The treatment strategy included addressing the underlying causes, infection and lesions, as well as addressing any behavioral issues that may exist. Identify any environmental changes that may be responsible and modify them to reduce anxiety.
A total of 30 cases out of 440 dermatological cases with prevalence of 6.81 per cent were diagnosed with ALD. It was found that there was maximum occurrence of psychogenic stressors with 19 cases (63.33%) followed by only organic stressors in 9 cases (30%) and combination cases which included primary organic stressors with secondary psychogenicstressors were 2 cases (6.66%). The maximum prevalence among organic stressors were reported with atopic dermatitis (16.66%) followed by demodicosis (6.66%), orthopaedic stressors (3.33%), hypothyroidism (3.33%), flea allergic dermatitis (3.33%) and lymphoma (3.33%). However, no relevant data was available on percent prevalence of etiology of ALD. The findings of present study correspond to the findings of
Patel (2010) and
Shumaker (2019) who found that creation of ALD lesion required multifactorial triggers and these might have both organic and behavioural causes.
Out of total 30 dogs, only 4 dogs had no history of prior treatment for ALD. Of the remaining 26 subjects, 8 had been on systemicantibiotic treatment (26.66%), 6 had history of bandages applied on the lesion (20%) and 12 were using local antibiotic ointments (40%).
The pre and post treatment values of three clinical scores in group 1 were compared using with Wilcoxon signed ranks test (p<0.05). The Mean±SE of licking score, ALD score and CGI score of the pre-treatment group were 4.9±0.454, 5.8±0.894 and3.9±0.423, respectively whereas the Mean±SE of licking score, ALD score and CGI score of the post-treatment group were 2.8±0.493, 2.2±0.741 and 2.6±0.647, respectively. Significant difference (p<0.05) was observed in the licking and ALD score values at the end of the trial, however, CGI score values were found to be non significant (p>0.05). The drug was found useful in controlling licking and inflammation associated with the disease but had poor recovery in some patients due to side effects which are discussed later. The findings of the present study are partially in agreement with the results of previous studies (
Wynchank and Berk’s 1998) who studied efficacy and tolerability of fluoxetine in the treatment of canine ALD and explained that the drug appeared to be a useful therapeutic modality for ALD disorder in dogs. In our study fluoxetinewas found to be efficient in the treatment of ALD but tolerability of drug was found less in dogs with ALD.
The pre treatment values of Group 2 (Mean±SE) of licking score, ALD score and CGI score were 4.9±0.378, 6.2±0.573, 3.8±0.359 respectively. The post treatment Mean±SE values of licking score, ALD score and CGI-C score in this group were 2.8±0.326, 2.5±0.601, 2.2±0.326, respectively.Significant difference (p<0.05) in pre and post treatment values of 3 scores (licking score, ALD score and CGI score) were recorded at the end of the trial. This study was in agreement with
Overall (1994) who reported clomipramine was the drug that had been reported as most successful in the treatment of canine compulsive diseases. Another study reported that clomipramine was also more effective than the other tricyclics as a treatment for obsessive compulsive disorder (
McTavish and Benfield 1990).
Post treatment score of Group 1 and Group 2 were compared using Mann-Whitney test (p<0.05). Dogs were compared for post treatment licking score, ALD score and CGI score with one assumption that all the dogs presented for the treatment of ALD were equally affected with disease. The mean±S.E. of licking score, ALD score, CGI-C score in post treatment group 1 were 2.8±0.493, 2.2±0.741, 2.6±0.647, respectively and the mean±S.E. of licking score, ALD score, CGI-C score in post treatment group 2 were 2.8±0.326, 2.5±0.601, 2.2±0.326, respectively. No significant difference (p>0.05) was observed in the post treatment score values between two groups suggesting both drugs were equally effective. However, on comparing pre and post treatment score values separately for two groups, clomipramine was found to be more effective than fluoxetine. This study was in line with
(Pigott et al., 1990 and
Yalcin 2010) who concluded that the two drugs were successful in the treatment of OCD and that they did not have superiority over each other. Although,
Jenike et al., (1990) had suggested that clomipramine had larger effect than fluoxetine in reduction of scores on the Yale-Brown Obsessive-Compulsive Scale.
This disease is viewed as disease with combination of both primary and perpetuating factors.All dogs presented for acral lick dermatitis were treated initially with antibiotics, as infection is a major contributor to the lesion’s persistence. The antimicrobial therapy was prescribed after culture and sensitivity test (CST) to control secondary bacterial infections for a period of 1 to 2 weeks along with the treatment of primary psychogenic triggers. Oral cephalexin was given at dose rate of 25 mg/kg body weight twice a day, oral clindamycin at the dose rate of 10 mg/kg body weight twice daily, enrofloxacin was given orally at the dose rate of 5 mg/kg body weight twice daily, (Amoxycillin + clauvulanic acid) orally at dose rate of 15 mg/kg body weight twice dailydepending upon the CST results.
Another crucial step in the treatment is to minimize access to the acral lick location. Even if the primary cause and underlying infection are properly managed, healing is unlikely if the dog is allowed to continue licking the wound. Physical restraint using Elizabethan collars was customised for dogs and was very effective.
Among the dogs treated under group 1, 6 (66.66%) dogs recovered completely with mean recovery in 24±2 (Table 3, Fig 1a and 1b) days and among dogs treated under group 2, 9 (90%) dogs showed recovery in mean 41±5 days (Table 3, Fig 2a and 2b).In the present study, it was seen that theanimals treated with fluoxetine (Group 1) recovered earlier than clomipramine (Group 2) which was contrary to the study of
Pigott et al., (1990) who reported that responses to clomipramine drug took as long to occur as responses to the fluoxetine drug.
Four out of thenine dogs (44.44%) under group 1 were reported with reoccurrence of symptoms after mean 105±47 days of their treatment completion whereas under Group 2, five out of ten dogs (55.55%) were reported with signs of reoccurrence after mean 37±21 days of their treatment completion (Table 4). The present study was in agreement with
Luescher (2003) and
Virga (2003) who reported that there is no single therapy that had been successfully shown to fix lesions without reoccurrence.
In group 1, nine dogs were treated with fluoxetine and 3 (33.33%) dogs were reported with adverse effects of drug as drowsiness and in Group 2, ten dogs were treated with clomipramine and 2(20%) dogs were presented with adverse effects; 1(10%) with loss of appetite and 1(10%) was reported with vomiting. The study was in agreement with
Irimajiri et al., (2009) who studied that the most commonly reported adverse effects with fluoxetine were lethargy 12(39%)and decreased appetite 7(23%). Another study reported lethargy, loss of appetite, diarrhoea and growling as the common side effects of clomipramine treatment
Rapaport et al., (1992). The present study was contradictory to
Pigott et al., (1990) findings who reported that there were significantly fewer total side effects reported with fluoxetine than with clomipramine treatment.
Therapeutic management of organic stressors; atopic dermatitis (n=5), demodicosis (n=2), orthopaedic stressors (n=1), hypothyroidism (n=1), flea allergic dermatitis (n=1) and lymphoma (n=1)creating pseudo lick wounds were carried out along with comparison of pre and post treatment scores of three scales used in the study (Table 5). Cases diagnosed with atopic dermatitis (n=5) stressorwere treated with prednisolone at anti- inflammatory dose 0.5 mg/kg twice a day for one week and tapered to dose 0.5 mg/kg once a day on alternative days in a period of 4 weeks. All the cases responded completelyto the primary treatment and no behavioural modification was required in any of the case (Fig 3a and 3b). Dogs diagnosed with demodicosis stressor (n=2) were treated with ivermectin at the dose of 400 mcg/kg subcutaneously weekly shots for four weeks. Recovery was seen in both the cases with no need of behavioural management. Orthopaedic stressors (n=1) were treated with carprophen 4 mg/kg bwt. orally once a day for a period of 5 days. Complete resolution in limping was seen with no improvement in lick wound, considering the licking as a learned way of acting, behavioural modification was done with serotonin reuptake blockers. Improvement in the wound afterwards noticed within a period of 1 month. Only one dog was diagnosed with hypothyroidism (n=1) and later treated with levothyroxine 20 µg/kg once a day for period of one month. Complete recovery in the lesion was seen with no need of behavioural modification. This study was in agreement with
(Jöchle. 1998) who used thyroxine for management of disturbed abnormal behaviour in dogs suffering from hypothyroidism. One dog with ALD was also diagnosed with flea allergic dermatitis primary treatment was done with fipronil (9.8% w/w)/ (s)-methoprene (8.89%w/w) spot on. Animal did not show complete recovery from licking. Behavioural modification was done afterwards.One case with lick wound diagnosed with lymphoma animal was treated with Doxorubicin 30 mg/m2, iv in NSS and repeated after a period of 21 days for 3 times. Animal showed complete recovery from wound after the treatment.
Denerolle et al., (2007) also mentioned in their study a case of lymphoma mimicked with canine acral lick dermatitis.
Dogs with ALD have been shown to have changes in their serotonergic and dopaminergic neurotransmission systems. Serotonin is a neurotransmitter that governs several physiological activities, including sleeping, eating, aggressiveness and self-grooming
(Vermeire et al., 2012). In dogs, antidepressants known as selective serotonin reuptake inhibitors (SSRIs) have shown considerable improvement in fluoxetine groups
(Wynchank and Berk 1998). Other pharmaco-therapeutic medications have also been demonstrated to be beneficial in combating ALD with varying responses, indicating that more than one transmitter or variables apart from serotonin are responsiblefor ALD. Clomipramine, a tricyclic antidepressant (TCA), was found to be beneficial for treatment of ALD in dogs. TCAs block both serotonin and norepinephrine reuptake, but SSRIs are more selective, blocking just serotonin reuptake; as a result, SSRIs are associated with less adverse side effects.
Thus ALD is known to be more complicated, with numerous potential underlying primary and perpetuating factors. As a result, a thorough diagnostic work-up is required to identify the primary trigger, whether organic, psychogenic, or a combination of both and to tailor the appropriate treatment plan. A multimodal treatment approach is required for a successful outcome, including identifying and treating any secondary infections and interrupting the itch-lick cycle.
