New and need help!

[Katiep123]

Hi I've just joined this forum as I'm looking for some help on my weimeraner 
She's 6 years old and recently been diagnosed with auto immune disorder and they said that her
Body is attacking her skin, it started the end of January and started as small lumps under her skin and lumps on and around her ears, then gradually got worse she ended up loosing fur and the lumps turned into scabs, for months the vets didn't know what was wrong with her as she was fine in herself,
Now  7 1/2 months on she still has bald patches all over hair isn't growing back, still got scabs on elbows wich still look quite sore, has been on steroids for about  7 months I'm just wondering is there anything else I can give her as  I've been told by my vet that the steroids will shorten her life span and all they seem to be doing is stopping her being so irritated rather than healing her skin, and the vet basically said there's nothing else she can do other than take steroids and adjust the dosage, if anyone has founds anything that will help please let me know willing to try homeopathy

Thanks

[Katiep123]

Forgot to mention that lumps appeared all over her body down her legs over her nose and that's whee the bald patches still are

[Clover]

What does she have, is it pemphigus?

There are usually other medications that are combined with the predisone/prednisolone that allowed the steroid dosage to be lowered, is your vet a specialist? If not, I would highly recommend demanding a referral to one (internal medicine).

[Catherine]

What autoimmune disease has she been diagnosed with - is it Discoid Lupus, Pemphigus, SLE or something else? Take a look here, this may help:

http://cimda.co.uk/smf/index.php/topic,14.0.html
http://cimda.co.uk/smf/index.php/topic,21.0.html
http://cimda.co.uk/smf/index.php/topic,20.0.html

Is she also on the correct medication? If it is not enough it will not help. Here is the medication protocol:
This example is base on a dog receiving an induction dose of 1.0mg/kg/q12hrs

Dose                Duration (based on clinical effect)

1.0mg/kg/q12h             10-28 days
0.75mg/kg/q12h            10-28 days
0.5mg/kg/q12h             10-28 days
0.25mg/kg/q12h                         10-28 days
0.25mg/kg/q24h                         10-28 days
0.25-0.5mg/kg/ Every other day      at least 21 days
0.25-0.5 mg/kg/ Every third day       at least 21 days

Azathioprine (a cytotoxic drug) can be used in combination with prednisolone at 2mg/kg/24 or 48 hrs and dose gradually reduced, when remission is achieved, over a period of months.
Clinical response to Azathioprine may take up to 6 weeks. (Plumb's Veterinary Drug Handbook)

Don't forget the gastroprotectant!

But there is also  more information on medication here: http://cimda.co.uk/smf/index.php/topic,19.0.html

[Jo CIMDA]

Hi

Correct steroid regime is extremely important to a successful outcome and if your Weim has not been on the correct dose this could be why she hasn't reached remission.   Check out the Michael J Day protocol that Catherine has posted. 

There are non-steroidal treatments that can be used for autoimmune skin diseases such as Discoid lupus or some of the pemphigus diseases (but not all of them).

In addition to different steroids, Cyclosporin, Azathioprine, Chlorambucil, mycophenolate mofetil, Leflunomide, Pentoxifylline, Natural Vitamin E and gold sodium thiomalate are alternative therapies (or combination therapies)  for autoimmune skin disease in dogs.   There is, however,  another therapy that many on this forum will be familiar with and that is doxycycline (an antibiotic) and niacinamide (a form of Vitamin B3).  This combination is commonly used for the autoimmune skin disease SLO (Symetrical lupoid onychodystrophy) an immune destruction of the nails.  Doxycycline  (or tetracycline) and niacinamide and all the recommended supplements (see below)  are very useful in the treatment of AI skin disease but not all of them so it really depends on what AI disease your Weim has as to what treatment you choose.  I presume no biopsies have been taken in an attempt to obtain a confirmed diagnosis (or perhaps they came back inconclusive)  so really you are treating spectulatively, which is not uncommon or unreasonable.

  The fact that she is not systemically ill probably suggests a lesser AI skin disease and maybe Doxycycline and niacinamide (and all the supplements) could be a good alternative to steroids.  The following is an extract from my seminar notes relating to SLO but the same treatments apply to Discoid lupus etc.... Please ignore the specific references to SLO.



Treatment Options for Autoimmune Skin Disease

Fortunately, there are different treatment options for autoimmune skin diseases and as primary SLO is not life threatening, the most popular treatment seems to be a combination of Tetracycline or Doxycycline with Niacinamide (Vitamin B3).
Tetracycline and Doxycycline are antibiotics which also have anti-inflammatory effects and suppress antibody production. It is an immunomodulating drug, meaning that it has the ability to adjust the immune response to a desired level.
Note: Tetracycline (and Oxytetracycline) should be used with caution in dogs with renal impairment as it is eliminated from the body via the glomerula filtration and a build up of the drug can occur if used for prolonged periods. If it is necessary to give a dog with renal impairment Tetracycline or Oxytetracycline the dose should be lower than recommended but a lower dose may not address the problem of SLO, and also the treatment is likely to be for many months at least.  However, Doxycycline is excreted in the faeces and does not affect renal function and can be used in animals with renal insufficiency. (Plumb's Veterinary Drug Handbook)
Tetracycline or Doxycycline is commonly used in combination with Niacinamide (vitamin B3) for the treatment of immune mediated skin diseases.  Niacinamide works with Tetracycline or Doxycycline to further suppress antibody production.
Important:  Niacinamide is also known as nicotinamide but it must not be confused with, Nicotinic Acid, (Niacin). Although Niacin acts identically as a vitamin, it increases the blood flow and blood pressure, and should not be used.
It will take 1-3 months before any positive results are seen (although duration of treatment is much longer) but, in spite of this, it seems to be the treatment of choice for SLO as it is usually well tolerated and it avoids the use of steroids and other stronger drugs.  Many dogs do very well on this treatment regime. When good clinical improvement is seen the drugs can be gradually reduced and the dogs weaned off medication over a period of months. 
Dose:  Tetracycline & Niacinamide
Dogs less than 10kg : 250mg each Tetracycline and niacinamide every 8 hours
Dogs more than 10kg : 500mg each Tetracycline and niacinamide every 8 hours
Note:  Food can significantly reduce (up to 50% or more) the amount of Tetracycline or Oxytetracycline absorbed.   Avoid giving oral tetracycline within 1-2 hours of feeding or giving milk or dairy products
Doxycycline (5mg/kg/24 hrs) can be prescribed instead of Tetracycline and may be more convenient as it is given only once a day and, unlike tetracycline, food and dairy products do not affect its absorption.
(Plumb's Veterinary Drug Handbook)
Note:
Some authors recommend eg.,  Michael J Day – Clinical Immunology of the Dog and Cat
Dogs less than 10kg : 250mg each Tetracycline and niacinamide every 12 hours
Dogs more than 10kg : 500mg each Tetracycline and niacinamide every 12 hours

Steroids
Steroids are life saving and can work like a miracle drug at times but, obviously unless you have no choice as in a life threatening situation, it is always worth trying other treatment options before using high doses of steroids and other more potent and expensive drugs. If you and your vet choose steroids to treat your dog's SLO you may see quicker results, because the effect of steroids on the immune system is rapid.  However, the usual side effects of steroids can be expected. 
Steroids suppress the immune system in order to stop the destruction. The dose of steroids has to be `immunosuppressive', anything less and the treatment will not work and remission will not be achieved.   Over a period of months the dose is gradually reduced.
Immunosuppressive doses of steroids:
Prednisolone 1-2mg/kg/12hrs – starting at the lowest dose and gradually reducing dose over a period of months.
(Clinical Immunology of the Dog and Cat by Michael J Day). 
Note:  Steroids can cause an excess of stomach acid so, as a precaution, giving something to protect the stomach, such as Antepsin and/or Ranitidine alongside steroid treatment, is prudent.  Dogs treated with steroids without a gastroprotectant may develop stomach ulcers and all the problems associated with this avoidable complication.
The side effects of steroids should be considered when deciding on a treatment for SLO.  I am not going expand on what to expect when your dog is on immunosuppressive doses of steroids, or the side effects of using steroids, but if you do decide to go down the steroid route and would like to have more information or clarification, please contact me.
Regardless of which treatment you opt for, the damage already done to the nails within the nail bed will have to be dealt with in the usual way, and as the damaged nails emerge through the skin they may have to be surgically removed.  Sometimes, if the nails are only deformed, and not split or fractured, they can be managed by keeping them short. Hopefully within a few months the new nails will emerge looking much healthier or at least, not broken or fractured, and the dog will be free of pain.
Other drug options, if your initial choice doesn't work, can include:
(Chlorambocil, Gold salts, Pentoxifiline, Retinoids, Azathioprine, Atopica)
•   Pain Relief especially in the early stages or after surgery may be necessary, eg. Tramadol.
•   Essential Fatty Acids (EFA's) are given in therapeutic doses, regardless of which primary treatment regime is used.  High doses of EFA's also play an `active' role in the treatment of skin diseases and should be included in the treatment regime and in low maintenance doses after remission.  EFA's are known to be `steroid sparing' in high doses. This means that they may ultimately, lead to a lower dose of steroids being used and this is especially useful in dogs that have to remain on steroids.
EFA Ratio
Quote: "Research is being performed to determine the optimal ratio of omega-6 to omega-3 fatty acids that should be consumed. Previously, it was thought that the ratio should be approximately 15:1. Current recommendations are for ratios of 10:1 to 5:1." (Omega fatty Acids: sources, Effects, and Therapeutic uses in Dogs, Veterinary Services Department, Drs Foster & Smith, Inc.  Holly Nash, DVM, MS)
Example Therapeutic Dose: Essential Fatty Acids
Quote: "Effect appears to be dose related and optimum doses and the most effective combinations of these oils have not yet been determined. Daily doses of:
•   Evening Primrose oil 172mg/kg/day
•   Fish oil @ 44mg/kg/day
have been used in dogs over a one year period without ill effects."
(Ref: The Veterinary Formulary by Yolande M Bishop)

•   EFA dose should start at a high level until a response is seen.  This can take up to 12 weeks. EFA's can cause loose stools. If this occurs, start on a lower dose and build up to highest dose over a couple of weeks. Avoid Evening Primrose Oil in dogs with epilepsy.  Branded veterinary products are available. Follow manufacturer's dosing recommendations.
•   Natural Vitamin E (400-800iu/12hrs) encourages new cell growth.
(Ref: Clinical Immunology of the Dog and Cat by Michael J Day). 
•   Chinese herbs are also noted as being effective but the owner would have to go to a vet who practices in natural treatments.
•   Biotin (*5mg/kg/day) improves the quality of the nails but it can be difficult to obtain. Some dogs with SLO have shown to be deficient in biotin. This may be due to their diet.  Foods with a relatively, high biotin content include cooked eggs, liver, chicken livers, kidneys, some vegetables eg., boiled broad beans, raw or canned tomatoes, raw cauliflower, dried skimmed or whole milk, fresh milk, bran, yeast and raw egg yolk.  Do not give raw egg white as it contains a substance called avidin which binds to biotin and prevents its absorption. This does not apply to cooked egg whites as the cooking process deactivates avidin.
•   Gelatine – *10 grains (one capsule) every 12 hours.   (*Ref: Muller, Kirks Small Animal Dermatology).  Some owners give 1-2 cubes of jelly every day.
•   Good quality high protein diet in case of deficiencies.
•   Antibiotics if secondary infection is present
•   Topical acrylic nail cement applied externally to permanent nail deformities, which suffer from re infection, could be strengthened and protected by this application.
I haven't known a dog to have external acrylic nail cement treatment but reference to this can be found in Muller, Kirks Small Animal Dermatology.
•   Removal of loose nails Loose nails may have to be removed, usually under anaesthesia. As you can imagine, recovery from this procedure is likely to be very painful.  Clipping, cleansing, removal of the fractured portion of claws may be necessary even after treatment is well under way.
•   Topical shampoos, Antiseptic soaks (Salt or Epsom Salt foot baths, Hibiscrub etc). Initially it may be necessary to bathe your dog's feet to keep them clean and to wash off the blood etc., but once they are dry and healing it seems better practice to try to keep their feet dry.  Antiseptic soaks or salt soaks will help to soothe and clean.  Epsom salt soaks are supposed to be very soothing when the dog has pain. When the feet are sore and weeping, you can use socks and boots (or strong plastic bags tied with string) when out walking.  This will keep the feet clean, but do remove the boots when indoors otherwise the feet may become warm and sweaty which could set up more secondary infection and prolong the healing time. New nails should be kept short.

Recovery
Tetracycline or Doxycycline/Niacinamide
Recovery is slow especially if the treatment is Tetracycline or Doxycycline and Niacinamide.  It takes at least 6 weeks before real improvement is seen. Although some owners have said that they have seen positive results within 4 weeks.  Dogs appear to tolerate this treatment very well, without any obvious side effects.  However, if adverse effects become a problem reduce the Niacinamide first, as this is more likely to cause an adverse reaction than the Doxycycline or Tetracycline. (Plumb's Veterinary Drug Handbook). 
Steroids 
Steroids are very powerful drugs.  The immune destruction is halted and inflammation reduced within days of starting treatment, but steroids cannot reduce the damage already done.  Nails will slough off in the usual manner.
Generally, a dog with any autoimmune disease benefits from being treated promptly and correctly as clinical signs will get worse the longer treatment is delayed. 
A more favourable outcome can be achieved if:
•   Diagnosed quickly
•   Treated correctly
•   The best choice of drugs used
•   Appropriate dose for the disease
•   Given for the correct duration of time
•   Correct protocol for weaning down drugs  -  minimises side effects  and optimises success of the drug regime. – very important when using prolonged, high doses of steroids
Relapses
Relapses are not uncommon. If the dog is in remission when a relapse occurs, then it is most likely that he has encountered another trigger factor.  Treatment must start again at the original dose.
If a relapse occurs whilst still on treatment, then it is possible that the dose of the drug had been lowered too quickly or the initial dose was not high enough to achieve remission.  The treatment regime must be reviewed, or changed. Consider the possibility of an unidentified, underlying cause.


There is still a lot you can try for your Weim's skin problem and if she is well in herself then I think the chances of you getting her into remission is really good.

Jo

[Katiep123]

Thank you all so much for your help! Will be taking her back to the vet and asking for a referal to a specialist! They didn't even tell me what auto immune disease she had been diagnosed with I've read up on things myself and her symptoms seem to match pemphigus, after she had been diagnosed they basically have me 3 months worth of steroids and to later the dosage as I see fit! Which I was not happy about. She started off on 2 tablets a day and has been cut down to one tablet a day but half in morning and half in evening the steroid they prescribed is called prednidale one tablet is 25 mg, and if I try to cut it down to half a day her skin gets worse and she seems to be more irritated  and I've  noticed her breathing is more laboured so obviously I want to find things to help her before she does start getting Ill in herself

[Jo CIMDA]

Hi

Giving 3 months of steroids and expecting you to alter the dose as you see fit is a disgrace! The vet deserves a repremand.  A dog on steroids should be monitored very carefully and seeing a specialist is the best thing to do.     I hope the vet refers you to a good specialist.  Don't assume they are all good! 

Jo

[Penel CIMDA moderator]

Definitely you need a second opinion - best of luck - let us know how you get on .