, just "try this over the counter medication and that will cure all itchies!"  Riiiiiight.

The internet has been a great resource for me, in looking for what can cause problems, so I know what I can do and how I can be prepared to support the work my vet does.  I can get some idea of what tests the vet might need to do, even sometimes in what order, and what they may find.  But there are so many ways I need my vet's help in making sure my dogs will be healthy and comfortable.  Seeing someone be unpleasant because you're trying to help them be informed made me downright pissy.

Galadriel September 3rd, 2009 11:54:04 AM

Dr. K, I feel your pain with posts like that.  As a long time host on PetHobbyist, we also get quite a few people in our chats or posting on our boards looking for a way to treat their animal without a trip to the vet.  Even when we tell them a vet could not and would not give them a diagnosis or treatment information without seeing the animal, they just don't get it.  As you do with your blogs, we try to educate and help but even telling them to get off the internet and to the nearest er vet doesn't work, they argue with us. 

FurriePrincess September 3rd, 2009 12:24:05 PM

Like one of the above posters,  I use dog/pet info from the internet for educational purposes and to learn and practice preventive measures.  They do help me understand what the vet is explainging.  As for curing the itchies online 100% of the time, don't see how!  My Cairn Terriers have been examined more than once for itchies and the vet is still only "pretty sure" it is grass allergies.

Debra Hawley September 3rd, 2009 12:28:47 PM

Of course, depending on the vet one goes to, info from the Internet may not help at all if they won't listen (and many won't). They focus on one or two treatments, as in "just "try this [medication I've got here] and that will cure all itchies!" Riiiiiight." which can come from the vet, too.  Then the best thing about that Internet info is to show that perhaps a different vet, who's willing to consider other options, might be in order.

KateH September 3rd, 2009 02:17:21 PM

I'd like to point out that even info on respected sites such as petMD or Veterinary Partner may be the opinion of the author and may not be one that is shared by other vets or even the majority of board certified specialists in that field. Just because it is written by a vet and is posted on the web doesn't mean it is entirely correct. I think you can use it as a starting position in a discussion with your vet and give them an opportunity to explain why they aren't in agreement with the opinion expressed by the web site.

virginian September 3rd, 2009 07:31:27 PM

This is striking close to the heart, today.  I belong to an internet group that supports people whose dogs have pancreatitis, which Louie also had early on in his illness career.  So often there are other issues with these dogs.  Pancreatitis in itself can be fatal, and none of us are there to provide expert advice.  Sometimes somebody will start talking about something they are trying for their dog which is meant to treat some other intestinal disease, and the confusion runs rampant with newbies wanting to know if they should try that for their own dog, or why their vet didn't suggest this or that.  

I have tried to explain that everyone really needs to work closely with their vets to make sure that a proper protocol is being followed which will allow the vet (and owner) to tease out the various issues that might be involved with the pet's problems.  So often people just want to make a food change or blame it on commercial foods, when those kinds of changes might be very dangerous to their pets.  The internet is certainly a vast repository of information as well as disinformation, but I have learned that it takes a discriminating mind to sort through the madness well enough to come up with useful information.  Nonetheless, I am grateful for the information, because there are many things I would not have known to do or try for Louie without having such good information at hand.  The vets were invaluable, but he has such a combination of issues and it was really up to me to become his advocate and to observe everything, and determine what might be important enough to further discuss with the vets.  The vets could not do it all on their own, and neither could I.  

Louie's Mom September 3rd, 2009 07:52:30 PM

"The vets could not do it all on their own, and neither could I."

Well said.

Dr. Patty Khuly September 4th, 2009 04:53:02 AM

Thanks for the post on NSAIDs, Dr. K.  Still waiting to her from my veterinary orthopedist on this one, but your thoughts on the matter can provide some fodder for when we do talk.

Julie in OH September 4th, 2009 08:06:36 AM

Julie: I know it's OT, but I should add this important point of view to my DailyVet post over on PetMD. This, from Dr. Marc Wosar, my favorite vet surgeon:

[On NSAIDs pre-exercise in dogs] my opinion is that there is a big difference between purely prophylactic use when the athlete has no pre-existing inflammatory disease -- and preempting inflammation pre-exercise when the athlete does have an inflammatory disease like DJD. In the former, I'll grudgingly accept that it may not help, and may hurt by slowing the natural inflammatory response to exercise. In the latter case, I think pre-empting pain and inflammation is very helpful. The question that is not answered is: dose and timing (full dose pre-exercise, half dose during exercise, etc?)

For example, personally, I use a half dose during exercise (or immediatly pre assuming 30 minutes to blood levels) on very long runs (like a half marathon). Because of my experience and knowing when the pain starts, my DJD doesn't really kick in until about mile 7 or 8. If I run less than that, I don't use it. So maybe my answer is to see what level of activity causes lameness, and treat with preempting that as the goal. Obviously, if the patient is allways lame, then pre-exercise dosing makes lots of sense. If it is a situation where the patient plays fine, but is sore later that evening, then it's harder to judge exact timing, but I still say: treat becasue you know he has preexisting inflammatory disease.

***

For others interested in the use of pain relievers pre-exercise, the entire post is here:

http://www.petmd.com/blogs/dailyvet/Sept/2009/03

Dr. Patty Khuly September 4th, 2009 08:20:29 AM

I am of two minds on the whole internet-medicine thing.

Sites like Pet MD and others are very useful for owners to do their own research on their pets disease, and I really encourage this because for one thing, it helps them ask intelligent questions of their vet and even know whether or not their vet is up to speed.

But it can be dicey when it comes to diagnosing online.  I've seen vets over on "Answer.com" giving advice to owners -- and being paid for that advice, and soliciting extra tips ($)  to boot -- that walks a perilously fine line between providing general education and diagnosing animals they've never seen.  

But WebMD, PetMD, etc are only as good as the people writing for them, and the "average" vet can be behind the times, and sometimes bone headed stuff shows up there.  Another very valuable, and in some cases superior resource, is online communities of caregivers.  For example, FelineDiabetes.com and the Yahoo Chronic Renal Failure Group -- have in my experience a body of knowledge that is -- I gotta say -- superior to that of the average vet.  Countless pet owners show up on those boards, announcing that their pet is newly diagnosed, and tell the community what treatment protocol has been advanced by their vet.  And at least on the feline diabetes list, I assert confidently that about 50% of the time, the posting owners vet is FAR BEHIND the current best practice in treating feline diabetes, and they learn LIFE SAVING information from those fellow pet lovers that have been in the trenches with the disease.

True, the "best practices" that I believe are promoted on that list have themselves been taken from the BEST and most knowledgable professional opnions that veterinary medicine has to offer.  The list is crawling with happily pet-centric people who are geeks and information sponges, researching protocols, paying for long distance consultations with feline endocrinologists and diabetes researchers and nutritionists.  So, it's a list whose long-timers have studied best practices in current feline diabetes treatment AND who have combined totals of THOUSANDS of person-cat-years collective hands-on knowledge of what works in reality day to day, with diabetic cats.  You really can't pay for that kind of knowldege database.

Could it all go south if all the informed long-timers suddenly left?  Maybe.  But I don't see it happening.

Relying on the internet alone for information can be dangerous, but so can relying on your in-the-flesh vet alone.  Hundreds of cats have been rescued from IMHO probable death due to diabetic complications by a community of fellow pet owners on the internet -- cats whose in-the-flesh-vets were 15 years behind the times in diabetic cat care.

Stefani September 4th, 2009 01:49:15 PM

Stefani: The problem most veterinarians see with sites like felinediabetes.com and other places where owner-published material abounds (in chatrooms, listserves and the like) is that much of it is anecdotal, some of it is inflammatory, and some owners do not understand that everything online must be taken with a grain of salt and only as an adjunct to a veterinarian's advice about the particular patient at hand.

An example sourced from my personal practice: Owner of cat diagnosed at 11 AM, sent her to felinediabetes.com, comes back to visit at 2 PM and proclaims that she will NOT accept insulin. Glipizide is her choice for her ketoacidotic diabetic. Much discussion had to ensue before I could talk this owner down from her ledge. Still didn't relent. I had to send her to the internist bc I couldn't reason with her. I even tried to go through the site with her to explain to her why she was choosing to head in the wrong direction. 

It happens sometimes. Sure, I want a well-educated client but 2 hours in front of a computer screen should raise questions, not proclamations. Get just one of those a week and all the great clients with great questions seem to fade to black by comparison.

Dr. Patty Khuly September 4th, 2009 04:18:35 PM

Dr. K, I know you don't spend much time on FDMB.  Because I can definitely tell you that the experienced people over there jump all over the glipizide thing warning that it is NOT a good option -- and usually they have to do so precisely because some vet told them this was a viable option.  Not you, of course, but some vet.

If she got the idea of glip from FDMB it would only be because perhaps there was SOMEONE there whose cat was on it who has yet to be convinced off of it, and your client was probably one of those people looking for any reason at all to avoid shots. The mere presence of someone whose cat is on glip, however much others are arguing against it there, might be all it took for her to glom onto that as a way to avoid the dreaded shots.

I can tell you sincererely for certain that the community voice over there is very much against glipizide as a first approach for dealing with diabetes in felines.  But you need not take my word for it -- just head on over there and do a site search of the word "glipizide" and see what people are saying.

Actually, a bit of an aside:

I have, in the past, been chided over there for my "tone" in being very adamant about some things, and the community goes through periods where "softer" language is enforced through peer monitoring. I.e., instead of saying: "Glipizide is MOST DEFINITELY NOT a good first approach for cats.  You cat NEEDS to be on insulin" -- some would argue it would be better to say:

"Hmmm, glipizide.  Well, many people find that doesn't work too well.  But if your vet is recommending it, OK, you might want to give it a shot.  Most people here have cats on insulin."

I find the latter approach unclear, misleading, etc.  Fortunately, there are plenty of blunt people like me.  But they worry about "scaring" newbies away with very direct statements especially, Dr. K, when they contradict the person's vet.

It really is usually vets that recommend, or lead a client to believe, that glip is an acceptable option -- not the old timers on that board.  Problem is, people don't want to say: "You're vet doesn't know what he's doing, find a new one."

I can't say that I've EVER seen "the board" recommend glip for a cat, unless of course the owner indicated that there was NO WAY they were ever going to give shots and they'd otherwise let there cat go entirely untreated and starve to death.  She really must have been hearing what she wanted to hear.

Stefani September 4th, 2009 07:10:32 PM

Dr. K, sorry to post again on this but I really don't want people thinking glip is a good first option for their cats.

I figure that instead of posting to the message board for advice (which would have taken some time, because you have to set up an account, introduce yourself, and all of that) your client probably looked at the articles library.

And, Lo and Behold, among the articles (written by vets, of course) was this:

http://www.felinediabetes.com/managingFDM.htm

I am betting this was what she found, is her cat obese?

This is clearly an article based on an outmoded veterinary approach, as it even says that she uses Humulin N, and doesn't even mention glargine, so I'm betting it was written some time ago.  That's the only thing there I imagine she could have found. 

I have posted to the community about this in the hopes that they will remove the article which is, at best, outdated.  In fact if you go to the "Initial Treatment" link the advice there is much more reflective of what people on the list advise. And yes, it does tell them to work with their vet.  So I"m betting she was digging in the Education or Health articles section.

It's like any other veterinary-authored article she could have found online from years ago, and its unlike the kind of advice she would have received if she'd actually posted to the group.  I'd put money on that.

Stefani September 4th, 2009 07:40:45 PM

Stefani: You're right about that:Some people just want the web to confirm that their preferred approach is the right one. Indeed, as I was scanning the FD website with her she couldn't tell me where exactly she'd found that info within it. 

Dr. Patty Khuly September 5th, 2009 07:49:16 AM

Stefani, unfortunately people start trusting a site such as the feline diabetes one and can believe everything on there in addition to the diabetes info. There is a recurring bit of anesthesia advice that appears on these diabetes forums that is incorrect. People recommend that only "gas" anesthesia be used on these diabetic cats and one vet on "another" diabetes site actually recommends that "injectables" never be used on diabetics. People on these forums don't understand what that means and often go into their vet and ask that "only" gas anesthesia be used. I don't think there is a single board certified veterinary anesthesiologist or vts (anesthesia) that would recommend that.

virginian September 5th, 2009 09:14:13 AM

Just an opinion, when I first got on the net in '96, there was very little information, around 2000-02, there was a wealth of reliable information with published studies by colleges and various informative articles by breed clubs OR groups dealing with specific canine/feline issues.

Now I find next to nothing as far as specifics go for various illnesses. Going to a site to read up on something and finding generalizations without suggestions for followup diagnosis or treatment options is fairly worthless to a lot of pet-owners. Compare it to the wealth of information for humans and we certainly aren't self-diagnosing and prescribing are own treatments---we need a physician to do that. But it may enable a patient to be more specific describing symptoms and narrow the possibilities.

What happened in the veterinarian field? Everything is all locked up in members only sites or pubmed type sites for a fee.

I belonged to one canine list long-term and that was the canine epilepsy site with two or three on board Veterinarians. It was a life-saver to (me) diagnosis an underlying problem that cured the seizure activity. It sure wasn't being diagnosed by either the GP vet or the neurologist specialist vet and even poopooed.

But no, I didn't engage in many of treatments: gold bead therapy, certain supplements, etc.

Barbara A./NH September 6th, 2009 05:20:56 PM

Virginian, I will agree that not every utterance from every keyboard of every member of FDMB (or any other pet-health community) is reliable, however, certainly if anyone hangs around for any length of time, rather than hop on, grab one post, and hop off forever -- the old timers who are very experienced caregivers will advise well, and their advice will be in agreement with the best of what vets are practising and preaching as well. 

However, your comment makes two good points:

You said that a "vet" on another diabetes site recommends something that board certified anesthesiologists would disagree with. Since that information is coming from a veterinarian, and merely being delivered via online mode rather than via paid consultation, the problem is not the mode but the source, and the source is a vet.  We have lots of ways of accessing vets now, and the problem you highlight is to say that there are many vets out there that are promulgating treatments or advising clients in a way that is out of step with standard of care.  I couldn't agree more, but the "modality" of communication isn't at fault, the lack of promulgated, accessible "standards" is.  I can go to 5 vets and get 5 opinions.  I don't see how the "modality" is to blame for vets who are not up to speed. 

The other point you made is that when a pet owner starts to trust information that comes to him via one modality and source type (i.e., internet based communities of fellow pet owners) he or she begins to "blindly trust" all information that comes to him or her via that source and modality.  I don't disagree with you -- this is a peril of the internet age, that it is difficult, if not impossible, for a layperson to discern what information is good and what is not.  However, the problem isn't really the internet, because as we've already discussed, goign to a vet-in-the-flesh rather than going online is also no guarantee that your pet will receive standard of care.  After all, you pointed out that some of that bad advice online is comiing from a vet, I doubt that vet counsels clients differently in person.

Also, "blind trust" is a problem in any modality or any source.  That is a problem that people have with in-the-flesh vets too.  They simply take everything they say as gospel without critically questioning it.

Which brings me to Barbara's remark, because frankly there lies the seed of an idea to address both problems.  The lack of availability of published, written standards of care that would be available both to vets AND clients.  If such a thing were available (provided it reflected current best practices) it would serve two purposes:  Educate vets, and help clients assess the advice they were being given either by a vet or by another source, whether it be the friend in the breed club or the online community.

Standards of care.  Published.  Accessible.  Imagine that.  Why doesn't it exist?

One possible answer is that there is too much disagreement within the veterinary community itself to come up with best practices and objective, publishable standards.  If there is that much variability in approach, then we really DO need communities like the FDMB to give us another body of information against which to measure.

If it's not a lack of consensus, but rather a desire NOT to publish such things, then I have some really good guesses as to why such a thing might be deemed undesireable.  But I will keep those to myself.

Stefani September 8th, 2009 03:58:37 PM

Stefani, I'm not denying that the internet can be very useful to pet owners. I think you and I agree on some basic points that people who are surfing the web for veterinary information should keep in mind.

The age of the web info. All recommendations should be dated. Veterinary medicine can advance very quickly in some areas. Something that was true two years ago can be very different today. I have seen recommendations on the web that were 10 years old.

The source. Look for those letters that mean a vet is board certified. ACVA, ACVIM, ACVS, etc. Unfortunately you won't find alot of board certified vets posting on the web. You do find some vets,  though, that are self-described "experts".This is true particularly in the area of nutrition. They may keep up with the latest in their field of interest but, then again, they may not. You have no way of knowing.

Use the info you have found to start a conversation with your vet. There may be some very good scientific reasons why he/she does not agree with what you have read. You will always be able to find a vet that will do what you want but that may not be in the best interest of your pet.

virginian September 8th, 2009 04:31:23 PM

I agree, it's really a "caveat emptor" situation when it comes to veterinary information on the web. I write my own cat advice column, and whenever an issue has even the slightest possibility of being health-related, the first thing I tell my readers is "take your cat to the vet and make sure s/he has a clean bill of health and that it's not an illness causing the problem."

I don't want any of my readers taking my advice as gospel. I'm not a vet, and I know it. In fact, I even put a disclaimer on my site that "None of the material at this site is meant to be a substitute for regular veterinary care. The author assumes no liability for the misuse of advice given in this or any other column at this site."

I've actually had readers take me to task for NOT providing veterinary advice. My answer is, was, and always will be, "I'm not a veterinarian. I don't know your cat, I don't have a DVM degree, I don't have the diagnostic tools, and even if I were qualified to make a diagnosis, I couldn't diagnose your cat without seeing him or her."

I hope that my readers will do as Virginian suggested and "use the info you have found to start a conversation with your vet."

Of course, I've got an excellent vet whom I trust a lot and who listens to me when I ask him about various issues. He enjoys talking with me because I don't get all up on my high horse and tell him that I know better than he does because I read something on the internet. :-)

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