Steroids are commonly used medications for a wide variety of diseases, including allergic skin disease. In this episode, Dr. Curtis Plowgian discusses the benefits and risks of steroids in the treatment of allergic cats and dogs.
Introduction
[00:01:06] Welcome everybody to today’s episode of Your Vet Wants You to Know. I am very excited, I have a special guest with me today, Dr. Curtis Plowgian. Dr. Plowgian is a board certified veterinary dermatology specialist. He went to veterinary school at Virginia tech and then did a dermatology internship in Philadelphia with Dr. Ian Spiegel. He also did his veterinary dermatology residency with Animal Dermatology Clinic. He is the first dermatology resident to complete a residency in three different states, starting off in California, then going to the Animal Dermatology Clinic in Georgia, and then finally landing in Indianapolis. At one point he spoke fluent French, and he almost did his dermatology residency at the University of Montreal, but we are very lucky to have him here in the States to help us out with these dermatology patients. So, Dr. Plowgian, welcome, and thank you very much for joining us on the show today. Thanks for having me. It’s great to be here.
[00:02:05] For our listeners, if they have listened to the episode on environmental allergies, they should be familiar with my dog, Russell Sprout. He is that funny looking terrier who is the mascot for Your Vet Wants You to Know. Russell was very young when I acquired him and when he was very young, we were first dealing with his allergies, he had several short courses of steroids to help to treat his itch. They worked really great for controlling the itch, but whenever he was on steroids, we had lots of accidents in the house because the steroids made him have to pee all the time. So for pet owners listening to today’s episode, whose pets have been prescribed steroids for treatments of their allergies, what do you think are the most important things that we should know and that we’re going to cover in today’s episode?
[00:02:51] Steroids are an issue that are kind of near and dear to my heart. I went and I spoke back at Virginia Tech for our five-year vet school reunion. I feel like since coming out of school and in working in a referral practice, I’ve encountered so many different owner responses and vet responses to steroids. There are owners who are completely terrified of steroids. There are new vets who are completely terrified of steroids, and there are kind of old school, cowboy vets who just want everything to have steroids. Even at my vet school, there were large animal vets who were like, “Don’t let anything die without steroids.” My goal is to kind of bring a little more of the nuance out in that we don’t have to never use any steroids, but we want to use steroids appropriately.
[00:03:40] So when we go over the goals of what we want to talk about today, we’re going to talk about a couple of things. We’re going to talk about when steroids are indicated, and there definitely are diseases that steroids are the right drug for them. There are also a lot of risks to steroids and so we’re going to talk about the benefits versus the risks of steroids and when we should use them, when we shouldn’t, when we should reach for something else and how, when we use steroids, we can use them as safely as possible, including monitoring and appropriate dosing.
Why your veterinarian might use steroids
[00:04:17] Great. That sounds like pet owners will get a lot of good information from what we have to say about steroids. So what are the main reasons why a family veterinarian might prescribe steroids for a pet that has allergies?
[00:04:29] Well there are several reasons that a vet might use them. In my case, if you come to see me as a dermatologist, I’m focused on allergic diseases that have a lot of inflammation or body parts that are very inflamed with allergies. So in particular, ears are number one. You see a dog who’s allergic, whose ears are swollen shut, and nothing is going to open those ears back up except for steroids. Another disease that as I’ve been out in practice, I find to be similar to the ears would be paws. You get dogs with interdigital furunculosis or what other people might call interdigital cysts. They’re these big, swollen, bags of tissue between the toes that are red and puffy. When you’ve got that degree of inflammation, none of the other allergy drugs that we use touches that. So those are definitely appropriate uses for dogs with allergies.
Images show swollen paws and ears in allergic dogs that would benefit from the anti-inflammatory effects of steroids.
[00:05:26] There are other reasons that your family vet may use steroids. Certainly in cases of financial limitations, steroids are by far the cheapest allergy drug we have, so they can be a money saver. But we have to be careful with that, because, for reasons that we’ll talk about, with some of the risks that steroids can pose, it may be penny wise, pound foolish. We don’t want to use the cheapest drug just to cause more problems down the road.
[00:05:57] I think a lot of pet owners that have pets with allergies, they think of their pet as itchy because of its allergies. We as dermatologists and family veterinarians as well, see a lot of inflammation or swelling in those pets. Definitely ears and paws, they can be really, really swollen in response to the animal’s allergy. So the ears, like you said, can be swollen shut, and those paws can be so inflamed that the pet doesn’t want to walk on them. I truly think that those are severe quality of life issues and situations where I’m going to recommend that steroids be used to provide rapid relief from that swelling while also helping to decrease the itch and make the animal more comfortable while we’re treating its allergies.
Shotgun Therapy
[00:06:43] We talk about inflammation and itch, but what do you think are some of the main benefits to using steroids? Why might they be a better therapy in certain situations than other allergy medications? So this relates a little back to what we were talking about, inflammation. That’s for me the first indication, if I’m seeing an allergy patient, that I’m going to reach for steroids. They do more for inflammation than any other drug. If I have a flea allergic dog, who’s just ripping themselves to shreds and they’re 10 out of 10 itchy, or a scabies dog, I think that steroids are a great put out the fire drug. So it’s not something that we want to stay on forever, but if we have not only an itchy, but a very inflamed dog and we need to just kind of knock everything back and reset the system a little bit. I tell my owners that steroids are shotgun therapy for allergies. They do the most of any drugs we use, but they also do the most collateral damage. So sometimes that’s appropriate. You know, when I use them, I think of them as like shock troops in the army. You want to get in and get out. Sometimes you have itch or inflammation that you just need to knock down quickly. In those cases steroids may be the most appropriate.
[00:08:12] I really like that shotgun therapy analogy steroids, for sure. Get the job done. If swelling and inflammation is the target, steroids are my weapon of choice to hit that target quickly. There are a lot of other allergy medications that we’ve talked about on other episodes that may be more targeted and excellent for providing itch relief. When it comes to swelling with allergies, nothing opens up an ear canal quickly quite light steroids do. Like you mentioned before, they’re also really inexpensive. For those pet owners that might not have the budget for some of the newer, safer allergy medications, steroids might be their only option. For those pet owners whose pets are on steroids for longterm management of allergies, it’s important to remember though, that blood work monitoring is recommended for patients that are receiving long-term steroids. Pet owners should factor in the cost of frequent blood work so that they can safely assess if the animal is tolerating those steroids. So they may be a cheaper medication, but the monitoring of that medication and the potential side effects may make it more costly long-term and that’s definitely one of the drawbacks that we see.
Drawbacks
[00:09:24] So what are some of the side effects that pet owners might be noticing or should be aware of when their pet is receiving steroids? What potential risks do they need to be aware of? This depends a little bit on how long and what dose you’re using. In general, what I say is, if you name a body system, there’s a steroid side effect for it. The classic side effects that almost every vet will warn their owners about, and that most people may have heard about are going to be your big three: increased appetite, increased thirst, increased urination. Some less common ones, but that we see in the short run, will be aggression or behavioral changes. Sometimes dogs are so hungry on steroids, you see them getting into the garbage or counter surfing, really going after food more aggressively than they ever have. That can cause conflicts with owners in the long run.
[00:10:21] If pets are put on steroids for a chronic disease, say allergies or an autoimmune disease, the number of side effects just grows and grows. We do blood work monitoring when we have pets on chronic steroids, because steroids can affect the liver and the kidneys. They can elevate blood pressure, which is a contraindication with some heart diseases. They can cause hair loss, thinning of the skin, muscle wasting, joint laxity, a disease called calcinosis cutis, which are calcium deposits that build up in the skin. I actually see a decent amount of pets that are referred to me because they’d been on chronic steroids for other things and it just blows up their skin. They lost half their hair. They have thickened plaques of minerals and calcium in their skin. They’re blowing up with infections and there are many, many different side effects we see with steroids. For all those reasons, that’s why many vets or many owners are afraid to use them, but we can often mitigate or avoid some of those if we’re using steroids responsibly.
[00:11:32] I think that goes back to your shotgun therapy analogy. The steroids will hit the inflammation and the swelling that we wanted to get, but they’re going to hit everything else in the process. A lot of those clinical signs of Cushing’s disease, which I talk about in another episode will be seen in pets receiving steroids long-term, so I totally agree. Short term, I expect to see that pet have an increased in thirst, urination and hunger. That’s something that the pet owner will notice for sure. Dogs can sometimes pant excessively and become really anxious. I mean, those steroids just make them high strung. Longer-term, I do worry about changes to their liver. So that’s where that blood work monitoring that I talked about before comes in handy to see if the liver enzymes are elevated. I agree with the infections, a lot of infections are going to pop up because steroids are suppressing the immune system. So while that works really good for treating allergies, because an allergic reaction is an overreaction of the immune system, if you suppress that immune system too much, then they can’t fight off normal infection. We’ll see things like demodex mites, or bacterial skin, ear, or urinary tract infections. I’ve got some really great pictures of the skin changes that you talked about that we can see with the chronic use of either topical steroids or oral steroids on the website, in the show notes for today’s episode. If you want to see pictures of those big calcinosis cutis, the big calcium plaques that Dr. Plowgian was talking about, those are on the website for you to get an idea of just how severely these animals can be affected with long-term steroid use. We can certainly see muscle wasting and the development of that potbelly appearance, ligament weakness can lead to orthopedic injuries, increased blood pressure, and heart failure.
[00:13:29] I would say my biggest concern by far is the development of diabetes, particularly in cats that are overweight. I try to explain to owners of cats with allergies that if the only way we manage the allergies is with steroids, it’s not a matter of if the cat is going to develop diabetes, it’s a matter of when. So really working on trying to find other ways to keep the animal comfortable while minimizing the amount of steroids they’re getting is going to be the safest long-term solution for these pets.
Images of three different dogs with side effects from chronic steroid use, including mineral (calcium) deposits, called calcinosis cutis, severely thinned skin to the point of tearing, and secondary bacterial infections. Images courtesy of Dr. Brittany Lancellotti and Dr. Matt Levinson.
Minimizing risk
[00:14:00] So let’s talk a little bit about minimizing risk. How can pet owners of allergic animals receiving steroids minimize the risks. This is an important one because we see lots of animals where steroids sometimes are the only option for them. There are ones sometimes due to finances. In the case of cats, there just aren’t as many drugs. There are really only two drugs labeled for allergies in cats, steroids and cyclosporine, the brand name Atopica. So if a cat won’t tolerate Atopica, or if they are not a safe candidate, outdoor cats are generally not safe candidates for that drug, then sometimes steroids are the only option that we have for them. There are some dogs that I have at least a handful in my practice who steroids are either the only drug that the owner could afford long-term or that they’ve tried every other drug and, of our big four, steroids were the ones that just happened to work the best.
[00:15:04] So if we’re going to put ourselves in that situation and we’ve got to use them long-term, the number one priority that I have is to get down to at least every other day dosing. With some steroids we’re even able to get down to twice a week. Some cats I’ve even been able to get down to once a week dosing of oral steroids. At some of the recent national conferences of dermatology, it’s been shown days between doses of steroids really allow the body some time to recover and minimize all of those different side effects that we talk about. Every cell, every tissue in the body has steroid receptors. And if we just keep hitting those every single day, we’re really driving up our risk of side effects. If we are able to get dogs or cats down to every other day dosing or ideally less than twice a week or once a week dosing, I’ve really seen in my patients that has quite a reduction of the side effects that we see. I’ve seen liver values get better. I have a mentor who even told me he has resolved a case of calcinosis cutis, those calcium deposits in the skin, just by taking a dog from daily steroids to every other day. That’s a steroid side effect that’s really difficult to get rid of. So I am definitely a believer in if we have to use steroids, be on it as few days a week as we can, while still maintaining the response that we want.
[00:16:34] I completely agree. Finding that lowest effective dose and frequency that keeps the pet comfortable while really working closely with your family veterinarian or a veterinary dermatology specialist to search for the reason why the pet is itching and is swollen in the first place is so important for making sure that your pet doesn’t develop those side effects that we discussed. For the majority of patients, steroids are a tool, not a solution to allergic skin disease. Fleas, food, environment. These are all the big causes of allergic skin disease. What is it that’s contributing to your specific pet’s itch. Go listen to those episodes, work with your veterinarian to find the underlying cause so that you can minimize the amount of potential side effects associated with any symptomatic treatment for allergies you are using. If you’re using good flea prevention, if you’ve been able to diagnose a food allergy and you’re avoiding the proteins that are in the diet, then you should be able to minimize the amount of steroids that are needed to keep your pet comfortable.
Different methods to administer steroids
[00:17:39] One other thing that we haven’t touched on that I think fits into this conversation is actually the route that we’re giving steroids. So we in dermatology are kind of blessed in that a lot of our diseases are there on the outside of the body, so we can treat them topically. For a lot of allergic conditions that would respond to an oral drug like prednisone, there are topical options that are safer. If we’re firing a shotgun at the whole body, we’re going to do more collateral damage than if we target the shot we’re taking at the area the dog is bothered. If the dog’s itch and inflammation is only focused on their ears or their feet, for example, we can give an ear drop with a topical steroid that can help start knocking that inflammation down. Or we can use a topical ointment or a cream to start reducing the swelling and the pain in those big, swollen red puffy paws.
[00:18:41] That being said, not all topical steroids are safe. They’re safer, but they’re not perfectly safe. One of the treatments out there that’s a little bit, I don’t know if I’d call it a pet peeve, but when I see it in the records coming in of pets to see me is something called a betagen spray or gentaspray or gentaved spray. There’s a million different names for it, but it’s a spray that combines gentamycin and betamethasone. Betamethasone is one of the strongest, if not the strongest, topical steroid out there. So, as we mentioned, every body system has those steroid receptors and you can still cause those skin and hair side effects. You can make hair fall out, you can build up calcium deposits in the skin, you can thin the skin, you can tear the skin. So you still can cause damage with topical steroids. But if we have topical options that let us spare the liver and the kidneys and some of the other things long-term, that can be a huge bonus to us.
First image shows a severe reaction from chronic overuse of topical steroid spray on the belly of a dog with allergies. Second image shows muscle wasting and hair loss on the head of a dog from chronic steroid use. Photos courtesy of Dr. Curtis Plowgian.
[00:19:50] So one route that I like even less than oral steroids or pills would be long-lasting injectables. So there’s a drug called Depomedrol. It’s a one month injectable steroid that we give to dogs and cats and that’s an average. Some pets get six, eight weeks from it. Some get less than four weeks. That is a drug I really try to avoid if I can. There are pets who, again, if it’s our last option, that’s where we have to go. But in general, if I have a pet who will take pills, that really helps me out because we have more control on a day-to-day basis of how much steroid the pet is getting. So if we can have a pet on oral steroids, if the pet is willing to take pills, we can put those little buffer days between our doses, such as an every other day steroid dog or cat. That really helps reduce our side effects. Whereas if the only option you have is to just put a big glob of steroids in the pet system with a Depo-Medrol injection, we have no control over how much steroid is in that dog’s bloodstream on a day-to-day basis. So I really try to avoid those when I can, while understanding there are some worst case scenarios where they’ve gotta be used.
[00:21:12] Yeah, I absolutely agree with that. I think it goes a long way towards minimizing those side effects that we talked about and being able to get to the lowest effective frequency of the steroid to give the pet’s body a break. If you give that big injection of steroid all at once, it is a whopping dose in the beginning and then it just kind of wears off. Whereas if we’re giving oral steroids, okay, maybe we can do once a day for a few days, and then very quickly based on how the animal responds, try and get to that every other day, every third day. If you are able to give your pet oral medications and we need to use steroids, the oral medications are going to be a lot safer, both short-term and long-term then giving an injection of a steroid. Do you have any other advice or gems that you want to share with pet owners regarding steroids in their pets?
First image shows redness, thinned skin, and comedones (blackheads) on the belly of a dog treated with chronic topical steroid spray. Second image is a month after discontinuing steroid spray and switching to other allergy therapy.
Summary
[00:22:07] Like I said at the beginning, I think we need to have an appropriate fear of steroids. If we say we’re never going to use them, there are some pets that really need them, that we’re never going to help. There are a lot of side effects and we need to keep those in mind and we want to mitigate those as best we can with responsible dosing, use of supportive medications, use of topicals, but we don’t want to cut them out completely. We want to have them, as you said, as a tool that can help us get your pet as comfortable as possible in the short run and the long run. Whether you’re seeing a dermatologist or whether you’re seeing your family, it can be appropriate and sometimes steroids are the best drug to use for your pet, but it’s just a matter of a balancing act using steroids responsibly and taking the appropriate monitoring measures and supportive measures to minimize the risks where we can.
[00:23:07] I talk about risk versus benefit on the show all the time. Steroids are a perfect example of this. When they’re used appropriately, like for those swollen ears and really swollen, painful paws, the benefit is so clear in those patients. They feel so much better once those ear canals are opened up, once they’re able to go for walks with their owner again. It’s important for us to understand the risks that steroids carry and not rely on them to be the solution for an animal that has a life long disease. I really want pet owners to try and work closely with their veterinarian to find out what the underlying cause is, so that you can go forward minimizing the amount of steroids a pet receives over the course of its lifetime.
[00:23:49] I’m really thankful that you took the time to come on here and talk to our pet owners about steroids, bringing your knowledge to them and sharing it with them so that they can make the appropriate decision with their veterinarian regarding what’s best for their individual animals. Thank you so much, Dr. Plowgian. You’re Welcome. Thanks for having me.
[00:24:08] If you have a pet that has been on steroids, I would love to hear about your experience. You can join the Facebook group, Your Vet Wants You to Know and tell about what your experience is with allergies in your pet, share pictures of your pet and talk to us about what’s been going on. Many family veterinarians are comfortable with managing pets with allergies, but there will be a link to find a dermatologist near you on the website if you would like to consult with a specialist.
[00:25:00] I like to end each one of our episodes with a short segment, I call “Scratching the itch.” “Scratching the Itch” is a segment that highlights something, either a human interest story, a product, a website, that either provides relief or just makes you feel good. Hence, “Scratching the Itch.” For those of you listening today, if you have a “Scratching the Itch” you would like to be featured on an episode, please visit the website to contact us so that we could include that in the future. Dr. Plowgian, do you have a “Scratching the Itch” for us?
[00:25:33] I do. So there’s a lot of stuff on social media among my veterinarian and veterinary technician friends that talk about how hard our job is and ways that we struggle. I don’t always know that enough gets shared about parts of the job that really get us pumped up and get us back to what got us into this job in the first place. Anybody who’s ever worked with me in a derm clinic probably knows that my favorite Derm disease of all time is scabies. One of my favorite stories of the last couple years was actually a scabies case that I had in Indianapolis. We had this little old German lady with her poodle who are both on the older side. They live together and the dog sleeps in the owner’s bed every night and one day they just got really, really itchy at the same time. We measure itch on a zero to 10 scale and they were both 10 out of 10 itchy. Before coming to our clinic, she had been seen by her primary care practitioner, she had taken her dog to the primary vet, she had even been sent to a specialist and had her own skin biopsied two or three times. She was saying that her doctors and her veterinarians were just telling her they didn’t know what was wrong, but they thought it was unlikely that her itch and the dog’s itch was related. She just knew it had started at the same time, she figured they had the same problem.
[00:27:09] Scabies is one of those diseases where I just hear the history and I light up cause I’m like, I’m going to be able to help you so much today. This dog was a classic scabies case. Once I came into the room and did my physical exam, there’s a test called a pinnal pedal response where if we scratch the dog’s ear, it makes it the dog’s foot go crazy, just swiping at itself. We look for crusting on the tips of the ears and the tips of the elbows. This dog was a crust factory on its ears and parts of its face. When we look for scabies, we don’t always find them. We’re actually mostly dependent on the history to make the diagnosis, but about 30 to 50% of the time, we can find them on a scrape. I think this dog had just had them for so long, this was the most scabies I had ever found.
[00:28:02] The lady had been seeing human and veterinary doctors for, I think, three to four months before she came to see us. She was very on edge and just looked tired and defeated and was so sad coming into the office. It made me so happy to just have a quick answer that I could give her. There aren’t very many quick answers in dermatology. The owner, at the dog’s first appointment, had welts and scabs and skin lesions all over her own skin. One of the places that scabies tends to affect people is the bra line and the waistline, so she had them all up and down her arms and legs, but I asked if it started at her bra and waistline and she was like, yeah, do you want to see? I told her I didn’t need to. Even by the four week recheck the dog was looking much better, the owner was just looking so much better and was so relieved. Anybody who gets into medicine, I think human or veterinary medicine, wants to make that kind of difference in somebody’s life. One of my favorite scabies superhero stories where I had the answer that just turned it all around. That’s why scabies is one of my favorite diseases.
[00:29:22] That’s wonderful. It’s certainly a very literal interpretation of the “Scratching the Itch” segment. I apologize to any listeners who will now be scratching at their arms and torso for the rest of the day. I’m glad that you were able to share that with us and that she got some relief and her pet got some relief as well. That definitely makes everything worthwhile when you can make that kind of a difference in somebody’s life. Well done, Dr. Plowgian. Thanks. That’s all for today’s episode. I look forward to seeing you at your next visit with Your Vet Wants You to Know .
References:
- Gortel, K. An embarrassment of riches: An update on the symptomatic treatment of canine atopic dermatitis. The Canadian veterinary journal = La revue veterinaire canadienne vol. 59,9 (2018): 1013-1016.
- Santoro D, Therapies in Canine Atopic Dermatitis: An Update,
Veterinary Clinics of North America: Small Animal Practice, Volume 49, Issue 1, 2019, Pages 9-26 - Saridomichelakis, M.N., Olivry, T., An update on the treatment of canine atopic dermatitis, The Veterinary Journal, Volume 207, 2016, Pages 29-37.
