TUGAS MATA KULIAH

ILMU BEDAH KHUSUS VETERINER

BEDAH ONCOLOGY
TEKNIK OPERASI GRANULOMA

NAMA/NIM

I Made Agus Suryanatha 1309005030

I Komang Alit Budiartawan 1309005042
Agnes Indah Widyanti 1309005052
Wanda Della Oktarin Hutagaol 1309005077
Satria Anugrah Dewantara 1309005083
Gusti Ayu Made Sri Antari 1309005125
Wahid Danang Pranantha 1309005141

LABORATORIUM BEDAH VETERINER

FAKULTAS KEDOKTERAN HEWAN
UNIVERSITAS UDAYANA
TAHUN 2016
 RINGKASAN

Granuloma merupakan nodul yang terjadi pada kulit yang sering juga disebut
dengan lick granuloma, acral lick dermatitis, acral pruritie nodule, acropruritie
granutomi, psycogenue dermatosis, dan neurodermatitis. biasanya disebabkan oleh
karena luka, benda asing, infeksi, nyeri otot, dan faktor psikogenik yang
mengakibatkan kebosanan, ketidakaktifan atau perubahan lingkungan. Tanda
klinisnya, adanya lesi dengan bulu yang jarang , kulit menebal, lengket, mengalami
ulserasi, eritematus dan dikelilingi oleh banyak pigmen serta jaringan superficial
mengalami erosi. Teknik operasinya dapat dilakukan Secara manual maupun laser
CO2.
Kata Kunci : granuloma, laser, bedah

SUMMARY

Granulomas are nodules that occur on the skin that is often also called lick
granuloma, acral lick dermatitis, pruritie acral nodule, acropruritie granutomy,
psycogenue dermatosis and neurodermatitis. usually caused by injuries, foreign bodies,
infection, muscle pain, and psychogenic factors that lead to boredom, inactivity or
environmental changes. A sign of clinical, lesion with rare feathers, skin thickening, sticky,
ulcerated, erythematous and surrounded by a lot of pigment and superficial tissues
eroded. Mechanical operation can be performed manually or CO2 laser.
Keywords: granuloma, laser, surgical

ii
 KATA PENGANTAR

Puji syukur kami haturkan kehadirat Tuhan Yang Maha Esa atas segala
limpahan rahmat dan hidayah-Nya sehingga Paper “BEDAH ONCOLOGY
TEKNIK OPERASI GRANULOMA” ini dapat diselesaikan tepat waktu.
Makalah ini dibuat dalam rangka menyelesaikan tugas yang akan dijadikan
landasan dalam penilaian softskill pada proses pembelajaran Mata Kuliah Ilmu
Bedah Khusus Veteriner Fakultas Kedokteran Hewan Universitas Udayana.
Ucapan terima kasih dan penghargaan yang setinggi-tingginya kami
sampaikan kepada dosen pengajar yang telah memberikan banyak bimbingan dan
arahan kepada kami dalam penyusunan makalah ini. Tidak lupa penulis juga
mengucapkan terima kasih kepada semua pihak yang telah membantu dan
memberikan dukungan pada kami.
Kami menyadari bahwa tulisan ini masih banyak kekurangan baik dari segi
materi, ilustrasi, contoh, maupun sistematika penulisan. Oleh karena itu, saran dan
kritik dari para pembaca yang bersifat membangun sangat kami harapkan. Besar
harapan kami karya tulis ini dapat bermanfaat baik bagi pembaca pada umumnya
terutama bagi dunia kedokteran hewan di Indonesia.

Denpasar, 16 November 2016

Penulis

iii
 DAFTAR ISI

COVER .................................................................................................................
RINGKASAN/SUMMARY ................................................................................. ii
KATA PENGANTAR ........................................................................................ iii
DAFTAR ISI ...................................................................................................... iv
DAFTAR GAMBAR ........................................................................................... v
DAFTAR LAMPIRAN ....................................................................................... vi
BAB I PENDAHULUAN .................................................................................... 1
1.1 LATAR BELAKANG .............................................................................. 1
1.2 RUMUSAN MASALAH ......................................................................... 1
BAB II TUJUAN DAN MANFAAT PENULISAN ............................................. 2
2.1 TUJUAN PENULISAN ........................................................................... 2
2.2 MANFAAT PENULISAN ....................................................................... 2
BAB III TINJAUAN PUSTAKA ......................................................................... 3
3.1 PENGERTIAN GRANULOMA............................................................... 3
3.2 TUJUAN DAN MANFAAT PEMBEDAHAN GRANULOMA ............... 4
BAB IV PEMBAHASAN .................................................................................... 5
4.1 PREOPERASI GRANULOMA ................................................................ 5
4.2 TEKNIK OPERASI GRANULOMA ....................................................... 7
4.3 PASCAOPERASI GRANULOMA .......................................................... 8
4.4 PENANGANAN GRANULOMA TANPA PEMBEDAHAN ................... 9
BAB V SIMPULAN DAN SARAN ................................................................... 10
5.1 SIMPULAN ........................................................................................... 10
5.2 SARAN .................................................................................................. 10
DAFTAR PUSTAKA ........................................................................................ 11
LAMPIRAN ...................................................................................................... 12

iv
 DAFTAR GAMBAR

Gambar 1. Granuloma pada kaki anjing ............................................................... 3

Gambar. Sebelum dan sesudah pengangkatan granuloma yang membengkak ....... 7
Gambar 3. kelebihan jaringan di sinari dengan laser CO2 ............................................................ 8
Gambar 4. hasil operasi menggunakan laser CO2 ................................................................................ 8

v
 DAFTAR LAMPIRAN

Lampiran 1. Veterinary Practice News, Page: 32. “Using CO2 Laser on Acral
Lick Granulomas.”
Lampiran 2. Veterinary World, 2011, Vol.4(6): 271-272. “Surgical Management
of Lick granuloma in a Boxer Dog.”
Lampiran 3. NAVC Clinician’s Brief. “Acral Lick dermatitis: Behavioral
solutions.”

vi
 BAB I
PENDAHULUAN

1.1 LATAR BELAKANG

Granuloma adalah istilah histopatologi yang mengacu pada koleksi
kecil sel-sel makrofag yang terbentuk ketika sistem imun mencoba untuk
menyekat zat-zat penyusup yang tidak dapat dihilangkan. Granuloma
terbentuk sebagai tanggapan terhadap benda asing, infeksi tertentu
(tuberkulosis, kusta, trauma) dan penyakit kulit inflamasi (granuloma anular,
granuloma fasial, sarkoidosis, )..Dalam praktik sehari-hari, dokter seringkali
menyebut granuloma untuk nodul seperti nevus atau tumor yang kecil.
Salah satu jenis granuloma adalah yang terjadi pada kulit yaitu acral
lick granuloma. Granuloma timbul karena jilatan atau gigitan yang terus-
menerus terjadi pada satu kaki (unilateral) yaitu pada aspek kranial dari
korpus metacarpus dan lateral tarsus atau metatarsus. Kejadiannya cukup
sering pada anjing dan memerlukan penanganan dengan pembedahan.
Penanganan dari granuloma akan dipaparkan pada paper ini.

1.2 RUMUSAN MASALAH

1. Apa yang dimaksud dengan granuloma?
2. Apa tujuan dan manfaat pembedahan granuloma?
3. Bagaimana teknik operasi granuloma?
4. Bagaimana penanganan granuloma tanpa operasi?

1
 BAB II
TUJUAN DAN MANFAAT PENULISAN

2.1 TUJUAN PENULISAN

1. Agar mahasiswa mengetahui yang dimaksud dengan granuloma.
2. Agar mahasiswa mengetahui tujuan dan manfaat pembedahan granuloma.
3. Agar mahasiswa mengetahui teknik operasi granuloma.
4. Agar mahasiswa mengetahui cara penanganan granuloma tanpa operasi?

2.2 MANFAAT PENULISAN

Penulis berharap paper ini dapat bermanfaat bagi pembaca khususnya
mahasisawa Fakultas Kedokteran Hewan yang menggambil mata kuliah
Bedah Khusus Veteriner, agar memahami mengenai granuloma dan teknik
pembedahnnya. Selain itu juga diharapkan paper ini mampu menjadi referensi
pembuatan paper lainnya dengan topik serupa.

2
 BAB III
TINJAUAN PUSTAKA

3.1 PENGERTIAN GRANULOMA

Granuloma merupakan nodul yang terjadi pada kulit yang sering juga
disebut dengan lick granuloma, acral lick dermatitis, acral pruritie nodule,
acropruritie granutomi, psycogenue dermatosis, dan neurodermatitis.
Granuloma timbul karena jilatan atau gigitan yang terus-menerus terjadi pada
satu kaki (unilateral) yaitu pada aspek kranial dari korpus metacarpus dan
lateral tarsus atau metatarsus. Granuloma biasanya disebabkan oleh karena
luka, benda asing, infeksi, nyeri otot, dan faktor psikogenik yang
mengakibatkan kebosanan, ketidakaktifan atau perubahan lingkungan.

Gambar 1. Granuloma pada kaki anjing

ALD (acral lick dermatitis) paling sering terjadi pada ras aktif besar,
namun anjing kecil mungkin akan terpengaruh juga. Dari keturunan besar
Doberman , Jerman Shepard , Great Dane , Golden Retriever , Labrador
Retriever dan tampaknya lebih cenderung untuk ALD daripada keturunan
besar lainnya.
Sebagian besar sepakat bahwa ALD adalah gangguan perilaku dengan
banyak kemungkinan penyebab. Menjilati diri dan gigitan merupakan pelepas
ketegangan untuk anjing yang bosan, terisolasi secara sosial, terkurung untuk
jangka waktu yang lama atau dihukum secara fisik terus-menerus oleh

3
 pemiliknya. Menjilati diri juga dapat disebabkan oleh pemilik overattentive
atau gugup yang secara tidak sengaja mendorong perilaku sararfi pada hewan
peliharaan mereka. Pengenalan hewan baru atau orang-orang ke dalam rumah
juga dapat memulai ALD. Hal ini sangat penting jika Anda melihat anjing
Anda menjilati terus-menerus bahwa kemungkinan penyebab lain
dikesampingkan seperti infeksi bakteri atau jamur, neoplasia, trauma, benda
asing dan alergi yang dapat menyebabkan gejala yang sama.
Dalam rangka untuk menyingkirkan penyebab lain dokter hewan perlu
mengambil kultur bakteri, radiografi, pemeriksaan histologis atau tes
laboratorium lainnya.
Granuloma biasanya ditandai dengan adanya lesi dengan bulu yang
jarang , kulit menebal, lengket, mengalami ulserasi, eritematus dan dikelilingi
oleh banyak pigmen serta jaringan superficial mengalami erosi.

3.2 TUJUAN DAN MANFAAT PEMBEDAHAN GRANULOMA

Tujuan dan manfaat dari operasi granuloma ini adalah menghilangkan
lesi granuloma pada kulit yang dapat mengganggu kenyamanan dari hewan
serta juga mengganggu penampilan dari hewan penderita.

4
 BAB IV
PEMBAHASAN

4.1 PREOPERASI GRANULOMA

1. Persiapan operasi
Sebelum kita memulai operasi kita harus melakukan
 Mempersiapkan alam, bahan, dan obat.
Siapkan alat-alat bedah minor. Alat-alat tersebut disterilkan terlebih
dahulu untuk menghindari kontaminasi dari alat ke daerah yang akan
dioperasi. Alat yang digunakan antara lain :
 Jas operasi  Kapas
 Masker  Tampon
 Gloves  Rivanol/alcohol 70 %
 Alat bedah mayor  Kain drapping
 Benang nonabsorbable
Obat yang digunakan antara lain:
 Antibiotik
 Obat anti radang nonsteroid
 Premedikasi dan anestesi
Untuk operasi menggunakan laser CO2, menggunakan laser dengan
20 Watt CO2 laser Novapulse ™ dengan straight handpiece dan 0,4 mm
tip keramik untuk reseksi. Scanner mekanis dengan pola 3 mm untuk
memindai ablasi / penguapan sisa jaringan granulasi .Dengan pengaturan
laser sebagai berikut:
 Reseksi
Spot Diameter : 0,4 mm
Output Power : 10 sampai 15 W
Beam Output: SP
 Ablasi
Spot Diameter : 3 mm scan pola menggunakan 0,8 mm daisywheel
Output Power : 10 W
Beam Output: SP

5
  Mempersiapkan ruang Operasi
Persiapan ruang operasi meliputi ruang operasi harus bersih, lantai
dan meja operasi hendaknya dibersihkan dan didesinfeksi, ruang operasi
hendaknya memiliki penerangan yang cukup.
 Mempersiapkan Pasien
Dilakukan anamnesa dan pemeriksaan fisik. Lakukan anmnesa
dengan beberapa cara yaitu biopsi, skin scrapping, aspirasi dengan spuite,
kultur bakteri dan radiografi. Keberhasilan diagnosis dan terapi dari Acral
Lick granuloma tergantung pada identifikasi akurat dari penyebab yang
mendasarinya. Karena Acral Lick granuloma dapat disebabkan oleh
berbagai faktor, diagnostik lengkap dan evaluasi pasien dianjurkan. Dokter
harus mempertimbangkan tes berikut: pemeriksaan darah, T4, TSH, tes
alergi, goresan kulit dalam, biopsi, kultur bakteri dan jamur / sensitivitas
daerah yang terkena dampak, radiografi dan investigasi sistem saraf.
Strategi pengobatan melibatkan mengobati lesi karena faktor etiologi yang
mendasari dan infeksi.
Setelah semua pemeriksaan selesai, hewan di anestesi lalu
diposisikan sesuai site operasi dan daerah yang akan dioperasi dibersihkan
terlebih dahulu meliputi pencukuran rambut serta pemberian yodium
tincture kemudian dipasangi kain drape.
 Mempersiapkan Operator
Operator prosedur operasi, dapat memprediksi hal-hal yang akan
terjadi selama operasi, dapat memperkirakan hasil operasi, mencuci tangan
atau personal hygiene, serta harus siap fisik, mental, tenang dan terampil.
2. Premedikasi dan anestesi
Premedikasi yang digunakan adalah dengan atropine dilanjutkan
dengan anestesi kombinasi dari ketamin dan xylazin disesuaikan dengan berat
badan dan dosis anjuran hewan. Dapat pula menggunakan anestesi Blok lokal
dengan menggunakan 2 % mepivicaine infus. Dapat juga dilakukan dengan
premedikasi dengan medetomedine, butorphanol, dan glycopyrrolate serta
Induksi inhalasi dengan isoflurane oksigen. Pemeliharaan anestesi umum
melalui tabung endotrakeal.

6
4.2 TEKNIK OPERASI GRANULOMA
Secara manual operasi pengankatan granuloma dapat dilakukan dengan
cara:
1. Lakukan anmnesa dengan beberapa cara yaitu biopsi, skin scrapping, aspirasi
dengan spuite, kultur bakteri dan radiografi.
2. Berikan anaesthesia dengan kombinasi dari atropin, ketamine-xylasine secara
IM.
3. Incisi granuloma jika terlihat membentuk seperti tumor, lakukan incisi rapi
sepanjang tepi yang membengkak.

Gambar 2. Sebelum dan sesudah pengangkatan granuloma yang membengkak.

4. Pasca pengangkatan granuloma, luka dapat dijahit dengan benang nilon lalu
ditutup dengan bandage pelindung dan diaplikasikan dengan mikropor.
Secara Laserasi CO2 dapat dilakukan dengan prosedur sebagai berikut:
Tahapan awal sama dengan tindakan bedah lick granuloma secara manual,
hanya saja laserasi lebih efektif pada lick granuloma yang permukaannya
cenderung datar bahkan cekung. Sebelum dilakukan laserasi, terlebih dahulu
rambut sekitar lick granuloma di cukur. Laserasi dapat langsung dilakukan
dengan memperhatikan jarak antara permukaan luka terhadap alat laser.
Dapat juga dengan mengangkat dahulu sebagian granuloma. Sebagian besar
bagian atas pada jaringan granulasi direseksi pada bagian
permukaan. Lakukan secara rapi hingga permukaan terbakar merata.
kemudian laser diatur untuk ablasi / penguapan dari setiap jaringan granulasi
yang tersisa hingga sedikit di bawah tingkat dermis normal di sekitarnya.
Sangat penting membersihkan arang atau jaringan karbonisasi dengan spons
garam dan kemudian tutup dengan kasa steril, boleh juga sejenis sofra-tulle
berupa kasa khusus yang berisi antibiotik. Tutup bekas luka sekedarnya,

7
 usahakan terjadi sirkulasi udara guna mencegah infeksi bakteri anaerob.
Biasanya tidak terjadi perdarahan pada pembedahan menggunakan laserasi
CO2, namun rekonstruksi kulit biasanya diperlukan melalui aposisi langsung,
flaps atau cangkok kulit pada kasus granuloma yang parah.

Gambar 3. kelebihan jaringan di sinari dengan laser CO2

Gambar 4. hasil operasi menggunakan laser CO2

4.3 PASCAOPERASI GRANULOMA

Untuk penanganan secara manual, luka insisi dibalut dengan perban
dengan sebelumnya diberikan iodine. jahitan umumnya dibuka sekitar 1-2
minggu tergantung dari besarnya luka insisi. Bekas jahitan kering dan

8
 kembali normal sekitar 10-14 hari. Dilakukan pemberian antibiotika,
antiradang dan vitamin A. digunakan antibiotic spectrum luas agar bakteri
yang bersifat aerob dan nonaerob dapat dibunuh, contohnya amoxicillin,
clindamimycin, trimetropim, untuk kucing menggunakan doxycyclin, anti
radang digunakan anti radang nonsteroid seperti aspirin dan vitamin A untuk
proses epitelisasi dan mempercepat kesembuhan atau perbaikan kulit.

4.4 PENANGANAN GRANULOMA TANPA PEMBEDAHAN

Penganganan granuloma lainnya dapat dilakukan dengan aktivitas atau
modifikasi lingkungan, pembalutan, pemasangan kolar, obat anti menggigit
topical, glukokortikoid, obat-obat lain : floucomlone, acetorid, flurixme
menglumil, dimethylsulfoxide, enzim proteolitik. Hasil pengobatan yang
tidak konsisten menjadikan kekambuhan sering terjadi kembali. Pembedahan
tidak umum dilakukan tetapi eksisi lick granuloma dengan pembedahan yang
diikuti dengan menggunakan konstruksi operasi langsung, penutup atau grafh
dapat dilakukan, kemudian dibalut sampai jahitannya dibuka. Namun
kekambuhan sering terjadi di tempat yang sama atau di tempat yang lain jika
faktor penyebabnya tidak dihilangkan.
Antidepresan yang paling sering digunakan, termasuk doksepin,
amitriptyline, fluoxetine, dan clomipramine. Jika faktor-faktor psikologis
tidak diperbaiki, umumnya akan kambuh setelah penggunaan obat
dihentikan. Endorphin blockers seperti naltrexone dapat digunakan untuk
mengurangi kecanduan atau endorphin pengganti seperti hydrocodone dapat
menurunkan dorongan untuk menjilat.
Licking dapat dicegah dengan penggunaan kerah Elizabeth, perban ,
salep anti-lick, dan strip anti-lick. Hal ini penting untuk menangkap lesi
seawal mungkin dan menjaga anjing agar tidak menjilati untuk mengurangi
peradangan. Obat topikal seperti kortikosteroid atau DMSO bersifat efektif
apabila digunakan lebih awal. Lesi kecil dapat disuntik dengan triamsinolon
atau metilprednisolon. Antibiotik oral dapat digunakan untuk mengendalikan
infeksi.

9
 BAB V
SIMPULAN DAN SARAN

5.1 SIMPULAN
Granuloma merupakan nodul yang terjadi pada kulit yang sering juga
disebut dengan lick granuloma, acral lick dermatitis, acral pruritie nodule,
acropruritie granutomi, psycogenue dermatosis, dan neurodermatitis.
Granuloma biasanya disebabkan oleh karena luka, benda asing, infeksi, nyeri
otot, dan faktor psikogenik yang mengakibatkan kebosanan, ketidakaktifan
atau perubahan lingkungan. Granuloma biasanya ditandai dengan adanya lesi
dengan bulu yang jarang , kulit menebal, lengket, mengalami ulserasi,
eritematus dan dikelilingi oleh banyak pigmen serta jaringan superficial
mengalami erosi. Teknik operasinya dapat dilakukan Secara manual maupun
laser CO2. Penganganan granuloma lainnya dapat dilakukan dengan aktivitas
atau modifikasi lingkungan, pembalutan, pemasangan kolar, obat anti
menggigit topical, glukokortikoid, obat-obat lain : floucomlone, acetorid,
flurixme menglumil, dimethylsulfoxide, enzim proteolitik.

5.2 SARAN
Hasil pengobatan yang tidak konsisten menjadikan kekambuhan sering
terjadi kembali. Penting untuk menghilangkan penyebab utama agar tidak
terjadi kejadian berulang,

10
 DAFTAR PUSTAKA

Arya, Ray. 2016. Using CO2 Laser on Acral Lick Granulomas. Laser Therapy
Treatment of Common Conditionsand. Veterinary Practice News, Page: 32
Das, A.K, U. Das, D. K. Das and J. Sengupta. 2009. Uncomplete Acral Lick
Granuloma . Vet. Rec. 84:124.
Higgins, A.A. 2010. Observation on the canine Granuloma as seen in the Bahamas.
Vet. Rec; 79: 67-71.
Haug, Lore I. 2012. Acral Lick dermatitis: Behavioral solutions. NAVC Clinician’s
Brief
Moulton,J.E. 2008. Tumours of domestic animals, third revised edun. University of
California Press, Barkely & Los Angeles 10:498-502
Samantara, Subharaj. 2011. Surgical Management of Lick granuloma in a Boxer
Dog. Veterinary Dispensary. India. Veterinary World, 2011, Vol.4(6): 271-
272

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LAMPIRAN

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 TheEducationCenter TheEducationCenter
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Using CO2 laser on acral lick granulomas

By Ray Arza, DVM gal or pressure point granulomas; demodicosis; and skin reconstruction usually is required via direct apposi-
Technique
The affected area is clipped and aseptically prepped
for surgery. It usually is unnecessary to debulk the le-
dure involves getting a feel for how deep to go or when
to stop removing tissue. It is critical not to go beyond
the normal dermal margins, or bleeding and delayed
mechanical or thermal trauma to the healthy surround-
ing tissues. There is virtually no bleeding intraopera-
tively, and laser energy effectively kills bacteria at the
For The Education Center calcinosis circumscripta.3-4 tion, flaps or skin grafts. Surgical excision often results in sion. In the case shown in Figures 1 to 6, however, the healing will occur. surgical site, thus reducing the risk of infection.
Successful diagnosis and therapy of acral lick gran- dehiscence or the development of a new lick granuloma. lesion was very large, and it was much quicker to first Surgical laser treatment results in uncomplicated

C
anine acral lick granuloma—also known as acral uloma depend on the accurate identification of the CO2 laser surgery allows for ablation of all or most of debulk (Figure 3) and then to vaporize the remainder of Post-Operative Care healing and esthetic clinical outcome. It is important to
lick dermatitis, acral pruritic furunculosis and underlying causes. Because the acral lick granuloma the affected tissue down to a more normal layer of der- granulomatous tissue. Typically, the technique involves A thick layer of Collasate and then a Telfa pad and remember that acral lick granulomas are caused by sev-
lick granuloma—is a self-induced dermatological can be caused by a wide variety of factors, a complete di- mis, facilitating a much faster resolution. vaporizing tissue layer by layer in a tracking linear mo- bandage are applied. The bandage is changed at least eral underlying etiological factors, such as behavioral
condition that develops as a result of excessive and pro- agnostic evaluation of the patient is recommended. The tion over the entire surface of the lesion. It is imperative once a week until the surgical site is completely healed. issues, infections, metabolic disease and osteoarthritis.
longed licking of one or more areas.1-2 clinician should consider the following tests: lab blood Patient to frequently wipe away char or carbonized tissue with The dog should wear an Elizabethan collar until the The patient should be monitored for these factors in
With time, this intense incessant licking leads to skin values, T4, TSH, allergy testing, deep skin scrapes, biop- A canine patient was presented for surgical ablation saline-soaked sponges. Doing so helps to ensure the op- lesion heals. The patient is rechecked at each bandage order to ensure the appropriate support therapy and
inflammation and can form a plaque or nodule with sy, bacterial and fungal culture/sensitivity of the affected of a severe acral lick granuloma overlying the anterior timal delivery of laser energy to the target tissue. change until complete resolution. Typically, the clinical to avoid possible recurrence of acral lick granuloma. l
a raised border. The lesion surface typically is thick, area, radiographs and neurological investigations.1,3,5 aspect of the left carpus. The client had been dealing After each pass, the depth of ablation is evaluated outcome of CO2 laser treatment is fairly cosmetic and
alopecic, erythematous and often eroded or ulcerated. The treatment strategy involves treating the lesion along with this for about five years, and the lesion was very in relation to the adjoining healthy dermis. The watt- has some hair regrowth (Figure 6). Dr. Ray Arza earned his DVM at the University of Ten-
Draining sinuses, hyperpigmentation, scaling and crust- with the underlying etiological factors and the infection. large, alopecic, firm, erythematous, irregularly shaped age selected depends on the surgeon’s preference and nessee in 1979. He was a small animal general prac-
ing sometimes may be present. Once support therapy is established, the acral lick and non-ulcerated. X-rays revealed no arthritic changes, the thickness of the granulomatous tissue to remove. I Conclusion titioner for 23 years with a special interest in surgery
Acral lick granuloma is typically a single unilateral granuloma lesion may resolve on its own. However, if the and a biopsy was not performed. normally set wattage very high at first (20 to 40 watts, A CO2 laser gives the surgeon precise control over and dentistry. Dr. Arza started using a surgical laser in
lesion, although two or more lesions occasionally have lesion is very large and ulcerated, and the veterinarian CW, 3 mm spot size), and then progressively decrease it the amount of tissue to be removed without extensive 1998, and soon thereafter became a popular lecturer
been noted. Most commonly, lick granulomas involve desires to expedite healing, surgical ablation with CO2 la- Anesthesia when getting close to completion. at conferences, universities, and seminars on laser
the anterior aspect of the carpal-metacarpal or tar- ser is indicated. In case of conventional surgical excision, Appropriate preanesthetic induction followed by The surgeon might see numerous microabscesses REFERENCES technologies. In 2002, he left private practice to join
sal-metatarsal areas. Oth- (Figure 3) throughout the granulation tissue, but as one industry as an educator, trainer, consultant, and lec-
er lesion locales include gets close to normal tissue, these should disappear (Fig- 1. Hedlund CS. Surgery of the integumentary system. In: Fossum turer. He acquired laser therapy expertise in 2005, and
TW, ed. Small animal surgery, 3rd ed, St. Louis, MO: Elseveir/Mosby,
the flank, tail base, stifle ure 4). When the laser procedure is finished, there should 2007;159-259. among other positions, has served LiteCure, LLC, as
and tibia.1 be no appreciable thickened tissue upon digital palpation, 2. Spiegel IB, Seltzer JD. ALD: causes and cures: dermatologic con- its veterinary medical director. He is the co-author of
Although any dog can but there should be dermis covering the subcutaneous dition remains frustrating for dogs and owners. DVM Newsmaga- both volumes of Class IV Laser Therapy Treatment of
zine. September 2007: 14S+. Health Reference Center Academic.
develop acral lick gran- tissue. There should be no appreciable bleeding, and the Common Conditionsand contributor to the veterinary
http://go.galegroup.com. Accessed Jan. 7, 2016.
ulomas, most commonly tissue should have a more normal appearance (Figure 4). 3. Patel A. Acral lick dermatitis. Compan anim. May 2010;15(4):1-4. protocols programmed in LiteCure’s veterinary lasers.
the lesions occur in older, 4. Denerolle P, White SD, Taylor TS, Vandenabeele SIJ. Organic diseas-
male, large-breed dogs Note es mimicking acral lick dermatitis in six dogs. J Am Anim Hosp Assoc.
This Education Center article was underwritten by
July-August 2007;43:215-20.
such as Labrador retriev- This procedure is relatively simple but can be quite Aesculight of Woodinville, Wash., the manufacturer
5. Berger N, Eeg PH. Veterinary laser surgery a practical guide. Ames,
ers, golden retrievers, time-consuming if the lesion is large and the granula- Iowa: Blackwell Publishing; 2006. of the only American-made CO2 laser.
German shepherds, Ger- tion tissue is thick. The most crucial part of the proce-
man shorthair pointers,
Saint Bernards, Great
Danes and pit bulls.1,3
Figure 1. Preoperative appearance of acral lick granuloma. Figure 4. Postoperative view of the surgical site. After the entire acral granuloma lesion is excised,
Acral lick granuloma the remaining excess tissue is ablated to the level of the dermis. No bleeding is present.
can be caused by numer-
ous etiological factors,
either organic or psycho- general anesthesia was
genic. Organic factors in- used.
clude food allergy, atopic
dermatitis, fungal or bac- Recommended Laser
terial infections, foreign Equipment, Settings
bodies, ectoparasites, Aesculight flexible hol-
painful bone and articu- low waveguide CO2 laser
lar diseases, local trauma with 0.4 mm and 3 mm la-
and hormonal imbalance. ser focal spot sizes.
Possible psychogenic n Resection and
causes are long-standing debulking: 10 to 15 watts
anxiety, boredom, stress, continuous wave (CW)
attention-seeking or ste- with 0.4 mm focal spot size
reotypic behavior. Differ- is used to excise most of
ential diagnosis includes Figure 2. Most of the excess tissue is debulked with a CO2 laser. Figure 5. Three weeks after surgery. the granulation tissue, en-
neoplasia; bacterial, fun- suring not to remove the
entire thickness (Figure 2).
Note that wattage may be
increased for thicker, more
fibrous tissue.
n Ablation/vaporiza-
tion: Initially vaporize the
remaining excess tissue
at 20 to 30 watts CW (de-
pending on the thickness
of the remaining tissue)
with 3 mm focal spot size.
Then progressively reduce
Figure 3. Intraopera- to 10 to 12 watts (ideal-
tive appearance with ly in SuperPulse mode)
the bulk of the acral to increase control of the
lick granuloma lesion speed of tissue ablation
excised. Several
abscesses can be and remove down to the
seen (arrows). level of normal dermis.
Figure 6. Thirteen weeks after surgery.
 TheEducationCenter TheEducationCenter
A RESOURCE A RESOURCE
32 l Veterinary Practice News l April 2016 FOR THE ASTUTE
PRACTITIONER www.VeterinaryPracticeNews.com FOR THE ASTUTE
PRACTITIONER April 2016 l Veterinary Practice News l 33
A special advertising section A special advertising section

Using CO2 laser on acral lick granulomas

By Ray Arza, DVM gal or pressure point granulomas; demodicosis; and skin reconstruction usually is required via direct apposi-
Technique
The affected area is clipped and aseptically prepped
for surgery. It usually is unnecessary to debulk the le-
dure involves getting a feel for how deep to go or when
to stop removing tissue. It is critical not to go beyond
the normal dermal margins, or bleeding and delayed
mechanical or thermal trauma to the healthy surround-
ing tissues. There is virtually no bleeding intraopera-
tively, and laser energy effectively kills bacteria at the
For The Education Center calcinosis circumscripta.3-4 tion, flaps or skin grafts. Surgical excision often results in sion. In the case shown in Figures 1 to 6, however, the healing will occur. surgical site, thus reducing the risk of infection.
Successful diagnosis and therapy of acral lick gran- dehiscence or the development of a new lick granuloma. lesion was very large, and it was much quicker to first Surgical laser treatment results in uncomplicated

C
anine acral lick granuloma—also known as acral uloma depend on the accurate identification of the CO2 laser surgery allows for ablation of all or most of debulk (Figure 3) and then to vaporize the remainder of Post-Operative Care healing and esthetic clinical outcome. It is important to
lick dermatitis, acral pruritic furunculosis and underlying causes. Because the acral lick granuloma the affected tissue down to a more normal layer of der- granulomatous tissue. Typically, the technique involves A thick layer of Collasate and then a Telfa pad and remember that acral lick granulomas are caused by sev-
lick granuloma—is a self-induced dermatological can be caused by a wide variety of factors, a complete di- mis, facilitating a much faster resolution. vaporizing tissue layer by layer in a tracking linear mo- bandage are applied. The bandage is changed at least eral underlying etiological factors, such as behavioral
condition that develops as a result of excessive and pro- agnostic evaluation of the patient is recommended. The tion over the entire surface of the lesion. It is imperative once a week until the surgical site is completely healed. issues, infections, metabolic disease and osteoarthritis.
longed licking of one or more areas.1-2 clinician should consider the following tests: lab blood Patient to frequently wipe away char or carbonized tissue with The dog should wear an Elizabethan collar until the The patient should be monitored for these factors in
With time, this intense incessant licking leads to skin values, T4, TSH, allergy testing, deep skin scrapes, biop- A canine patient was presented for surgical ablation saline-soaked sponges. Doing so helps to ensure the op- lesion heals. The patient is rechecked at each bandage order to ensure the appropriate support therapy and
inflammation and can form a plaque or nodule with sy, bacterial and fungal culture/sensitivity of the affected of a severe acral lick granuloma overlying the anterior timal delivery of laser energy to the target tissue. change until complete resolution. Typically, the clinical to avoid possible recurrence of acral lick granuloma. l
a raised border. The lesion surface typically is thick, area, radiographs and neurological investigations.1,3,5 aspect of the left carpus. The client had been dealing After each pass, the depth of ablation is evaluated outcome of CO2 laser treatment is fairly cosmetic and
alopecic, erythematous and often eroded or ulcerated. The treatment strategy involves treating the lesion along with this for about five years, and the lesion was very in relation to the adjoining healthy dermis. The watt- has some hair regrowth (Figure 6). Dr. Ray Arza earned his DVM at the University of Ten-
Draining sinuses, hyperpigmentation, scaling and crust- with the underlying etiological factors and the infection. large, alopecic, firm, erythematous, irregularly shaped age selected depends on the surgeon’s preference and nessee in 1979. He was a small animal general prac-
ing sometimes may be present. Once support therapy is established, the acral lick and non-ulcerated. X-rays revealed no arthritic changes, the thickness of the granulomatous tissue to remove. I Conclusion titioner for 23 years with a special interest in surgery
Acral lick granuloma is typically a single unilateral granuloma lesion may resolve on its own. However, if the and a biopsy was not performed. normally set wattage very high at first (20 to 40 watts, A CO2 laser gives the surgeon precise control over and dentistry. Dr. Arza started using a surgical laser in
lesion, although two or more lesions occasionally have lesion is very large and ulcerated, and the veterinarian CW, 3 mm spot size), and then progressively decrease it the amount of tissue to be removed without extensive 1998, and soon thereafter became a popular lecturer
been noted. Most commonly, lick granulomas involve desires to expedite healing, surgical ablation with CO2 la- Anesthesia when getting close to completion. at conferences, universities, and seminars on laser
the anterior aspect of the carpal-metacarpal or tar- ser is indicated. In case of conventional surgical excision, Appropriate preanesthetic induction followed by The surgeon might see numerous microabscesses REFERENCES technologies. In 2002, he left private practice to join
sal-metatarsal areas. Oth- (Figure 3) throughout the granulation tissue, but as one industry as an educator, trainer, consultant, and lec-
er lesion locales include gets close to normal tissue, these should disappear (Fig- 1. Hedlund CS. Surgery of the integumentary system. In: Fossum turer. He acquired laser therapy expertise in 2005, and
TW, ed. Small animal surgery, 3rd ed, St. Louis, MO: Elseveir/Mosby,
the flank, tail base, stifle ure 4). When the laser procedure is finished, there should 2007;159-259. among other positions, has served LiteCure, LLC, as
and tibia.1 be no appreciable thickened tissue upon digital palpation, 2. Spiegel IB, Seltzer JD. ALD: causes and cures: dermatologic con- its veterinary medical director. He is the co-author of
Although any dog can but there should be dermis covering the subcutaneous dition remains frustrating for dogs and owners. DVM Newsmaga- both volumes of Class IV Laser Therapy Treatment of
zine. September 2007: 14S+. Health Reference Center Academic.
develop acral lick gran- tissue. There should be no appreciable bleeding, and the Common Conditionsand contributor to the veterinary
http://go.galegroup.com. Accessed Jan. 7, 2016.
ulomas, most commonly tissue should have a more normal appearance (Figure 4). 3. Patel A. Acral lick dermatitis. Compan anim. May 2010;15(4):1-4. protocols programmed in LiteCure’s veterinary lasers.
the lesions occur in older, 4. Denerolle P, White SD, Taylor TS, Vandenabeele SIJ. Organic diseas-
male, large-breed dogs Note es mimicking acral lick dermatitis in six dogs. J Am Anim Hosp Assoc.
This Education Center article was underwritten by
July-August 2007;43:215-20.
such as Labrador retriev- This procedure is relatively simple but can be quite Aesculight of Woodinville, Wash., the manufacturer
5. Berger N, Eeg PH. Veterinary laser surgery a practical guide. Ames,
ers, golden retrievers, time-consuming if the lesion is large and the granula- Iowa: Blackwell Publishing; 2006. of the only American-made CO2 laser.
German shepherds, Ger- tion tissue is thick. The most crucial part of the proce-
man shorthair pointers,
Saint Bernards, Great
Danes and pit bulls.1,3
Figure 1. Preoperative appearance of acral lick granuloma. Figure 4. Postoperative view of the surgical site. After the entire acral granuloma lesion is excised,
Acral lick granuloma the remaining excess tissue is ablated to the level of the dermis. No bleeding is present.
can be caused by numer-
ous etiological factors,
either organic or psycho- general anesthesia was
genic. Organic factors in- used.
clude food allergy, atopic
dermatitis, fungal or bac- Recommended Laser
terial infections, foreign Equipment, Settings
bodies, ectoparasites, Aesculight flexible hol-
painful bone and articu- low waveguide CO2 laser
lar diseases, local trauma with 0.4 mm and 3 mm la-
and hormonal imbalance. ser focal spot sizes.
Possible psychogenic n Resection and
causes are long-standing debulking: 10 to 15 watts
anxiety, boredom, stress, continuous wave (CW)
attention-seeking or ste- with 0.4 mm focal spot size
reotypic behavior. Differ- is used to excise most of
ential diagnosis includes Figure 2. Most of the excess tissue is debulked with a CO2 laser. Figure 5. Three weeks after surgery. the granulation tissue, en-
neoplasia; bacterial, fun- suring not to remove the
entire thickness (Figure 2).
Note that wattage may be
increased for thicker, more
fibrous tissue.
n Ablation/vaporiza-
tion: Initially vaporize the
remaining excess tissue
at 20 to 30 watts CW (de-
pending on the thickness
of the remaining tissue)
with 3 mm focal spot size.
Then progressively reduce
Figure 3. Intraopera- to 10 to 12 watts (ideal-
tive appearance with ly in SuperPulse mode)
the bulk of the acral to increase control of the
lick granuloma lesion speed of tissue ablation
excised. Several
abscesses can be and remove down to the
seen (arrows). level of normal dermis.
Figure 6. Thirteen weeks after surgery.
Veterinary World, 2011, Vol.4(6): 271-272, DOI:10.5455/vetworld.4.271 CLINICAL

Surgical Management of Lick granuloma in a Boxer Dog

Subharaj Samantara

Veterinary Dispensary, Kotpad, India.

* Corresponding author email : subharaj36ovc@gmail.com
Published online at www.veterinaryworld.org on 25-03-2011

Introduction in the Veterinary Dispensary, Kotpad with a history of

Lick granuloma or acral lick dermatitis or
neurodermitis a common psychogenic dermatitis
(Jubb et. al., 1993) characterized by deep-seated and
slow-healing skin infection as a result of excessive,
chronic licking (Vegad and Kathiyar, 2004) seen
particularly in large and active breeds of Dogs.
However, it can be seen irrespective of breed of
canines whose causes are various. Many authors hold
the view that this is a constitutional disease. However,
psychological factors like anxiety, boredom and
stress, hypothyroidism, local trauma, present fracture
or painful bones and joints, neuropathies, presence of
foreign bodies, neoplasia, fungal and bacterial
infections, ectoparasites and other irritating etiology
in and around the paw may cause this condition.
Hence, medicinal treatment with antiseptics,
antibiotics, antifungals, antihistaminics, antianxietics
and cortisone injections has been undertaken with
inconsistent results. In the present case there was no
fracture and it was refractory to all the medicinal
treatments. So, radical excision was attempted and
became quite successful.
Case History and Clinical Observation
An eight year old male Boxer dog was presented
non-healing wound on the lateral digit of his hind limb
since last one year (Fig. 1). It was refractory to the
previous medicinal treatments.
Treatment and Discussion
For identification of the underlying cause a
number of tests like skin scraping, skin biopsy, fine
needle aspiration, fungal and bacterial culture and
radiography were undertaken but these could not
provided any positive evidence which ruled out other
conditions from lick granuloma. The dog was weighed
to be 14kg. It was anaesthetized with a combination of
0.56 mg of atropine sulphate @ 0.04mg/kg body
weight, 14 mg of xylazine hydrochloride @ 1mg/kg
body weight and 140 mg of ketamine hydrochloride @
10mg/kg body weight given intramuscularly. The
growth was excised under aseptic precautions. Lateral
digital artery was ligated using No. 1 chromic cat gut
and the second phalanx of the lateral claw was
disarticulated along with the bone as the distal end of
the second phalanx was found to be included inside the
growth (Fig. 2). The skin wound was closed using
nylon and protective bandage was applied using
micropore. An Elizabethan collar was applied to
prevent further licking. Postoperatively cephalaxin @

Figure. 1 Presented clinical case with lick granuloma Figure. 2. Excised mass

www.veterinaryworld.org Veterinary World, Vol.4 No.6 June 2011 271

 Surgical Manangement of Lick granuloma in a Boxer Dog
250 mg was administerd orally for a period of 3 weeks.
Local wound care was undertaken using Betnovate-
GM (Miconazole nitrate 2%w/w, Betamethasone
valerate 0.12%w/w, Gentamycin sulphate 0.1%w/w,
Glaxo Smith Kline Pharmaceuticals Limited, Nashik,
India.). The dog was kept on a balanced diet and
supplemented with omega fatty acids. During the
period of treatment the dog was given ample exercise
and entertainment. Time inside the confinement was
minimized. The animal recovered uneventfully and
the skin suture was removed on the 12th day.
Conclusion
Proper diagnosis of lick granuloma is very
difficult. Because the initiating factor is usually not
identified and because there is such a strong habit that
forms, treatment can also be very frustrating. If we
approach the case in a logical way then we can be able
********
www.veterinaryworld.org Veterinary World, Vol.4 No.6 June 2011
to treat the case successfully. In this case surgical
excision of the mass along with proper managemental
and feeding practices made the treatment a great success.
Acknowledgement
The author is thankful to Dr. I. Nath, Dr. S.
Nayak, Dr. T. K. Pattanaik, Dr. J. K. Das, Department
of Veterinary Surgery and Radiology, College of
Veterinary Science & Animal Husbandry, O.U.A.T.,
Bhubaneswar, Odisha for providing proper guidance
in treatment of the case.
References
1. Jubb,K.V.F. and Kennedy,P.C. and Palmer,N. (1993).
Pathology of Domestic Animals, Vol.- I, 4th Edn., Academic
Press Limited, London, Pp. 581-582.
2. Vegad,J.L. and Kathiyar,A.K. (2004). A Textbook of
Veterinary Systemic Pathology, 1st Edn., International Book
Distribution Co., Lucknow, Pp. 510.
272
 Lore I. Haug, DVM, MS, DACVB
h o w i tr e a t B E H AV I O R / D E R M ATO L O G y Texas Veterinary Behavior Services
Sugar Land, Texas
Peer Reviewed

Acral Lick dermatitis:

Behavioral solutions
In the June 2012 issue, Dr. Karin Beale addressed acral lick
dermatitis (ie, lick granulomas) from a dermatologist’s
perspective. This article presents a behaviorist’s view of
the same affliction.

C
anine acral lick dermatitis (ALD) is a ALD in dogs has served as a model for compul-
relatively common condition in which sive disorder in humans.1 Neuroimaging and
excessive licking can lead to raised, firm, pharmacologic studies have demonstrated evi-
alopecic, eroded to ulcerated lesions that are gen- dence of dysfunction in the prefrontal–basal
erally on the dorsal aspect of a forelimb as well as ganglia–thalamic circuits and the serotonergic
metatarsal/tarsal areas. ALD is multifactorial but neurotransmitter systems in both human and
can often be caused by an underlying medical veterinary obsessive-compulsive patients.2
component. If ALD persists after medical causes Regardless of origin, ALD can be difficult and
have been controlled or eliminated, it can be con- frustrating to treat.
sidered a stereotypic behavior.
Prognosis for controlling or resolving ALD is
highly variable, as chronic severe lesions are often
difficult to resolve. Relapse
may be common, particularly
How I Treat if medication is withdrawn
Acral Lick Dermatitis and/or environmental stressors
are not adequately addressed. If
❏ Assess patient health status owners are attentive to enrich-
❏ Assess patient behavioral history ment and behavior modifica-
❏ Institute management to prevent further injury tion, affected dogs can often
be cured.
❏ Initiate treatment of local lesion
CoNtiNues
❏ Implement environmental changes
❏ Institute behavior modification for environmental &
social stressors
❏ Initiate psychopharmacologic treatment
❏ Monitor treatment response
ALd = acral lick dermatitis

how i treat / NAVC Clinician’s Brief / August 2012................................................................................................................................................................................59

H o w I Tr e a t CONTINUED

✔ Assess patient health status

❏ chronic environmental deprivation (eg,
Physical Examination confinement)3
➤ Complete physical examination to identify
➤ Frequency, time of occurrence, and duration
ancillary health issues that may exacerbate or can influence treatment
complicate ALD treatment
➤ Determine extent, location, and severity of the
Information About Dog’s Routine
➤ Diet and frequency of feeding
ALD lesion; lesions in certain locations can
➤ Time spent indoors vs outdoors
help define the underlying cause (eg, arthritis,
➤ Type and extent of physical, aerobic exercise
abdominal pain, trauma)
(including off-property excursions)
➤ Other animals in the home and their relation-
Diagnostics & Imaging
➤ Perform minimum database in anticipation of
ship with the patient
➤ Location where the patient sleeps and spends
psychopharmacologic use
➤ Perform ancillary diagnostics
time when left alone
➤ Toys or activities available and whether they
➤ As appropriate for patient’s age, breed, and
health status are used
➢ Rule out medical disorders (including any
that might complicate wound healing) Information About Dog’s Behavior
➤ Consider additional owner complaints about
➢ Rule out endocrine disorders (eg, hypo-
thyroidism, hyperadrenocorticism) the dog’s behavior before delineating the treat-
➤ As necessary, including skin scraping, fungal
ment program (Figure 1)
➤ Aggression (eg, toward people, animals)
culture, biopsy, culture and sensitivity test-
➤ Anxiety (eg, separation, noise, general)
ing, radiography
➤ Assess underlying osseous change ± radiographs
✔ Institute management to prevent
❏
✔ Assess patient behavioral history
❏ further injury
➤ In a behavioral diagnosis, ALD is often ➤ Facilitate healing with immediate control of
attributed to boredom excessive licking
➤ However, assessment inadequately describes ➤ Apply local bandages ± concurrent application
degree of behavioral pathology generally of bitter substances
necessary for self-mutilation ➤ Apply restraint collar
➤ Compulsive behavior is customarily attrib- ➤ Behavioral profile can influence the nature
uted to environmental stress, conflict, or and type of restraint device
ALd = acral lick dermatitis

1
Before deciding the best
treatment protocol, practi-
tioners need to consider all
information related to the
individual dog’s routine
and behavior, including
owner complaints such as
(A) aggression toward peo-
ple or (B) extreme anxiety
behavior displayed as
a result of noise/storm
phobia. A B

60................................................................................................................................................................................NAVC Clinician’s Brief / August 2012 / how i treat

 ➢ Fearful, anxious dogs may do poorly with ➤ Encourage moving outdoor dogs indoors or
large (especially opaque) Elizabethan providing more opportunities for them to
collars socialize with family members

✔ Initiate treatment of local lesion

❏ ✔ Institute behavior modification for
❏
➤ Administer appropriate long-term systemic environmental & social stressors
antibiotics based on deep culture and sensitiv- ➤ Keep the dog isolated from situations that
ity testing, especially if considerable granula- incite anxious and/or aggressive behavior
tion tissue is present to prevent rehearsal of negative behavior
➤ Administer topical products to reduce inflam- patterns
mation and irritation ➤ Consistently reinforce relaxed behavior with
➤ Consider laser therapy attention, praise, small food treats, or favored
➤ Consider allergy potential activities (eg, fetch, walks)
➤ Recommend dog–owner interactions in which
✔ Implement environmental changes
❏ the owner only interacts with the dog when it
➤ Note that environmental deprivation and is calm (ie, reinforcing the behavior)
minimal opportunities for species-appropriate ➤ Train basic obedience cues using positive
behaviors often contribute to compulsive or reinforcement to enrich and facilitate
repetitive behaviors relaxation
➤ Encourage physical, aerobic exercise appropri- ➤ Reinforce alternative desirable behaviors (bone
ate to age, breed, and health status chewing, play, resting, playing with other ani-
➤ Recommend excursions unless the dog’s mals) to reduce time spent licking excessively
behavior (eg, uncontrollable aggression in ➤ Begin contextual relaxation conditioning
public) prevents it ➤ Reinforce behaviors for relaxation in the
➤ Initiate use of food-dispensing toys and presence of controllable cues (eg, special
activities (Figure 2) training mat; Figure 3)
➤ Develop opportunities for breed-specific ➤ Calm behaviors include sighing, moderate
behavior (eg, digging pits for terriers, herding blinking, lateral recumbency, resting with
activities for herding breeds, lure coursing for head on the ground, observable reductions
sight hounds) in skeletal muscle tension
➤ Encourage canine sports (eg, rally, agility, ➤ Relaxation training is used to countercondi-
tracking) tion the dog to environmental stressors (eg,
➤ Encourage sufficient and quality socialization other animals, visitors, storms/noises, gradual
with humans owner departures)4
CoNtiNues

2 3
Proactive environ- Contextual relax-
mental modification ation conditioning
includes designated involves behavior
areas for appropri- reinforcement
ate play activities, based on control-
along with food- lable cues. Special
dispensing devices training mats, such
and other toys. as the one shown
here, help reinforce
alternative desirable
behaviors.

how i treat / NAVC Clinician’s Brief / August 2012................................................................................................................................................................................61

 US - 973772
H o w I Tr e a t CONTINUED
Surolan®
otic suspension
(miconazole nitrate, polymyxin B sulfate, prednisolone acetate)
$QWLIXQJDODQWLEDFWHULDODQGDQWLLQÀDPPDWRU\
For otic use in dogs only

CAUTION: Federal (USA) law restricts this drug to use by or on the order of a licensed
veterinarian.
DESCRIPTION: SUROLAN contains 23 mg/mL miconazole nitrate, 0.5293 mg/
mL polymyxin B sulfate and 5 mg/mL prednisolone acetate. Inactive ingredients are
FROORLGDOVLOLFRQGLR[LGHDQGOLTXLGSDUDI¿Q
INDICATIONS: SUROLAN is indicated for the treatment of canine otitis externa
associated with susceptible strains of yeast (Malassezia pachydermatis) and bacteria

If owners are attentive to enrichment and (Staphylococcus pseudintermedius).

DOSAGE AND ADMINISTRATION: Shake well before use. The external ear should
be thoroughly cleaned and dried before the initiation of treatment. Verify that the
behavior modification, affected dogs can eardrum is intact. Instill 5 drops of SUROLAN in the ear canal twice daily and massage
the ear. Therapy should continue for 7 consecutive days.
CONTRAINDICATIONS: SUROLAN is contraindicated in dogs with suspected or
potentially be cured. known hypersensitivity to miconazole nitrate, polymyxin B sulfate, or prednisolone
acetate. Do not use in dogs with known perforated tympanum. Do not use with drugs
known to induce ototoxicity.
WARNINGS: Not for use in humans. Keep this and all drugs out of reach of children.
ANIMAL WARNINGS: Do not administer orally. For otic use only.
PRECAUTIONS: Before instilling any medication into the ear, examine the external
ear canal thoroughly to be certain the tympanic membranes are not ruptured. If over-
growth of non-susceptible bacteria or fungi occurs, treatment should be discontinued
➤ Positive punishment using electronic treatments require slower weaning and appropriate therapy instituted. Long-term use of topical otic corticosteroids has
been associated with adrenocortical suppression and iatrogenic hypoadrenalcorti-
shock may be successful in some to prevent relapse cism in dogs. The safe use of SUROLAN in dogs used for breeding purposes, during
pregnancy, or in lactating bitches, has not been evaluated.
cases5; however, this approach is ADVERSE REACTIONS:,QWKH¿HOGVWXG\GRJVWUHDWHGZLWK6852/$1ZHUH

controversial ✔ Monitor treatment response

❏ included in the safety database. Two dogs experienced reduced hearing at the end of
treatment; on follow-up one dog had normal hearing capacity while the other case was
lost for follow-up. The owner of another dog reported that on day 4 of treatment, build-
➤ Track response to medications up of the medication decreased the dogís hearing. At the end of treatment, this dog
✔ Initiate psychopharmacologic
❏ closely and frequently, especially
had normal hearing as assessed by the investigator. Residue build-up was reported in
GRJDQGSDLQXSRQGUXJDSSOLFDWLRQLQDQRWKHUGRJ$WRWDORIGRJVWUHDWHGZLWK
the active control was included in the safety database and adverse reactions were
treatment within 6–8 weeks after initiation reported in 8 dogs treated with the active control. One dog experienced reduced hear-
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➤ Start treatment; reevaluate after 4 ➤ Adverse reactions to serotonergic GXULQJWUHDWPHQWGRJVKRZHGUHGSXVWXOHVRQWKHSLQQDDQGKHDGVKDNLQJZDV
observed in another dog. Foreign market experience: the following adverse events
weeks agents generally arise within the were reported voluntarily during post-approval use of the product in foreign markets:
deafness, reduced hearing, topical hypersensitivity reactions and red blisters on pinna.
➤ Titrate if little or no response first 6 weeks For a copy of the Material Safety Data Sheet (MSDS), for technical assistance or to
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➤ Administer anticompulsive medica- ➢ Sedation, appetite suppression PHARMACOLOGY: By virtue of its 3 active ingredients, SUROLAN has antibacterial,
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tions with serotonergic modulation1,6,7 ➢ Agitation, restlessness polypeptide antibiotic with activity against both Gram-positive and Gram-negative
species. Miconazole nitrate is a synthetic imidazole derivative with antifungal activity
and antibacterial activity against Gram-positive bacteria. Moreover, synergistic effects
➤ Clomipramine at 2–3 mg/kg q12h ➢ Increased fearfulness, noise between miconazole nitrate and polymyxin B sulfate have been demonstrated in an in
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➤ Fluoxetine at 1–2 mg/kg q6h hypersensitivity $VWXG\SHUIRUPHGXVLQJDQH[SHULPHQWDOO\LQGXFHGPRGHORIHDULQÀDPPDWLRQLQPLFH
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➤ Sertraline at 1–3 mg/kg q6–12h ➤ Journal (eg, written, verbal) behavior either alone or in combination with the other active ingredients of SUROLAN(2).
MICROBIOLOGY: The compatibility and additive effect of each of the components
➤ Opioid antagonists (naltrexone, issues to allow objective assessment in SUROLAN was demonstrated in a component effectiveness and non-interference
study. An in vitro study of organisms collected from clinical cases of otitis externa at a
nalmefene) have proven useful in of treatment response veterinary teaching hospital and from dogs enrolled in the clinical effectiveness study
for SUROLAN determined that polymyxin B sulfate and miconazole nitrate inhibit
some ALD cases8 ➤ Catalog size of dermatologic lesions the growth of bacteria and yeast commonly associated with canine otitis externa.
Furthermore, a synergistic effect of the two antimicrobials was demonstrated. The
➤ Continue medication for >3 months on weekly or monthly basis addition of prednisolone acetate to the combination did not impair antimicrobial activity
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past resolution of lesion(s) and ANIMAL SAFETY: The following adverse reactions were reported in a study when
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behavioral signs See Aids & Resources, back page, for recommended treatment duration) in laboratory Beagles: hypersensitivity reactions
which included mild erythema and hyperemia, painful and sensitive ear canals on ex-
➤ Wean medications slowly; longer references & suggested reading. amination, changes in hematology, clinical chemistry and urinalysis values consistent
with the systemic absorption of topical corticosteroids, and veterinary observations
of pale ear canals.
EFFECTIVENESS:2IGRJVHQUROOHGLQWKH¿HOGVWXG\GRJVZHUHLQFOXGHGLQ
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an FDA-approved active control. Clinical evaluations of otitis externa included pain/
discomfort, swelling, redness, and exudate. A non-inferiority evaluation was used to
compare SUROLAN with the active control with respect to each clinical sign of otitis
externa and overall clinical improvement. SUROLAN was determined to be non-inferior
to treatment with the active control for otitis externa. Malassezia pachydermatis and
Take-Home Points 6WDSK\ORFRFFXVSVHXGLQWHUPHGLXVZHUHLGHQWL¿HGSUHWUHDWPHQWLQDWOHDVWFDVHV
that were clinically responsive to SUROLAN.
Table 1. Mean Percentage of Improvement in Clinical Signs of Otitis Externa

Clinical Sign SUROLAN Active control

● Immediate control of excessive licking N=91 N=85

3DLQGLVFRPIRUW 94.4% 

is necessary to facilitate healing
Swelling  90.5%
● Before planning treatment, consider
Redness  
additional concerns (eg, aggression, Exudate  
anxiety) Overall  95.2%

● Human socialization, breed-specific HOW SUPPLIED:6852/$1LVDYDLODEOHLQP/DQGP/SODVWLFGLVSHQVLQJ

bottles with applicator tip for otic use.
activities, and obedience training can be STORAGE AND HANDLING: Store at or below 25 oC (77 oF).
1$'$$SSURYHGE\)'$
beneficial Manufactured for Vétoquinol USA Inc. by:
-DQVVHQ3KDUPDFHXWLFD19
Turnhoutseweg 30
B-2340 Beerse
Belgium
Copyright © 2009, Janssen Animal Health
Date of most recent labeling revision: 09/2009

REFERENCES
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62................................................................................................................................................................................NAVC Clinician’s Brief / August 2012 / how i treat