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Feline atopic dermatitis demystified
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The atopic cat can be frustrating to diagnose and treat, but in this paper Jennifer Schissler demystifies some of the issues surrounding the condition.
Jennifer Schissler
DVM, MS, Dip. ACVD
Dr. Schissler graduated from the CSU professional veterinary program in 2005 and went on to complete a combined master’s degree and dermatology residency at The Ohio State University. A Diplomate of the American College of Veterinary Dermatology, she joined the CSU faculty in 2011 with a clinical, teaching and research appointment. Her interests include otology, infection control, multidrug resistant staphylococci, and Ehlers-Danlos syndrome.
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Key points
- Atopic dermatitis is a diagnosis of exclusion in cats, and a stepwise approach is essential to reach an accurate diagnosis.
- Pruritic behavior may or may not be apparent, but recognition of characteristic lesions can help direct the clinician towards the appropriate diagnostic steps.
- Pruritus relief with consideration for acute and chronic treatment phases is essential; aim to minimize or eliminate glucocorticoids in the chronic phase.
- Client communication is paramount for success, and owners must be aware that atopic dermatitis is managed lifelong and not cured.
Introduction
Feline atopic dermatitis is an inflammatory, almost invariably pruritic condition with characteristic clinical presentations. Compared to canine atopy, the clinical presentation can be quite different, and less is known about the etiopathogenesis, although – as with dogs – it is a hypersensitivity reaction to certain environmental allergens including pollen, house dust mite and mold. Unlike atopic dermatitis in people and dogs, it is unclear if IgE plays an essential role in the pathogenesis of the condition in the cat, therefore recent publications have advocated for and used the phrase “feline non-flea, non-food hypersensitivity dermatitis” 1. The nomenclature used to describe feline cutaneous allergy is evolving and is not universally accepted; commonly used historic terms include “feline atopy”, “feline atopic syndrome”, “feline atopic-like dermatitis”, and “feline atopic dermatitis”. For the sake of consistency, the latter term is used in this article, given its general historical familiarity to readers, and because this condition is the practical clinical counterpart of canine atopic dermatitis.
Diagnosis
Atopic dermatitis is a diagnosis of exclusion. Cutaneous adverse food reactions and flea bite hypersensitivity present with identical clinical signs and may be comorbid with feline atopic dermatitis. Additionally, secondary Staphylococcus and Malassezia infections can increase dermatitis and pruritus severity. Consideration for and exclusion of infections and infestations, as well as an elimination diet trial in non-seasonal presentations, will prevent unnecessary chronic immunomodulation. A stepwise approach is therefore essential for an accurate and efficient diagnosis, and the following points should be considered in a patient with clinical signs and a history consistent with feline atopic dermatitis:
- Assess for and treat any known or suspected infestations, and ensure compliance with flea control recommendations.
- Assess for and treat infections, and assure cytologic resolution of infection.
- Conduct an elimination diet trial if the patient has non-seasonal signs.
Feline atopic dermatitis will not respond completely to these measures. Although histopathology of feline cutaneous hypersensitivities does not discriminate between flea bite hypersensitivity, cutaneous adverse food reaction or atopic dermatitis, biopsies can support the diagnosis of hypersensitivity in ambiguous presentations. Consider referral of patients with equivocal or incompatible historical features, clinical findings, or lack of therapeutic response to a veterinary dermatologist.
Note that anti-pruritic medications during treatment trials will enhance patient quality of life and owner compliance, but strategic discontinuation of anti-pruritic medication is necessary to assess for response to diagnostic trials.
Clinical signs and diagnosis
Feline atopy manifests a diverse array of characteristic lesions, body distributions, and differential diagnoses. These presentations may occur in isolation or in combination. Some cats present for aggressive hair pulling, scratching and excoriations, whilst pruritic behaviors in other cases may occur in secret, with the patient presenting for progressive, grossly non-inflammatory, symmetric alopecia.
There are four recognized feline cutaneous hypersensitivity clinical patterns: eosinophilic granuloma complex lesions, miliary dermatitis, head and neck excoriation, and symmetric alopecia.
Eosinophilic granuloma complex
Lesions include indolent ulcer (rodent ulcer), eosinophilic plaque, and eosinophilic granuloma (linear or collagenolytic granulomas). Indolent ulcers present unilaterally or bilaterally on the upper lip as eroded plaques (Figure 1) and can progress, distorting the upper lip via overall surface ablation and dermal expansion. Eosinophilic plaques present as multiple or singular raised, well-circumscribed erythematous and moist erosions, and are commonly located on the abdomen (Figure 2). [...]
![Figure 1. A cat with an indolent ulcer in partial remission; erosions remain on the upper left lip and tissue loss of the upper lip is permanent. © Jennifer Schissler](/sites/default/files/images/media/image/vf-311-article-2-figure-1-eng.png)
Figure 1. A cat with an indolent ulcer in partial remission; erosions remain on the upper left lip and tissue loss of the upper lip is permanent. © Jennifer Schissler
![Figure 2. Multifocal moist, erythematous plaques on the inguinal area and inner thigh. © Jennifer R. Schissler](/sites/default/files/images/media/image/vf-311-article-2-figure-2-eng.png)
Figure 2. Multifocal moist, erythematous plaques on the inguinal area and inner thigh. © Jennifer R. Schissler
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