#171: Atopy Update: Making Skin Cases Less Frustrating. With Dr Dani Hoolahan

In theory, itchy skins should be simple to treat, right? There's a fairly limited list of things that can go wrong, and a fairly predictable list of levers we can pull to manage atopy. So WHY ARE SKIN CASES STILL SO FRUSTRATING?!

In this episode, dermatologist Dr Dani Hoolahan helps us figure out why our atopy cases keep coming back, why clients aren't always following our carefully constructed treatment plans, and what we can do differently to get better results.

Dani takes us beyond simply controlling the itch to building a proper multimodal management plan. We talk about the often-neglected skin barrier, why desensitisation still matters in the age of Apoquel and Cytopoint, and how to choose and combine treatments for those frustrating flare cases. We also get into the practical stuff: stopping those boomerang ear infections, making better use of therapeutic diets, and getting clients on board with a treatment plan that they can actually stick to.

It's a practical rethink of how we approach one of the most common and frustrating problems in general practice, with plenty of tips you can put to use in your next skin consult.

Topics Covered:

• Why dermatology is so hard, even when you know what you're doing

• The commonly neglected parts of a multimodal atopy management plan

• When to refer, and why desensitisation still matters

• Explaining skin barrier dysfunction to clients, and practical ways to support it

• Apoquel, Cytopoint or prednisolone? Choosing the right treatment for intermittent vs chronic cases

• Managing breakthrough itch, including combining antipruritics and topical therapies

• What does successful itch control actually look like?

• Stopping those recurrent ear infections with a proper maintenance plan

• The role of therapeutic nutrition in skin barrier support, food trials and long-term management

• Practical strategies for improving client compliance without turning every skin consult into an hour-long conversation

Episode guide

This guide follows Dr Dani Hoolahan's approach to canine atopic dermatitis in the episode: identify the gaps in the management plan, define what good control looks like, and make the plan practical for the person who has to carry it out.

Why do skin cases keep coming back despite itch treatment?

Dani describes a familiar referral patient: the dog is already receiving Apoquel or Cytopoint, yet still develops skin infections, ear infections and breakthrough itch. For her, that pattern is a reason to review the whole management plan rather than assume that another antipruritic prescription will solve it.

Her multimodal approach brings together several jobs:

• Identify and manage flare factors, including secondary infections, parasites and a possible food allergy component.
• Support the defective skin barrier.
• Consider allergy modulation through allergen-specific immunotherapy, also called desensitisation.
• Control pruritus and inflammation well enough to keep the patient comfortable.

The useful question is whether each part of that plan has been addressed, including the parts that are easy to overlook during a busy skin consult.

How can you explain the skin barrier to clients?

Dani uses a brick wall analogy: skin cells are the bricks, with a lipid matrix between them. In an atopic dog, gaps in that barrier allow moisture to escape and allergens and microbes to penetrate more easily. She recommends accompanying the explanation with a picture so the client can see what you mean.

The episode explores topical barrier support, moisturising and therapeutic nutrition as different ways to support that barrier. Dani also makes a practical distinction: a dedicated owner might manage several interventions, while a busy owner may need a simpler starting plan. The best theoretical combination is of limited use if it never gets applied.

When should a GP consider dermatology referral?

Dani would like to see difficult atopic patients earlier, before their owners become emotionally and financially exhausted. She distinguishes the dog that stays comfortable with occasional seasonal treatment from the dog needing ongoing medication while still developing recurrent pyoderma, Malassezia dermatitis or otitis.

Referral can help establish a shared management plan and explore allergen-specific immunotherapy. Dani argues that having effective itch medications has not removed the role of desensitisation. Her example is a previously difficult French bulldog that, after treatment of secondary infections and a broader management overhaul, was maintained on immunotherapy and a therapeutic diet. That is an individual clinical example, rather than a promise of the same outcome for every patient.

Apoquel, Cytopoint or prednisolone: what changes the conversation?

The distinction Dani keeps returning to is intermittent treatment versus ongoing management. A dog with occasional, short-lived flares raises a different discussion from a dog needing medication throughout the year. Owners of the latter need to understand that the plan is for a chronic condition, rather than a series of treatments expected to cure it.

When presenting options, Dani leads with safety, efficacy and her recommendation for that patient before discussing cost. Practical preferences, such as whether an owner finds tablets or injections easier, also matter. She cautions against deciding what a client will spend before explaining the options.

Why do ear infections recur when the dog's skin seems better?

One of the episode's clearest distinctions is between controlling generalised itch and maintaining comfortable ears. Dani warns against expecting Apoquel or Cytopoint alone to prevent recurrent allergic otitis.

In her approach, resolving an active ear infection clinically and cytologically is followed by a separate maintenance plan. That includes individualised cleaning and topical anti-inflammatory treatment selected by the treating vet. She explains that inflammation in the external ear canal can create an environment in which yeast and bacteria proliferate. Treating each infection without addressing that ongoing inflammation leaves an important part of the problem unresolved.

What does successful itch control actually look like?

Dani uses an itch score of around three out of ten or less as her practical target. She translates that into something an owner can recognise: occasional licking, chewing, scratching or rubbing, without skin lesions or behaviour frequent enough that the owner feels the need to interrupt it.

A dog that remains five or six out of ten itchy and visibly inflamed would prompt her to reassess the plan. With breakthrough itch, she first returns to secondary infection and parasite prevention before treating the episode as an atopic flare. The score gives vet and client a shared way to discuss whether the current plan is doing enough.

Where does nutrition fit if food allergy is not the problem?

Hugh identifies a common blind spot: once a food allergy seems unlikely, it is easy to stop thinking about nutrition. Dani separates assessing food allergy from using a diet to support the skin barrier in an environmentally allergic dog.

She discusses diet selection in the context of the whole patient, including growth, palatability, an owner's ability to follow a trial, and conditions that may require a low-fat option. Her preferences vary with the case. The conversation is about matching nutritional goals to the patient, rather than treating every therapeutic skin diet as interchangeable.

How can the team make an atopy plan easier to follow?

Dani's workflow spreads education across the team and beyond the consultation. A nurse can start explaining environmental allergies, food allergies or dietary trials while the vet examines cytology. The vet then reinforces those ideas, and the client leaves with handouts and an individual treatment plan.

Follow-up matters too. In Dani's practice, nurses help owners with questions between visits. Her rule of thumb is that a conversation needing more than five minutes should become a booked consultation. The practical lesson for GP teams is to give owners a clear route for clarification and review, while recognising when the case needs another appointment.

Frequently asked questions

Can Apoquel and Cytopoint be used together?

Dani describes using them together in selected chronic or refractory patients, including some with breakthrough itch. This is an individual prescribing decision within a broader management plan. She also cautions about combining immunomodulatory medicines, particularly prolonged concurrent use of Apoquel and prednisolone.

Does allergy testing diagnose canine atopic dermatitis?

No. The 2023 AAHA Management of Allergic Skin Diseases Guidelines describe atopy as a diagnosis of exclusion. Intradermal or serum allergy testing is used to identify allergens when immunotherapy is planned. This guideline provides further clinical context for the episode's discussion of referral and desensitisation.

This episode is supported by Hill's Pet Nutrition, Australia's #1 trusted and recommended pet food brand among surveyed vets. Hill's Prescription Diet Derm Complete supports the skin barrier and microbiome as part of a multimodal approach to managing allergic skin disease.

Visit myhillsvet.com.au for therapeutic nutrition information, educational resources and tools to support your recommendations.

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This episode is intended for veterinary professionals. The discussions, opinions and information presented on this podcast are for informational and educational purposes only. They are based on the professional experience and research of the hosts and guests. This podcast is not intended to provide veterinary medical advice, diagnosis, or treatment for individual pets. If you are a pet owner and you have any concerns regarding your pet's health, please always consult your licensed veterinarian.