The DermVet, Dr. Ashley Bourgeois returns to help us navigate canine allergies. In this episode of The Cone of Shame Veterinary Podcast, Dr. Andy Roark welcomes board-certified veterinary dermatologist Dr. Ashley Bourgeois to discuss managing difficult canine allergy cases that don’t respond well to Apoquel or Cytopoint. Dr. Bourgeois offers practical advice on identifying hidden infections in claw folds, using consistent treatment regimens, and when to consider alternatives like skin biopsies or recognizing allergy mimickers such as autoimmune diseases or lymphoma. Tune in for insights on allergy testing, immunotherapy, and effective long-term strategies for managing atopic dermatitis. Gang, let’s get into this episode!
You can also listen to this episode on Apple Podcasts, Google Podcasts, Amazon Music, Soundcloud, YouTube or wherever you get your podcasts!
LINKS
Dr. Ashley Bourgeois: https://thedermvet.com/about
Dr. Ashley Bourgeois on Instagram: https://www.instagram.com/thedermvet/
Dr. Ashley Bourgeois on LinkedIn: https://www.linkedin.com/in/ashley-bourgeois-dvm-dip-acvd-9169208/
Exam Room Communication Toolkit: https://drandyroark.com/exam-room-communication-toolkit/
Charming the Angry Client Course: https://drandyroark.com/charming-the-angry-client/
Dr. Andy Roark Swag: https://drandyroark.com/store/
ABOUT OUR GUEST
Dr. Ashley Bourgeois is a board-certified veterinary dermatologist passionate about providing practical knowledge to general practitioners to help itchy pets! She completed her bachelor’s degree at Iowa State University and graduated from the University of Missouri’s College of Veterinary Medicine in 2010. She then completed a one-year small animal internship at Purdue University. Upon finishing her internship, she accepted a residency position with the Animal Dermatology Clinic’s Tustin, California location in 2011. She became a Diplomate of the American College of Veterinary Dermatology in 2014. Dr. Bourgeois moved to Portland, Oregon in 2016 to help expand the company. She is an owner within the company and on the board of directors. She has a strong interest in autoimmune skin diseases, allergies, cytology, and otology. In her leisure, Dr. Bourgeois enjoys outdoor activities, traveling, and watching sports. She and her husband stay busy with their daughter, son, and rescue Lab/Boxer/Pit mix. Dr. Bourgeois is passionate about educating veterinarians in dermatology and work/life integration through her podcast, lecturing, and social media presence (The Derm Vet).
EPISODE TRANSCRIPT
Dr. Andy Roark: Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I got a good one here. I am with my friend Dr. Ashley Bourgeois she is a veterinary dermatologist, and we are talking about allergies when Apoquel doesn’t work. That’s right, if you’ve been in practice for a while, you’ve seen those cases roll in, and you’re like, Oh, we tried Apoquel, we tried Cytopoint, and we’re still, we’ve still got an itchy dog and I talked with Ashley here. She’s got all kinds of pearls and insights and we walked through what do you do with these cases? is a fantastic episode. I hope you’re gonna get a ton out of it I got a ton out of listening to Ashley break it down, And so anyway, let’s get into it.
Kelsey Beth Carpenter: (singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.
Dr. Andy Roark: Welcome to the podcast, Dr. Ashley Bourgeois how are you?
Dr. Ashley Bourgeois: I am doing so good. We are actually going to talk about one of my favorite topics today. So I’m just so excited to go through this journey with you today.
Dr. Andy Roark: I love when I have brilliant people on the podcast, and I take them problems, and they’re like, this is one of my favorite things to talk about.
Dr. Ashley Bourgeois: But I’m a dermatologist I like, I could say that about any topic, but this is such a common issue. I can’t wait to shed some light onto it.
Dr. Andy Roark: Oh, yeah, what we want to talk about today, and sort of what I went to you with, is, Ashley, what are your, what are your tips and tricks for treating the canine allergy patient who’s getting Apoquel or Cytopoint and it’s still not cutting it? And so I’m thinking of the case, let’s say we’ve sent home flea and tick preventative and we have, you know, tried to, treat these allergies in the classic way, and they’re getting Apoquel or Cytopoint, things like that.
And we’re still having issues. I think a lot of times people kind of look at their hands and go, Oh boy, you know, what do we need to do here? What do we need to do here? I’ll tell you. I always have a panic moment at, at that, at that, at that point. Not that I don’t have other tools, but it’s almost like, oh, my go-to move isn’t working.
And and I, I need to, I need to walk this back or, or try to approach this differently. So let me just pause there and kind of turn it over to you and say, how often do you see. Allergy cases that make their way to you that are getting sort of what you consider to be quality Sort of top line therapy and you’re still seeing breakthroughs.
Dr. Ashley Bourgeois: Yeah. I think it’s a bit of a double edged sword because let’s say it’s typical for me to get that history where the client comes in and says that, right. But I’d say the two things I see, if that is not true, let’s say like the client comes in with that impression, maybe the veterinarian has that impression.
But I kind of get to the point where I’m not really sure that’s true. I’d say there’s two, two fold one for sure. Flare factors. So like things aren’t infection aren’t controlled. So we see oftentimes where if they do break out with Malassezia or a pyoderma, you know, interdigital spaces, claw folds, claw folds are huge.
When I lecture about cytology, it’s one of the best things you could be doing. Is getting a toothpick, scraping material out of that claw fold. If you have a dog that’s looking and chewing their paws incessantly, but when you look at the paws, they don’t look that bad. Check those claw folds. Malassezia, infection, bacteria really like to hide in there, and they can look pretty darn normal, and then all of a sudden you’ll find a bunch of stuff hiding there.
Dr. Andy Roark: You’re not seeing you’re not seeing kind of pus crusty stuff around the the edges there? You’re not seeing hair loss anything like that?
Dr. Ashley Bourgeois: You can be, you don’t have to. I mean, especially if they have long coats. Like a lot of times I have pictures where they look totally normal. You flip back the claw fold and there is stuff in there or you flip back the claw fold. You don’t see too much, but then when you get a sample, there’s actually quite a bit of infection that’s hiding in that tissue.
So they don’t have to necessarily be lesional, but I always check those areas. I’d say the second kind of, it didn’t work, but actually I think it maybe could, is not consistent. So, Apoquel is a great tool, and I think as a general practitioner, you probably get away a little bit more with, Oh, let’s just do two weeks and you can stop.
But when you keep doing the two weeks and stop, two weeks and stop, two weeks and stop, and the dog keeps breaking out, then they come to us and I’ll say, well, have you just given it consistently? And they’ll say, no, I’m like, well, you might be a dog that just needs it consistently. So I think those are probably the more common things I see.
Now there can be true statements to that. I’ve certainly had cases that don’t respond. You know, I am managing the infections. I have them on the flea control. We’ve done the diet trials. Like they truly are atopic. I don’t have a flare factor present and they’re just not responding. No medication is a hundred percent.
So certainly there are some difficult cases. And that’s when I start thinking of either alternatives or I’d say the flip side is, is it actually allergies? Because sometimes we have allergy mimickers that can present as well.
Dr. Andy Roark: Okay. Tell me tell me more about that. What what are your what are your top allergy mimickers?
Dr. Ashley Bourgeois: So I would say some of the main mimickers we think of are either like autoimmune or neoplastic. I think when we talk about, say, like, pymphagus, right? Because that’s the one people always think of. They think, oh, it has to be the dog coming in where the nose is completely crusted and depigmented and their paw pads are completely crusted.
But if you think about it, pyoderma, what does that look like? It can be colorette, scaly, but it can also be crusty. So when you get some of these pymphagus cases that their mucous membranes aren’t affected, you know, they are just kind of crusty throughout the trunk. And we don’t do cytology. We don’t identify like, oh, there’s not an infection causing that.
They actually can look a lot like allergies. And then I would say one of the other big ones, and it’s going to sound crazy, but it’s so true. And we see this a lot is skin lymphoma. Skin lymphoma can do anything from being detrimental. You know, completely eating away the skin ulcerative. They look awful to a focal area of erythema and scaling.
I mean, it really can be pretty mild in some of these early cases. And a lot of times our till for that is it has started when they’re older and they haven’t really had a history of dermatologic issues in the past.
Dr. Andy Roark: Okay, so old dog with a lesion and that’s, that’s not, not normal for this dog. You would have like cutaneous lymphoma on your, on your list. Are you going to see anything on that with, with cytology, like just regular skin cytology? Are you going to pick anything up or no?
Dr. Ashley Bourgeois: You can. So a lot of times you will pick up these neoplastic cells. And what I try to tell general veterinarians, because some of them will be like, well, I don’t feel comfortable saying that. Yeah.
Dr. Andy Roark: Oh, I definitely don’t want to say that.
Like,
I’m like, ooh, we need to send this out and get, get a second, get a second opinion on this.
Dr. Ashley Bourgeois: and you totally could. And what I would tell you as a dermatologist is, I don’t really care if you would say, Oh, I’m Andy Roark. And I feel like this looks like cutaneous lymphoma. Like what I care about is that you can say that’s weird, right? Because if you can even say that’s weird, like that happens to me all the time, you know, I’m a dermatologist, but I’ll look at something.
I’m like, well, that’s weird. Okay. But at least I know my next step should be, well, you know, I can’t, I shouldn’t probably refer, I mean, I could refer to someone else, but it should be me, but you would refer or you’d biopsy. Right? So like you could at least say, okay, well maybe we don’t just throw apoquel at this case.
So to me, there’s a ton of value in that, even if you’re not confident to say. This is an autoimmune disease. You can say, well, there’s not bacteria here. That’s pretty weird. So now what do I think about in this case?
Dr. Andy Roark: Have you got any pearls for me on skin biopsies? I mean, they’re pretty, they’re pretty straightforward. I do love, I love a, I love a punch biopsy. It makes me feel so cultured. I don’t know. It works well. It tends to go well. I know what I’m doing. But I, if, if another doctor turned to me and said, Andy, I hey, you got any concerns about me biopsying this weird spot?
Is there anything that should be on my radar, or should I say, no, go for it?
Dr. Ashley Bourgeois: Yeah, I’d say multiple things. I would collect cytology first because if it’s severely infected, you’re probably better off trying to treat that infection first, because if there’s just a rip roaring bacterial folliculitis, you’re going to get a biopsy that says there’s a bacterial folliculitis. And that’s not going to be that helpful.
You know, other basic stuff is if there’s diffuse lesions, you know, you should be getting multiple sites. You should not just be taking one site if there is diffuse. And it’s not just like a mass you’re taking off. You do not want to sterilely prep them. So I think surgeons probably lose their mind when they walk by a dermatologist biopsying them.
Right. Cause we want the crests. Like sometimes that’s how you get your diagnosis. So we are almost never sterilely prepping unless we’re removing a nodule or mass, but. Or we’re doing a tissue culture, but for just a run of the mill histopathology, we’re actually getting the crust. We’re getting the nasty stuff with it.
And then just making sure that you’re getting bigger punches. So we shouldn’t really be taking two millimeter punches. Like we should be doing more like eight millimeter punches if we’re doing diffuse disease.
Dr. Andy Roark: Not sterilely prepping the area feels like sacrilege. But I mean, I know, I know I’m supposed to do it, but I feel people looking at me like, are you just gonna, you’re just gonna. Do it like that and yeah,
Dr. Ashley Bourgeois: Just come spend a day in derm. Like, I mean, we are just like, you know, crust and nasty and like I said, the surgeons probably lose their mind because we’re just like not sterilely prepping. And I will tell you, I biopsy all the time. I’ve just done derm now for like 13 years. None have ever been like, Oh my God, you cause this patient to be septic
cause he took a skin biopsy. Right. Cause I’ve done cytology. If there’s infection, I’m probably going to treat them anyway. But you’ll, you’ll be
okay.
Dr. Andy Roark: That totally makes sense.
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let’s get back into this episode.
Dr. Andy Roark: We’ve laid down a lot a lot of different possibilities here, but we’ve got something. We feel like it’s it should be resolving and it’s not we’re digging in the nail beds Which I think is a beautiful little pearl i’m going to put in my pocket and keep for sure we’ll move towards skin biopsy thing things like that. Are there are there anything that that pet owners should be aware of is there anything that I should
you say to them about where this treatment path might go so that they’re prepped?
Dr. Ashley Bourgeois: Yeah. I mean, usually when I’m giving, so let’s assume it is an allergic case, right? Like it’s not a mimicker. It’s truly an allergic case. That’s like not responding. I certainly talked to owners about, I kind of break it into two options. If I’m managing atopic dermatitis, one is symptom treatment.
And I break that into infection control because we know. We have to control the infection or the itch won’t fully resolve. And then my second kind of symptom control category is the allergic itch itself. And when I do that for dogs, I write Apoquel, cytopoint, cyclosporine and steroids. The reason being, apoquel and cytopoint have been amazing tools for us, you know, you can certainly use them together, you can do all sorts of things, but again, no medication is 100%, so we certainly have cases that do not respond.
They’re allergic, they’re not a mimicker, we’re managing infection, they don’t respond. And you cannot forget about those other possibilities. And I would say I still have cases that respond better to cyclosporine. It’s a more broad spectrum anti inflammatory. It’s certainly something, especially with our crazy pododermis titus cases, things like that, where they can still respond the best.
So just because they don’t respond to apoquel or cytopoint, you know, they’re allergic doesn’t mean you have no option. And then sometimes we do end up with steroids. Like we try not to. You know, but again, if the reality is they didn’t respond to anything else, then we got to still provide comfort. And then I’m also pushing my second category of managing allergies is pushing allergy testing and immunotherapy, especially if they’re a younger, middle aged dog, right?
If they’re not responding to apoquel cytopoint, like what is the next 10 years look like for that dog? We’re going to have a better chance to desensitize them earlier in the disease process if we can.
Dr. Andy Roark: so I got a couple questions here. So when we’re talking about apoquel cytopoint, cyclosporine, steroids What are your feelings about overlapping these? Are you trying to kind of? say we’re not getting the results that we want. Are we adding in something else with the idea that we may keep all the things?
Or are you going to add in something else and maybe wean off of one of our earlier treatments? Are you, so yeah, talk, talk to me about that is, I don’t want to end up, you know, throwing everything in the kitchen sink at this problem, especially if we’re not getting results. But I always wonder, you know, if I take this dog off of Apoquel to try something else, am I gonna, am I gonna make things worse?
How do you sort of assess what to do with that crossroads?
Dr. Ashley Bourgeois: Yeah, it is a very good question. I’m very individual in the case, but I agree with you. So if I started a dog on let’s say we, for that particular case, we started with Apoquel. They recheck with me and let’s say like, they’re like kind of better, but it’s not a hundred percent better, and I want to try Cytopoint.
I usually have them still give a few days of Apoquel initially. After I give the Cytopoint, a lot of the studies show within three days is when you usually get that response, like a bit over half within a day, see a response. The nice thing about Apoquel is you can start, stop it, right? So I usually say, give it a few days.
If you’re starting to notice the pet’s doing really well, try to stop it and let’s see what happens. So I give them the freedom to do that. If we’re starting something like Cyclosporin, if they were on Apoquel, you can very safely bridge the gap. Like, you can keep them on Apoquel because cyclosporine doesn’t act really quickly, right?
It can take a few weeks, a month to work. So you can still safely keep them on Apoquel in that time if you need to. A lot of times I am using like low dose steroid as I’m bridging them to the cyclosporine as a way to provide some comfort. But that’s why the rechecks are important, right? Cause I want to check in and if the dog’s doing awesome, I’m with you.
I want to try to take things away. Like I already have a lot of my patients on a lot of things. I always want to try to take things away, but I also want to see them, evaluate them to make sure they’ve responded the way that I want.
Dr. Andy Roark: How often do you recheck these types of cases, Ashley? Are you getting them every week or is it a sort of a longer, do you have a tapering where you’re like, I’ll see you in a week and then two weeks and then it’s to go from there? Like, how, how is that?
Dr. Ashley Bourgeois: Yeah, I mean, we actually don’t usually see them back within a week, unless it’s like a rip roaring crazy ear or, you know, like, I think you’ve got some terrible autoimmune disease and I’m just treating the infection to know when to biopsy you, but for an allergy case, at least for me, I would say pretty typical is like, I try something, have them come back three weeks, maybe four weeks.
A lot of that’s very dependent on infection. But if it’s just your response to a medication, yeah. Then usually if I’m going to start on Apoquel, you know, I may do the twice daily for 14 days and then drop down. But I always tell people to let me know if things are not improving and we could try to get them in sooner.
But I give them a bit of time and just don’t want to frustrate the owner if I’m trying to jump the gun a bit quickly and see them that soon. So I would say usually like three weeks is fairly typical, maybe four if we’re not dealing with a bunch of infection.
Dr. Andy Roark: I know that you’re a big fan of allergy testing and immunotherapy in cats. How big are you on this, in our canine patients? So, just, just in us talking, you know, we’ve got a pretty good list of medications that we go through, and then you kind of felt like you added on allergy testing immunotherapy as a sort of like, man, if there’s nothing, if that doesn’t work.
Then, then let’s talk about this. Is that, is that really how you kind of feel or should we be thinking about immunotherapy earlier in our canine patients?
Dr. Ashley Bourgeois: Ooh, I’m really glad you’re asking us to differentiate this cause I’m going to not want to give that impression. I am an advocate to allergy tests whenever the owner is willing. So I love a dog that comes in. It doesn’t happen often, but I love a dog that comes in. They’re doing well on their symptomatic treatment, whether it’s cytopoint cyclosporine, whichever one is working for them.
And they are coming because they, they know it’s a young dog. They want to try to minimize drugs long time, and they want to allergy test them. That is actually most of our dreams as a dermatologist. It doesn’t happen very often. Usually it’s, Oh, this worked. And until it did it, and now you should go see them.
But we absolutely, if owners are willing, we are a hundred percent. So happy to allergy test them at a, at a young age, or even when they’re symptomatically doing well, just to see if we can get ahead of it. Remember, this is a progressive disease. So just because they’re doing great on apoquel when they’re three years old, doesn’t mean when they’re eight years old, they’ll necessarily be controlled.
We know that there’s a progression to it, and that’s what I try to explain to owners, too, is if they’re proactive, it gives us the best chance to try to keep that in control.
Dr. Andy Roark: How do you talk about immunotherapy compared to, you know, medical management in a way that sets good expectations? Like, I guess my idea is if I said to the owner as well, I can do this cytopoint injection or we can do allergy testing and then maybe immunotherapy, which is its own set of injections.
What do you want to do? How do you, how do you sort of explain that in the way the owner says, okay, I understand the investment immunotherapy and I would, I’m going to invest my time and energy there now instead of just taking the, the short term medical fix.
Dr. Ashley Bourgeois: Yeah, to me, it’s not necessarily an or, right? It’s almost an and, because the reality is if I allergy test them, Most of the time they’re on some sort of symptom control while we are giving that time to work. So I really try to have them think more of longevity marathon, you know, rather than like the sprint, the comfort now both are really important, but if we are trying to get ahead of the longterm aspect of this disease, none of us have a crystal ball, you know, if you knew that dog would just get cytopoint and be great the rest of its life with no progression of disease, Cool.
But we don’t know that. So ultimately I really tried to break down kind of that longterm aspect. And let me tell you this, not all of my clients allergy test. I have plenty that don’t, I mean, we love it, but we have to meet that owner where they’re at. And I know I can still help them even if that’s not the route they’re going to go.
But to me, what I tell them is these things can make them comfortable. It can still be tools in our toolbox. What I can do is try to identify what they’re allergic to, put it in a bottle, give it to them in small amounts, and basically see if I can teach their immune system to not react the way it’s reacting.
But that takes time and every response is different.
Dr. Andy Roark: No, that, that totally makes sense. Are there any final pearls, any last words of wisdom for people who are looking at some of these more challenging allergy cases?
Dr. Ashley Bourgeois: I would say for sure, like, control the controllable is one thing I like to say. So I know we have talked about this when we’ve discussed cats, but controlling the controllable means don’t forget the other things, right? The flea control, you know, being able to bathe these pets if they’re able to. There’s a reason you always hear dermatologists talk about multimodal therapy.
This is actually a very complex disease. We think of it being simple, right? Allergies, they’re itchy. You know, you know, we, you and I were talking about how we’re getting to be the older ones now. But when we first started practicing, we didn’t have apoquel or cytopoint. You know, that came out at the end of my residency.
So I did my years with not those tools. And so, you know, those things are, have been amazing. And I hope we keep getting lots of tools. But the reality is like we say multimodal because it’s a complex disease. They’re itchy. They’re skin barrier defects, right? Like. There is an abnormal immune system, their microbiome, we’re starting to learn more about.
So that’s why you often see dermatologists do all the things bathing and, you know, skin support and things like that. So definitely control the things that we can control because there’s a lot that we can’t control. And then certainly like going back to your point, if you are able to, I know not everyone has a dermatologist by them, try to refer them earlier.
You know, it is just nice to start with these cases before it’s been, Oh, well, now we’re eight and we have a methicillin resistant staph pyoderma, and we have to get through that and spend all the money there. And then we’re like, Oh yeah, we also could do this. And we’ve lost all those years to maybe get ahead of it.
Dr. Andy Roark: And the owners are tired and, you know, and they’re frustrated and they’re like, I just don’t want to deal with this anymore.
Dr. Ashley Bourgeois: Yeah. I mean, we set aside that time, right? Like we are usually setting aside longer appointment times. We don’t have the emergency hit by car trying to rush in the same day. So don’t get me wrong, like we’re busy and I know a lot of us have waiting lists. But ultimately like that is what we’re experts in and we have a better success rate if we kind of start managing them earlier.
I think people think I’ve heard even some of my local vets be like, well, they’re not bad enough. I’m like, I can see things besides train wrecks all day. I’m so happy to see the one year old boxer that wants to allergy tests, like bring them on. So I would definitely say like get to know your local dermatologist if you can, and do not be afraid to refer them earlier in the disease process.
Dr. Andy Roark: Dr. Ashley Bourgeois thank you so much for being here. Where can people find you online?
Dr. Ashley Bourgeois: Yeah. Everything I do is under the Derm vet. So I have a podcast that I put weekly tips on, and then a lot of social media that I put under the Derm vet, including cases and just day to day clinical tips. I really like to keep things real life for you guys, and hopefully you guys find that information helpful.
Dr. Andy Roark: That’s fantastic. Thanks so much for being here. Guys, thanks for listening everybody. Take care of yourselves. I’ll talk to you later on.
Dr. Andy Roark: and that’s what I got for you guys. I hope you enjoyed it I hope you got something out of it. Thanks to Ashley for being here. Thanks to you guys for being here. Take care I’ll talk to you guys later on
