IMHA, Prednisone & Calcinosis Cutis

[Arinashdad]

Puddles has been really doing well with all her numbers in line with heavy prednisone use since mid December.   Since being diagnosed she has been reduced from 50mg/day to now 20mg/day and is set to be reduced this week down to 15mg/day.  It will have been 30 days since her reduction from 25mg/day so she is due.   Her PCV has been a steady 41% since we bought her home with the exception of it dipping down to 38% once and then back up to 41%.  Muscles are coming back and she's more active, not much weight gain thanks to green beans.  Her problem now is I think she has calcinosis cutis on the back of her neck. The doctor thinks it's hot spots and treated her for such but I'm starting to disagree. I met with the Vet yesterday and found out our Chocolate Lab (birthday today, one year) is probably going to have allergies, lucky us.  I told her the skin around the 4 sores seemed to be harndened or thick which I'm assuming is why it's called calacinosis.  Other than reduction is there anything I can do for her.   She's doesn't seem to be uncomfortable and since she's a bulldog this is an area she can't chew.  Thank you!!!

[Jo CIMDA]

Hi

It is good to know that Puddles is doing well. 

The skin problem Puddles has on the back of her neck is a common site for drug induced calcinosis cutis and is a result of the prednisolone she has been receiving.   Not all dogs get it but it is common in drug induced Cushing's.  See this extract:

https://en.wikivet.net/Hyperadrenocorticism

Cortisol stimulates protein catabolism for gluconeogenesis so patients exhibit muscle weakness. Protein catabolism and weakness gives poor wound healing. Collagen damage due to protein catabolism allows the deposition of calcium in the skin. Calcium acts as a foreign body producing a granulomatous reaction. This is called Calcinosis Cutis.

Other good links:

http://todaysveterinarypractice.navc.com/dermatology-details-dermatologic-markers-of-internal-disease-in-dogs-cats/

The most common underlying cause of calcinosis cutis is hyperadrenocorticism—either endogenous or iatrogenic Cushing's disease. Additionally, metastatic calcification can occur in dogs or cats with chronic renal failure.3

http://www.vetbook.org/wiki/dog/index.php/Calcinosis_cutis

When a dog is on high doses of steroids for a prolonged period of time, in addition to the calcium deposits,  the skin barrier starts to break down and this is when skin lesions start to show.

Puddles is on the reducing dose of prednisolone now so it would be a good idea to start giving her Natural Vitamin E to encourage new cell growth (400iu twice a day Ref: Clinical immunology of the Dog and Cat by Michael J Day) and also essential fatty acids.  It has been proven that essential fatty acids in therapeutic doses not only repair the skin barrier but they are also anti-inflammatory and have steroid sparing effects.

https://www.petmd.com/dog/care/fatty-acids-pet-skin-and-haircoat-health

You will have to watch that broken skin doesn't get infected, and if it does then you might need antibiotics or an antibacterial wash.

Happy birthday to your black lab for yesterday.  Essential fatty acid supplementation might help too.

Skin problems following long term treatment with preds are common and it can, and does, resolve when the preds are weaned off or at a low every other day dose but supplementation helps the function of the skin to return to normal.  It can get worse and sometimes ulcers develop, which are painful and stubborn to heal, and this is why giving supplements nourishes and helps the skin to recover.  It is not a quick fix though and  it will take several weeks before any improvement is seen, and within a few months things should be so much better if not resolved altogether.

Jo



This is an extract from another posting that may help:


Holland and Barratt, and other health food shops,  and Boots The Chemist  sell Natural Vitamin E, and you can buy Evening primrose oil and fish oil from the same, or from the supermarket.   Below are some links that might be useful to you but you can also check with your vet.
 
https://www.decodedscience.org/vitamin-e-another-tool-help-treat-canine-atopic-dermatitis/52103

https://thewholedog.com/omega3sdogs/

https://www.petcoach.co/article/omega-fatty-acids-sources-effects-and-therapeutic-uses-in-d/

https://www.carnivora.ca/html/Learning-Centre/EFA-Supplementation/index.cfm

https://www.petmd.com/blogs/nutritionnuggets/dr-coates/2014/august/using-omega-3-fatty-acids-effectively-and-safely-31972

[Arinashdad]

Thank you for the information.  I give all three dogs a fish oil vitamin every morning and night when I take mine.  Is over the counter human grade enough or do I need to go to a pet store?  A couple of spots have ulceratied but crusted over and we are watching them regularly, especially now since she is off antibiotics.  I will ask the doctor about the vitamin E supplement.  The fish oil pill she is taking now twice daily is 1200mg 360mg Omega-3 (EPA) and 240mg DHA.  Is there any ointment to put on the skin to soften it up, it seems leathery around the ulcers.

[Jo CIMDA]

Hi

This problem will lessen as the preds are lowered and with the addition of EFA's and natural Vitamin E.  The synthetic form of Vit E is not effective, so it has to be the natural type. 

There are several options for softening the skin.

Calendula cream has wound healing properties and is very soothing,  also my vet said Bepanthan cream soothes sore areas of skin and it is gentle as it can be on tender skin of premature babies. Likewise Sudacrem (nappy cream) can be used for dogs. (I have used all three of these creams)   

Aveeno is another human product that can be bought over the counter and his used for moisturising and healing inflamed skin. 

I came across this cream but I haven't used it:

http://www.sheaalchemy.co.uk/ingredients/ccfd50.html

I do hope you see an improvement very soon.

Jo

[Arinashdad]

I took Puddles to the vet on Monday and she agrees with what I suspected from the beginning and thinks she has CC.  She also said some of the skin is dead (about the 1.5 inches round).  She suggested doing a biopsy Thursday morning to see what medicine is needed to treat the infection (started oozing pus Sunday morning). We have been rinsinsing the wound with Chlorhexidine Gluconate diluted with saline  and then rinsed with a saline solution about 3 times a day.  I'm not excited about them removing the areas with the dead skin and was wondering what your thoughts are.  Thank you.

[Jo CIMDA]

Hi

I am not a vet and I can only give you a personal opinion. If Puddles were mine I would definitely not have a biopsy done for these reasons.  Whilst Puddles is on prednisolone the healing capacity of the skin is greatly reduced and as a result it inhibits healing of any sores, lesions or surgery.   You may end up with areas that have been biopsied and will not heal until the preds are so much lower.  This wounded skin and tissue then leads to a risk of secondary infection.

Also, if Puddles is going to be put under a general anaesthetic for this biopsy then I certainly wouldn't agree to this as it could yet again trigger an AI response and you may get a flare up of the IMHA. 

Why can't your vet treat these sores speculatively? this is the usual course of action.  CC happens when a dog has been on steroids and has iatrogenic Cushing's syndrome.  It is not an unknown problem.  You have to take steps to improve the skin and strengthen the skin barrier, deal with any secondary infection and use appropriate preparations to lessen the effect of CC until such times the steroids can be significantly reduced and hopefully withdrawn.

http://www.nevetdermatology.com/calcinosis-cutis-in-dogs/ 

Calcinosis cutis usually resolves with removal of the underlying cause. It is important to treat all secondary infections. Frequent bathing in medicated shampoos and hydrotherapy are helpful. Sometimes, surgical removal of isolated lesions may be recommended if the surgeon feels wound healing would be successful in the individual patient. Recently, the use of minocycline for treatment of CC was reported. Though minocycline is an antibiotic, it chelates calcium and directly inhibits collagenolytic enzymes. Treatment with DMSO gel may hasten resolution of lesions. A thin film is applied 1-2 times a day. If glucocorticoids are being used and are the cause they must be tapered and discontinued. Resolution is not immediate and takes time. The skin often looks worse before it looks better.

I have to repeat that this is only my personal opinion.

The whole picture is to be considered not just the CC and Puddles has had a serious AI disease, and she is not yet in remission, and she has still not finished treatment yet.  I would allow the treatment for her AI disease to be completed and then reassess her skin issues.  Common sense is needed.

Good luck

Jo

[Arinashdad]

The vet is worried about the skin causing her to become septic and can she continue another 2 months of Prednisone until we get her reduced down to a small enough dosage to correct the problem? 

[Jo CIMDA]

HI

I have know dogs with CC to be managed on antibiotic treatment and lotions/shampoos etc.  How about a compromise and ask your vet about using minocycline as the article previously referenced suggests?

Minocycline/doxycycline/tetracycline are all from a group of antibiotics that also have immunomodulatory and anti-inflammatory effects and are used in the treatment of autoimmune skin disease.  Also, essential fatty acids are known to be 'steroid sparing' and assist in immunosuppression and natural Vitamin E encourages new cell growth.   You have to weigh up the pros and cons of what is suggested.

Jo

[Arinashdad]

I decided to take her back to the hospital where she was diagnosed with the IMHA for a second opinion.  She's with the doctor in the back now.  Thank you.

[Jo CIMDA]

I hope it all goes well.  That is a really good decision.

Jo

[Arinashdad]

Good morning... I wanted to give you a brief update on Puddles and thank you for asking about her through Karen.  She is doing great and her calcinosis seems to be contained for the most part.  We are noticing little spots that are popping up and then they go away.  I think she has some on her left side because the skin seems thicker and has what looks like hives.  The sores on her back look awesome and are healing (most have healed) and now has pink skin.  We are having to keep her back covered with gauze, an ace bandage and diaper to keep her from scratching them.  This Friday will be a week since her reduction from 10mg/day to 5mg/day and her PCV has remained steady at 41% throughout and will be taking her in this week for her CBC.  She's running up the ramp and kicking and running after she potties and is keeping up with the other two when food comes out.  She's a bulldog and has always been laid back and easy going.  Based on what I have seen I don't think she will have a problem with the CC while we wait the 3 weeks before reducing her again.  Thank you again for all your help and advice.  Without you, Karen and Susan we would have probably gone through with the surgery and who knows where we would be now.  Even the doctor was delighted when she saw the wounds weren't deep and she had skin growing under them. 

[Jo CIMDA]

This is brilliant news and you have a lot to look forward to now.

Jo