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KEITH A. HNILICA
ADAM P. PATTERSON
EDITION 4
SMALLDERMATOLOGY
ANIMAL
A COLOR ATLAS AND THERAPEUTIC GUIDE
KEITH A. HNILICA, DVM, MS, MBA, DACVD

The Itch Clinic
Allergy, Dermatology, Otology
Knoxville, Tennessee
www.TheItchClinic.com www.itchnot.com
A DAM P. P ,
ATTERSON DVM, DACVD
Chief of Dermatology
College of Veterinary Medicine & Biological Sciences
Texas A&M University
College Station, Texas
3251 Riverport Lane
St. Louis, Missouri 63043
SMALL ANIMAL DERMATOLOGY: A COLOR ATLAS AND ISBN: 978-0-323-37651-8

THERAPEUTIC GUIDE, FOURTH EDITION
Copyright © 2017, by Elsevier Inc. All rights reserved.

Previous editions copyrighted 2011, 2006, and 2001.
Chapter 14 by Amy Leblanc is the work of US Government employee. Hence, chapter 14 is in public
domain.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Details on how to seek permission, further
information about the Publisher’s permissions policies and our arrangements with organizations such
as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on their
own experience and knowledge of their patients, to make diagnoses, to determine dosages and the
best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Names: Hnilica, Keith A. | Patterson, Adam P.

Title: Small animal dermatology : a color atlas and therapeutic guide / Keith A. Hnilica,
Adam P. Patterson.
Description: Fourth edition. | St. Louis, Missouri : Elsevier, 2016. | Includes index.
Identifiers: LCCN 2016019464 | ISBN 9780323376518 (alk. paper)
Subjects: LCSH: Dogs—Diseases. | Cats—Diseases. | Veterinary dermatology.
Classification: LCC SF992.S55 M44 2016 | DDC 636.7/08965—dc23 LC record available at
https://lccn.loc.gov/2016019464
Content Stategy Director: Penny S. Rudolph

Associate Content Development Specialist: Laura Klein
Publishing Services Manager: Hemamalini Rajendrababu
Project Manager: Umarani Natarajan
Design Direction: Christian J. Bilbow
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Contributors
Cheryl Greenacre, DVM, DABVP (Avian Practice),

DABVP (Exotic Companion Mammal)
Professor
Department of Small Animal Clinical Sciences
College of Veterinary Medicine
University of Tennessee
Knoxvllle, Tennessee
Amy K. LeBlanc, DVM Diplomate ACVIM (Oncology)

Director, Comparative Oncology Program
Center for Cancer Research, National Cancer Institute
National Institutes of Health
Bethesda, Maryland
v
Favorite quotes from Keith’s children and Keith
Choose happiness and never be afraid of hard work.

Sara Mae H.
To have pursued your dreams and fail is better than to have never pursued your dreams at all.
Max T.
Promise me that you will not spend so much time treading water and trying to keep your head
above the waves that you forget, truly forget how much you have always loved to swim.
Tyler Knott Gregson
Sam T.
It’s not about the size of the dog in the fight, it’s about the size of the fight in the dog.
Mark Twain
Caleb M.
I’ve seen a look in a dog’s eyes, a quickly vanishing look of amazed contempt, and I am con-
vinced that basically that dogs think humans are nuts.
John Steinbeck
Caroline M.
Good works matter; DO GOOD WORKS!

Keith A. Hnilica
This book is dedicated to my patients and students. It is only possible because of my great
teachers and mentors who shared their knowledge, wisdom, and know-how—thank you Karen
Campbell, Jennifer Matousek, Carol Lichtensteiger, Linda Frank, Rod Rosychuk, Rosanna
Marsella, George Doering, Patrick Breen, John August, Joanne Mansell, and Mark Hitt. I
cannot thank Keith Hnilica enough for his training in the practical application of veterinary
dermatology because it has helped shape the way I approach and now teach; I am honored
you asked me to join you in this edition. To my parents, Pat and Laura—your love and support
have always been unwavering. And to Carly, my wife—I finally found you.
Only the lead mule gets to enjoy the change in scenery.

Granddaddy
Adam P. Patterson
Preface
From its conception, this textbook was designed to be a practi- Also new in the fourth edition are critical updates on MRS
cal color atlas that also included current treatments for each infections and new ground-breaking therapies for the treat-
disorder. Great effort has gone into making this book an easy- ment of allergy. We have expanded the useful pattern-based
to-use reference for practicing small animal veterinarians and approach concept with additional outlines, charts, and graph-
students alike. This atlas began as a companion text for Muller ics. A breed predilection list has been incorporated for fast
and Kirk’s Small Animal Dermatology; however, it has grown in reference, and disease topographies have been added for the
use and popularity and become a useful, stand-alone textbook most common diseases to simplify the diagnostic process.
in its own right. Expanded Author’s Notes were incorporated to provide a
New to this fourth edition is Dr. Adam P. Patterson, who contemporary feeling for the most important issues surround-
has provided a fresh and enhanced perspective to the science ing select disorders. The Author’s Notes are ultimately the
and skill of practical veterinary dermatology. opinion of the authors; however, the information has been
A key feature of this text is the relevant clinical images. collected from many sources over many years and reflects an
Numerous new images have been added to provide a useful endless pursuit of practical knowledge, which truly makes a
perspective of the most common lesions and patterns caused difference in the diagnosis and treatment of each disease.
by each disease. By reviewing all of the images for a given I hope you find the special efforts taken to provide a practi-
disease, the practitioner should acquire a working knowledge cal approach to veterinary dermatology useful.
of the most common presentations for that disease. Dermatol-
ogy relies heavily on the identification of patterns in the Keith A. Hnilica, DVM, MS, MBA, DACVD
patient’s signalment, history, lesion type, and pattern. The TheItchClinic.com
images in each disease section were selected not for their
extreme nature but rather because each image demonstrates a
common feature of the disease.
ix
Acknowledgments
Many thanks to those whose generosity made this book possible:

Donna Angarano, John MacDonald, Anthony Yu, Gail Kunkle,
Michaela Austel, Craig Greene, Alice Wolfe, Karen Campbell,
Richard Malik, Linda Frank, Lynn Schmeitzel, Patricia White,
Dunbar Gram, Jim Noxon, Linda Messinger, Elizabeth Willis, Terese
DeManuelle, William Miller, Thomas Manning, Kimberly Boya-
nowski, Norma White-Weithers, Manon Paradis, Robert Dunstan,
Kelly Credille, Pauline Rakich, Charles Martin, Clay Calvert, Sherry
Sanderson, Mary Mahaffey, Sue McLaughlin, E. Roberson, Gary
Norsworthy, Michael Singer, Sandy Sargent, Alison Diesel, Amanda
Friedeck, John August, Cheryl Greenacre, Amy LeBlanc, and any
whom we mistakenly missed.
Thank you,
Keith A. Hnilica
Adam P. Patterson
xi
C H A P T E R || 1
Differential Diagnoses
■ Essential Questions ■ Papules
■ Ten Clinical Patterns ■ Miliary Dermatitis
■ What Are the Infections? ■ Plaques
■ Why Are They There? ■ Follicular Casts
■ Differentials Based on Body Region ■ Epidermal Collarettes
■ Diseases Primarily Limited to the Face ■ Comedones
■ Diseases of Nasal Depigmentation ■ Lichenification
■ Diseases with Oral Lesions ■ Inflammatory or Pruritic Alopecic Diseases
■ Ear Margin Dermatitis ■ Noninflammatory or Nonpruritic Alopecic Diseases
■ Nasodigital Hyperkeratosis ■ Cellulitis and Draining Lesions
■ Interdigital Pododermatitis ■ Nodular Diseases
■ Diseases of the Claw ■ Pruritic Diseases
■ Diseases of the Footpads ■ Seborrheic Diseases
■ Differentials Based on Primary and Secondary ■ Hyperpigmentation
Lesions ■ Hypopigmentation
■ Vesicular and Pustular Diseases ■ Breed Predispositions to Select Skin Conditions in
■ Erosive and Ulcerative Diseases Dog and Cats
Almost all dermatology patients have a primary or underlying After the origin of a patient’s dermatosis is known, it is a simple
disease that causes secondary infections. These infections must matter of therapeutic follow-through to resolve the problem.
be eliminated and prevented but will recur rapidly unless the Recognition of basic patterns allows a practical approach
primary disease is identified and controlled. to most of the common skin diseases.
Most skin cases seen in a veterinary practice can be success-
fully managed if two essential questions can be answered: Ten Clinical Patterns
(1) What are the secondary infections? and (2) Why are these What are the secondary infections? (always secondary)
secondary infections there? 1. Folliculitis: Folliculitis is the most common “pattern” of
disease mimicking other patterns. However, it is common
Essential Questions for it to be concurrent with other disease patterns (e.g.,
1. What are the infections? yeast dermatitis). The major differentials to consider for fol
■ Folliculitis liculitis are superficial staphylococcal pyoderma or bacterial
– Pyoderma folliculitis, demodicosis, and dermatophytosis. Pyoderma
– Demodex is the mostly likely cause in the dog, with demodicosis a
– Dermatophyte close second if not a concurrent factor. Juvenile-onset
■ Pododermatitis demodicosis may affect the patient in a symmetric fashion.
– Bacterial A good rule of thumb is to consider all dermatologic
– Yeast patients to have folliculitis until proven otherwise and
■ Otitis then search for predisposing underlying diseases (e.g.,
– Bacterial allergy, endocrinopathy, cornification disorder or defect).
– Yeast 2. Pododermatitis: Always scrape the dorsal pedal surface
■ Malassezia yeast dermatitis when it is alopecic because both demodicosis and allergic
2. Why are they there? skin disease may cause pododermatitis; steroids are not
■ Allergies appropriate for the former. Hemorrhagic bullae are mani-
– Atopy festations of deep pyoderma; therefore, they should be
– Food allergy cultured. A lesion on the paw pads is usually an indica-
– Scabies tion to biopsy. P3 digit amputation is rarely needed
■ Endocrinopathy to make a diagnosis of symmetric lupoid onychodystro-
– Hypothyroidism phy because the history with typical clinical findings is
– Cushing’s sufficient for a firm tentative diagnosis.
1
2 CHAPTER 1 ■ Differential Diagnoses
■ Single paw: trauma, foreign body, infection (e.g., bac- exfoliative dermatitis, plaques, nodules, depigmentation,
teria, yeast), localized demodicosis, cutaneous horn, +/- lesions affecting nonhaired skin, consider cutaneous
neoplasia, arteriovenous pedal fistula T-cell lymphoma (CTCL) and biopsy.
■ Multiple paws: infection (e.g., bacteria, yeast, hook- Distribution patterns and differential diagnoses for
worms, distemper, leishmaniasis), generalized demo pruritus:
dicosis, allergic skin disease, split paw pad disease, ■ Dorsum: pediculosis, cheyletiellosis, flea allergy der-
palmar or plantar interdigital comedones and follicu- matitis (FAD), +/- AD in terriers
lar cysts, autoimmune- or immune-mediated dermato- ■ Face, ears, paws, axillae, inguinum, and perineum: cuta-
sis (e.g., pemphigus foliaceus, vasculitis, symmetric neous adverse food reaction (CAFR), AD
lupoid onychodystrophy or onychomadesis), dermato- ■ Pinnal margins, elbows, hocks, and ventral trunk: sarcop-
myositis, metabolic dermatosis (e.g., hepatocutaneous tic mange
syndrome, zinc-responsive dermatosis, nasodigital ■ Rear or perineum: anal sacculitis, trichuriasis, FAD,
hyperkeratosis), and sometimes neoplasia (e.g., cuta- CAFR, AD, psychocutaneous disorder
neous lymphoma, subungual small cell carcinoma or ■ Sparsely haired body regions: allergic contact dermatitis
melanoma in heavily pigmented dogs) (rare)
3. Otitis: Because the ear is just an extension of the skin, 6. Nonpruritic alopecia (endocrine): Always exclude fol-
a good dermatologic examination of the skin may pro liculitis when confronted with alopecia (especially when
vide clues (other “patterns”) about potential causes of other typical lesions are present) because it is the most
ear disease. Resolution of otitis externa is achievable if common reason for it and often a resultant feature of
primary causes are identified and managed. Similarly, other diseases within the pattern of “nonpruritic sym-
otic cytology should be used on every case to initially metrical alopecia.” Consider an endocrinopathy as a
determine the infection(s) present, as well as monitor cause of recurring infection when pruritus resolves with
response to therapy during reexaminations. By and large, infection control. Exclude castration- or neuter-responsive
correctly administered topical antimicrobial treatments dermatosis, hypothyroidism, and hyperadrenocorticism
(volume and duration) are more effective for infected before considering alopecia X. Many alopecic conditions
canals than systemic therapy. Rigid palpable canals (ossi- have breed predilections, so consult a text for a listing of
fied) are usually beyond medical resolution and would these associations.
be better removed (total ear canal ablation and bulla ■ Endocrinopathy: hypothyroidism, hyperadrenocorti-
osteotomy). cism, sex hormone–related dermatoses
Is the pinna or canal affected? ■ Follicular dysplasias: color dilution alopecia, black hair
■ Pinnae: trauma, aural hematoma, sarcoptic mange, fly follicular alopecia, canine recurrent flank alopecia
bite or strike hypersensitivity, allergic skin or ear (CRFA), breed-related follicular alopecia
disease, ear margin seborrhea or dermatosis, vasculitis ■ Hair cycle arrest: Alopecia X, CRFA, defluxions, canine
or other autoimmune dermatoses, neoplasia pattern alopecia or baldness
■ Otitis externa: facets and differentials (chart below) 7. Autoimmune- or immune-mediated skin disease: Hepa-
4. Malassezia yeast dermatitis: The pattern is characteristic tocutaneous syndrome, zinc-responsive dermatosis, der-
of Malassezia yeast, but any chronic pruritic skin disorder matomyositis, eosinophilic dermatitis with edema (Well’s
may resemble it, including folliculitis (superficial pyo- syndrome), mucocutaneous pyoderma, and some forms
derma, demodicosis, dermatophytosis), ectoparasitism, of dermatophytosis may mimic this pattern of disease.
and allergic skin disease. Yeast dermatitis is often over- Skin biopsy is useful to correctly diagnose the disease so
looked as a cause of pruritic skin disease. The author’s a reasonable prognosis can be offered to the client and a
favorite way to find yeast is with the use of acetate tape treatment plan tailored to the patient can be developed
cytology. Just the finding of a single yeast from rep- (some autoimmune- or immune-mediated diseases do
resentative lesions is significant (yeast hypersensitivity?) not require systemic glucocorticoids).
and warrants topical or systemic (or both) treatment based Distribution patterns and differential diagnoses for
on the severity of pruritus. However, if cytology is “nega- autoimmune- or immune-mediated dermatoses:
tive” for yeast when confronted with this pattern, assume ■ Face, pinnae, or nasal planum: pemphigus foliaceus,
they are there, treat accordingly, and search for predispos- pemphigus erythematosus, discoid lupus erythemato-
ing underlying diseases (e.g., allergy, endocrinopathy, cor- sus, vasculitis, uveodermatologic syndrome, drug
nification defect). reaction, vitiligo
Why are they there? (the key to preventing relapse of ■ Oral cavity +/- other body areas: pemphigus vulgaris,
infections) subepidermal blistering dermatosis, systemic lupus
5. Pruritus (allergies, mites, fleas): When confronted with erythematosus, vasculitis, erythema multiforme, drug
pruritus, always exclude infection and parasites first! reaction
Many times pruritus is reassessed after controlling for ■ Pads and elsewhere on the body: basically any of the
microorganisms before determining the “next step.” aforementioned diseases
Atopic dermatitis (AD) is a clinical diagnosis based on 8. Keratinization defects: Exclude secondary reasons for a
the exclusion of other causes of pruritus; “allergy tests” scaling disorder before considering primary ones. Some
do not diagnosis it. If you see pruritic erythroderma, hereditary cornification defects are tardive, not being
So, What Is the Solution? 3
recognized until the dog is 2 to 5 years old. Follicular

casts are typical of a cornification defect.
What Are the Infections?
■ Primary scaling disorders: primary seborrhea (usually For every dermatitis case every time you evaluate the patient,
of spaniels and terriers), ichthyosis, Schnauzer ask yourself, “What are the infections?”
comedo syndrome, ear margin seborrhea or dermato- Unless you have microscopic vision, answering this ques-
sis, nasal parakeratosis of Labrador retrievers, tail tion will require the use of cytology. Unfortunately, most
gland hyperplasia, nasodigital hyperkeratosis general practices do not routinely perform skin and ear cytol-
■ Secondary scaling disorders: environmental, nutritional, ogy for dermatitis; instead they rely on the doctor’s best guess.
folliculitis, Malassezia dermatitis or otitis, ectoparasit- Sometimes this can be successful (even a broken clock is
ism, leishmaniasis, allergic skin disease, endocrinopa- correct twice a day); however, a more precise method is avail-
thy, follicular dysplasias, hair cycle arrest, sebaceous able. Use of diarrhea and the fecal examination as a compari-
adenitis, autoimmune- or immune-mediated derma- son and as a model for improvement works well because both
toses, metabolic dermatoses (e.g., hepatocutaneous skin cytology and fecal examinations involve the use of a
syndrome, zinc-responsive dermatosis, vitamin A– microscope, can easily identify the type of infection, and can
responsive dermatosis), neoplasia be performed by trained technical staff.
9. Lumps, bumps, and draining tracts: Wear gloves when ■ So why does your clinic perform fecal examinations?
confronted with this pattern of disease because some ■ When is a fecal examination performed (before the doc-
infectious agents are transmissible to people. Infectious tor’s examination or during)?

etiologies must be excluded when these lesions are ■ Who performs the fecal examination?
present. Acral lick dermatitis (lick granuloma) is a form ■ Does the clinic charge for the fecal examination?
of deep pyoderma; tissue culture (deep dermis with epi- The answers to these questions should be the same for skin
dermis removed) is helpful. cytology: The minimum dermatologic database (skin scrap-
■ Infectious inflammatory: bacterial, atypical bacterial, ings, impression smears, tape preps, and otic swabs).
mycobacterial, fungal, oomycete, parasite The practical solution for determining the best method
■ Noninfectious inflammatory: cyst, xanthoma, hygroma, by which to answer the question, “What are the infections?”
cutaneous histiocytosis, pyogranuloma or granuloma is to implement a minimum database infection screening
syndrome, sterile nodular panniculitis, perianal procedure to be performed by the technician before the veteri-
fistula narian examines the patient. Every dermatology patient should
■ Neoplasia: benign, malignant undergo otic cytology, skin cytology (an impression smear or
■ Mineral deposition: calcinosis circumscripta, calcinosis a tape prep), and a skin scrape at every examination (initially
cutis and at every recheck visit). The three-slide technique (Figure
10. Weirdopathies: Commonly, this pattern is an unusual 1-1) can be performed easily and interpreted by a technician
manifestation of an aforementioned “pattern” or is before the doctor completes an evaluation, which is exactly
formed by several overlapping ones. After “folliculitis” how diarrhea and fecal examinations are handled in most
has been excluded, skin biopsy (± culture) is usually clinics. Moving the cytologic evaluation to the beginning of
warranted when confronted with an “oddopathy.” Several the dermatology appointment and thereby empowering the
skin biopsies of representative lesions will help better technical staff to accomplish the evaluation optimizes the
categorize the disease process—infectious, allergic,
autoimmune- or immune-mediated, endocrine or fol
licular abnormality, cornification defect, congenital, or
neoplasia—assuming the proper technique is used and
the pathologist is provided a detailed history with clinical
findings. Ideally, a dermatopathologist should be sought.
Calcinosis cutis often appears as an oddopathy. A patient
with an oddopathy might be best examined by a
dermatologist.
So, What Is the Solution?

A vast majority of dogs with allergy or endocrine disease have
or will have a secondary bacterial or yeast infection. Yeast
dermatitis is the most commonly missed diagnosis in general
practice dermatology. Bacterial pyoderma is often identified
but is usually mistreated with too low doses of antibiotics
administered for too short a time. Otitis is now recognized
and treated better than it was in years past; however, treatment Skin scrape Skin cytology Ear cytology
for otitis that is based on actual documented organism types (cocci/yeast)
and relative counts on follow-up evaluations is a rare FIGURE 1-1 The Three-Slide Technique. Skin scrapes, cutaneous
occurrence. cytology, and otic swabs.
dermatology appointment and provides essential information

AUTHOR’S NOTE
in the most efficient manner.
When an owner brings a pet into the clinic for a small Could clinical dermatology really be this easy?
hairless spot, it would be appropriate to question the necessity Yes. Unfortunately, most of us were taught derma-
for an otic cytology even when there is no sign of otitis and tology from the perspective of a NASA engineer
when the hairless spot is the problem. However, the three- who is determined to address and eliminate every
slide technique is most helpful in these exact types of cases. If possible scenario regardless of how rare its occur-
focal pruritus occurs in a dog and the patient has a secondary rence. Based on any standard of logic, statistics, or
otitis (which the technician identified during the infection common sense, the most likely disease should be
screen), the veterinarian should more aggressively discuss this addressed first. It is illogical to perform diagnostic
and work up the patient for possible allergy. If the patient did tests or therapeutic trials for rare or unlikely dis-
not have otitis, the pruritus could be minimized in the hope eases as part of the initial dermatologic workup, yet
that it was a short-term problem that is likely to self-resolve. this is exactly how most veterinarians are taught to
Similarly, there is no excuse for mistreating a patient who diagnose atopy: “a diagnosis of exclusion.” If a
has demodicosis. Lesions caused by demodicosis can look patient is seasonally foot licking, the most likely
identical to folliculitis lesions caused by bacterial pyoderma diagnosis is atopy.
and dermatophytosis. Clinical appearance is not an acceptable
criterion for ruling in or ruling out demodicosis. When the
technician performs a skin scrape as part of the infection
screen, demodicosis can be identified and treated easily and
accurately. Optimizing owner understanding and compliance: Much of
the problem that veterinarians face when treating an aller-
gic patient is the pet owner’s lack of understanding and
Why Are They There? ability to adhere to long-term prevention and treatment
Infections are always secondary to a primary disease; however, protocols. There is great information available regarding
all too often, the patient is not evaluated or treated for the cognitive psychology that can optimize the human
primary disease for three main reasons: (1) only the secondary factors that limit successful outcomes. Here are some
infections are treated over and over again, (2) the nature of suggestions:
the allergy is confusing, and (3) cheap steroids that have 1. Have the pet owner complete a patient history form.
delayed repercussions are accessible. This allows the client to focus on the details of the skin
Why are the infections there? This question should be disease and symptoms and primes the client to listen
asked and answered for every dermatology patient if successful better and accept the diagnosis and information that
outcomes are to be achieved. will be provided by the veterinarian.
Most dermatology patients have allergy or endocrine 2. Try to avoid a rambling, stream-of-consciousness
disease. Through signalment, a good patient history, and rec- approach to the discussion of allergy. Many of us have
ognition of unique patterns of lesions, a prioritized differen- an “automatic” allergy spiel that only confuses the
tial list can be formulated quickly. client and dose not focus on the specific problems of
By knowing the most unique and frequent symptoms asso- the individual patient.
ciated with each allergic disease, an astute clinician can deter- 3. Use simplified charts and handouts to organize the
mine the most likely allergy with approximately 85% accuracy; diagnosis and treatment phases of the allergy educa-
this rate rivals many other diagnostic testing results for some tion discussion. These focus the educational message
of the most common assays. and improve the understanding of the client. Addition-
For example, a dog that is foot licking is likely atopic. If the ally, draw and write on these handouts and give
owner reports a seasonal pattern to the podopruritus, then you them to the client to review later. This increases accep-
have a reasonably accurate diagnosis—EASY. tance of the message and improves compliance with
Atopy: foot licking; seasonal; when pruritus first started, typi- therapy.
cally between 1 and 3 years of age 4. Organize the diagnostic testing and treatment options
Food allergy: perianal dermatitis (erythema, alopecia, licheni- into groups based on the severity of the patient and
fication); gastrointestinal disease; younger than 1 year old response to previous treatments (mild patients need a,
or older than 5 years of age when started; German breeds b, c; moderately severe patients need d, e, f; and severe
Flea allergy: dermatitis predominantly affecting the lumbar patients need g, h, i).
region (caudal to the last rib) 5. Assess the risk to the patient and family members
Scabies: positive pinnal-pedal reflex (ear scratch test) for methicillin-resistant Staphylococcus aureus (MRS)
Hypothyroidism: large-breed dog that is disproportionately infections. Families at risk for MRS contagion and zoo-
obese for food intake and has a poor hair coat with areas nosis must be willing to accept aggressive medical
of alopecia over areas of friction management to reduce the risk. All three species of
Cushing’s disease: patient with a long history of steroid MRS can be transmitted from dogs to people and from
abuse, or small-breed dog with polyphagia, polyuria (PU), people to dogs. If family members have a history of
and polydipsia (PD), and symmetrical alopecia MRS, consider aggressively monitoring the patient with
Why Are They There? 5
cultures because dogs can acquire MRS from humans. need the most aggressive diagnostic workup and treat-
If family members are immunosuppressed, monitor ments achievable to protect the entire family from con-
the patient for MRS pseudintermedius and MRS tagion and zoonosis. In these families, avoid the use of
schleiferi, which can be a source of contagious infection steroids or fluoroquinolone antibiotics, which can
to at-risk, immunosuppressed people. These patients increase the risk of MRS.
Text continued on p. 12
WHAT IS MAKING MY DOG SO ITCHY?

Evaluation Form
A thorough history can help us find the source of your dog’s itching more quickly.
Please answer the following questions to help guide the diagnostic process.
Date Pet owner name
Name of dog Age Breed Weight
PHYSICAL EVALUATION
Please check any that describe your dog and circle problem areas on the drawing.
Hair loss
Foul odor
Inflammation or redness
Itching/Scratching CIRCLE PROBLEM AREAS
(Itching, hair loss, lesions, etc.)
Otitis (ear infections)
Licking/Chewing
Skin lesions (sores)
Changes in skin (reddish brown stains, discolorations and/or areas that are thick and leathery)
Other
• Has your dog ever had ear problems? Yes No
• Does your dog have any chronic gastrointestinal signs like diarrhea or vomiting? Yes No
SEVERIT Y EVALUATION On a scale of 0 to 10 rank the severity of your dog’s symptoms.

SEVERITY OF CONDITION OVERALL
0 1 2 3 4 5 6 7 8 9 10
No symptoms Severe
SEVERITY OF SKIN LESIONS

0 1 2 3 4 5 6 7 8 9 10
No lesions Severe
SEVERITY OF SCRATCHING/LICKING/CHEWING
0 1 2 3 4 5 6 7 8 9 10
No signs Severe
ONSET AND SEASONALIT Y EVALUATION

• Yes No
<1 yr 1-3 yrs 4-7 yrs 7+ yrs
– If no, has it occurred around the same time of year each time? Yes No
– If no, approximate time of year symptoms occur.
• How long have the current symptoms been going on?
• Did the itch start gradually and over time become worse? Yes No
• Did the itch come on suddenly without warning? Yes No
• Simultaneous
PAR ASITE CONTROL

• Yes No
– If yes, what product(s)?
• What months do you administer the preventative?
• When was the last time you administered the parasite control?
FIGURE 1-2 Medical History and Information Forms (A–F) to be Filled Out by Owners. (Courtesy Novartis Animal Health US, Inc.)
Novartis Animal Health is now Elanco.
LIFE ST YLE EVALUATION

• Where does your dog live? ❑ Indoors ❑ Outdoors ❑ Both
– If outdoors, please describe environment:
• Are there other pets in your household? ❑ Yes ❑ No
– If yes, do these pets have the same symptoms? ❑ Yes ❑ No
– If these pets are cats, do they go outside? ❑ Yes ❑ No
• Do you board your dog, take him or her to obedience school, training or groomers? ❑ Yes ❑ No
– If yes, when was the last time you took your dog?
• Have you taken your dog on a trip to another location? ❑ Yes ❑ No
– If yes, please indicate when and location:
• Have you recently moved? ❑ Yes ❑ No
• Have you been to a new dog park or walking trail? ❑ Yes ❑ No
• Have you used any new shampoo or topical skin treatments recently? ❑ Yes ❑ No
• Are any humans in your household exhibiting signs? ❑ Yes ❑ No
DIETARY EVALUATION
• What pet food are you feeding?
• Do you feed the same food all the time or provide a variety? ❑ Always same ❑ Variety
• Have you changed his or her diet recently? ❑ Yes ❑ No
• Do you give your dog packaged treats? ❑ Yes ❑ No
• Do you feed your dog “human” food? ❑ Yes ❑ No
REL ATIONSHIP/BEHAVIORAL EVALUATION

Indicate if and how your dog’s itching has affected his/her behavior and relationship with you. (CIRCLE ALL APPROPRIATE ANSWERS)
SLEEPS THROUGH THE NIGHT
Always Usually Occasionally Never
ACTIVITY LEVEL
Inactive Much less active Somewhat less active No change
SOCIAL BEHAVIOR
Unsocial A lot less social Somewhat less social No change
RELATIONSHIP CHANGES
Fewer walks No longer sleeps in bed/same room Interacts less with family
PRIOR TREATMENTS
• Has your dog been treated for itching before? ❑ Yes ❑ No
• Indicate previous treatments administered to your dog: (CHECK ALL THAT APPLY)
❑ Steroids ❑ Shampoos ❑ Sprays ❑ Ointments ❑ Antibiotics ❑ Hypoallergenic food
❑ Essential fatty acids ❑ Antihistamines ❑ Immunotherapy
❑ Other (PLEASE SPECIFY)
Next Steps
Laboratory Testing:
Physical Exam:
Ear Swab–To identify any infections in the ear including yeast
A thorough physical evaluation and/or bacteria.
of your dog will help us
Skin Scrape/Hair Pluck–To detect scabies or demodex mites.
identify obvious problems and
conditions like parasites. Impression Smear/Tape Prep–To detect other parasites and
check for presence of yeast and/or bacteria.
©2008 Novartis Animal Health US, Inc. ATO080228A
FIGURE 1-2, cont’d Continued

DERMATOLOGY WORK-UP
SEVERITY OF ITCHING PET’S NAME:
1 2 3 4 5 6 7 8 9 10
Minor Severe
1 WHAT ARE THE INFECTIONS?

Perform 3-Slide Technique during the physical exam on multiple sites/lesions.
TM
Slide 1 Skin Scrape (hairplucks): Positive for / Negative

Slide 2 Ear Swab: Positive for / Negative
Slide 3 Tape Prep/Impression Smear: Positive for / Negative
Pyoderma Otitis (Cocci, Yeast, Pseudomonas)
Demodex Pododermatitis (Cocci, Yeast)
Dermatophytosis Yeast Dermatitis
2 COMMON ALLERGIC SIGNS1
A. LUMBAR DERMATITIS B. EAR-SCRATCH TEST

Flea Allergy: (very reliable pattern) Scabies: (1-2 are highly reliable)
1. Caudal 1/3 of body
2. Ear margin, distal legs, lateral elbow, ventrum
3. Multiple animals involved or humans affected 3. Variable responsive to steroids
4. Variable response to steroids
5. Fall and Spring are often worse but can 5. Skin Scrapes are often falsely negative
be year-round
C. PERIANAL DERMATITIS
S D. FFOOT LICKING
Food Allergy: (less common but
ut Atopic
A
Atop Dermatitis:
1-5 increase probability) (1-5 are highly reliable)
(1-
1. Perianal dermatitis 1. Started at
2. GI symptoms; more than 6 months – 3 years of age
ting,
3 BM/day, diarrhea, vomiting, 2. Front feet affected
3. Inner ear pinnae erythema
3. Less than 1 year or older than
5 years at onset 4. Lives indoors
4. Labradors and German Breeds may 5. Ruling out Scabies (ear margin
be predisposed dermatitis) and Flea Allergy
(lumbar dermatitis)
5. Variable response to steroids
6. Seasonal symptoms progressing
Hypothyroidism: (can mimic allergic dermatitis) to year-round
1. Recurrent infection may cause pruritus
2. Lethargy, weight gain, dry coat, hypotrichosis
3. Nonpruritic when infections are resolved
FIGURE 1-2, cont’d

2 PATTERN RECOGNITION
Flea Allergy Atopy Scabies
3
Food Allergy Yeast (Malassezia) Pyoderma (Bact)
TREAT THE ACUTE FLARES:
3 Cause Recommended Treatment

Bacterial Pyoderma
Yeast Infections
Otitis
Flea Infestation
Scabies Treatment
Steroid “Crisis” Therapy
Topical Short-Term Steroid
TREATMENT, CONTROL AND PREVENTION OF FUTURE FLARES:
Cause Recommended Treatment

Immunotherapy
4
Allergy Vaccine
Atopy
Atopica® (Cyclosporine
capsules, USP) MODIFIED
Thyroid Supplementation bid
AVOIDING THE TRIGGERS:
Cause Treatment Recommended Treatment

Bacteria Regular bath with an antimicrobial
Yeast shampoo. Wipe off affected areas (feet,
Pollens face, etc.) as often as possible
Otitis Routine Ear Treatment/cleaning
Flea and Intestinal Parasites Year-round Prevention
Food Triggers Restricted diet
House Dust Mites Dehumidify, replace dog bed,
anti-allergy spray (benzyl benzoate)
PROMOTE SKIN HEALTH AND RESTORE BARRIER FUNCTION:
Cause Recommended Treatment

Essential Fatty Acids
Antihistamines
Soothing, Leave on
Conditioner
RECHECK APPOINTMENT: ________________________________________________

1
Source: Keith Hnilica, DVM, MS, DACVD.
2
Source: R.S. Mueller DipACVD, FACVSc, S.V. Bettenay BVSc, FACVSc, and M.Shipstone BVSc, DipACVD, FACVSc: Value of the pinnal-pedal
The Veterinary Record, Vol 148, Issue 20, 621-623.
3
Source: The ACVD task force on canine atopic dermatitis (XIV): clinical manifestations of canine atopic dermatitis, 2001.
4
© 2011 Novartis Animal Health US, Inc. 3-Slide Technique is a trademark of Novartis AG. ATO110020A
FIGURE 1-2, cont’d Continued

HOW ITCHY IS YOUR DOG?

DAILY ITCH REPORT CARD
Keep track of how itchy your dog is for the next 30 PET’S NAME:
days. Measure the severity of itch on a scale of 1-10,
PET OWNER:
1 being mild and 10 being the most severe. Bring this
report card back on your next visit. START DATE:
SEVERITY OF ITCHING
DAY 1 1
Minor
2 3 4 5 6 7 8 9 10
Severe
DAY 2 1 2 3 4 5 6 7 8 9 10
DAY 3 1 2 3 4 5 6 7 8 9 10
DAY 4 1 2 3 4 5 6 7 8 9 10
DAY 5 1 2 3 4 5 6 7 8 9 10
DAY 6 1 2 3 4 5 6 7 8 9 10
DAY 7 1 2 3 4 5 6 7 8 9 10
DAY 8 1 2 3 4 5 6 7 8 9 10
DAY 9 1 2 3 4 5 6 7 8 9 10
DAY 10 1 2 3 4 5 6 7 8 9 10
DAY 11 1 2 3 4 5 6 7 8 9 10
DAY 12 1 2 3 4 5 6 7 8 9 10
DAY 13 1 2 3 4 5 6 7 8 9 10
DAY 14 1 2 3 4 5 6 7 8 9 10
DAY 15 1 2 3 4 5 6 7 8 9 10

SEVERITY OF ITCHING
DAY 16 1
Minor
2 3 4 5 6 7 8 9 10
Severe
DAY 17 1 2 3 4 5 6 7 8 9 10
DAY 18 1 2 3 4 5 6 7 8 9 10
DAY 19 1 2 3 4 5 6 7 8 9 10
DAY 20 1 2 3 4 5 6 7 8 9 10
DAY 21 1 2 3 4 5 6 7 8 9 10
DAY 22 1 2 3 4 5 6 7 8 9 10
DAY 23 1 2 3 4 5 6 7 8 9 10
DAY 24 1 2 3 4 5 6 7 8 9 10
DAY 25 1 2 3 4 5 6 7 8 9 10
DAY 26 1 2 3 4 5 6 7 8 9 10
DAY 27 1 2 3 4 5 6 7 8 9 10
DAY 28 1 2 3 4 5 6 7 8 9 10
DAY 29 1 2 3 4 5 6 7 8 9 10
DAY 30 1 2 3 4 5 6 7 8 9 10
© 2010 Novartis Animal Health US, Inc. ATO100022A

Differentials Based on Body Region
Diseases Primarily Limited to the Face

Dogs
Mucocutaneous pyoderma
Nasal pyoderma
Chin pyoderma
Eosinophilic furunculosis of the face
Pemphigus erythematosus
Pemphigus foliaceus
Discoid lupus erythematosus
Uveodermatologic syndrome
Juvenile cellulitis
Nasal depigmentation
(Early) Familial canine dermatomyositis
FIGURE 1-4 Nasal Depigmentation.
Cats
Discoid lupus erythematosus Diseases with Oral Lesions
Feline acne
Mosquito bite hypersensitivity Dogs
Idiopathic facial dermatitis of Persian cats Candidiasis
Indolent ulcer Pemphigus vulgaris
Feline herpes or rhinotracheitis virus dermatitis Bullous pemphigoid
Feline solar dermatosis Systemic lupus erythematosus
Vesicular cutaneous lupus erythematosus
Eosinophilic granuloma
Cutaneous drug reaction
Vasculitis
Erythema multiforme or toxic epidermal necrolysis
Contact dermatitis
Epitheliotropic lymphoma
Melanoma
Squamous cell carcinoma
Cats
Indolent ulcers
Eosinophilic granuloma
Pemphigus vulgaris
FIGURE 1-3 Facial Dermatitis. Bullous pemphigoid
Systemic lupus erythematosus
Diseases of Nasal Depigmentation Contact dermatitis
Dogs Vasculitis
Contact dermatitis Squamous cell carcinoma
Pemphigus erythematosus Epitheliotropic lymphoma
Pemphigus foliaceus
Pemphigus vulgaris
Bullous pemphigoid
Discoid lupus erythematosus
Vitiligo
Neoplasia (cutaneous lymphoma)
Differentials Based on Body Region 13
FIGURE 1-5 Oral Lesions. FIGURE 1-6 Ear Margin Dermatitis.
Ear Margin Dermatitis Nasodigital Hyperkeratosis

Dogs Dogs
Canine leproid granuloma syndrome Canine distemper
Scabies Leishmaniasis
Fly bite dermatitis Zinc-responsive dermatosis
Ear margin dermatitis Hepatocutaneous syndrome
Vasculitis Idiopathic nasodigital hyperkeratosis
Pemphigus erythematosus Hereditary nasal parakeratosis of Labrador retrievers
Pemphigus foliaceus Familial footpad hyperkeratosis
Pemphigus vulgaris Pemphigus foliaceus
Bullous pemphigoid Systemic lupus erythematosus
Discoid lupus erythematosus Cutaneous horn
Drug reactions
Solar dermatitis
Cats
Atopy
Food allergy
Mosquito bite hypersensitivity
Eosinophilic plaque
Feline scabies
Vasculitis
Pemphigus foliaceus
Pemphigus vulgaris FIGURE 1-7 Nasal Keratosis.
Bullous pemphigoid
Systemic lupus erythematosus Interdigital Pododermatitis
Drug reactions
Solar dermatitis
Dogs
Squamous cell carcinoma Bacterial infections
Malassezia
Dermatophytosis
Demodicosis
Trombiculiasis
Hookworm dermatitis
Pelodera dermatitis
Atopy
Food hypersensitivity
Contact dermatitis
Interdigital pyogranuloma
Neoplastic tumor
Differentials Based on Body Region—cont’d
Cats Diseases of the Footpads

Bacterial infections
Dermatophytosis Dogs
Malassezia Contact dermatitis
Trombiculiasis Canine distemper
Neoplastic tumor Leishmaniasis
Pemphigus foliaceus
Pemphigus vulgaris
Bullous pemphigoid
Vasculitis
Hepatocutaneous syndrome
Familial footpad hyperkeratosis
Idiopathic nasodigital hyperkeratosis
Zinc-responsive dermatosis
Cutaneous horn
Cats
Plasma cell pododermatitis
Mosquito bite hypersensitivity
FIGURE 1-8 Interdigital Pododermatitis. Contact dermatitis
Pemphigus foliaceus
Diseases of the Claw Pemphigus vulgaris
Bullous pemphigoid
Dogs Systemic lupus erythematosus
Trauma Vasculitis
Bacterial infections Hepatocutaneous syndrome
Dermatophytosis
Leishmaniasis Cutaneous Horn
Vasculitis
Symmetrical lupoid onychodystrophy
Melanoma
Cats
Trauma
Bacterial infections
Dermatophytosis
Vasculitis
Pemphigus foliaceus
FIGURE 1-10 Diseases of the Footpads.
FIGURE 1-9 Diseases of the Claw.

Differentials Based on Primary and Secondary Lesions 15
Differentials Based on Primary and Secondary Lesions
Vesicular and Pustular Diseases Erosive and Ulcerative Diseases

(Uncommon but specific lesions associated with folliculitis or (Uncommon and nonspecific lesions often subsequent to a
autoimmune skin diseases) vesicle or pustule usually caused by infection or autoimmune
skin diseases)
Dogs
Chin pyoderma Dogs
Superficial pyoderma Mucocutaneous pyoderma
Impetigo Pyotraumatic dermatitis
Dermatophytosis Deep pyoderma
Contact dermatitis Candidiasis
Pemphigus foliaceus Protothecosis
Pemphigus erythematosus Blastomycosis
Pemphigus vulgaris Cryptococcosis
Bullous pemphigoid Fly bite dermatitis
Systemic lupus erythematosus Rocky Mountain spotted fever (RMSF)
Vesicular cutaneous lupus erythematosus Cutaneous leishmaniasis
Cutaneous drug reaction Neosporosis
Epidermolysis bullosa Pemphigus vulgaris
Canine familial dermatomyositis Bullous pemphigoid
Subcorneal pustular dermatosis Systemic lupus erythematosus
Sterile eosinophilic pustulosis Vesicular cutaneous lupus erythematosus
Vasculitis
Cats Erythema multiforme or toxic epidermal necrolysis
Superficial pyoderma Cutaneous drug reaction
Impetigo Epidermolysis bullosa
Dermatophytosis Canine familial dermatomyositis
Contact dermatitis Perianal fistulae
Pemphigus foliaceus Neoplasia
Pemphigus vulgaris Cats
Cutaneous drug reaction Pyotraumatic dermatitis
Epidermolysis bullosa Candidiasis
Sporotrichosis
Blastomycosis
Feline calicivirus
Feline rhinotracheitis virus
Cutaneous leishmaniasis
Neosporosis
Pemphigus vulgaris
Vasculitis
Epidermolysis bullosa
Eosinophilic plaque
Indolent ulcer
Plasma cell podermatitis
Idiopathic ulcerative dermatosis
Feline solar dermatosis
FIGURE 1-11 Vesicle Pustule. Neoplasia
Differentials Based on Primary and Secondary Lesions—cont’d
Trombiculiasis
Pediculosis
Feline immunodeficiency virus (FIV) infection
Atopy
Flea allergy dermatitis
Contact dermatitis
Pemphigus foliaceus
Pemphigus vulgaris
Early neoplasia
FIGURE 1-12 Ulcer Erosion.
Miliary Dermatitis
Papules
(Nonspecific lesions caused by a cellular infiltrate)
Cats
Superficial pyoderma
Dogs Dermatophytosis
Demodicosis
Chin pyoderma
Cheyletiellosis
Ear mites
Impetigo
Atopy
Dermatophytosis
Canine scabies
Cheyletiellosis
Pemphigus foliaceus
Ear mites
Lupus
Trombiculiasis
Pediculosis
FIV infection
Atopy
Flea allergy
Food allergy
Contact dermatitis
Pemphigus foliaceus
Pemphigus vulgaris
Bullous pemphigoid
Canine familial dermatomyositis
Subcorneal pustular dermatosis
Sterile eosinophilic pustulosis
Calcinosis cutis
FIGURE 1-13 Miliary Dermatitis.
Early neoplasia
Plaques
Cats (Larger lesions that usually are formed by numerous papules
Superficial pyoderma that coalesce)
Dermatophytosis
Demodicosis Dogs
Canine scabies Dermatophytosis
Cheyletiellosis Contact dermatitis
Ear mites Cutaneous drug reaction
Calcinosis cutis
Early neoplasia
Cats
Dermatophytosis
Demodicosis
Cheyletiellosis
Ear mites
Trombiculiasis
FIV infection
Contact dermatitis
FIGURE 1-16 Follicular Cast.
Epidermal Collarettes
(Specific lesions that develop subsequent to a pustule or
vesicle; most often found in association with folliculitis)
Dogs
Impetigo
Demodicosis
Dermatophytosis
Pemphigus foliaceus
FIGURE 1-14 Plaque.
Follicular Casts
(Specific lesions often associated with primary keratinization
defects)
Dogs
Primary seborrhea
Vitamin A–responsive dermatosis
Sebaceous adenitis
FIGURE 1-17 Epidermal Collarette.
Comedones
(Specific lesions that are caused by plugging of the hair
follicles)
Dogs
Chin pyoderma
Demodicosis
Dermatophytosis
Canine hyperadrenocorticism
Schnauzer comedone syndrome
Vitamin A–responsive dermatosis
Hairless breeds
Color dilution alopecia
FIGURE 1-15 Excoriation. Follicular dysplasias
Cats Inflammatory or Pruritic

Feline acne Alopecic Diseases
(Nonspecific lesions caused by any inflammatory dermatitis)
Dogs
Mucocutaneous pyoderma
Pyotraumatic dermatitis
Malasseziasis
Canine scabies
Cheyletiellosis
Ear mites
Trombiculiasis
Pediculosis
Hookworm dermatitis
Pelodera dermatitis
Atopy
FIGURE 1-18 Comedone.
Contact dermatitis
Pemphigus foliaceus
Acral lick dermatitis
Lichenification Subcorneal pustular dermatosis
(Characteristic lesion of yeast dermatitis in dogs but can also Sterile eosinophilic pustulosis
be caused by chronic inflammatory disease) Hepatocutaneous syndrome
Dogs Cats
Malasseziasis Superficial pyoderma
Chronic inflammation Pyotraumatic dermatitis
Parasitic infections Malasseziasis
Hypersensitivities Feline scabies
Keratinization diseases Cheyletiellosis
Ear mites
Trombiculiasis
Pediculosis
Atopy
Contact dermatitis
Idiopathic facial dermatitis of Persian cats
Psychogenic alopecia
Feline lymphocytic mural folliculitis
Eosinophilic plaque
Idiopathic ulcerative dermatosis
Feline paraneoplastic alopecia
FIGURE 1-19 Lichenification.

FIGURE 1-20 Inflammatory Alopecia.
FIGURE 1-21 Noninflammatory Alopecia.

Noninflammatory or Nonpruritic
Alopecic Diseases Cellulitis and Draining Lesions
(Relatively specific lesions associated with endocrine disease (Nonspecific lesions caused by severe cellular infiltrates;
or follicular dysplasia) usually associated with infection or neoplasia)
Dogs Dogs
Hyperadrenocorticism Deep pyoderma
Hypothyroidism Actinomycosis
Sex hormone imbalance Nocardiosis
Alopecia X Opportunistic mycobacteriosis
Recurrent flank alopecia Tuberculosis
Congenital hypotrichosis Pythiosis
Color dilution alopecia Lagenidiosis
Black hair follicular dysplasia Zygomycosis
Canine pattern baldness Blastomycosis
Idiopathic bald thigh syndrome of greyhounds Coccidiomycosis
Anagen and telogen defluxion Juvenile cellulitis
Postclipping alopecia Blepharitis
Traction alopecia Perianal fistulae
Injection reaction
Alopecia areata Cats
Subcutaneous abscess
Cats Actinomycosis
Allergic alopecia L-form infection
Hyperadrenocorticism Nocardiosis
Congenital hypotrichosis Opportunistic mycobacteriosis
Feline preauricular and pinnal alopecia Tuberculosis
Anagen and telogen defluxion Plague
Injection reaction Phaeohyphomycosis
Alopecia areata Pythiosis
Feline lymphocytic mural folliculitis Lagenidiosis
Sporotrichosis
Zygomycosis
Blastomycosis
Coccidiomycosis
Blepharitis
Anal sac disease
Canine solar dermatosis

Neoplastic tumors
Nodular dermatofibrosis
Fibropruritic nodule
Collagenous nevus
Follicular cyst–intraepidermal inclusion cyst
Calcinosis circumscripta
Cats
Botryomycosis
Actinomycosis
Nocardiosis
Opportunistic mycobacteriosis
Subcutaneous abscess
Feline leprosy
FIGURE 1-22 Cellulitis. Plague
Tuberculosis
Nodular Diseases Dermatophytosis
Eumycotic mycetoma
(Nonspecific lesions caused by any cellular infiltrate; most
Phaeohyphomycosis
often associated with neoplasia or infection)
Protothecosis
Pythiosis
Dogs Lagenidiosis
Botryomycosis Sporotrichosis
Actinomycosis Zygomycosis
Nocardiosis Blastomycosis
Opportunistic mycobacteriosis Coccidiomycosis
Subcutaneous abscess Cryptococcosis
Tuberculosis Histoplasmosis
Canine leproid granuloma syndrome Cuterebra
Dermatophytosis Dracunculiasis
Eumycotic mycetoma Feline cowpox
Phaeohyphomycosis Viral papillomatosis
Protothecosis Leishmaniasis
Pythiosis Cutaneous neosporosis
Lagenidiosis Sterile nodular panniculitis
Sporotrichosis Eosinophilic granuloma
Zygomycosis Neoplastic tumors
Blastomycosis Follicular cyst–intraepidermal inclusion cyst
Coccidiomycosis
Histoplasmosis
Cuterebra
Dracunculiasis
Viral papillomatosis
Leishmaniasis
Cutaneous neosporosis
Cutaneous vesicular lupus erythematosus
Sterile nodular panniculitis
Idiopathic sterile granuloma and pyogranuloma
Tail gland hyperplasia
Acral lick dermatitis
Callus
Hygroma
Eosinophilic granuloma FIGURE 1-23 Nodules.
Pruritic Diseases
(Nonspecific symptoms caused by any inflammatory dermati-
tis; some diseases have characteristic patterns that are more
clinically relevant)
Dogs
Malasseziasis
Canine scabies
Cheyletiellosis
Ear mites
Trombiculiasis
Pediculosis
Hookworm dermatitis
Pelodera dermatitis
Atopy FIGURE 1-24 Pruritus.
Contact dermatitis Seborrheic Diseases
Pemphigus foliaceus (Nonspecific lesions that usually are secondary to a primary
Acral lick dermatitis dermatologic disease but can be caused by a primary keratini-
Subcorneal pustular dermatosis zation defect)
Sterile eosinophilic pustulosis
Hepatocutaneous syndrome Dogs
Cutaneous lymphoma
Malasseziasis
Cats Dermatophytosis
Superficial pyoderma Demodicosis
Malasseziasis Canine scabies
Feline scabies Cheyletiellosis
Cheyletiellosis Pediculosis
Ear mites Leishmaniasis
Trombiculiasis Food hypersensitivity
Pediculosis Pemphigus foliaceus
Atopy Pemphigus erythematosus
Food hypersensitivity Systemic lupus erythematosus
Flea allergy dermatitis Cutaneous drug reaction
Contact dermatitis Hyperadrenocorticism
Idiopathic facial dermatitis of Persian cats Hypothyroidism
Psychogenic alopecia Sex hormone imbalances
Feline lymphocytic mural folliculitis Canine primary seborrhea
Eosinophilic plaque Vitamin A–responsive dermatosis
Idiopathic ulcerative dermatosis Ichthyosis
Feline paraneoplastic alopecia Epidermal dysplasia of West Highland white terriers
Hepatocutaneous syndrome Sebaceous adenitis
Zinc-responsive dermatosis
Canine ear margin seborrhea
Neoplasia
Cats Hyperpigmentation
Superficial pyoderma (Common, usually nonspecific, change caused by inflamma-
Dermatophytosis tion of long duration)
Malasseziasis
Demodicosis Dogs
Feline scabies
Lentigo
Cheyletiellosis
Chronic trauma
Cat fur mite
Chronic inflammation
Pediculosis
Allergy
Pemphigus foliaceus
Post-infection
Cushing’s
Sex hormone alopecia
Alopecia X
Recurrent flank alopecia
Melanoma
Idiopathic facial dermatitis of Persian cats
Neoplasia
FIGURE 1-27 Hyperpigmentation.
FIGURE 1-25 Seborrhea.

Hypopigmentation
(Uncommon lesion)
Autoimmune skin disease
Vitiligo
FIGURE 1-26 Crust.
FIGURE 1-28 Hypopigmentation.

Breed Predispositions to Select Skin Conditions in Dogs and Cats 23
Breed Predispositions to Select Skin Conditions in Dogs and Cats
Dog Breed Skin Condition

Afghan hound Hypothyroidism
Airedale terrier Canine recurrent flank alopecia; hypothyroidism; melanoma
Akita Pemphigus foliaceus; sebaceous adenitis; uveodermatologic syndrome
Alaskan malamute Alopecia X or follicular arrest; follicular dysplasia; postclipping alopecia; zinc-responsive dermatosis
American bulldog Allergic skin disease; ichthyosis; solar dermatosis; squamous cell carcinoma
American Staffordshire Allergic skin disease; demodicosis
bull terrier
Basset hound Allergic skin disease; intertrigo; Malassezia dermatitis; otitis, primary keratinization defects
Bearded collie Black hair follicular dysplasia; lupoid onychodystrophy; pemphigus foliaceus
Beauceron Dermatomyositis
Belgian shepherd dog Vitiligo
Bernese mountain dog Cutaneous or systemic histiocytosis; malignant histiocytic sarcoma
Borzoi Hypothyroidism
Boston terrier Allergic skin disease; demodicosis; hyperadrenocorticism; mast cell tumor; pattern alopecia;
zinc-responsive dermatosis
Bouvier de Flandres Canine recurrent flank alopecia
Boxer Allergic skin disease; chin pyoderma, acne, or folliculitis; demodicosis; canine recurrent flank
alopecia; interdigital hemorrhagic bulla, pedal furunculosis, or cyst; histiocytoma;
hyperadrenocorticism; hypothyroidism; mast cell tumor; pattern alopecia; Sertoli cell tumor
Bullmastiff Callus; interdigital hemorrhagic bulla or cyst
Bull terrier Allergic skin disease; demodicosis; interdigital hemorrhagic bulla or pedal furunculosis or cyst;
lethal acrodermatitis; solar dermatosis; squamous cell carcinoma
Cairn terrier Ichthyosis
Cavalier King Charles Ichthyosis; Malassezia dermatitis; primary secretory otitis media; keratinization and seborrheic
spaniel disorders
Chesapeake Bay retriever Allergic skin disease; follicular dysplasia
Chihuahua Color dilution alopecia; demodicosis; pattern alopecia; injection site alopecia; pinnal vasculopathy
Chinese crested Congenital hypotrichosis; cystic comedones
Chow chow Allergic skin disease; alopecia X or follicular arrest; color dilution alopecia; demodicosis;
hypothyroidism; pemphigus foliaceus; postclipping alopecia
Cocker spaniel Allergic skin disease; hypothyroidism; intertrigo (lip fold); Malassezia dermatitis; melanoma; otitis
externa; plasmacytoma; primary keratinization defects; sebaceous adenoma; vitamin A-responsive
dermatosis
Collie Cutaneous histiocytosis; cutaneous or systemic lupus; dermatomyositis; pemphigus erythematosus
Curly coated retriever Follicular dysplasia
Dachshund Color dilution alopecia; ear margin dermatosis; hyperadrenocorticism; juvenile cellulitis; Malassezia
dermatitis; onychodystrophy; pattern alopecia; pinnal vasculopathy; sterile nodular panniculitis;
sterile pyogranuloma syndrome; sternal callus
Dalmatian Allergic skin disease; deafness associated with coat color; solar dermatosis; squamous cell
carcinoma
Doberman pinscher Acral lick dermatitis; chin pyoderma, acne, or folliculitis; cutaneous drug eruptions; color dilution
alopecia; demodicosis; follicular dysplasia; hypothyroidism; interdigital hemorrhagic bulla, pedal
furunculosis or cyst; pemphigus foliaceus; vitiligo
Dogue de Bordeaux Demodicosis; footpad hyperkeratosis
Continued
Breed Predispositions to Select Skin Conditions in Dogs and Cats—cont’d

English bulldog Allergic skin disease; canine recurrent flank alopecia; chin pyoderma, acne, or folliculitis;
demodicosis; interdigital hemorrhagic bulla or cyst; intertrigo; Malassezia dermatitis
English springer spaniel Acral mutilation syndrome; intertrigo; lichenoid psoriasis–form dermatitis; Malassezia dermatitis;
otitis externa; primary seborrhea
Flat-coated retriever Malignant histiocytic sarcoma
French spaniel Acral mutilation syndrome
Fox terrier Allergic skin disease; demodicosis; dermatomyositis; vasculopathy
German shepherd dog Acral lick dermatitis; allergic skin disease; calcinosis circumscripta; cutaneous or systemic lupus;
dermatomyositis; facial eosinophilic furunculosis; German shepherd dog (deep) pyoderma; lupoid
onychodystrophy; metatarsal fistula; mucocutaneous pyoderma; pythiosis; nodular
dermatofibrosis; perianal fistula; vasculopathy
German shorthaired Acral mutilation syndrome; cutaneous lupus
pointer
Golden retriever Allergic skin disease; acral lick dermatitis; cutaneous or systemic histiocytosis; cutaneous
lymphoma; ichthyosis; hypothyroidism; juvenile cellulitis; nasal depigmentation; postclipping
alopecia; pyotraumatic dermatitis or folliculitis
Gordon setter Black hair follicular dysplasia; juvenile cellulitis; lupoid onychodystrophy
Great Dane Acral lick dermatitis; chin pyoderma, acne, or folliculitis; calcinosis circumscripta; callus; color
dilution alopecia; demodicosis; hygroma; hypothyroidism; interdigital hemorrhagic bulla or cyst
Greyhound Color dilution alopecia; footpad keratosis (corns); hemangioma; pattern alopecia; solar dermatosis;
vasculopathy
Havanese Sebaceous adenitis
Irish setter Acral lick dermatitis; allergic skin disease; hypothyroidism; ichthyosis; primary seborrhea
Irish terrier Footpad hyperkeratosis
Irish water spaniel Follicular dysplasia
Jack Russell terrier Allergic skin disease; demodicosis; dermatomyositis; ichthyosis; vasculopathy
Keeshond Alopecia X or follicular arrest; melanoma; postclipping alopecia
Kerry blue terrier Footpad keratosis (corns); hair follicle tumors; spiculosis
Labrador retriever Acral lick dermatitis; allergic skin disease; hypothyroidism; interdigital hemorrhagic bulla, cyst, or
pedal furunculosis; nasal depigmentation; nasal hyperkeratosis; nasal parakeratosis; pyotraumatic
dermatitis; systemic histiocytosis
Lhasa Apso Allergic skin disease; intertrigo; Malassezia dermatitis; injection site alopecia
Maltese terrier Allergic skin disease; injection site alopecia; traction alopecia
Manchester terrier Pattern alopecia
Miniature pinscher Pattern alopecia; pinnal vasculopathy; vitiligo
Newfoundland Malassezia dermatitis; hypothyroidism; pemphigus foliaceus; pyotraumatic dermatitis
Norfolk terrier Allergic skin disease; ichthyosis; vasculopathy
Norwegian elkhound Alopecia X or follicular arrest; keratoacanthoma; postclipping alopecia
Old English sheepdog Allergic skin disease; demodicosis
Pekingese injection site alopecia; intertrigo
Pointer Acral mutilation syndrome
Pomeranian Alopecia X or follicular arrest; injection site alopecia
Poodle Allergic skin disease; alopecia X or follicular arrest; hyperadrenocorticism; hypothyroidism;
injection site alopecia; otitis externa; melanoma; sebaceous adenitis
Breed Predispositions to Select Skin Conditions in Dogs and Cats 25

Portuguese water dog Follicular dysplasia
Pug Allergic skin disease; demodicosis; intertrigo
Rhodesian ridgeback Dermoid cyst
Rottweiler Acral lick dermatitis; calcinosis cutis; lupoid onychodystrophy; malignant histiocytic sarcoma;
systemic histiocytosis; vasculopathy; vitiligo
Saint Bernard Acral lick dermatitis; intertrigo; callus; dermal arteritis; hygroma; pyotraumatic dermatitis
Samoyed Alopecia X or follicular arrest; follicular dysplasia; sebaceous adenitis; uveodermatologic syndrome
Schipperke Pemphigus foliaceus
Schnauzer Allergic skin disease; aurotrichia; canine recurrent flank alopecia; comedo syndrome; cutaneous
drug eruptions; hyperadrenocorticism; hypothyroidism; lupoid onychodystrophy; melanoma
Scottish terrier Allergic skin disease; cutaneous lymphoma; hyperadrenocorticism; melanoma; vasculopathy
Shar Pei Allergic skin disease; cutaneous mucinosis; demodicosis; hypothyroidism; intertrigo; otitis externa;
vasculopathy
Shetland sheepdog Allergic skin disease; cutaneous drug eruptions; cutaneous histiocytosis; cutaneous or systemic
lupus; dermatomyositis; Sertoli cell tumor
Shih tzu Allergic skin disease; demodicosis; intertrigo; Malassezia dermatitis; sebaceous adenoma
Siberian husky Alopecia X or follicular arrest; eosinophilic granuloma (oral); follicular dysplasia; postclipping
alopecia; uveodermatologic syndrome; zinc-responsive dermatosis
Silky terrier Color dilution alopecia; injection site alopecia; Malassezia dermatitis
Vizsla Sebaceous adenitis
Weimaraner Color dilution alopecia; mast cell tumor; melanoma; pattern alopecia
Welsh corgi Dermatomyositis
West Highland white Allergic skin disease; demodicosis; ichthyosis; Malassezia dermatitis; primary seborrhea
terrier
Whippet Color dilution alopecia; hemangioma; lupoid onychodystrophy; pattern alopecia
Yorkshire terrier Allergic skin disease; demodicosis; dermatophytosis; follicular dysplasia; injection site alopecia
melanoderma and alopecia; pinnal alopecia; traction alopecia
Cat Breed Skin Condition
Abyssinian Psychogenic alopecia
Burmese Congenital hypotrichosis
Devon rex Congenital hypotrichosis; Malassezia dermatitis
Himalayan Dermatophytosis
Orange cats Lentigo
Persian Dermatophytosis; idiopathic facial dermatitis
Siamese Periocular leukotrichia; pinnal alopecia; psychogenic alopecia
Sphynx Allergic skin disease; follicular dysplasia; Malassezia dermatitis
26
Pruritic dog
Identify and treat all secondary infections.

CHAPTER 1
■
Folliculitis
Otitis Pododermatitis Yeast dermatitis
Pyoderma, Demodex,
Bacteria, Malassezia
dermatophytosis
Aggressively treat all secondary infections for 30 days because they complicate case evaluation.
(Steroid therapy will make it difficult to evaluate the pruritus and its association with the secondary infections.)
Pruritus resolved without secondary Pruritus persists without secondary infections?

infections?
Consider endocrine Consider food allergy. Lesions on the nasal Follicular casts, entire
diseases. planum, ear pinnae, skin surface affected
Food allergy is the one footpads
Hypothyroidism and allergic disease that can Primary keratinization
hyperadrenocorticism can be nonpruritic. Food Autoimmune skin defects (sebaceous
cause a relative allergy can change the diseases are usually not adenitis, primary
immunosuppression that normal function of the considered pruritic; seborrhea, ichthyosis,
predisposes the dog to skin, predisposing it to however, the cutaneous epidermal dysplasia)
secondary infections. The secondary infections inflammation and crusts change the normal skin
secondary infections can that are pruritic. If the can cause mild to defense functions,
be pruritic, mimicking pruritus resolves when the moderate pruritus. predisposing the dog to
allergy; however, if the infections are treated, secondary infections
pruritus resolves when the endocrine disease or food that may be pruritic
infections are controlled, allergy is most likely.
allergy is less likely. Atopy and scabies are
almost always pruritic.
FIGURE 1-29 Algorithm for Working Up a Pruritic Dog. GI, Gastrointestinal.

Pruritus persists without secondary infections?
Lesions on the nasal planum, Lumbar dermatitis

ear pinnae, footpads
Flea allergy dermatitis is the most common
Autoimmune skin diseases are cause of lumbar dermatitis. With flea allergy
usually not considered pruritic; dermatitis, the majority of the lesions are
however, the cutaneous caudal to the rib cage. Additionally, foot Pruritus on the face, feet, and ventrum
inflammation and crusts can licking is not typically associated with flea
cause mild to moderate allergies.
pruritus.
Foot licking Pinnal pedal reflex Perianal dermatitis No foot licking

Seasonal symptoms Ear margin lesions Younger than 1 year old No pinnal pedal reflex
Started between 1 and 3 Elbow lesions Older than 5 years Nonseasonal pruritus
years of age
Younger than 1 year old GI symptoms No perianal dermatitis
Extremely responsive
to steroid therapy More than one dog These are suggestive of No GI symptoms
affected a food allergy. A 10- to
These are most 12-week food trial with a No ear margin or elbow lesions
consistent with atopy Intense uncontrollable novel protein source and
(environmental pruritus 1–5 years of age
extremely limited diet
allergies). Flea exposure with subsequent food These are nonspecific symptoms that
These are most typical
can mimic the seasonal challenge should could be caused by atopy, food allergy,
of scabies but could be
nature of atopy and confirm or eliminate or scabies. Consider treating for scabies,
features of food allergy.
should be ruled out. food allergy. performing a food trial, and finally
Skin scrapes and
response to aggressive considering allergy testing if the patient’s
scabicidal therapy will pruritus persists.
confirm or rule out
scabies. Skin scrapes are
only 20% accurate.
Pinnal pedal reflex 80% accurate.

27
28
Feline dermatitis
Miliary dermatitis
CHAPTER 1
“Allergic” alopecia Eosinophilic granuloma syndrome

■
This is the most common clinical Alopecia with or without apparent Eosinophilic plaques, eosinophilic
presentation in cats and can be caused by cutaneous inflammation is common in granulomas, linear granulomas, indolent
numerous conditions. cats with allergies or ectoparasites. ulcers, and fat chin syndrome are all
manifestations of eosinophilic dermatitis
associated with numerous etiologies.
Rule out dermatophytosis

DTM fungal cultures, trichogram,
Wood’s lamp
Dermatophyte is the most common skin

infection in cats and is zoonotic, making it
an important differential.
Skin scrapes positive

Treat the parasitic infestation with
appropriate therapy for sufficient Skin scrapes negative
duration to eliminate the parasites.
Cytology of lesions Cytology of lesions

Cytology of lesions
Bacteria or Malassezia identified Acantholytic cells and neutrophils
identified Eosinophils
Treat these secondary infections with
topical and systemic treatments. Identify Biopsy the skin lesion to confirm
the primary/underlying disease (e.g., diabetes, possible pemphigus. Pemphigus in cats
hyperthyroidism, allergies, ectoparasites). often causes an erosive dermatitis around
the nipples and nail beds (paronychia).
FIGURE 1-30 Algorithm for Working Up a Pruritic Cat.

Aggressive flea control
Flea allergy dermatitis is the most
common cause of feline dermatitis. Because
fleas may not be apparent, aggressive flea
control on all contact pets to eliminate
the flea population is the primary of
confirming this diagnosis.
Young to middle-age cat Old cat with sudden onset of dermatitis
Biopsy, consider
Lime sulfur dip trial Food trial medical workup and
Allergy testing Atopica; abdominal
Ectoparasites such as cyclosporine ultrasound
Food allergy is one Environmental
Demodex gatoi, of the more common allergies, including Very well
Cheyletiella, and causes of feline Paraneoplastic
insect tolerated
Otodectes can cause dermatitis. Feeding a dermatitis caused by
hypersensitivity, can in cats
dermatitis and be novel protein source hepatic and pancreatic
occur in cats but are and treats
difficult to find on skin in an extreme limited- adenocarcinoma or
less common than most allergic
scrapes. Weekly dips ingredient diet for cutaneous lymphoma
flea and food etiologies,
with lime sulfur for 4–6 10–12 weeks will can mimic allergies but
allergies. Allergy except
weeks should resolve confirm or eliminate occurs in old cats that
testing of cats is flea allergy.
any infections. this differential. usually present with
difficult because of the
Treatment with weight loss and other
lack of specific
avermectins will kill evidence of metabolic
serum testing and the
Otodectes and disease.
poor reactivity of
Cheyletiella but are skin tests.
ineffective for D. gatoi.
Biopsy
This will identify the etiology or at least be able to suggest an infection (folliculitis or diffuse pyogranulomatous dermatitis),
hypersensitivity reaction (eosinophils and mast cells), autoimmune skin disease (interface dermatitis), neoplasia, or psychogenic
(complete absence of inflammation).

29
CHAPTER | 2
Diagnostic Techniques
■ Diagnostic Testing ■ Cultures
■ Skin Scrapes ■ Polymerase Chain Reaction Assays
■ Cutaneous Cytology ■ Serology
■ Acetate Tape Preparations ■ Immunostaining Techniques
■ Otic Swabs ■ Diascopy
■ Dermatophyte Test Medium Fungal Cultures ■ Allergy Testing
■ Trichoscopy ■ Patch Testing
■ Wood’s Lamp Examination ■ Therapeutic Trials
■ Biopsy
with hair, it may be necessary to clip a small window to access

Diagnostic Testing
the skin. In an attempt to find the relatively few sarcoptic
The dermatologic diagnostic minimum database includes skin mites that may be present on a dog, large areas (1–2 inches)
scrapes, otic swabs, and cutaneous cytology. The goal should are scraped. Applying mineral oil directly to the skin to be
be to identify all secondary infections (e.g., pyoderma, demo scraped helps dislodge debris and makes it easier to collect the
dicosis, dermatophytosis, otitis, Malassezia dermatitis, infec scraped material. Because these mites do not live deep within
tious pododermatitis) and then formulate a diagnostic plan the skin, it is not necessary to visualize capillary oozing or
for identifying and controlling the underlying or primary blood. The most productive sites for sarcoptic mites include
disease (i.e., allergies, endocrinopathies, keratinization defects, the ear margin and the lateral elbows. Anecdotal reports
and autoimmune skin diseases) (Box 2-1). suggest that Demodex gatoi in cats may be found more easily
on the lateral shoulder. Usually, several slides are needed to
Skin Scrapes spread the collected material thinly enough for microscopic
examination.
Skin scrapes are the most common dermatologic diagnostic
tests (slide #1 in the three-slide technique). These relatively
simple and quick tests can be used to identify many types
Deep Skin Scrapes (for Demodex spp. except
of parasitic infections (Table 2-1). Although they are not D. gatoi). A dulled scalpel blade or dermal spatula is held
always diagnostic, their relative ease and low cost make them perpendicular to the skin and is used with moderate pressure
essential tests in a dermatologic diagnostic minimum to scrape in the direction of hair growth. If the area is covered
database. with hair (usually, alopecic areas caused by folliculitis are
Many practitioners reuse scalpel blades when performing selected), it may be necessary to clip a small window to access
skin scrapes; however, this practice should be stopped because the skin. After several scrapes, the skin should appear pink,
of increased awareness of transmittable diseases (e.g., Barton- with the capillaries becoming visible and oozing blood. This
ella, Rickettsia, feline leukemia virus [FeLV], feline immunode ensures that the material collected comes from deep enough
ficiency virus [FIV], herpes, papillomavirus). within the skin to allow the collection of follicular Demodex
mites. Most people also squeeze (pinch) the skin to express
Procedure mites from deep within the follicles into a more superficial
area so they may be collected more easily. If scraping fails to
Superficial Skin Scrapes (for Sarcoptes, Notoedres, provide a small amount of blood, then the mites may have
Demodex gatoi, Cheyletiella, Otodectes, and Chig- been left in the follicle, resulting in a false-negative finding. In
gers). A dulled scalpel blade or dermal spatula is held some situations (with Shar Peis or deep inflammation with
perpendicular to the skin and is used with moderate pressure scarring), it may be impossible to scrape deeply enough to
to scrape in the direction of hair growth. If the area is covered harvest Demodex mites. These cases are few in number but
30
Skin Scrapes 31
require biopsy for identification of mites within the hair fol a 10× objective). A search of the entire slide ensures that if only
licles. Hair plucks from an area of lesional skin may be used one or two mites are present (as is typical of scabies infection),
to help find follicular mites. This technique is especially the user will likely find them. It may be helpful to lower the
helpful in areas or situations when a skin scrape would be microscope condenser; this provides greater contrast to the
difficult: around the eyes or excited puppies. mites, thereby enhancing their visibility. (One must be sure to
Regardless of the collection technique used, the entire slide raise the condenser before looking for cells or bacteria on stained
should be searched for mites with the use of low power (usually slides.)
BOX 2-1 What Are the Infections?

For every dermatitis case, every time you evaluate the and interpreted by a technician before the doctor com-
patient, ask yourself, “What are the infections?” pletes an evaluation, which is exactly how diarrhea cases
Using diarrhea and the microscopic fecal examination and fecal examinations are handled in most clinics.
as a comparison works well because both skin cytology
and fecal examinations involve the use of a microscope,
can easily identify the type of infection, and can be per-
formed by trained technical staff. So why does your clinic
perform fecal examinations? When is a fecal examination
performed (before the doctor’s examination)? Who per-
formed the fecal examination? Does the clinic charge for
the fecal examination? The answers to these questions
should be the same for skin cytology (skin scrapings,
impression smears, tape preps, and otic swabs).
The practical solution for determining the best method
by which to answer the question, “What are the infec-
tions?” is to implement a minimum database “infection
screening” procedure to be performed by the technician
before the veterinarian examines the patient. Every der-
matology patient should undergo otic cytology, skin Skin scrape Skin cytology Ear cytology
cytology (an impression smear or a tape prep), and a skin (cocci/yeast)
scrape at every examination (initially and at every recheck FIGURE 2-1 The Three-Slide Technique. Skin scrapes, cutaneous
visit). This three-slide technique can be performed easily cytology, and otic swabs.
TABLE 2-1 Diagnosing Common Cutaneous Parasites

Mite Diagnostic Test Accuracy Other Tests Additional Tests
Demodex canis Deep scrape High Biopsies may be needed with
extremely thickened lesions
Demodex cati Deep scrape High
Demodex gatoi Superficial scrape Low Lime sulfur dip trial, response to
Mites may be treatment
difficult to find
Sarcoptes Superficial scrape Low (only 20%) Response to treatment Pinnal-pedal reflex (80%)
Otodectes Otic mineral oil prep, superficial High
scrape
Cheyletiella Flea comb, tape prep, superficial Moderate Vacuum collection techniques are Possible identification of
scrape, vacuum preferred by some veterinarians mites by fecal flotation
Lice Tape prep (usually grossly visible) High
Notoedres cati Superficial scrape High
Trombicula Targeted scrape on focal lesion Moderate
32 CHAPTER 2 ■ Diagnostic Techniques
A B
D
C
FIGURE 2-2 Diagnostic Techniques. A, This microscopic image (10×

objective) demonstrates the typical angular shape of a normal, mature
keratinocyte. Note the absence of a nucleus and the small melanin
granules (often mistaken for bacteria but pigmented brown). B, This
microscopic image (10× objective) reveals the brown pigmented
melanin granules within the anuclear keratinocyte with typical angular
cell walls. Note the dark blue structure, which is likely a rolled-up
keratinocyte. C, This microscopic image demonstrates the typical
appearance of a neutrophil at 10× magnification. D, To collect a
sample ideal for cytologic evaluation, the superficial crust should be
gently scraped away and the glass slide applied firmly to the skin.
E, To collect a sample ideal for cytologic evaluation, the superficial
crust should be gently scraped away and the glass slide applied firmly
to the skin. Note: It may be easier to collect the sample if the skin is E
slightly elevated by pinching or rolling the skin into a mound.
AUTHOR’S NOTE
Cutaneous Cytology
There is no excuse for mistreating a patient who
has demodicosis. Lesions caused by demodicosis Cutaneous cytology is the second most frequently used der
matologic diagnostic technique (slide #2 in the three-slide
can look identical to folliculitis lesions caused by
technique). Its purpose is to help the practitioner to identify
bacterial pyoderma and dermatophytosis. Clinical
bacterial or fungal organisms (yeast) and assess the infiltrating
appearance is not an acceptable criterion for ruling
cell types, neoplastic cells, or acantholytic cells (typical of
in or ruling out demodicosis. When the technician
pemphigus complex).
performs a skin scrape as part of the infection
screen called the three-slide technique, demodico-
Procedure
sis can be identified and treated easily and
accurately. Direct Impression Smear. Moist exudate is collected from
pustules, erosions, ulcers, or draining lesions. Alternatively,
Cutaneous Cytology 33
A B
C D
FIGURE 2-3 Skin Scrape. A, A new, dulled scalpel blade is used to

scrape in the direction of hair growth. B, For deep skin scrapes, after
capillary oozing is initiated, the skin is usually squeezed before a final
scrape is performed to collect the material. C, Capillary oozing is
apparent as the sample material is collected. D, The collected sample
E is evenly distributed in mineral oil on a glass slide. E, Microscopic
image of the Demodex mite as seen with a 10× objective.
crusts or the leading edge of an epidermal collarette can be identify individual cell types, as well as bacterial or fungal
lifted, revealing a moist undersurface. Papular lesions may be organisms.
traumatized by the corner of a glass slide or a needle and then
squeezed to express fluid. Yeast dermatitis can be sampled by Fine-Needle Aspirate Method. A needle (22–25 gauge)
repeated sticking of the slide onto lichenified lesions or and a 6-mL syringe should be used to aspirate the mass. The
through the use of a dry scalpel blade to collect material that area should be cleaned if necessary with alcohol or chlorhexi
is then smeared onto a dry slide. Regardless of which tech dine. The lesion is then immobilized. The practitioner should
nique is used, the moist exudate collected on the slide insert the needle into the nodule while aiming for the center
is allowed to dry. The slide is then stained with a commer of the lesion, pull back on the plunger to apply suction, release
cially available cytology stain (e.g., modified Wright’s stain and redirect, pull back on the plunger again, and stop if any
[Diff-Quik is the most common]), and it is gently rinsed. A blood is visible in the hub of the needle because this will
low-power objective is used to scan the slide to allow selection dilute the cellular sample. Negative pressure should be released
of ideal areas rich in basophilia for closer examination. A before the needle is removed from the lesion. An alternative
high-power (40× or, preferably, 100× oil) objective is used to technique involves repeated insertion of the needle without
the syringe into the lesion while redirecting several times. This but false-negative results are common with all yeast collection
latter technique (without negative pressure), which decreases techniques.
the frequency of inadvertent dilution of the sample with
blood, works best for soft masses. After the sample has been Otic Swabs
collected, the material is expressed onto a microscope slide by
blowing a syringe-full of air through the needle to spray the Screening
cells onto the slide. The material is smeared gently to thin the Otic swabs are useful for determining whether a normal-
clumps of cells before staining, and finally the sample should appearing ear canal actually has exudate deep within the ear
be stained with cytology stain. The slide should be scanned (slide #3 in the three-slide technique). If a cotton swab is used
with low power (4×–10×) to reveal a suitable area for closer to gently collect a sample, and if it is relatively clean, then the
examination. A high-power (40×) objective may be used to ear most likely is normal. If the sample demonstrates a black
reveal the infiltrating cell type and the cellular atypia. waxy exudate, then a mineral oil prep should be performed
for identification of any mites (e.g., Otodectes or Demodex
spp.). If the sample is light brown or demonstrates a purulent
AUTHOR’S NOTE exudate, cytology should be performed for identification of
The infections are always secondary to a primary bacteria or yeast.
disease; however, all too often, the patient is not
evaluated or treated for the primary disease for Mites
three major reasons: Mineral oil can be used to dissolve the black waxy material
1. Only the secondary infections are treated collected from an otic swab. The swab should be stirred in the
repeatedly. oil to remove the exudate and to make the sample suitable for
2. The nature of the allergy is confusing. examination. The entire slide should be examined under low
3. Cheap steroids that have delayed repercussions power (4× or 10× objective) for identification of any mites.
are available. Usually, Otodectes mites are easy to visualize, but dropping the
condenser and scanning the entire slide may make the practi
tioner more certain of the diagnosis.
Acetate Tape Preparations
Bacteria and Yeast
Tape preps are used to evaluate a variety of different condi
Otic cytology is used to identify secondary yeast and bacterial
tions. The basic technique involves the use of crystal clear tape
otitis externa. Debris is collected with a cotton swab. An easy
(single- or double-sided tape) to collect a sample of hair or
and quick technique is to roll the swab from the right ear onto
superficial skin debris.
the right side of the slide and then swab from the left ear onto
the left side of the slide, assuming that the slide has markings
Tape Preps for Mites by which to identify which direction is up. If the material is
Tape preps can be an effective method of collecting and very waxy, the end of the slide should be heated to help melt
restraining Cheyletiella and lice for microscopic examination. the wax and allow the stain to penetrate the sample. The
The mites are usually large enough to be seen, so a piece of sample should be stained with cytology stain (modified
tape can be used to capture a specimen. The tape prevents the Wright’s stain [Diff-Quik]) and then examined under low
creatures from escaping. power (10× objectives), so that a cellular area likely to include
organisms can be identified. Then the high-power objective
Tape Preps for Hair (Trichoscopy) (40× or 100× oil immersion) should be used to identify the
Tape is used to secure the hair sample in position on a glass organisms that are causing the secondary otitis.
slide. The sample is examined under low power (4×–10×
objective). (See the “Trichoscopy” section for more informa AUTHOR’S NOTE
tion on analysis techniques.) Oil may be a better medium for When an owner brings the pet into the clinic for a
use with trichoscopy. small hairless spot, it would be appropriate to ques-
tion the necessity for an otic cytology when the
Tape Preps for Yeast hairless spot is the problem. However, the three-
Tape preps for yeast dermatitis are the most efficient and effec slide technique is most helpful in these exact types
tive methods of identifying Malassezia skin infections. The of cases. If focal pruritus occurs in a dog and the
lichenified lesion (elephant skin on the ventral neck or patient has a secondary otitis (which the technician
ventrum) or moist pedal erythematous skin is sampled by identified during the infection screen), the veteri-
repeated application of the sticky side of the tape onto the narian should more aggressively discuss and work
lesion. The tape is then adhered to a glass slide (sticky side up the patient for possible allergy. If the patient did
down) and is stained with a cytology stain (only the last dark not have otitis, the skin pruritus could be minimized
blue stain is needed). The tape serves as a coverslip and can in the hope that it was a short-term problem that
be examined under high power (100× oil immersion) for may self-resolve.
visualization of Malassezia organisms. This technique is useful,
35
A B
C D
E F
FIGURE 2-4 Cytology. A, A glass slide is pressed onto a cutaneous

lesion to collect the moist exudates for cytologic evaluation
(impression smear). B, A needle is inserted into a nodular lesion to
collect cells for cytologic evaluation (fine-needle aspirate). C, After it
is dry, the cytology slide is processed with the use of a modified
Wright’s stain (Diff-Quik). D, Microscopic image of neutrophils and
Staphylococcus organisms, as viewed with a 100× (oil) objective.
E, Microscopic image of Malassezia yeast, as viewed with a 100× (oil)
objective. F, Microscopic image of a keratinocyte, melanin granules,
and Simonsiella organisms, as viewed with a 100× (oil) objective.
Simonsiella is a common oral bacterium; its presence suggests that
the patient has been licking (pruritus). G, Microscopic image of
G neutrophils and acantholytic cells, as viewed with a 100× (oil)
objective. Acantholytic cells are suggestive of pemphigus.
A B
C D
FIGURE 2-5 Tape Preps. A, Clear acetate tape is pressured repeatedly into the interdigital space for collection of a superficial sample. B, The tape is
processed with a modified Wright’s stain (Diff-Quik) with omission of the first light blue alcohol solution, which dissolves the tape adhesive. C, After
processing has been completed, the sample material is easily visible under the tape. D, Microscopic image of Malassezia organisms and keratinocytes,
as viewed with a 100× (oil) objective.
AUTHOR’S NOTE Procedure

Otic cytology is necessary for identifying the type The area to be sampled is usually cleaned by gentle application
of secondary infection present, so that the best of alcohol to the hair and skin. The alcohol should dry before
medical therapy can be selected. Additionally, otic the specimen is collected. Samples of hair, crust, or scale are
cytology is useful for evaluating a patient’s response collected from lesional skin with the use of a sterile forceps.
to treatment, especially when the otitis has not Use of a Wood’s lamp to collect fluorescing hairs may enhance
completely resolved. In these cases, otic cytology diagnostic accuracy. The collected material should be gently
can be used to determine whether the number and applied to DTM, with care taken not to bury the sample within
the mixture of organisms are improving. This deter- the medium. Bringing the medium to room temperature
mination is crucial for preventing premature dis- before the sample is placed on it helps to hasten fungal
growth. Fungal culture plates with a large removable or flip-up
continuation or switching of treatments, which may
lid (e.g., standard petri dish or Bactilabs culture plates) make
lead to increased antimicrobial resistance.
sample deposition much easier. For animals with no lesions
(i.e., those with resolving infection, or subclinical carriers), a
new toothbrush can be used to brush the entire hair coat. The
Dermatophyte Test Medium collected sample is then distributed onto the culture plate.
Claws can be cultured by clipping an affected nail and
Fungal Cultures grinding or shaving its surface to produce small particles
Dermatophyte test medium (DTM) fungal cultures are used to that are deposited onto the medium. Dermatophytes grow
isolate and identify dermatophyte organisms. DTM is made within the keratin structure of the claw, causing distinctive
with special ingredients that inhibit bacterial growth and turn onychodystrophy.
red when dermatophytes grow. Alternatively, proprietary The DTM culture plates should be examined daily for 2 to
media plates that have unique attributes are available; however, 3 weeks. With dermatophytes, the medium will change color
DTM cultures remain the customary technique. as soon as a white- or buff-colored fluffy colony becomes
Trichoscopy 37
A B
C D
FIGURE 2-6 Otic Cytology. A, Before an otic sample is obtained for cytologic evaluation, the ear canal and the tympanic membrane should be
evaluated visually. B, A cotton swab is used to obtain a sample of exudates from the ear canal. C, The exudates collected on the swab are smeared
onto the slide. The left ear sample has been smeared onto the left half of the slide, and the right ear sample onto the right side of the slide.
D, Microscopic image of otic cytology demonstrating numerous neutrophils and mixed bacteria, as viewed with a 10× objective.
visible on the medium. Some contaminants (usually black, cultures. If such species are suspected, swab samples and tissue
gray, and green) will be able to change the medium to red but specimens should be submitted to and cultured by well-
only after growing for several days. If the culture plate has not equipped microbiology laboratories.
been evaluated daily, it will be impossible to determine when
the color change occurred in relation to the appearance of AUTHOR’S NOTE
fungal colony growth.
Macroconidia only come from the culture plate
After the fungal colony has been growing for several days,
it begins to produce macroconidia. Keeping the culture warm
colony and cannot be retrieved from the hair or
in a humid environment facilitates the formation of conidia. skin. Macroconidia-like structures found on the skin
The macroconidia should be sampled and microscopically or hairs are usually pollen or other species of mold
examined so that the dermatophyte species can be identified. and not dermatophyte macroconidia.
Clear acetate tape is touched to the surface of the white- or
buff-colored fluffy fungal colony to be evaluated. The tape is Trichoscopy
then adhered to a glass slide, and a drop of cytology stain
is applied. The macroconidia are usually apparent under a A trichoscopy is used to visualize the hair for evidence of
low-power (10×) objective. This is especially important in pruritus, fungal infection, and pigmentation defects and to
dogs because the identification of Microsporum canis may assess the growth phase (for evaluation of hair tips, roots, and
indicate the presence of an infected asymptomatic cat in the shafts).
immediate environment. Identification of Trichophyton or
Microsporum gypseum suggests an environmental source for the Procedure
dermatophyte infection (other than an infected cat). A small amount of hair to be examined is epilated. Tape or
Some fungal species that cause deep infection or cellulitis mineral oil is used to secure the hair sample in position on a
(e.g., blastomycosis, pythiosis, histoplasmosis, coccidioido glass slide. The sample is examined under a low-power (4× or
mycosis) represent a zoonotic hazard when grown as in-house 10×) objective.
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to get a ladder and climb up and look in would have beheld John
Carroll seated at his table, busy with a pile of accounts.
In an age so notoriously avid of pleasure as the one in which we live
it is rare to find a young man of such sterling character that he
voluntarily absents himself from a village concert in order to sit at
home and work: and, contemplating John, one feels quite a glow. It
was not as if he had been unaware of what he was missing. The
vicar, he knew, was to open the proceedings with a short address:
the choir would sing old English glees: the Misses Vivien and Alice
Pond-Pond were down on the programme for refined coon songs:
and, in addition to other items too numerous and fascinating to
mention, Hugo Carmody and his friend Mr. Fish would positively
appear in person and render that noble example of Shakespeare's
genius, the Quarrel Scene from Julius Cæsar. Yet John Carroll sat in
his room, working. England's future cannot be so dubious as the
pessimists would have us believe while her younger generation is
made of stuff like this.
John was finding in his work these days a good deal of consolation.
There is probably no better corrective of the pangs of hopeless love
than real, steady application to the prosaic details of an estate. The
heart finds it difficult to ache its hardest while the mind is busy with
such items as Sixty-one pounds, eight shillings and fivepence, due to
Messrs. Truby and Gaunt for Fixing Gas Engine, or the claim of the
Country Gentlemen's Association for eight pounds eight and
fourpence for seeds. Add drains, manure, and feed of pigs, and you
find yourself immediately in an atmosphere where Romeo himself
would have let his mind wander. John, as he worked, was conscious
of a distinct easing of the strain which had been on him since his
return to the Hall. And if at intervals he allowed his eyes to stray to
the photograph of Pat on the mantelpiece, that was the sort of thing
that might happen to any young man, and could not be helped.
It was seldom that visitors penetrated to this room of his—indeed, he
had chosen to live above the stables in preference to inside the
house for this very reason, and on Rudge's big night he had looked
forward to an unbroken solitude. He was surprised, therefore, as he
checked the account of the Messrs. Vanderschoot & Son for bulbs,
to hear footsteps on the stairs. A moment later, the door had opened
and Hugo walked in.
John's first impulse, as always when his cousin paid him a visit, was
to tell him to get out. People who, when they saw Hugo, immediately
told him to get out generally had the comfortable feeling that they
were doing the right and sensible thing. But to-night there was in his
demeanour something so crushed and forlorn that John had not the
heart to pursue this admirable policy.
"Hullo," he said. "I thought you were down at the concert."
Hugo uttered a short, bitter laugh, and, sinking into a chair, stared
bleakly before him. His eyelids, like those of the Mona Lisa, were a
little weary. He looked like the hero of a Russian novel debating the
advisability of murdering a few near relations before hanging himself
in the barn.
"I was," he said. "Oh yes, I was down at the concert all right."
"Have you done your bit already?"
"I have. They put Ronnie and me on just after the Vicar's Short
Address."
"Wanted to get the worst over quick, eh?"
Hugo raised a protesting hand. There was infinite sadness in the
gesture.
"Don't mock, John. Don't jeer. Don't jibe and scoff. I'm a broken
man."
"Only cracked, I should have said."
Hugo was not attuned to cousinly badinage. He frowned austerely.
"Less back-chat," he begged. "I came here for sympathy. And a
drink. Have you got anything to drink?"
"There's some whisky in that cupboard."
Hugo heaved himself from the chair, looking more Russian than
ever. John watched his operations with some concern.
"Aren't you mixing it pretty strong?"
"I need it strong." The unhappy man emptied his glass, refilled it, and
returned to the chair. "In fact, it's a point verging very much on the
moot whether I ought to have put any water in it at all."
"What's the trouble?"
"This isn't bad whisky," said Hugo, becoming a little brighter.
"I know it isn't. What's the matter?"
The momentary flicker of cheerfulness died out. Gloom once more
claimed Hugo for its own.
"John, old man," he said. "We got the bird."
"Yes?"
"Don't say 'Yes?' like that, as if you had expected it," said Hugo, hurt.
"The thing came on me as a stunning blow. I was amazed.
Astounded. Absolutely nonplussed."
"Could I have knocked you down with a feather?"
"I thought we were going to be a riot. Of course, mind you, we came
on much too early. It was criminal to bill us next to opening. An
audience needs careful warming up for an intellectual act like ours!"
"What happened?"
Hugo rose and renewed the contents of his glass.
"There is a spirit creeping into the life of Rudge-in-the-Vale," he said,
"which I don't like to see. A spirit of lawlessness and licence.
Disruptive influences are at work. Bolshevik propaganda, I shouldn't
wonder. Would a Rudge audience have given me the bird a few
years ago? Not a chance!"
"But you've never tried them with the Quarrel Scene from Julius
Cæsar before. Everybody has a breaking point."
The argument was specious, but Hugo shook his head.
"In the good old days I could have done Hamlet's Soliloquy, and the
hall would have rung with hearty cheers. It's just this modern
lawlessness and Bolshevism. There was a very tough collection of
the Budd Street element standing at the back, who should never
have been let in. They started straight away chi-yiking the vicar
during his short address. I didn't think anything of it at the time. I
merely supposed that they wanted him to cheese it and let the
entertainment start. I thought that directly Ronnie and I came on we
should grip them. But we were barely a third of the way through
when there were loud cries of 'Tripe!' and 'Get off!'"
"I see what that meant. You hadn't gripped them."
"I was never so surprised in my life. Mark you, I'll admit that Ronnie
was perfectly rotten. He kept foozling his lines and saying 'Oh, sorry!'
and going back and repeating them. You can't get the best out of
Shakespeare that way. The fact is, poor old Ronnie is feeling a little
low just now. He got a letter this morning from his man, Bessemer, in
London, a fellow who has been with him for years and has few
equals as a trouser presser, springing the news out of an absolutely
clear sky that he's been secretly engaged for weeks and is just going
to get married and leave Ronnie. Naturally, it has upset the poor
chap badly. With a thing like that on his mind, he should never have
attempted an exacting part like Brutus in the Quarrel Scene."
"Just what the audience thought, apparently. What happened after
that?"
"Well, we buzzed along as well as we could, and we had just got to
that bit about digesting the venom of your spleen though it do split
you, when the proletariat suddenly started bunging vegetables."
"Vegetables?"
"Turnips, mostly, as far as I could gather. Now, do you see the
significance of that, John?"
"How do you mean, the significance?"
"Well, obviously these blighters had come prepared. They had meant
to make trouble right along. If not, why would they have come to a
concert with their pockets bulging with turnips?"
"They probably knew by instinct that they would need them."
"No! It was simply this bally Bolshevism one reads so much about."
"You think these men were in the pay of Moscow?"
"I shouldn't wonder. Well, that took us off. Ronnie got rather a beefy
whack on the side of the head and exited rapidly. And I wasn't going
to stand out there doing the Quarrel Scene by myself, so I exited,
too. The last I saw, Chas. Bywater had gone on and was telling Irish
dialect stories with a Swedish accent."
"Did they throw turnips at him?"
"Not one. That's the sinister part of it. That's what makes me so sure
the thing was an organized outbreak and all part of this Class War
you hear about. Chas. Bywater, in spite of the fact that his material
was blue round the edges, goes like a breeze, and gets off without a
single turnip, whereas Ronnie and I ... well," said Hugo, a hideous
grimness in his voice, "this has settled one thing. I've performed for
the last time for Rudge-in-the-Vale. Next year when they may come
to me, and plead with me to help out with the programme, I shall
reply, 'Not after what has occurred!' Well, thanks for the drink. I'll be
buzzing along." Hugo rose and wandered somnambulistically to the
table. "What are you doing?"
"Working."
"Working?"
"Yes, working."
"What at?"
"Accounts. Stop fiddling with those papers, curse you."
"What's this thing?"
"That," said John, removing it from his listless grasp and putting it
out of reach in a drawer, "is the diagram of a thing called an Alpha
Separator. It works by centrifugal force and can separate two
thousand seven hundred and twenty-four quarts of milk in an hour. It
has also a Holstein butter-churner attachment, and a boiler which at
seventy degrees centigrade destroys the obligatory and optional
bacteria."
"Yes?
"Positively."
"Oh? Well, damn it, anyway," said Hugo.
IV
Hugo crossed the strip of gravel which lay between the stable yard
and the house, and, having found in his trouser pocket the key of the
back door, proceeded to let himself in. His objective was the dining
room. He was feeling so much better after the refreshment of which
he had just partaken that reason told him he had found the right
treatment for his complaint. A few more swift ones from the cellarette
in the dining room and the depression caused by the despicable
behaviour of the Budd Street Bolshevists might possibly leave him
altogether.
The passage leading to his goal was in darkness, but he moved
steadily forward. Occasionally a chair would dart from its place to
crack him over the shin, but he was not to be kept from the cellarette
by trifles like that. Soon his fingers were on the handle of the door,
and he flung it open and entered. And it was at this moment that
there came to his ears an odd noise.
It was not the noise itself that was odd. Feet scraping on gravel
always make that unmistakable sound. What impressed itself on
Hugo as curious was the fact that on the gravel outside the dining-
room window, feet at this hour should be scraping at all. His hand
had been outstretched to switch on the light, but now he paused. He
waited, listening. And presently in the oblong of the middle of the
three large windows he saw dimly against the lesser darkness
outside a human body. It was insinuating itself through the opening
and what Hugo felt about it was that he liked its dashed nerve.
Hugo Carmody was no poltroon. Both physically and morally he
possessed more than the normal store of courage. At Cambridge he
had boxed for his university in the light-weight division and once, in
London, the petty cash having run short, he had tipped a hat-check
boy with an aspirin tablet. Moreover, although it was his impression
that the few drops of whisky which he had drunk in John's room had
but scratched the surface, their effect in reality had been rather
pronounced. "In some diatheses," an eminent physician has laid
down, "whisky is not immediately pathogenic. In other cases the
spirit in question produces marked cachexia." Hugo's cachexia was
very marked indeed. He would have resented keenly the suggestion
that he was fried, boiled, or even sozzled, but he was unquestionably
in a definite condition of cachexia.
In a situation, accordingly, in which many householders might have
quailed, he was filled with gay exhilaration. He felt able and willing to
chew the head off any burglar that ever packed a centrebit. Glowing
with cachexia and the spirit of adventure, he switched on the light
and found himself standing face to face with a small, weedy man
beneath whose snub nose there nestled a waxed moustache.
"Stand ho!" said Hugo jubilantly, falling at once into the vein of the
Quarrel Scene.
In the bosom of the intruder many emotions were competing for
precedence, but jubilation was not one of them. If Mr. Twist had had
a weak heart, he would by now have been lying on the floor
breathing his last, for few people can ever have had a nastier shock.
He stood congealed, blinking at Hugo.
Hugo, meanwhile, had made the interesting discovery that it was no
stranger who stood before him but an old acquaintance.
"Great Scot!" he exclaimed. "Old Doc. Twist! The beautiful, tranquil-
thoughts bird!" He chuckled joyously. His was a retentive memory,
and he could never forget that this man had once come within an
ace of ruining that big deal in cigarettes over at Healthward Ho, and
had also callously refused to lend him a tenner. Of such a man he
could believe anything, even that he combined with the duties of a
physical culture expert a little housebreaking and burglary on the
side. "Well, well, well!" said Hugo. "Remember March, the Ides of
March remember! Did not great Julius bleed for justice' sake? What
villain touched his body that did stab and not for justice? Answer me
that, you blighter, yes or no."
Chimp Twist licked his lips nervously. He was a little uncertain as to
the exact import of his companion's last words, but almost any words
would have found in him at this moment a distrait listener.
"Oh, I could weep my spirit from my eyes!" said Hugo.
Chimp could have done the same. With an intense bitterness he was
regretting that he had ever allowed Mr. Molloy to persuade him into
this rash venture. But he was a man of resource. He made an effort
to mend matters. Soapy, in a similar situation, would have done it
better, but Chimp, though not possessing his old friend's glib tongue
and insinuating manners, did the best he could. "You startled me," he
said, smiling a sickly smile.
"I bet I did," agreed Hugo cordially.
"I came to see your uncle."
"You what?"
"I came to see your uncle."
"Twist, you lie! And, what is more, you lie in your teeth."
"Now, see here...!" began Chimp, with a feeble attempt at
belligerence.
Hugo checked him with a gesture.
"There is no terror, Cassius, in your threats, for I am armed so strong
in honesty that they pass by me like the idle wind, which I respect
not. Must I give way and room to your rash choler? Shall I be
frightened when a madman stares? By the gods, you shall digest the
venom of your spleen though it do split you. And what could be fairer
than that?" said Hugo.
Mr. Twist was discouraged, but he persevered.
"I guess it looked funny to you, seeing me come in through a
window. But, you see, I rang the front door bell and couldn't seem to
make anyone hear."
"Away, slight man!"
"You want me to go away?" said Mr. Twist, with a gleam of hope.
"You stay where you are, unless you'd like me to lean a decanter of
the best port up against your head," said Hugo. "And don't flicker,"
he added, awakening to another grievance against this unpleasant
little man.
"Don't what?" inquired Mr. Twist, puzzled but anxious to oblige.
"Flicker. Your outline keeps wobbling, and I don't like it. And there's
another thing about you that I don't like. I've forgotten what it is for
the moment, but it'll come back to me soon."
He frowned darkly: and for the first time it was borne in upon Mr.
Twist that his young host was not altogether himself. There was a
gleam in his eyes which, in Mr. Twist's opinion, was far too wild to be
agreeable.
"I know," said Hugo, having reflected. "It's your moustache."
"My moustache?"
"Or whatever it is that's broken out on your upper lip. I dislike it
intensely. When Cæsar lived," said Hugo querulously, "he durst not
thus have moved me. And the worst thing of all is that you should
have taken a quiet, harmless country house and called it such a
beastly, repulsive name as Healthward Ho. Great Scot!" exclaimed
Hugo. "I knew there was something I was forgetting. All this while
you ought to have been doing bending and stretching exercises!"
"Your uncle, I guess, is still down at the concert thing in the village?"
said Mr. Twist, weakly endeavouring to change the conversation.
Hugo started. A look of the keenest suspicion flashed into his eyes.
"Were you at that concert?" he said sternly.
"Me? No."
"Are you sure, Twist? Look me in the face."
"I've never been near any concert."
"I strongly suspect you," said Hugo, "of being one of the ringleaders
in that concerted plot to give me the bird. I think I recognized you."
"Not me."
"You're sure?"
"Sure."
"Oh? Well, that doesn't alter the cardinal fact that you are the bloke
who makes poor, unfortunate fat men do bending and stretching
exercises. So do a few now yourself."
"Eh?"
"Bend!" said Hugo. "Stretch!"
"Stretch?"
"And bend," said Hugo, insisting on full measure. "First bend, then
stretch. Let me see your chest expand and hear the tinkle of buttons
as you burst your waistcoat asunder."
Mr. Twist was now definitely of opinion that the gleam in the young
man's eyes was one of the most unpleasant and menacing things he
had ever encountered. Transferring his gaze from this gleam to the
other's well-knit frame, he decided that he was in the presence of
one who, whether his singular request was due to weakness of
intellect or to alcohol, had best be humoured.
"Get on with it," said Hugo.
He settled himself in a chair and lighted a cigarette. His whole
manner was suggestive of the blasé nonchalance of a sultan about
to be entertained by the court acrobat. But, though his bearing was
nonchalant, that gleam was still in his eyes, and Chimp Twist
hesitated no longer. He bent, as requested—and then, having bent,
stretched. For some moments he jerked his limbs painfully in this
direction and in that, while Hugo, puffing smoke, surveyed him with
languid appreciation.
"Now tie yourself into a reefer knot," said Hugo.
Chimp gritted his teeth. A sorrow's crown of sorrow is remembering
happier things, and there came back to him the recollection of
mornings when he had stood at his window and laughed heartily at
the spectacle of his patients at Healthward Ho being hounded on to
these very movements by the vigilant Sergeant Flannery. How little
he had supposed that there would ever come a time when he would
be compelled himself to perform these exercises. And how little he
had guessed at the hideous discomfort which they could cause to a
man who had let his body muscles grow stiff.
"Wait," said Hugo, suddenly.
Mr. Twist was glad to do so. He straightened himself, breathing
heavily.
"Are you thinking beautiful thoughts?"
Chimp Twist gulped. "Yes," he said, with a strong effort.
"Beautiful, tranquil thoughts?"
"Yes."
"Then carry on."
Chimp resumed his calisthenics. He was aching in every joint now,
but into his discomfort there had shot a faint gleam of hope.
Everything in this world has its drawbacks and its advantages. With
the drawbacks to his present situation he had instantly become
acquainted, but now at last one advantage presented itself to his
notice—the fact, to wit, that the staggerings and totterings
inseparable from a performance of the kind with which he was
entertaining his limited but critical audience had brought him very
near to the open window.
"How are the thoughts?" asked Hugo. "Still beautiful?"
Chimp said they were, and he spoke sincerely. He had contrived to
put a space of several feet between himself and his persecutor, and
the window gaped invitingly almost at his side.
"Yours," said Hugo, puffing smoke meditatively, "has been a very
happy life, Twist. Day after day you have had the privilege of seeing
my uncle Lester doing just what you're doing now, and it must have
beaten a circus hollow. It's funny enough even when you do it, and
you haven't anything like his personality and appeal. If you could see
what a priceless ass you look it would keep you giggling for weeks. I
know," said Hugo, receiving an inspiration; "do the one where you
touch your toes without bending the knees."
In all human affairs the semblance of any given thing is bound to
vary considerably with the point of view. To Chimp Twist, as he
endeavoured to comply with this request, it seemed incredible that
what he was doing could strike anyone as humorous. To Hugo, on
the other hand, it appeared as if the entertainment had now reached
its apex of wholesome fun. As Mr. Twist's purple face came up for
the third time, he abandoned himself whole-heartedly to mirth. He
rocked in his chair, and, rashly trying to inhale cigarette smoke at the
same time, found himself suddenly overcome by a paroxysm of
coughing.
It was the moment for which Chimp Twist had been waiting. There is,
as Ronnie Fish would have observed in the village hall an hour or so
earlier if the audience had had the self-restraint to let him get as far
as that, a tide in the affairs of men which, taken at the flood, leads on
to fortune. Chimp did not neglect the opportunity which Fate had
granted him. With an agile bound he was at the window, and,
rendered supple, no doubt, by his recent exercises, leaped smartly
through it.
He descended heavily on the dog Emily. Emily, wandering out for a
last stroll before turning in, had just paused beneath the window to
investigate a smell which had been called to her attention on the
gravel. She was trying to make up her mind whether it was rats or
the ghost of a long-lost bone when the skies suddenly started raining
heavy bodies on her.
V
Emily was a dog who, as a rule, took things as they came, her
guiding motto in life being the old Horatian nil admirari, but she could
lose her poise. She lost it now. A startled oath escaped her, and for a
brief instant she was completely unequal to the situation. In this
instant, Chimp, equally startled but far too busy to stop, had
disengaged himself and was vanishing into the darkness.
A moment later Hugo came through the window. His coughing fit had
spent itself, and he was now in good voice again. He was shouting.
At once Emily became herself again. All her sporting blood stirred in
answer to these shouts. She forgot her agony. Her sense of
grievance left her. Recognizing Hugo, she saw all things clearly, and
realized in a flash that here at last was the burglar for whom she had
been waiting ever since her conversation with that wire-haired terrier
over at Webleigh Manor.
John had taken her to lunch there one day and, fraternizing with the
Webleigh dog under the table, she had immediately noticed in his
manner something aloof and distinctly patronizing. It had then come
out in conversation that they had had a burglary at the Manor a
couple of nights ago, and the wire-haired terrier, according to his
own story, had been the hero of the occasion. He spoke with an ill-
assumed offhandedness of barking and bitings and chasings in the
night, and, though he did not say it in so many words, gave Emily
plainly to understand that it took an unusual dog to grapple with such
a situation, and that in a similar crisis she herself would inevitably be
found wanting. Ever since that day she had been longing for a
chance to show her mettle, and now it had come. Calling instructions
in a high voice, she raced for the bushes into which Chimp had
disappeared. Hugo, a bad third, brought up the rear of the
procession.
Chimp, meanwhile, had been combining with swift movement some
very rapid thinking. Fortune had been with him in the first moments
of this dash for safety, but now, he considered, it had abandoned
him, and he must trust to his native intelligence to see him through.
He had not anticipated dogs. Dogs altered the whole complexion of
the affair. To a go-as-you-please race across country with Hugo he
would have trusted himself, but Hugo in collaboration with a dog was
another matter. It became now a question not of speed but of craft;
and he looked about him, as he ran, for a hiding place, for some
shelter from this canine and human storm which he had unwittingly
aroused.
And Fortune, changing sides again, smiled upon him once more.
Emily, who had been coming nicely, attempted very injudiciously at
this moment to take a short cut and became involved in a bush. And
Chimp, accelerating an always active brain, perceived a way out.
There was a low stone wall immediately in front of him, and beyond
it, as he came up, he saw the dull gleam of water.
It was not an ideal haven, but he was in no position to pick and
choose. The interior of the tank from which the gardeners drew
ammunition for their watering cans had, for one who from childhood
had always disliked bathing, a singularly repellent air. Those dark,
oily looking depths suggested the presence of frogs, newts, and
other slimy things that work their way down a man's back and
behave clammily around his spine. But it was most certainly a place
of refuge.
He looked over his shoulder. An agitated crackling of branches
announced that Emily had not yet worked clear, and Hugo had
apparently stopped to render first aid. With a silent shudder Chimp
stepped into the tank and, lowering himself into the depths, nestled
behind a water lily.
Hugo was finding the task of extricating Emily more difficult than he
had anticipated. The bush was one of those thorny, adhesive
bushes, and it twined itself lovingly in Emily's hair. Bad feeling began
to rise, and the conversation took on an acrimonious tone.
"Stand still!" growled Hugo. "Stand still, you blighter dog."
"Push," retorted Emily. "Push, I tell you! Push, not pull. Don't you
realize that all the while we're wasting time here that fellow's getting
away?"
"Don't wriggle, confound you. How can I get you out if you keep
wriggling?"
"Try a lift in an upward direction. No, that's no good. Stop pushing
and pull. Pull, I tell you. Pull not push. Now, when I say 'To you ...'"
Something gave. Hugo staggered back. Emily sprang from his grasp.
The chase was on again.
But now all the zest had gone out of it. The operations in the bush
had occupied only a bare couple of minutes, but they had been
enough to allow the quarry to vanish. He had completely
disappeared. Hugo, sitting on the wall of the tank and trying to
recover his breath, watched Emily as she darted to and fro,
inspecting paths and drawing shrubberies, and knew that he had
failed. It was a bitter moment, and he sat and smoked moodily.
Presently even Emily gave the thing up. She came back to where
Hugo sat, her tongue lolling, and disgust written all over her
expressive features. There was a silence. Emily thought it was all
Hugo's fault, Hugo thought it was Emily's. A stiffness had crept into
their relations once again, and when at length Hugo, feeling a little
more benevolent after three cigarettes, reached down and scratched
Emily's head, the latter drew away coldly.
"Damn fool!" she said.
Hugo started. Was it some sound, some distant stealthy footstep,
that had caused his companion to speak? He stared into the night.
"Fat head!" said Emily. "Can't even pull somebody out of a bush."
She laughed mirthlessly, and Hugo, now keenly on the alert, rose
from his seat and gazed this way and that. And then, moving softly
away from him at the end of the path, he saw a dark figure.
Instantly, Hugo Carmody became once more the man of action. With
a stern shout he dashed along the path. And he had not gone half a
dozen feet when the ground seemed suddenly to give way under
him.
This path, as he should have remembered, knowing the terrain as he
did, was a terrace path, set high above the shrubberies below. It was
a simple enough matter to negotiate it in daylight and at a gentle
stroll, but to race successfully along it in the dark required a Blondin.
Hugo's third stride took him well into the abyss. He clutched out
desperately, grasped only cool Worcestershire night air, and then,
rolling down the slope, struck his head with great violence against a
tree which seemed to have been put there for the purpose.
When the sparks had cleared away and the firework exhibition was
over, he rose painfully to his feet.
A voice was speaking from above—the voice of Ronald Overbury
Fish.
"Hullo!" said the voice. "What's up?"
VI
Weighed down by the burden of his many sorrows, Ronnie Fish had
come to this terrace path to be alone. Solitude was what he desired,
and solitude was what he supposed he had got until, abruptly,
without any warning but a wild shout, the companion of his school
and university days had suddenly dashed out from empty space and
apparently attempted to commit suicide. Ronnie was surprised.
Naturally no fellow likes getting the bird at a village concert, but
Hugo, he considered, in trying to kill himself was adopting extreme
measures. He peered down, going so far in his natural emotion as to
remove the cigarette holder from his mouth.
"What's up?" he asked again.
Hugo was struggling dazedly up the bank.
"Was that you, Ronnie?"
"Was what me?"
"That."
"Which?"
Hugo approached the matter from another angle.
"Did you see anyone?"
"When?"
"Just now. I thought I saw someone on the path. It must have been
you."
"It was. Why?"
"I thought it was somebody else."
"Well, it wasn't."
"I know, but I thought it was."
"Who did you think it was?"
"A fellow called Twist."
"Twist?"
"Yes, Twist."
"Why?"
"I've been chasing him."
"Chasing Twist?"
"Yes. I caught him burgling the house."
They had been walking along, and now reached a spot where the
light, freed from overhanging branches, was stronger. Mr. Fish
became aware that his friend had sustained injuries.
"I say," he said, "you've hurt your head."
"I know I've hurt my head, you silly ass."
"It's bleeding, I mean."
"Bleeding?"
"Bleeding."
Blood is always interesting. Hugo put a hand to his wound, took it
away again, inspected it.
"By Jove! I'm bleeding."
"Yes, bleeding. You'd better go in and have it seen to."
"Yes," Hugo reflected. "I'll go and get old John to fix it. He once put
six stitches in a cow."
"What cow?"
"One of the cows. I forget its name."
"Where do we find this John?"
"He's in his room over the stables."
"Can you walk it all right?"
"Oh yes, rather,"
Ronnie, relieved, lighted a cigarette, and approached an aspect of
the affair which had been giving him food for thought.
"I say, Hugo, have you been having a few drinks or anything?"
"What do you mean?"
"Well, buzzing about the place after non-existent burglars."
"They weren't non-existent. I tell you I caught this man Twist...."
"How do you know it was Twist?"
"I've met him."
"Who? Twist?"
"Yes."
"Where?"
"He runs a place called Healthward Ho near here."
"What's Healthward Ho?"
"It's a place where fellows go to get fit. My uncle was there."
"And Twist runs it?"
"Yes."
"And you think this—dash it, this pillar of society was burgling the
house?"
"I caught him, I tell you."
"Who? Twist?"
"Yes."
"Well, where is he, then?"
"I don't know."
"Listen, old man," said Ronnie gently. "I think you'd better be pushing
along and getting that bulb of yours repaired."
He remained gazing after his friend, as he disappeared in the
direction of the stable yard, with much concern. He hated to think of
good old Hugo getting into a mental state like this, though, of course,
it was only what you could expect if a man lived in the country all the
time. He was still brooding when he heard footsteps behind him and
looked round and saw Mr. Lester Carmody approaching.
Mr. Carmody was in a condition which in a slimmer man might have
been called fluttering. He, like John, had absented himself from the
festivities in the village, wishing to be on the spot when Mr. Twist
made his entry into the house. He had seen Chimp get through the
dining-room window and had instantly made his way to the front hall,
proposing to wait there and see the precious suitcase duly deposited
in the cupboard under the stairs. He had waited, but no Chimp had
appeared. And then there had come to his ears barkings and
shoutings and uproar in the night. Mr. Carmody, like Othello, was
perplexed in the extreme.
"Ah, Carmody," said Mr. Fish.
He waved a kindly cigarette holder at his host. The latter regarded
him with tense apprehension. Was his guest about to announce that
Mr. Twist, caught in the act, was now under lock and key? For some
reason or other, it was plain, Hugo and this unspeakable friend of his
had returned at an unexpectedly early hour from the village, and Mr.
Carmody feared the worst.
"I've got a bit of bad news for you, Carmody," said Mr. Fish. "Brace
up, my dear fellow."
Mr. Carmody gulped.
"What—what—what...."
"Poor old Hugo. Gone clean off his mental axis."
"What! What do you mean?"
"I found him just now running round in circles and dashing his head
against trees. He said he was chasing a burglar. Of course there
wasn't anything of the sort on the premises. For, mark this, my dear
Carmody: according to his statement, which I carefully checked, the
burglar was a most respectable fellow named Twist, who runs a sort
of health place near here. You know him, I believe?"
"Slightly," said Mr. Carmody. "Slightly."
"Well, would a man in that position go about burgling houses? Pure
delusion, of course."
Mr. Carmody breathed a deep sigh. Relief had made him feel a little
faint.
"Undoubtedly," he said. "Hugo was always weak-minded from a boy."
"By the way," said Mr. Fish, "did you by any chance get up at five in
the morning the other day and climb a ladder to look for swallows'
nests?"
"Certainly not."
"I thought as much. Hugo said he saw you. Delusion again. The
whole truth of the matter is, my dear Carmody, living in the country
has begun to soften poor old Hugo's brain. You must act swiftly. You
don't want a gibbering nephew about the place. Take my tip and
send him away to London at the earliest possible moment."
It was rare for Lester Carmody to feel gratitude for the advice which
this young man gave him so freely, but he was grateful now. He
perceived clearly that a venture like the one on which he and his
colleagues had embarked should never have been undertaken while
the house was full of infernal, interfering young men. Such was his
emotion that for an instant he almost liked Mr. Fish.
"Hugo was saying that you wished him to become your partner in
some commercial enterprise," he said.

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Small Animal Dermatology: A Color

Atlas and Therapeutic Guide, 4th

Atlas of Small Animal Wound Management and

Canine and Feline Cytology: A Color Atlas and

Fitzpatrick's Color Atlas and Synopsis of Clinical

Fitzpatrick's Color Atlas and Synopsis of Clinical

Weinberg’s Color Atlas of Pediatric Dermatology 5th

Fitzpatrick’s Color Atlas and Synopsis of Clinical

Atlas of Small Animal Ultrasonography 2nd Edition –

Atlas of Small Animal Diagnostic Imaging Nathan C.

KEITH A. HNILICA, DVM, MS, MBA, DACVD

SMALL ANIMAL DERMATOLOGY: A COLOR ATLAS AND ISBN: 978-0-323-37651-8

Copyright © 2017, by Elsevier Inc. All rights reserved.

Library of Congress Cataloging-in-Publication Data

Names: Hnilica, Keith A. | Patterson, Adam P.

Content Stategy Director: Penny S. Rudolph

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Cheryl Greenacre, DVM, DABVP (Avian Practice),

Amy K. LeBlanc, DVM Diplomate ACVIM (Oncology)

Choose happiness and never be afraid of hard work.

Good works matter; DO GOOD WORKS!

Only the lead mule gets to enjoy the change in scenery.

Many thanks to those whose generosity made this book possible:

recognized until the dog is 2 to 5 years old. Follicular

infectious agents are transmissible to people. Infectious tor’s examination or during)?

So, What Is the Solution?

dermatology appointment and provides essential information

WHAT IS MAKING MY DOG SO ITCHY?

SEVERIT Y EVALUATION On a scale of 0 to 10 rank the severity of your dog’s symptoms.

SEVERITY OF SKIN LESIONS

ONSET AND SEASONALIT Y EVALUATION

PAR ASITE CONTROL

LIFE ST YLE EVALUATION

REL ATIONSHIP/BEHAVIORAL EVALUATION

©2008 Novartis Animal Health US, Inc. ATO080228A

FIGURE 1-2, cont’d Continued

1 WHAT ARE THE INFECTIONS?

Slide 1 Skin Scrape (hairplucks): Positive for / Negative

2 COMMON ALLERGIC SIGNS1

A. LUMBAR DERMATITIS B. EAR-SCRATCH TEST

FIGURE 1-2, cont’d

TREAT THE ACUTE FLARES:

3 Cause Recommended Treatment

TREATMENT, CONTROL AND PREVENTION OF FUTURE FLARES:

Cause Recommended Treatment

AVOIDING THE TRIGGERS:

Cause Treatment Recommended Treatment

PROMOTE SKIN HEALTH AND RESTORE BARRIER FUNCTION:

Cause Recommended Treatment

RECHECK APPOINTMENT: ________________________________________________

FIGURE 1-2, cont’d Continued

HOW ITCHY IS YOUR DOG?

FIGURE 1-2, cont’d

© 2010 Novartis Animal Health US, Inc. ATO100022A

FIGURE 1-2, cont’d

Differentials Based on Body Region

Diseases Primarily Limited to the Face

FIGURE 1-5 Oral Lesions. FIGURE 1-6 Ear Margin Dermatitis.

Ear Margin Dermatitis Nasodigital Hyperkeratosis

Differentials Based on Body Region—cont’d

Cats Diseases of the Footpads

FIGURE 1-10 Diseases of the Footpads.

FIGURE 1-9 Diseases of the Claw.

Differentials Based on Primary and Secondary Lesions

Differentials Based on Primary and Secondary Lesions—cont’d

Differentials Based on Primary and Secondary Lesions—cont’d

Differentials Based on Primary and Secondary Lesions—cont’d

Differentials Based on Primary and Secondary Lesions—cont’d