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Therapeutic options for the pruritic cat
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The clinician presented with an itchy cat has fewer options than when dealing with a pruritic dog – or is that true? Jay Korbelik offers some ideas backed by clinical studies.
Jay Korbelik
BVSc, MSc, Dip. ACVD
Originally from Canada, Dr. Korbelik graduated with honors from the University of Queensland in 2008 and then returned home to complete a Small Animal Rotating Internship at Saskatoon’s Western College of Veterinary Medicine. In 2015 he decided to pursue his passion for dermatology and completed a Residency at Yu of Guelph Veterinary Dermatology, concurrently achieving a Master of Science in Pathobiology at the University of Guelph. He now resides in Vancouver, where he practices at a private dermatology clinic.
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Key points
- Feline atopic dermatitis is currently diagnosed based upon a compatible history and clinical presentation, with exclusion of other pruritic dermatoses.
- The pruritic cat will present with various signs, including head and/or neck excoriations, symmetrical self-induced alopecia, miliary dermatitis, or eosinophilic granulomas complex lesions.
- Treatment options available for feline atopic dermatitis are limited when compared to dogs, and may involve off-license drugs.
- No single treatment is effective in controlling signs of feline atopic dermatitis in all cases, and a multi-modal approach is often necessary.
Introduction
Pruritic disorders in cats are often attributed to hypersensitivity dermatides (HD) including flea bite hypersensitivity (FBH), food-induced hypersensitivity dermatitis (FIHD) and atopic dermatitis (AD) 1. Use of the term feline AD remains debatable because the clinical presentation, histologic features and role of IgE differ significantly to that of human and canine atopy 1 2. The significance of IgE in the pathogenesis of this condition has not been firmly established, and there are currently very few studies that have investigated the role of IgE in feline AD 3. The term non-flea, non-food induced hypersensitivity dermatitis (NFNFIHD) is sometimes used to refer to this condition. Feline AD is suggested to be the second most common HD in cats 4; one study reported a prevalence of 12.5% of all feline dermatoses 2, and also found that Abyssinian, Devon Rex and domestic breed cats were over-represented. Clinical signs typically start manifesting in young cats (under 3 years of age) 5 although one study did find that 22% of cats with feline AD were over 7 years of age 2. This study also found that 93% of cats with feline AD were perceived as being pruritic by their owners, and importantly, trichogram analysis in the remaining 7% confirmed broken hairs consistent with pruritic behavior. The majority of cats (80%) in this study had non-seasonal signs.
Cats with HD will present with one or more of the following patterns: head and/or neck excoriations (Figure 1), symmetrical self-induced alopecia, miliary dermatitis, or eosinophilic granulomas complex lesions (Figures 2 and 3) 1 2. Other presentations, including pododermatitis, facial erythema, seborrheic disorders or ceruminous otitis have also been reported 3 5. It is impossible to distinguish between the different causes of HD based on clinical presentation; although one study found that cats with FIHD were more likely to present with lesions on the head and neck, and cats with FBH were more likely to present with lesions on the dorsal aspect of the body (rump and tail) 1, this finding was not considered statistically significant. Figure 4 shows the most commonly affected sites of HD with the different causes.
Feline AD is currently diagnosed based upon a compatible history and clinical presentation, along with exclusion of other pruritic dermatoses 5. It is especially important for the clinician to rule out FBH with appropriate ectoparasite treatment and, for cats exhibiting non-seasonal signs, a restricted diet trial (for typically 8 weeks) to rule out FIHD 5. Diagnosing and treating feline AD can be challenging and frustrating for even the most seasoned clinician for several reasons:
- There are currently no widely established clinical diagnostic criteria for feline AD as there are in dogs 6.
- Treatment options available for feline AD are limited.
- It can be notoriously difficult to administer oral medication to cats 5.
This article will discuss some of the pharmaceutical treatment options used to control pruritus caused by AD in feline patients.
![Figure 1. Head and neck excoriations in a cat with AD. © Dr. Vincent Defalque, North West Veterinary Dermatology Services Ltd.](/sites/default/files/images/media/image/Schermafbeelding%202021-05-29%20om%2022.23.29_0.png)
Figure 1. Head and neck excoriations in a cat with AD. © Dr. Vincent Defalque, North West Veterinary Dermatology Services Ltd.
![Figure 2. A cat with indolent ulcers on the upper lips, a common presentation of lesions associated with the eosinophilic granuloma complex. © Dr. Jay Korbelic](/sites/default/files/images/media/image/Schermafbeelding%202021-05-29%20om%2022.23.41.png)
Figure 2. A cat with indolent ulcers on the upper lips, a common presentation of lesions associated with the eosinophilic granuloma complex. © Dr. Jay Korbelic
![Figure 3. Eosinophilic plaques in a cat, another common presentation of lesions associated with the eosinophilic granuloma complex. © Dr. Tyler Udengerg, North West Veterinary Dermatology Services Ltd.](/sites/default/files/images/media/image/Schermafbeelding%202021-05-29%20om%2022.24.38.png)
Figure 3. Eosinophilic plaques in a cat, another common presentation of lesions associated with the eosinophilic granuloma complex. © Dr. Tyler Udengerg, North West Veterinary Dermatology Services Ltd.
![Figure 4. Silhouettes depicting the proportion of distribution of lesions in cats with hypersensitivity dermatides. Reprinted from 1. © Veterinary Dermatology/Redrawn by Sandrine Fontègne](/sites/default/files/images/media/image/Schermafbeelding%202021-05-29%20om%2022.25.21.png)
Figure 4. Silhouettes depicting the proportion of distribution of lesions in cats with hypersensitivity dermatides. Reprinted from 1. © Veterinary Dermatology/Redrawn by Sandrine Fontègne
Corticosteroids
Corticosteroids have long been the mainstay of treatment for feline AD, and are frequently used as cats appear to be generally more resistant to the adverse effects of this class of drugs than dogs 5. Although feline AD has been reported as typically corticosteroid responsive 5, one study found that a good response to systemic corticosteroids was only reported in 55% of cats, although the type, dosage and duration of therapy were not evaluated 2. No studies have examined the most effective way to taper corticosteroids, but an induction dosage is generally employed for the first week and then tapered at 1-2 week intervals, with the aim of attaining the lowest every other day dosage that maintains remission and minimizes side effects 7. In cats, prednisolone is recommended over prednisone due to significantly higher bioavailability (100% vs. 21% respectively) 8. One study showed that methylprednisolone (1.41 mg/kg q24H) or triamcinolone (0.18 mg/kg q24H) were effective at inducing remission of pruritus in 90.6% of allergic cats within 7-14 days, while prednisolone (1 mg/kg q24H) only achieved remission in 45.5% of cats after 28 days 7. This study also indicated that 0.54 mg⁄kg q48H of methylprednisolone or 0.08 mg⁄ kg q48H of triamcinolone were effective at maintaining remission in these cats.
Adverse effects of corticosteroid treatment can include marked cutaneous atrophy, congestive heart failure, iatrogenic hyperadrenocorticism and increased risk of diabetes mellitus, among others 9. A preliminary study suggested that dexamethasone exhibited a greater diabetogenic effects in cats than the equivalent dose of prednisolone 10.
For patients that require long-term maintenance therapy, injectable glucocorticoids (e.g., methylprednisolone acetate) are usually not recommended, as oral administration is more precise and is associated with a lower risk for side effects 9. Additionally, a poorly understood but well recognized phenomenon called steroid tachyphylaxis (i.e., resistance) can occur when the drug is administered long-term, and in these cases changing the type of corticosteroid administered can often result in better clinical response 9. Topical corticosteroids, including mometasone furoate and hydrocortisone aceponate, are reported to provide good control of pruritus in some cats, or can be used to reduce the need for systemic corticosteroids 2 9. [...]
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