Categories
Diseases

Diseases Of The Ear: Crusting And Scaling Dermatoses

Scabies and Mange

Erythematous, papular dermatitis of the distal pinnae associated with significant pruritus is an early manifestation of Sarcoptes scabiei in dogs. Crust and scale will usually first affect the tip of the pinna or ear margin. The pinnal-pedal reflex (i.e. rubbing the pinna resulting in a pelvic limb scratch reflex) is often associated with sarcoptic mange but is not pathognomonic for the condition. Concurrent lesions often involve the lateral hocks and elbows and may spread to the rest of the body. The diagnosis is usually made with skin scrapings; however, multiple scrapings may be necessary to achieve the diagnosis. The presence of a single mite, egg, or fecal droppings is diagnostic for the disease. All animals in the household should be treated, and the condition is zoonotic, so owners and handlers should be made aware of the condition. Initial treatment consists of removal of crusts and debris, followed by an acaracidal dip such as lime sulfur, permethrin, organophosphate, or amitraz, which may shorten time to resolution of clinical signs and diminish zoonotic potential. Ivermectin administered subcutaneously, twice at 14-day intervals, or orally three times at 7-day intervals, results in cure. A similar dose schedule exists for milbemcyin. Topical application of selamectin or fipronil may also be curative.

Feline mange, caused by Notoedres cati, results in alopecia, pruritus, excoriations, and thick crusts of the rostral pinnae and is usually restricted to the ears and head. The extremities and perineum may also be affected due to the sleeping and grooming habits of cats. The parasite may also inhabit dogs, foxes, and rabbits; transient lesions have been reported in humans. The diagnosis is made with skin scrapings, and lime sulfur or amitraz dips are effective treatments. Ivermectin given two or three times subcutaneously is also effective.

Fly Strike Dermatitis

Insect bite dermatitis, primarily caused by the stable fly, Stomoxys cakitrans, results in serosanguineous, crusting dermatitis on the ear tips in dogs with erect ears or on the folded edge of the pinna in dogs with pendulous ears. Chronic fly strike dermatitis can become granulomatous in nature. Horse flies (Tabanus species) and deer flies (Chrysops species) may also plague dogs that are housed outdoors, but their bites are usually less reactive than stable flies. The diagnosis is based on an environmental history and response to limiting outdoor exposure. Fly repellents containing permethrin, citronella, or diethyltoluamide (DEET) in petroleum jelly may be used to diminish repeated fly bites. Topical corticosteroid with an antibiotic may hasten the resolution of clinical signs. Black flies (Simulium species) may also cause papular dermatitis and alopecia in dogs.

Cats can develop a seasonal hypersensitivity to mosquito bites. Papules, erythema, alopecia, and hypopigmentation occur on the pinnae and face. Pyrexia, lymphadenopathy, and footpad lesions may also occur.

Actinic Dermatitis and Squamous Cell Carcinoma

Damage to the skin by long-term sun exposure occurs most often in white cats, although the condition is also reported in dogs and in cats with pigmented skin. The pinna is most often affected due to its sparse hair covering; the nose, lips, and eyelids may be similarly affected. Waxing and waning ear tip erythema may progress to the development of fine scale and alopecia early in the disease. Erosive, crusted, hemorrhagic lesions and folding of the pinna occur as a precancerous condition, which may ultimately lead to carcinomatous change., Squamous cell carcinoma is most often diagnosed in older cats (mean age, 12.8 years) with either skin scrapings or biopsy.

Treatment of actinic dermatitis ideally consists of limiting sun exposure between the hours of 10 AM and 4 pm by housing indoors and eliminating sunbathing behavior. Application of sunscreen of SPF 15 or greater may also decrease the effects of solar radiation. β-carotene and canthaxanthin administered orally and the use of retinoic acids (i.e. isotretinoin, etretinate) have also been reported. An initial response to therapy may be seen, but long-term effectiveness has not been thoroughly investigated. Strontium plesiotherapy has been used in the treatment of actinic dermatitis. Failure to respond to medical management is an indication for pinnectomy.

Squamous cell carcinoma is usually locally invasive and slow to metastasize to either local lymph nodes or the lung. Pinnectomy is an effective mode of therapy for severe actinic dermatitis and squamous cell carcinoma. Cryosurgery, radiotherapy, brachytherapy, hyperthermic, and photodynamic therapy have also been used on focal lesions; systemic chemotherapy is not considered effective.

Frostbite

Animals affected by frostbite are usually systemically ill or have recendy moved to a cold environment. The ear tips are pale, cyanotic, hypoesthetic, and cool to the touch after exposure. With warming, the tissues become hyperemic and develop scale, crust, and alopecia. The ear tips may curl, necrose, and eventually slough. Initial treatment consists of rewarming with warm water and subsequent symptomatic therapy for scaling and crusting dermatitis. Amputation of necrotic tissue results in improved cosmesis with haired skin and decreases the risk of recurrent freezing, which is more likely in previously frostbitten tissue.

Vasculitis

The underlying cause of vasculitis is often unknown, but the condition occurs subsequent to Type I and Type III hypersensitivity reactions and the deposition of antigen and antibody complex within the vascular wall. The lesions are characterized by erythema, edema, and eventual necrosis and sloughing, leading to a “punched out” or ulcerated appearance to the pinnae. Other affected areas include the lips, tail, pads, and nails. A neutrophilic, eosinophilic, or lymphocytic vasculitis may be evident on histopathology. Proliferative thrombovascular necrosis of the pinnae is a form of vasculitis reported in dogs. Inflammatory vasculitis is not evident in this syndrome and cause is unknown. Conditions such as rickettsial disease, drug eruption, immune-mediated disease, and other underlying systemic conditions should be ruled out. Therapy should be directed at treating the underlying cause. Idiopathic vasculitis cases may respond to immunosuppressive doses of corticosteroids. Other reported treatments include pentoxy-phylline, sulfasalazine, or dapsone. Surgical excision of the affected portion of the pinna with wide surgical margins may be indicated if medical management is unsuccessful.

Hyperkeratosis

Crusting and scaling of the pinnae may be caused by idiopathic defects in keratinization, primary disease conditions causing seborrhea, and secondary changes in keratinization due to parasitism. Ear margin dermatosis is common in dachshunds and other breeds with pendulous ears. Seborrheic changes begin at the ear margin and progress to confluence of scale and significant alopecia. Pruritus is variable but may be present in severe cases. The condition is not curable but controllable with keratolytic keratoplastic shampoos (e.g. sulfur-asalicylic acid, benzoyl peroxide or benzoyl peroxide-sulfur, selenium sulfide). Severe cases may require topical or systemic corticosteroid treatment due to inflammation associated with removal of crusts or ear fissure formation.

Sebaceous adenitis is associated with an inflammatory process of the sebaceous glands. Follicular disruption, alopecia, and surface scale initially affect the pinna and may involve the ear canal and trunk. No direct therapy exists for lost sebaceous glands, and supportive care with fatty acids, humectants, and anti-inflammatory corticosteroids can be useful. Retinoids have been used in cases with a granulomatous response to the process.

Other less common disorders can cause hyperkeratosis of the pinna. Idiopathic benign lichenoid keratosis has been diagnosed in four dogs with multiple wartlike papules and hyperkeratotic plaques on the pinnae. Lichenoid psoriaform dermatosis is a rare condition in which erythematous papules and lichenoid plaques appear on the concave surface of the pinna, external ear canal, and ventral head and trunk. Treatment consists of antimicrobial shampoo, systemic antibiotics, and corticosteroids. Lupoid dermatosis is a heritable condition of German short-haired pointers in which progressive, nonpruritic scale occurs on the pinnae, face, and trunk. No therapy is available for the condition.

Nutritional Dermatoses

Zinc deficiency caused by dietary insufficiency or inability to absorb dietary zinc results in crusting lesions of the pinna, and perioral, periorbital, perianal, and perivulvar sites of dogs. Food allergy can result in steroid-resistant alopecia, crust, scale, hyperpigmentation, and lichenification of the pinnae. Dietary restriction followed by feeding trials is diagnostic of the condition, which may be associated with lesions and pruritus on other parts of the body.

Categories
Horses

Treatment of Pastern Dermatitis

The appropriate therapy obviously involves identification of the predisposing, perpetuating, and primary factors. In general, avoiding pastures/paddocks with mud, water, or sand may minimize predisposing factors. Keeping patients stalled during wet weather and until morning dew has dried is often rewarding. Use of alternate sources of bedding may be beneficial because the chemicals in treated or aromatic types of wood shavings may result in contact dermatitis. Lastly, clip hairs — especially feathers — to avoid moisture retention.

Perpetuating factors should be addressed according to the severity of the condition. The most conservative approach includes cleansing lesions with antimicrobial shampoos (benzoyl peroxides, chlorhexidine, ethyl lactate, imidazoles) twice daily for 7 to 10 days and then tapering in frequency. If a dry environment is not possible, the affected pastern areas can be protected with ointments (creating a moisture barrier); with padded and water-repellent bandages (changed q24-48h); or with Facilitator, a hydroxy-ethylated amylopectin liquid bandage that is replenished every 1 to 3 days. If the lesions are exudative, astringent solutions — such as lime sulfur (LymDyp), aluminum acetate solutions, black tea bag or sauerkraut poultices, or acetic acid/boric acid wipes (Malacetic Wipes, Dermapet Inc., West Plains, Mo.) — should be used after cleansing.

Topical sprays, creams, or ointments that contain antibiotics, steroids, antifungal agents, or a combination thereof may benefit the patient, depending on the diagnosis. A 2% mupirocin ointment (Bactoderm), with excellent tissue penetration, is the author’s preference for addressing localized dermatophilosis and bacterial dermatitis. A DMSO / thiabendazole / sulfa ointment has also been described in the fourth edition of Current Therapy in Equine Medicine. If generalized to all four limbs, treatment of the bacterial dermatitis is best accomplished with daily systemic antibiotics (trimethoprim/sulfa 30 mg/kg/day or cephalexin 22 mg/kg q8hrs) until 7 days after clinical resolution.

Lime sulfur dips and chlorhexidine / imidazole-containing shampoos, sprays, and residual leave-on products comprise the current antifungal arsenal in veterinary medicine. Topical enilconazole (Imaverol), labeled for use in horses in various countries other than the United States, has been used to treat fungal infections with reported success. Many veterinary dermatologists feel that systemic griseofulvin lacks efficacy for the treatment of equine dermatophytosis.

Ectoparasiticidal therapy consists of avermectins, topical organophosphates (malathion, coumaphos), pyrethroids (permethrin, flumethrin), lime sulfur, and fipronil (Frontline). The latter has had recent success in the treatment of Chorioptes bovis within a group of heavier cob and draught-cross horses. Of note was the ability of the parasite to survive off the host, enduring solely in the presence of skin debris in a moist and dark environment and thus emphasizing the need for environmental management to prevent recurrence.

Immunomodulators have been used for the condition. Interferon-a2a given at 1000 IU/ml on a cycle of 1.0 ml per horse daily for 3 weeks and then off for 1 week has been used by the author to help stimulate the local immune defense system, with very little cost or side effects. Immune-mediated conditions such as PLV, however, require a significant immunosuppressive effort to achieve resolution and control of the clinical signs. High-dose glucocorticoids, preferably dexamethasone (0.1-0.2 mg/kg q24h for 7-14 days, then taper over the next 4-6 weeks), along with reduction of UV light exposure by stabling or covering with a light bandage, appears to control — if not resolve-many cases. Should resolution of clinical signs not be achieved by 14 days, the author has achieved excellent results by adding pentoxifylline (PTX), a phosphodiesterase inhibitor. PTX has been reported to have multiple immunomodulatory effects that potentiate the effectiveness of traditional immunosuppressive drugs (i.e., steroid-sparing effect). These include inhibition of lymphocyte activation and proliferation; increased lymphocyte suppression; suppression of tumor necrosis factor (TNF)-a, lymphotoxin, and interferon-7 production; and upregulation of IL-10 mRNA that leads to increased IL-10 serum levels. Oral absorption varies considerably between individuals; thus reported dosages range between 4 to 8 mg/kg every 12 hours.

Once the skin has returned to normal, long-term control of PLV may be achieved by a combination of topical steroids (betamethasone valerate 0.1%, aclometasone 0.05%), coupled with an every other day systemic regimen of PTX and, if necessary, low-dose dexamethasone on an alternate day basis.

The prognosis and healing time of equine pastern dermatitis depends on the stage of disease when treatment begins and on the ability to identify the etiology. Ensuring that predisposing, primary, and perpetuating factors are encompassed in a diagnostic and treatment plan will optimize the likelihood of a positive outcome.

Categories
Horses

Dermatophilosis

Dermatophilosis or “rain scald” has a worldwide distribution, although the prevalence of the disease varies with geographic location. It is a moist, exudative dermatitis caused by the actinomycete Dermatophilus congolensis. D. congolensis is a gram-positive, non-acid fast, branching, filamentous bacterium that can cause a superficial bacterial dermatitis in a variety of species in addition to the horse. It is seen more commonly in humid, tropical regions of the world, and the incidence increases during periods of prolonged heavy rainfall.

Normally, the intact stratum corneum and its associated lipid layer provide an effective barrier against invasion by the organism. However, when the skin has prolonged exposure to moisture, it is more susceptible to maceration or trauma. Damaged epithelium must occur for an infection to develop. The natural reservoir of the organism is not known, and attempts to isolate it from soil have been unsuccessful. Exposure to the organism can occur by direct contact with other infected animals, fomites (grooming or tack equipment), or insects. Motile zoospores of D. congolensis germinate in a moist defect of the stratum corneum, thus forming a mycelium that proliferates within viable epidermis and hair follicles. An acute inflammatory response composed primarily of neutrophils is induced when the organism invades the viable epidermis. The organism is unable to penetrate the dermis or the neutrophilic inflammation. When the epithelium is restored and the overlying crusts are shed, the bacteria are typically eliminated with the crusts and can survive in crusts shed into the environment for several years, thus remaining a source of future infection for other horses.

Dermatophilosis: Clinical Signs

Clinical lesions in the acute stage include papules and pustules that develop into suppurative crusted lesions with exudation and matted hair. Alopecia is variable. Horses with long hair tend to develop larger areas of matted hairs and crusts than horses with short hair. Horses with short hair tend to have smaller, crusted papular lesions. If crusts are removed, the underlying epithelial surface is moist, gray to pink, and indurated. When crusts are removed, adherent tufts of hair are usually removed as well. The pattern of the matted hair and crusts are described as having a “paintbrush” appearance. Lesions are found in areas most susceptible to moisture accumulation and trauma, such as the dorsal midline, distal limbs, muzzle, and periocular regions. Racehorses may develop lesions on the cranial surface of the hind legs in areas where traumatic abrasions from track debris can occur. Areas of nonpigmented skin may be more susceptible to infection. Alopecia and hyperpigmentation can develop in cases of chronic infection. Affected areas are more likely to be painful than pruritic. Secondary infection with other bacteria, staphylococci, streptococci, or corynebacteria can develop in more chronic cases.

Diagnosis of Dermatophilosis

Differential diagnoses to consider include dermatophytosis, bacterial folliculitis, pemphigus foliaceus, and drug eruptions. Diagnosis is based on compatible history and clinical signs, cytologic examination of exudate (the lesion’s surface or undersurface of a crust), or emulsified crusts, bacterial and fungal cultures and histopathologic examination of skin biopsies. Direct smears can be stained with new methylene blue, Giemsa or Gram’s stain. The organism appears as a gram-positive, branching, filamentous bacterium that forms parallel rows of cocci that create a railroad track-like appearance. The organism grows on blood agar but not on Sabouraud’s medium or dermatophyte culture media that contain phenyl red indicator. The organism is more easily isolated from acute lesions because chronic lesions are secondarily infected with other bacteria. Incubating culture plates in an environment with reduced amounts of atmospheric oxygen (microaerophilic) may improve the chance of successful cultures. Histologic examination of the crusts is more likely to result in identification of the organism than examination of the epidermis. Consequently the lesions should not be clipped or scrubbed before biopsy, so as to ensure that the crust is included with the submitted sample. A palisade-layer crust, intracellular keratinocyte edema, and neutrophilic epidermal inflammation are common histologic lesions seen in dermatophilosis.

Treatment of Dermatophilosis

Equine dermatophilosis often is self-limiting, and many cases will resolve without any treatment. Removal of predisposing factors such as moisture, trauma and exposure to infected animals is important for successful treatment and to prevent transmission. Horses should be kept in a dry environment. Loose crusts and hair should be removed by clipping and soaking with either an antiseborrheic (tar- or sulfur-containing) or antibacterial shampoo (povidoneiodine or chlorhexidine). Care should be taken not to contaminate the environment with infected hair and crusts. The organism is sensitive to many antibacterial agents. Daily topical therapy may be sufficient for most mild cases. Topical therapy with either 2% to 5% lime sulfur or povidone iodine should be used daily for 7 to 10 days and then twice weekly until lesions have resolved completely. Systemic antibiotics are used in severe, generalized cases. Procaine penicillin (22,000-44,000 IU/kg) given intramuscularly every 12 hours for 5 days usually is effective.

Categories
Horses

Dermatophytosis

Dermatophytosis is a common, contagious, superficial fungal infection of keratinized tissues — including the superficial epidermis, hair, and, less commonly, hooves. Synonyms include ringworm or “girth itch.” Horses of all ages can become infected with dermatophytes, but young horses are more commonly affected. Although multiple fungal genera are capable of producing dermatophytosis, the majority of infections result from infection with either Trichophyton spp. or Microsporum spp. Trichophyton equinum (var. equinum and var. autotrophkum) and Trichopyton mentagrophytes are the species most commonly isolated from equine infections. Trichophyton verrucosum, Microsporum gypseum, M. equinum, and M. canis are potential less common causes of equine dermatophytosis. Most of these fungal species are zoophilic dermatophytes, and transmission requires direct contact with infected animals or contact with infected hair or crusts in the environment. Infected rodents or cats are the most common sources for infection with T. mentagrophytes. Cats are also the typical source for infection with the very contagious species Microsporum canis, whereas cattle are the source for infection with T. verrucosum. Microsporum gypseum is a geophilic fungus that inhabits soil. Consequently, culture and speciation may be beneficial in delineating source of infection.

The prevalence of dermatophytosis increases in hot, humid climates or under conditions of close contact in dark, moist environments. In North America, more cases are seen in the fall and winter months. Young animals with no previous exposure lack immunity and are therefore more vulnerable to dermatophytosis. Horses with poor nutritional status or secondary debilitating diseases can be immunocompromised and more susceptible to dermatophytosis. Not all animals exposed to dermatophytosis develop clinical signs. The incubation period is typically between 1 and 4 weeks, depending on environmental temperature and humidity. Spores in the environment can persist for months to years, and contaminated tack and grooming equipment can be modes of transmission between animals.

Dermatophytosis: Clinical Signs

Hair loss is the most common clinical sign of dermatophytosis. Alopecia results because infected hair shafts are weakened and break more easily and also because hairs within inflamed hair follicles epilate more readily. Lesions are often multifocal, asymmetric, annular areas of alopecia that vary in size from 2 to 4 mm to several centimeters in diameter. Scales and crusts are often associated with the alopecia but inflammation and erythema may be minimal. Papules may be present and are often most noticeable at the advancing edge of lesions. Initial presentation can mimic urticaria with erect hairs in a circular plaque or papular lesion that may exude serum. However, these lesions quickly progress to become well-circumscribed areas of alopecia, scale, and crusting. Once it occurs, hair re-growth starts in the center of the lesion. Areas most commonly affected in the horse include the head, neck, shoulders, and lateral thorax. Skin abrasions or trauma often precede dermatophytosis; lesions consequently are often seen in areas of saddle or girth friction. Horses are only infrequently pruritic with dermatophytosis.

Diagnosis of Dermatophytosis

Dermatophytosis may be overdiagnosed when annular skin lesions are erroneously assumed to result from dermatophyte infection. Differential diagnoses include dermatophilosis, bacterial folliculitis, pemphigus foliaceus, or urticaria due to hypersensitivity reactions. Alopecic lesions with minimal scale or crusting should also have the differential diagnoses of telogen effluvium or demodicosis considered. The flat or plaque sarcoid is a differential diagnosis to consider for solitary lesions. Diagnosis may be suspected based on compatible clinical signs and history, but positive growth on dermatophyte culture medium from samples of hair and/or crusts obtained from representative lesions is necessary for the definitive diagnosis. Fungal culture medium requires vitamin enrichment with nicotinic acid to culture T. equinum, and it requires thiamine and inositol to culture T. verrucosum. Two drops of a commercial multivitamin B complex can be added to a commercial dermatophyte culture medium to provide these additional nutrient requirements. Microscopic examination of hyphae and conidiae allows for species identification.

Treatment of Dermatophytosis

Treatment of dermatophytosis is not always necessary, because cases can be self-limiting and resolve in 1 to 3 months. Based on culture and identification of the species of dermatophyte involved, the source of infection should be identified and eliminated whenever possible. The goals of therapy are to reduce the severity of the skin lesions, prevent transmission to other animals, and reduce environmental contamination. All infected horses should be kept isolated from noninfected horses. The skin around lesions can be clipped, with caution taken to dispose of hair and crusts to minimize contamination of the environment. Those people who handle infected horses also should take care because dermatophytosis is a zoonotic infection that can cause skin lesions in people. All in-contact animals should be treated. Topical fungicidal therapy should be applied daily for 7 to 10 days and then twice weekly until all clinical lesions have resolved.

Therapy may take up to 6 to 8 weeks until all skin lesions resolve. Topical fungicides that can be used to treat dermatophytes in the horse include 3% to 5% lime sulfur, 0.5% to 2.0% chlorhexidine, povidone iodine, 0.5% sodium hypochlorite, and, when available, enilconazole. Lime sulfur is nonirritating and safe, but owners should be forewarned about the strong unpleasant odor and the potential for discoloring the hair coat. Enilconazole is an imidazole that is not available in the United States. It is available in other countries and is reported to have excellent efficacy against dermatophytes. Captan has been listed as a therapy in the past but should not be recommended, as it is a carcinogen and can produce contact skin reactions in people. Whole body treatment with topical fungicides is usually more efficacious than is focal treatment of localized lesions, as many horses can quickly develop generalized dermatophytosis. Systemic therapy with griseofulvin (100 mg/kg daily for 10 days) has been used to treat dermatophytosis, but the ideal therapeutic dose is not known in the horse, and efficacy is difficult to ascertain because many horses will self-cure in 1 to 2 months. Griseofulvin should never be considered in pregnant mares, as it is a teratogen.

The environment also needs to be disinfected. Stalls, tools, tack, blankets, and grooming equipment should be cleaned with a sporicidal antifungal agent. Povidone iodine, 6% sodium hypochlorite, 5% lime sulfur, benzalkonium chloride, enilconazole, natamycin, or 1% lime plus 1.5% copper sulfate can all be used to treat the environment or equipment.

Categories
Horses

Mites and Ticks

Mange (Mite Infestation)

Ticks

Horses are exposed to a number of species of ticks, according to the geographic area (). The importance of ixodid (“hard”) ticks is mainly due to the transmission of infectious diseases like babesiosis or ehrlichiosis. However, a direct effect can be observed due to the skin damage, mechanical irritation, and pain (ticks preferentially bite areas where the skin is thin) or secretion of neurotoxic products. Ticks are also important in horses because they favor the development of bacterial infections (such as dermatophilosis) or myiasis.

Tick bites from adult ticks occur more commonly at the base of the ears, the anal and genital area, skin folds, and fetlocks and are characterized by erythema, papules, and black crusts. When larval forms are involved, they are generally numerous and may produce a papular dermatitis with tufts of erect hairs and papules. The entire body can be affected, particularly the head and limbs. One unique condition has been described in horses in Australia and is caused by immature stages of Boophilus microplus that results in an intense pruritus of sudden onset. The lesions, mostly localized to the head and limbs, are multiple papules and wheals that surround feeding larva and are probably due to a hypersensitivity response.

Ear Infestations

The spinose ear tick Otobius megnini (an argasid, or “soft” tick) originated in western North America and has spread to Africa and Asia. It is primarily a parasite of horses, donkeys, and cattle but has been recorded from a range of hosts. The larvae infest the host and develop in the ear canal in two successive nymphal stages. The parasitic phase may last from 5 weeks to several months. Dermacentor (Anocentor) nitens, also called the tropical horse tick, lives deep in the ear canal. This is a one-host tick (larva to adult on the same host). The ear ticks cause intense inflammation and irritation. The lesions vary from benign otitis with periaural alopecia to thick crusts and abundant cerumen with pruritus or even ataxia with neurologic signs.

Remembering that other parasites besides ticks may produce otitis in horses is important. Psoroptes spp. may cause a true otacariasis with erythema, excess cerumen, and head shaking comparable to psoroptic infestation in rabbits. Head shaking may be the only sign associated with a trombiculid infestation.

Diagnosis

Identification of mite infestation is initially based on clinical and epidemiologic observations. In cases of pruritus associated with mite infestation (Psoroptes, Sarcoptes mites) the itch reflex can be obtained in some horses. When scratched over the lateral neck or the withers, they tuck the nose close to the chest or extend the head and make a smacking noise with marked movements of the upper lips. Different mites may cause similar clinical signs, and the treatment may be the same. However, a precise diagnosis is recommended because their prognoses, contagion potential, and overall control can differ.

Acarial infestations can be contagious (mange mites) or pseudocontagious (trombiculids, ticks, and nonparasitic mites). Even apparently healthy horses can be infested.

In cases of mange infestation, a nonspecific eosinophilia is sometimes present. The histopathologic findings in such diseases are also usually nonspecific unless parasites (or fragments thereof) are present in the sections. If present, Sarcoptes spp., Psoroptes spp., the stylostome of trombiculids, and the chelicerae of ticks are most often seen. Skin biopsies reveal varying degrees of superficial perivascular dermatitis with numerous eosinophils that are compatible both with ectoparasites and hypersensitivities. Occasionally a deep perivascular dermatitis with lymphoid nodules is observed. The presence of microabscesses with eosinophils is a suggestive finding for ectoparasites. However, in many cases secondary infections may change the histopathologic pattern, thus masking suggestive findings. One exception is demodicosis, in which biopsies may reveal hair follicles distended to varying degrees with recognizable demodectic mites.

A definitive diagnosis of mite or tick infestation is based on recovery of the organism from the affected host. Multiple skin scrapings are generally needed to recover superficial mites such as Sarcoptes or Chorioptes. Skin scrapings can be negative in asymptomatic carriers or in chronic disease. As in the dog, skin scrapings may reveal the mites, their eggs, or feces. It is preferable to clip the hair before sampling affected skin areas.

In cases of demodicosis (a deep or follicular mite) multiple skin scrapings may also be necessary. In one case in Minnesota only 9 of 42 skin scrapings were positive, thus giving a total of 12 mites. The skin should be grasped and squeezed between the thumb and forefinger to improve the evacuation of follicular content. Ticks are carefully collected with forceps to obtain the entire rostrum necessary for identification.

Identification of mange mites is relatively easy (they measure 0.25-0.75 mm in length). Sarcoptes mites have a rounded body with a short rostrum and short legs ending in long peduncles; Chorioptes mites have a conical rostrum and relatively long legs with suckers directly fixed to the extremity; and Psoroptes mites are larger with an elongated rostrum and long legs with triarticulate sucker-bearing peduncles. Trombiculids are characterized by their orange color (size 0.25 to 1 mm), the long and plumose setae, and a typical rostrum. Identification of adult hard ticks is relatively easy at the genus level, and Otobius nymphs have a typical spiny integument and a ventral rostrum. Precise identification of species and of larval stages of ticks is a matter for the specialist.

Control

The methods and efficacy of control of mites and ticks in horses depends on each parasite. Many acaricidal drugs can be safely used in horses with the exception of Amitraz. Topical acaricidals safely used in horses are organophosphates (i.e., dimpylate, malathion, coumaphos, phoxim), organochlorines (lindane), carbamates (carbaryl), and lime sulfur. Dosages are not detailed here. The drugs available or licensed for horses depend on the country. Other topical products such as phenylpyrazole (fipronil) are well-tolerated and have demonstrated successful off-label use against Chorioptes spp. Formulations such as sprays, spongeons, and powders are more effective against superficial and temporary parasites, whereas topical control of mange mites often requires clipping the hair coat and thorough application. The frequency of application is usually once or twice a week for at least 3 weeks. The systemic acaricidal most commonly used is ivermectin; the usual dose is 0.2 mg/kg every 2 weeks, given 3 times. However, the route of administration influences the efficacy of ivermectin. Orally administered ivermectin produces a peak blood concentration 4 to 6 hours after administration, with a higher concentration than the injectable route until 36 hours after administration. At that time the concentration rapidly decreases, whereas the blood concentration of injectable ivermectin increases for four days and maintains high levels for ten days, thus probably making it more effective. However, it should be borne in mind that injectable ivermectin can cause serious side effects in some horses. In two studies with different protocols of oral ivermectin there was no complete cure in some of the treated horses. The best treatment for the control of mange is probably to combine the systemic action of macrocyclic lactones with the application of a topical acaricidal.

Frequent application of pyrethroids is probably the treatment of choice against ticks in situations of risk for transmission of tickborne diseases. Parasiticidal treatments must be also combined with other methods: isolation of all contaminated horses (for contagious infestations), avoidance of infested areas (important for chiggers, ticks, and Dermanyssus spp.), change of food source (Pyemotes and other hay or straw mites), and disinfection of barns and material (mange, Dermanyssus spp.). Medication for the control of inflammation and/or pruritus (i.e., corticosteroids) is generally contraindicated except in trombiculidosis.

Categories
Complementary Medicine

Mange

Mange (Demodectic / Sarcoptic)

Definition and cause

Demodex is a localized or generalized parasitic disease caused by Demodex spp. mites. The underlying cause is believed to be genetic or related to immune deficiency or imbalance. In cats it is most often associated with other systemic disease such as FIV. Sarcoptic mange is a highly pruritic parasitic disease caused by the mite Sarcoptes scabiei.

Medical therapy rationale, drug(s) of choice, and nutritional recommendations

For demodex the medical therapies of choice are Amitraz, Ivermectin, or Milbemycin, all of which have potential side effects and are potentially toxic. Amitraz is particularly toxic to humans, and proper precautions should be taken to protect humans from exposure to its active ingredient. None of these treatments address the underlying immune imbalance. Therapy for sarcoptic mange involves mitocidal shampoos or dips along with the medications used in demodex, and / or the use of Selamectin. In addition, antipruritic medications such as antihistamines and corticosteroids are often recommended.

Anticipated prognosis

Localized demodectic mange usually carries a good prognosis. Generalized demodecosis in immune-compromised animals often has a more guarded prognosis. Sarcoptic mange has a good prognosis.

Integrative veterinary therapies

Mange is a nondescript term meaning infestation with one of several mite ectoparasites. These ectoparasites cause irritation through their waste products and physical injury to the host (burrowing), and by their physical presence on the host, which triggers various responses directed at elimination of the mites (pruritus, grooming, self destructive behavior). Damage directly from the mite’s activities and or from the host response leads to a worsening condition.

The integrative approach expands the medical therapy to include the immune system. The integrative approach is cellular protective for the potential toxic effects of medication and mitacidal dips, and helps improve immune function and its ability to rid the body or prevent re-infestation of the mites and lessens inflammation, pruritus, and discomfort.

Nutrition

General considerations / rationale

While medical therapy is focused locally upon destruction of the mite and the skin (inflammation and / or pruritus), the nutritional approach adds gland support for the organs of the immune system as well as nutrients to help decrease local inflammation and improve waste elimination. Because mange, especially demodex, can range in severity from local to generalized and can affect other organs, it is recommended that blood be analyzed both medically and physiologically to determine associated organ involvement and disease. This gives clinicians the ability to formulate therapeutic nutritional protocols to address the skin and organ involvement such as liver inflammation secondary to medication or chemical dips (see site, Nutritional Blood Testing, for more information).

Appropriate nutrients

Nutritional / gland therapy: Glandular adrenal, thymus and lymph provide intrinsic nutrients and help neutralize cellular immune organ damage and protect organs from ongoing inflammation and eventual degeneration (See site, Gland Therapy, for more information).

Sterols: Plant-derived sterols such as betasitosterol show antiinflammatory properties, which appear to be similar to corticosteriods. A cortisone-like effect without the associated immune suppressing effects is beneficial in inflammatory skin conditions. Bouic (1996) reports on the immune-enhancing and balancing effect that plant sterols have on the body.

Quercetin: Quercetin functions like an antihistamine and an antioxidant, and is beneficial for the skin. In its antihistamine role, quercetin has been shown to inhibit cells from releasing histamines, which makes it helpful in treating inflammatory dermatitis.

Lecithin / phosphatidyl choline: Phosphatidyl choline is a phospholipid that is integral for cellular membranes. It is an essential nutrient required by the skin, which is the body’s largest cellular organ.

Essential fatty acids: Much research has been conducted on the importance of essential fatty acids on the clinical management of allergic dermatitis. In addition, the importance of the ratio between omega-6 and omega-3 fatty acids has been substantiated. Research on the use of poly-unsaturated fatty acids has shown their beneficial and antipruritic effects on skin.

Vitamin C: De la Fuente (1998) and Penn (1991) showed that vitamin C in combination with other vitamins significantly improved immune function as compared with a placebo.

Chinese herbal medicine / acupuncture

General considerations / rationale

Mange is a result of parasites in both Western and traditional Chinese medicine theory. Both modalities have the same treatment objectives: kill the parasite, decrease discomfort, and prevent secondary infections. It may also be prudent in some patients to improve immune function to allow the patient to clear the parasite.

Appropriate Chinese herbs

For topical application:

Alumen (Ming fan): Has been shown to inhibit bacterial growth, which may help to prevent secondary bacterial infections in lesions caused by scratching.

Cnidium (She chuang zi): Has antibiotic properties. It also decreases itching. In a study involving 607 patients with severe pruritis, it stopped itching in 84% of the participants.

Prickly ash (Hua jiao): Possesses antibacterial and antidermatophyte properties. This may help prevent secondary infections.

Realgar (Xiong huang): Has traditionally been used to kill internal and external parasites by traditional Chinese medicine practitioners. It has been shown to treat pinworms and malaria, which are internal parasites. The efficacy shown against internal parasites suggests that it would also be effective topically against external parasites.

Sulfur (Liu huang): Is commonly used topically in Western medicine for mange, often as a lime sulfur dip. It has been used as a component for the treatment of psoriasis. For immunosuppression:

Angelica root (Dang gui): Increases the phagocytic activity of macrophages.

Astragalus (Huang qi): Stimulates the cellular and humoral immune systems. It contains astragalan, which enhances phagocytic activity of macrophages and antibody synthesis.

Codonopsis (Dang shen): Enhances the immune system by increasing the weight of the spleen and thymus and the total number of white blood cells and lymphocytes.

Dioscorea (Shan yao): Enhances both the cellular and humoral immune systems.

Fleece flower root (He shou wu): Increases the total white cell count, especially the T-cells, and increases the phagocytic activity of macrophages.

Licorice (Gan cao): Can enhance the phagocytic activity of macrophages.

Lotus seed (Lian zi): Was shown to increase the number of T cells in the thymuses in mice, which implies that it may be useful in treating immunosuppression.

Poria (Fu ling): Contains pachman, which increases the phagocytic function of macrophage.

Psoralea (Bu gu zhi): Stimulates the phagocytic actions of macrophages.

Rehmannia (Shu di huang): Increases the phagocytic activity of macrophages.

Schizandra (Wu wei zi): Can prevent cyclophosphamide-induced decrease in the white blood count.

White atractylodes (Bai zhu): Increases the TH cell count and the TH / TS ratio. It increases the phagocytic function of macrophages.

Wolfberry (Gou qi zi): Increases the phagocytic activity of macrophage phagocytic and raises the total T cell count.

Zizyphus (Suan zao ren): Enhances cellular and humoral immunity.

Homotoxicology

General considerations / rationale

A genetic predisposition (Degeneration Phase) is involved with demodectic mange, and affected individuals should not be used for breeding.

Palmquist relies on conventional therapy to treat most of these (lyme dip and Ivermectin in breeds which can tolerate the drug), but in certain cases it may prove helpful to support immune function, detoxification, and repair of tissues injured by homotoxins. Antihomotoxic agents may have a place in therapy in such cases. The authors are unaware of any work reporting single use of homo-toxicology in the management of veterinary mange cases.

Appropriate homotoxicology formulas

BHI-Hair and -Skin: May help repair skin and hair in recovery phase and detoxification, provide support in cases of damage from vaccines, and promote vicariation of chronic diseases.

BHI-Skin: Treats eczema on elbows, scaly scratchy dermatitis, ulcerations, and urticarial reactions.

Coenzytne compositum: Contains cis-Aconitum acidum for pruritus, skin diseases, and psoriasis. Several of the active skin catalysts in Coenzytne compositum are common to Cutis compositum.

Cutis compositum: Provides support of all skin conditions. This is a critical skin remedy, named primarily for Cutis suis, and indicated in allergic reactions, dermatoses, eczema, seborrheic conditions, pemphigus, psoriasis, dermatomycoses, neurodermatitis, and other skin conditions, as well as disturbances of renal excretion. Contains Ichthyolum, which has pustular acne and violent pruritus (facial) as its main indications. Ichthyol ointment serves to soften and clear out abscesses and is a stimulative treatment in inflammations. Sulphur is also a critical component (See Sulphur-Heel). The remedy contains Cortisone in homeopathic dilution, which is indicated for diseases manifested in the connective tissue, such as disorders of the skin, blood, and vascular systems. Fumaricum acidum, Alpha ketoglutaricum, and Natrum oxalaceticum included are for pruritus, skin diseases, and psoriasis. These catalysts are also found in Coenzytne compositum. Funiculus umbicalis suis is indicated for rehabilitation of tissue. This is a connective tissue remedy indicated in almost all chronic diseases. It repairs damage to connective tissue, and is used for psoriasis, skin eruptions, and dermatitis.

Echinacea compositum: Used for secondary infections. Arsenicum is indicated for skin eruptions and other symptoms of a stubborn nature that may border on the phase of Degeneration. It also contains Sulphur (see Sulphur Heel) and Cortisonum acidum (see Cutis compositum).

Engystol N: Is immune supportive in allergic and viral cases, and contains sulfur, which is indicated in chronic issues.

Graphites homaccord: Treats pigmented, greasy lesions without hair.

Hepar compositum: Improves detoxification status by its action on the liver.

Psorinoheel: A phase remedy in Excretion and Impregnation cases. Psorinum is an extract of scabies mange excretions and has been used in classical homeopathy for many years. This also contains Sulfur, which is indicated in chronic conditions (see Sulphur-Heel). May be helpful in so-called constitutional cases.

Schwef-Heel: Works through its higher potency of Sulfur.

Solidago compositum: Used in Deposition phases, this remedy assists the skin by its support of the kidney.

Sulphur-Heel: Primarily named for the contained remedy, Sulphur, known for its use in various skin diseases, especially those of chronic nature, and pruritic eczema and suppurative skin diseases. Sulphur is one of the most important components of tissue in the body. Therefore, Sulphur is the major remedy in practically all cellular phases, particularly in the Impregnation Phase, which still displays a tendency to turn regressive. This also contains Mezereum, which is useful for pruritic skin irritations and skin suppuration, and has several other skin-active remedies as components.

Traumeel S: Treats inflammatory lesions with much inflammation.

Authors’ suggested protocols

Nutrition

Skin and immune support formula: 1 tablet for every 25 pounds of body weight BID.

Lymph support formula: One-half tablet for every 25 pounds of body weight BID.

Betathyme: 1 capsule for every 35 pounds of body weight BID. (maximum 2 capsules BID.)

Lecithin / phosphatidyl choline: One-fourth teaspoon for every 25 pounds of body weight BID.

Eskimo fish oil: One-fourth to 1 teaspoon per meal for cats. 1 teaspoon for every 35 pounds of body weight per meal for dogs.

Oil of evening primrose: 1 capsule for every 25 pounds of body weight SID.

Additional vitamin C: 100 mg for every 25 pounds of body weight BID.

Quercetin: 50 mg for every 10 pounds of body weight SID.

Chinese herbal medicine

To kill the mites, the authors use a combination of sulfur (Liu huang), 30g; realgar (Xiong huang), 15g; Alumen dehydratum (Ming fan), 45g; prickly-ash (Hua jiao), 25g; and Cnidium seed (She chuang zi), 25g. Mix well and apply topically daily for 2 to 3 weeks.

The authors also recommended H7 Immune Stimulator for 6 months in conjunction with Mitaban dips, daily Interceptor, Ivermectin, or herbal parasite dips to counteract immunosuppression. The H7 ImmuneStimulator is dosed at 1 capsule for every 10 to 20 pounds twice daily. In addition to the herbs mentioned above, Immune Stimulator contains euryale (Qian shi), longan fruit (Long yan rou), saussurea (Mu xiang), and white peony (Bai shao). These herbs increase the efficacy of the formula.

Homotoxicology

(Dose: 10 drops PO for 50-pound dog; 5 drops PO small dog or cat)

Psorinoheel and Schwef-Heel: Mixed and given twice daily orally.

Cutis compositum: Given initially, and then as needed.

Autosanguis Therapy:

1. Traumeel

2. Hepar compositum

3. Galium-Heel

4. Cutis Heel

5. Ubichinon compositum

Oral cocktail: Schwef homaccord, Psorinoheel, and Lymphomyosot, plus the remains of autosanguis in a syringe, taken orally BID to TID.

Echinacea compositum forte tabs: Use if needed.

Ivermectin: Give PO daily in breeds that can tolerate the drug.

Nutraceuticals: AFA Algae, GlutaDMG, vitamin E, fatty acids.

Product sources

Nutrition

Skin, immune and lymph support formula: Animal Nutrition Technologies. Alternatives: Immune System Support — Standard Process Veterinary Formulas; Immuno Support — Rx Vitamins for Pets; Immugen — Thorne Veterinary Products; Canine Dermal System Support — Standard Process Veterinary Formulas; Derma Strength — Vetri Science Laboratories.

Betathyme: Best for Your Pet. Alternative: Moducare — Thorne Veterinary Products.

Oil of evening primrose: Jarrow Formulas.

Eskimo fish oil: Tyler Encapsulations.

Lecithin / phosphatidyl choline: Designs for Health.

Quercetin: Source Naturals; Quercetone — Thorne Veterinary Products.

Chinese herbal medicine

Formula: H7 Immune Stimulator Natural Solutions, Inc.

Homotoxicology

BHI / Heel Corporation

Categories
Complementary Medicine

Fungal Infections

Definition and cause

Dermatophytosis is a cutaneous fungal infection caused by Mycosporum canis and other dermatophte fungi. This fungal infection is contagious, and generally the only clinical manifestation is hair loss and a crusted lesion. Other fungi can cause infections, which can also become systemic and can cause disease in other organs, such as the sinus and the lungs.

Medical therapy rationale, drug(s) of choice, and nutritional recommendations

Systemic treatment with Griseofulvin, Ketoconazole, and Itraconazole are often prescribed. While fairly effective, they have potential side effects such as anemia and white blood cell suppression (with Griseofulvin) and hepatopa-thy (with Ketoconazole and Itraconazole). Topical cleaning, clipping the hair, and applying topical agents such as lime sulfur is also effective.

Anticipated prognosis

Most infestations are self limiting and the prognosis is good.

Integrative veterinary therapies

According to the American Academy of Allergy, Asthma and Immunology, sinusitis in humans and fungal infections are on the rise. This indicates that the common treatments, e.g. antifungals, are not getting to the root of the problem, which is not caused by infection, but is actually an immune disorder caused by fungus. Researchers have found that fungal organisms were present in the mucus of 96% of patients who had surgery for chronic sinusitis, and inflammatory cells were clumped around fungi, suggesting an immune disorder caused by fungus.

This is easy to comprehend when we consider that mold spores contain numerous digestive enzymes that directly attack and damage tissue. A healthy immune system should be able to aggressively defend itself against mold spores. Direct damage by fungal spores coupled with environmental toxins is a perfect formula to initiate allergic responses. As this damage progresses we see an excellent example of progressive vicariation, which rapidly can attain the Degeneration Phase and may predispose to Degeneration Phase disease processes (see Homotoxicology, General Considerations).

In the veterinary field, we see an array of fungal conditions, not only in the skin but also systemic forms, and as the body attempts to destroy the fungus, the immune system damages the surrounding tissues. The integrative approach to such fungal infestations, either local or systemic, is to reduce exposure to infectious agents, support immune function, and improve and enhance the elimination of toxins from the body.

Nutrition

General considerations / rationale

The nutritional support used to address fungal infection is usually done in combination with medical therapy, although in this approach, topical medication is preferred. The therapeutic nutritional approach is to help reduce inflammation locally and balance and enhance immune function systemically.

Some approaches to fungal infection involve dietary changes, because high-carbohydrate diets may contribute to fungal overgrowth, and supplementing with a high level of omega-3 fatty acids can improve immune function. Several foods rank high on the list for dietary avoidance, including: corn, which is highly contaminated with fumonisin, aflatoxins, and other fungal toxins (Council for Agricultural Science); wheat and wheat products, because wheat is often contaminated with mycotoxins; barley; cottonseed; sugar cane; sorghum; and sugar beets.

Many disease entities have been linked to fungal overgrowth. To learn more about their sources, read Diseases Caused by Fungi and Their Mycotoxins by Costantini (see Product Sources).

Appropriate nutrients

Nutrition / gland therapy: Glandular therapy support of the skin as well as the immune system organs (adrenals, thymus, and lymph) is indicated (see site, Gland Therapy, for additional information).

Quercetin: Quercetin is in the flavonoids family (see site, Phytonutrients). It functions like an antihistamine and has antioxidant properties. It has been shown to inhibit cells from releasing histamines, so it is beneficial in the treatment of allergic conditions such as dermatitis, eczema, and asthma.

Phosphatidyl choline: This phospholipid is integral to cellular membranes and is an essential nutrient for healthy skin.

Evening primrose oil: evening primrose oil has been proven to have both antiinflammatory and antipruritic effects and, as part of a balanced nutritional program, can exert a positive effect on animals with skin disease. Studies suggest that evening primrose oil is beneficial in people with atopic dermatitis and eczema.

Chinese herbal medicine / acupuncture

General considerations / rationale

Fungal infections are a result of Wind, Heat, and Damp invading the body. Wind blows the pathogen into the body. Heat and Damp refer to the inflammation and moist skin lesions, respectively. Treatment is aimed at eliminating the pathogen, clearing inflammation, and preventing secondary bacterial infections.

Appropriate Chinese herbs

Anemarrhena rhizome (Zhi mu): Has demonstrated inhibitory effects against some dermatophytes and some bacteria, including Staphylococcus aureus. This herb can attack the primary pathogen while simultaneously preventing secondary bacterial infections.

Angelica root (Dang gui): An immunostimulant that may help the patient eliminate the infection.

Arctium (Niu bang zi): Inhibits bacteria, including Staphylococcus aureus and beta streptococcus, and various fungi (Group of Internal Medicine, Group of Virology).

Atractylodes rhizome (Cang zhu): Inhibits Staphylococcus aureus and some dermatophytes. It can decrease xylene-induced ear swelling and carrageenin-induced foot swelling. It may decrease the inflammation associated with fungal infections.

Gypsum (Shi gao): Has dual activities of decreasing inflammation and stimulating immunity. It increases the phagocytic activity of macrophages. At the same time it decreases inflammation. In 1 trial 126 human patients with various inflammatory disease processes were treated with gypsum. Most showed improvement.

Licorice (Gan cao): Can inhibit Staphylococcus aureus.

Rehmannia (Sheng di huang): Reduces swelling and inflammation.

Schizonepeta stem (Jing jie hui): Decreases acute and chronic inflammation.

Siler (Fangfeng): Inhibits Staphylococcus aureus.

Sophora root (Shan dao gen): Increases IgM and IgG levels. It also has antibiotic activity.

Homotoxicology

General considerations / rationale

Fungal infections may occur if an overwhelming amount of infectious fungal agent gains access to the body. Simple dermatophytosis is a Reaction Phase disorder, while chronic, recurrent, or refractory cases indicate more serious systemic involvement.

Immune suppression by a wide variety of causes predisposes to fungal infection as does residing in a contaminated area. Systemic mycoses involve both of these factors. Many fungal infections occur following compromise of the greater defense system and are more common in Deposition, Impregnation, Degeneration, and Dedifferen-tiation phases. Yeast infections are commonly associated with allergic disorders, wherein homotoxins accumulate and alter the connective tissue’s responses.

Homotoxicology agents are viewed as additional therapy in these cases, because antifungal drugs are both important and useful in treating systemic and topical forms. However, the clinician must remember that these drugs are homotoxins and can cause further damage to the body, particularly the liver and kidney. No cases of successful use of antihomotoxic therapy could be found in the veterinary literature at this time, but one case of feline cryptococcal encephalitis was treated successfully using an integrative approach by the author.

Appropriate homotoxicology formulas

The best known of the classical homeopathic remedies for fungal infection / dermatophytosis are: Sepia for brown, scaly patches; Tellurium for prominent, well-defined, reddish sores; Graphites for thick scales or heavy discharge; and Sulphur for excessive itching.

BHI-Allergy: A remedy that contains Arnica for itching, burning skin, and a host of other remedies for skin irritations and eruptions. It also contains, most notably, Tellurium metallicum, which is mentioned in classical repertories. Marked skin (Herpes circinatus) is another indication for this remedy, as is a very sensitive back, itching of hands and feet, herpetic spots, ringworm (Tuberc), ringshape lesions, offensive odors from affected parts, and circular patches of eczema. Lesions tend to be equally distributed on either side of the body. Also recommended for Pityriasis versicolor and eruptions — herpetic. BHI-Allergy also contains Graphites (see Graphites homaccord) and Sulphur (see Sulphur heel and Engystol N).

BHI-Skin: A good support remedy that includes Rhus Toxicodendron (also in Aesculus compositum, Arnica-Heel, Echinacea compositum, BHI-Inflammation, BHI-Skin, et. al.) Rhus toxicodendron (poison ivy) contains rhoitannic acid. A component of the sap, urushiol, is a strong skin irritant. It has been recommended for violent itching, and possibly for an eruption like measles all over the body, a vesicular eruption (herpes), a crusty eruption on the head, and eruptions of a vesicular nature, particularly when the eruptions are bluish-grey in color. It is one of the main remedies for Herpes zoster. However, Rhus toxicodendron is also valuable in chronic skin diseases, especially in eczema with vesicle formation. It is also a main remedy for facial and frontal impetigo if there is violent itching. This remedy also contains Graphites (see Graphites homaccord) and sulphur (see Sulphur-Heel and Engystol N).

Coenzytne compositum: Provides metabolic support and repair of damage to mitochondria by therapeutic agents.

Cutis compositum: Provides support and drainage of the skin and associated adnexa. This remedy is of huge value in skin disorders, as one might expect from the name. It contains Cutis suis, for which the principal indications are: allergic reactions, dermatoses, eczema, seborrhea, dermatomycoses, neurodermatitis, and other chronic problems. It also has Hepar suis (found in Hepar compositum, Syzygium compositum, Thyre-oidea compositum, Tonsilla compositum, etc.) for chronic eczemas, neurodermatitis, psoriasis, erythemas, dermatomycoses, and eruptions that are papular or in blotches which itch and that appear on the head, face, back, female genitalia, or extremities. It also contains Sulphur (see Sulphur Heel) and Graphites (see Graphites Homaccord). The ingredient Thuja can also be of value in chronic skin conditions. The oil from the red cedar, from which Thuja is taken, is known as an antifungal agent.

Echinacea compositum: Provides immune support in Reaction and Impregnation phases.

Galium-Heel: Contains Aurum metallicum, which has been used successfully in a case of Feline Aspergillosis (Hoare).

Graphites homaccord: Used to treat dry, crusty or weepy patches of pigmented dermatitis. Graphites (also found in BHI-Allergy, BHI-Skin, Cutis compositum, Placenta compositum, Thyroidea compositum, Tonsilla compositum, etc.) shares indications with Carbo vegetabilis and other antipsorics, particularly Sulphur. There is a tendency toward the formation of cracks, and to various skin diseases, proceeding with crusty eruptions and the discharge of a sticky, honey-like fluid, which hardens into scabs. These are often localized in the folds and creases of the skin. Itching is aggravated by heat. There may be general loss of hair, which is hard and brittle, and alopecia areata, and possibly chronic ear discharge smelling like herring-brine.

Graphites, as a constituent, is also a remedy indicated for eczema capitis, fissures in general, intertrigo and fungal infections of the nails, and psoriasis on fingertips, nipples, corners of the mouth, and between the toes. Another important constituent, Sepia (in BHI-Skin and others) is one of the most frequently needed homeopathic remedies, and is mainly used for chronic diseases and dyscrasias (i.e., both cellular and also chronic humoral phases such as chronic eczemas and chronic discharges such as leucorrhoea). Worthy of particular note are the skin symptoms of Sepia, namely soreness and itching, which is frequently transformed into burning as a result of scratching (cf. Sulphur), with localization in the creases of the knees. These patients may show large, suppurating pustules, which repeatedly relapse; brown patches on the face, chest, and abdomen; and vesicles and scabies-like conditions, particularly if Sulphur has not completed the cure. The skin symptoms may express in the form of pustules, eczema, neurodermitis, herpes, yellowish-brown scaly patches, or sloughing of the epidermis in round patches on the hands and fingers, possibly associated with painless ulcers. Chronic dermatophytosis is another condition that may respond to this remedy.

Lymphomyosot: Used in lymph draining and in eczema.

Psorinoheel: A phase remedy in Excretion Phase disorders and in chronic, constitutional cases. One of the most useful components is Bacillinum, which is used in eczema and impetigo and is indicated in alopecia. It is useful for Pityriasis versicolor and other skin disorders, as well as general weakness and debilitation. The ingredient Bufo has been used for purulent blisters (pemphigus) on the skin and mucosa, and for paronychia and glandular and dermal inflammations accompanied by a tendency toward suppuration.

Psorinum nosode (also in Tonsilla compositum (was introduced into the homeopathic Materia Medica by Hering in 1833-34, and was the first nosode to be so included. It is said to be useful in chronic and acute eczemas with violent itching, especially at night, that is relieved by scratching until it bleeds. Other skin dyscrasias also respond well to intercurrent doses of Psorinum. According to some popular materia medicas, there is a wide variety of relationships with well-known polychrests, such as: Arsenicum album (complaints and restlessness at night, fear of death, desquamating skin eruptions); Petroleum (dry skin with cracks and oozing eruptions); and Sulphur, which is the most closely related remedy regarding discharges, burning of the skin, eruptions, vicarious conditions, and general chronicity. Thus, it is appropriately used in chronic eczema, impetigo, all kinds of skin eruptions, asthma alternating with eczema, psoriasis, boils, acne, seborrhoea, etc. Also contains Sulphur (see Sulphur-Heel, Engystol N, and Scbwef-Heel).

Schwef-Heel A Sulphur-containing remedy for red, itchy skin. It is used as a catalyst, and is given intermittently in skin conditions. This is a homaccord of Sulphur, which has deeper reaching potencies than other antihomotoxic formulas.

Sulphur-Heel: Named for Sulphur, one of the most important single remedies in homeopathy. This is easily appreciated when one discovers the number of antihomotoxic agents that contain it, such as Causticum compositum, Cutis compositum, Echinacea compositum, Engystol, Ginseng compositum, Hepar compositum, Mucosa compositum, Psorinobeel, Pulsatilla compositum, Scbwef-Heel, Tbyreoidea compositum, Tonsilla compositum, BHI-Allergy, BHI-Enzyme, BHI-Skin, and many others.

Typical of Sulphur indications in Impregnation phases is the affection of the skin, which itches and then burns after being scratched. The body is trying to eliminate intermediate homotoxins, particularly histamine, via the skin, causing a wide variety of discharges, which are excoriating and cause reddening of the orifices and an offensive body odor. Sulphur should be given intercur-rently, e.g. as an intravenous injection, in cases that do not respond to well-indicated biotherapeutic or antihomotoxic remedies. This should be done regardless of the system, e.g. chronic heart disease; skin diseases such as lichen planus, acne vulgaris, eczema, neurodermitis, and dermatoses; and liver disease..

This combination also contains a variety of remedies that are useful in itchy, eczematous, eruptive skin lesions, such as Caladium, Pix liquida, Mezereum, Arsenicum, and others.

Tonsilla compositum: Provides immune support in Impregnation, Degeneration, and Dedifferentiation phases. It contains Conium (also in Ginseng compositum, Testis compositum, Thyroidea compositum, Ubichinon compositum, and others), which is used for glandular swellings and induration, prickling and stinging, and conditions that are stonyhard to the touch. Tonsilla compositum also contains the aforementioned Graphites, Hepar suis, Psorinum, and Sulphur. Funiculus umbicalis suis is included for regeneration of damaged tissues.

Traumeel S: Used as a phase remedy and in cases of regulation rigidity.

Authors’ suggested protocols

Nutrition

Skin and immune support formulas: 1 tablet for every 25 pounds of body weight BID.

Lymph support formula: One-half tablet for every 25 pounds of body weight BID.

Quercetin: 50 mg for every 10 pounds of body weight SID.

Lecithin / phosphatidyl choline: One-fourth teaspoon for every 25 pounds of body weight BID.

Oil of evening primrose: 1 capsule for every 25 pounds of body weight SID.

Chinese herbal medicine / acupuncture

The patent formula is Xiao Feng San. It contains 3 g each of angelica root (Dang gui), rehmannia (Sheng di huang), siler (Fang feng), cicada (Chan tui), anemarrhena rhizome (Zhi mu), sophora root (Shan dao gen), sesame seeds (Hei zhi ma), schizonepeta stem (Jing jie hui), atractyloides rhizome (Cang zhu), arctium (Niu bang zi), and gypsum (Shi gao), and 1.5 g of licorice (Gan cao) (Handbook of traditional Chinese medicine Practitioners). It is dosed according to the supplier’s recommendations.

Homotoxicology

(Dose: 10 drops PO for 50-pound dog; 5 drops PO small dog or cat)

Graphites homaccord, Psorinoheel, Cutis compositum autosanguis: Give every 2 to 4 weeks, as needed.

Echinacea compositum: Give every 3 days orally.

Hepeel compositum: Give every 3 days.

Coenzyme compositum and Ubichinon compositum: Give on alternate days.

Detox Kit and Galium-Heel: Give daily BID PO for 30 days, possibly with the aforementioned autosanguis mixed in.

Echinacea comp forte, Traumeel plus Mucosa compositum and Chelidonium homaccord (for intestinal mycosis): Injected e.o.d., preferably as an autosanguis. European practitioners have reported good results from this combination.

Product sources

Nutrition

Skin, immune, and lymph support formulas: Animal Nutrition Technologies. Alternatives: Immune System Support — Standard Process Veterinary Formulas; Immuno Support — Rx Vitamins for Pets; Immugen — Thorne Veterinary Products; Derma Strength — Vetri Science Laboratories; Canine Dermal Support — Standard Process Veterinary Formulas.

Quercetin: Source Naturals; Quercetone — Thorne Veterinary Products.

Lecithin / phosphatidyl choline: Designs for Health.

Oil of evening primrose: Jarrow Formulas.

Chinese herbal medicine

Patent formula: Xiao Feng San — Mayway.

Homotoxicology

BHI / Heel Corporation