Acral Lick Granuloma

A ten year-old female Labrador crossbreed dog was presented with a large lick granuloma at the lateral aspect of the right antebrachium. The acral lick granuloma was associated with carpal arthrosis and pain. The treatment included 50mg of Carprofen (Rimadyl) once daily to reduce possible associated pain. The VetGold cream was then applied three times a day on the affected area. Antibiotics were not given.

ANTEBRACHEAL LICK GRANULOMA TREATED WITH RIMADYL AND
VETGOLD CREAM IN A LABRADOR CROSSBREED DOG
Nitzan Kroter BVSC (Pretoria) MRCVS

PRESENTATION & HISTORY
A ten-year-old neutered female crossbreed dog weighing 23kg. Presented with a large lick granuloma at the lateral aspect of the right antebrachium extending from proximal to the carpus to just distal to the elbow.

The dog did not have history of any skin condition or any related allergic condition.  She was fed on hill’s science diet for many years, and no dietary change was noted recently. The owner reported that she would lick the area with vigour for a period of three weeks.

CLINICAL EXAMINATION & INVESTIGATION
She was responsive and alert. Her body condition and coat quality appeared to be very satisfactory. Full clinical examination appeared to be unremarkable apart of resentment to manipulation of the right carpus, particularly upon flexion. The rest of the examination was within normal limits.

Bacterial and fungal cultures were negative. Radiographic examination revealed moderate athrosis at the carpus. Examination of the history, presenting complaint and behavioural analysis ruled out other possible differential diagnosis. It was suspected that the lick granuloma is due to a referred pain, as a result of the carpal arthrosis.

PROBLEM LIST AND DIFFERENTIAL DIAGNOSIS
Superficial dermatitis (infectious or allergic)
Contact dermatitis
Foreign body reaction
Psychological stimuli
Fungal or other infectious dermatitis
Orthopaedic implants or arthritic pain

DIAGNOSIS
Acral lick Granuloma associated with carpal arthrosis and pain.

MANAGEMENT
Carprofen (Rimadyl) 50mg once daily was given orally to reduce possible associated pain and VetGold cream was applied three times a day on affected area. Antibiotics were not given. Elizabethan collar was not fitted, as the dog would not tolerate any form of restrain.

One week post treatment with VetGold cream

 

DISCUSSION
Lick granuloma, (Acral lick granuloma or Acral lick dermatitis) is a disease usually resulting from self-trauma directed at the distal limbs. Lesions are well-circumscribed plaques, ulcers, or, less commonly, nodules that frequently have a hyperpigmented border. Various etiologies have been proposed,  Including behavioral disorders, allergy, pyoderma, trauma, or joint disease. Behavioral problems such as anxiety, phobia, stress, boredom, or obsessive-compulsive disorder may manifest as repetitive licking,

  • Boredom is a major underlying factor in some cases of Lick Granuloma e Some believe that allergic inhalant dermatitis creates stress in the skin resulting in inflammation and pruritus, which triggers the dog’s propensity to lick
  • A foreign body or bee sting might start up a reaction in the skin, which leads to drawing the dog’s attention to the spot.
  • Bone or joint pain can draw the dog’s attention to the carpus or hock area and in an attempt to alleviate the discomfort, the dog licks over the top of the joint.
  • Psychological stimuli such as separation anxiety, a new pet or child at home, or neighbour dogs invading the dog’s “territory” can create psychological stress. Self-stimulation such as picking out an area to concentrate on and licking for extended periods are a way for the dog to relieve the “stress”.
  • Hypothyroidism had been implicated in some cases of Acral Lick Granuloma (ALG).
  • Tumours, fungal or other infections, orthopaedic implants are all possible causes the may initiate licking that results in a granuloma like lesion.

Diagnostic tests are important since many skin conditions look the same, even though they have different causes and are treated differently. In some situations, ALG can occur simultaneously with other skin diseases and not just as a disease entity. Therefore full skin workup, including Skin Scraping,  fungal and deep bacterial Culture, Radiography, Skin biopsy and/or fine needle aspiration, and Allergy testing should be part of the normal protocol for the approach to any lesion resemble lick granuloma.

ALG tends to be a chronic disease that leads to significant frustration. The wide varieties of treatments that are used to treat ALG are an indication of the complexity of this disease and the fact that many different causes may be involved. One cannot over emphasize the importance of proper flea control in any pet that has a skin condition. Cortisone could be used initially to minimize swelling and licking. Long term use should be discourage due to the chronic infection associated with the lesion and the retardation of healing by the steroids, which may prevent healthy healing.

The use of Elizabethan collars may be used to try and break the cycle of licking and protect the area. This however not very affective as if the cause was not removed than the dog will lick again once the collar removed and it usually take a day or two to reach the starting point. Oral antibiotics are probably the most important treatment offered today for ALG. In some cases, it would be indicated to use them for 4-6 months due to the chronic nature of the problem. It is important to continue them for at least 3 weeks after the skin looks healed. In some dogs pulse therapy for life may achieve good outcome. In the above case antibiotics were not use as the suspected cause was not attributed to infection.

Antibiotics most commonly used:

  • Cephalosporins
  • Potentiated sulphonamides
  • fluroquinalones
  • Amoxicillin/Clavulanate
  • Clindamycin

Laser therapy had some success in the treatment of this problem. It usually takes at least three treatments, and in some cases can be a significant help in minimizing the licking. If a deep-seated fungal infection is diagnosed, oral fungal medication should be used for an extended period. Immunotherapy can be a good way to minimize itching without using cortisone. Should there is an allergic components to the ALG. The less we use cortisone to minimize itching the faster the problem will resolve. Some allergic dogs and cats scratch less when supplemented with essential fatty acids and will benefit from hypoallergenic diet. Surgery is often not a rewarding way to treat ALG since the problem commonly recurs after the surgery.

It is a natural tendency to want to use topical medication only on a skin problem. If used in combination with long-term oral antibiotics this topical medication can be beneficial. They are usually not effective when used alone as the do not adhering the possible underline cause. In this case, VetGold was used in combination with Carprofen to stimulate skin healing and to reduce pain associated with the carpal joint. Some dogs are compulsive lickers without any obvious cause. Some veterinarians believe that the incessant licking in ALG is similar to the exaggerated grooming
habits of people with obsessive-compulsive disorders. This area of the management for ALG may be important and is explored vastly in literature. Some how, it lacks objectivity, and therefore difficult to evaluate when measuring treatment efficacy.

There is a lot of disagreement as to the best treatment to attempt first in a case of lick granuloma and unfortunately still today we are all battling with the management of Acral Lick Granuloma. In this case, VetGold was found to be beneficial as an adjunct to other systemic therapy.

Copyrights © 2007 Nitzan Kroter 6