08/10/2021
Acral Lick Granuloma
ABOUT THE DIAGNOSIS
Acral lick dermatitis, also known as lick granuloma, is a self-induced
skin lesion. The term acral refers to the legs and feet. Acral lick
dermatitis mainly is a problem of dogs, rarely cats. The dog continually licks at one area of the leg, producing hair loss, sores, and thickening of the skin. Typical appearance is a raised, red, hairless, oval patch of skin or skin lump found over the front surface of one leg. Occasionally, more than one leg may be affected. The most common locations are over or near the carpus (“wrist”) of the front paw or just below or above the hock on the rear leg. Breeds most likely to develop acral lick dermatitis include the Doberman pinscher, Great Dane, Labrador retriever, Irish setter, golden retriever, and German shepherd, but any breed of dog can be affected. Males are affected twice as often as females. The condition may appear at any age; however, most dogs are over 5 years of age when presented for treatment. Although several conditions that cause discomfort of the skin can cause persistent licking , in many dogs with acral lick dermatitis no underlying problem can be found. In these cases, acral lick dermatitis is considered a psychogenic disease; that is, it is caused by a behavioral disorder.
For example, sometimes excessive licking or chewing can result from boredom or can be used as attention-seeking behavior; Sometimes anxiety is the stimulus for stereotypic behaviors like repetitive licking.
Stereotypic behaviors are excessive, repetitive behaviors engaged
in to relieve psychological distress such as boredom or anxiety.
Diagnosis: Several other skin conditions may appear similar to
acral lick dermatitis. These include skin tumors, granulomas (masses due to chronic inflammation), and deep bacterial or fungal infections. In addition, several conditions that cause pain or itching can be involved in the development of lick granulomas, since dogs will lick areas where they feel tingling or discomfort. Depending upon the appearance of the skin lesion and your pet’s history, your veterinarian may need to run several tests to check for similar conditions and underlying disorders, including skin scrapings, bacterial or fungal cultures, and skin biopsies. In some cases, x-rays may be warranted to look for joint or bone disease, such as arthritis, or bone infections that can cause pain and therefore cause a dog to lick over the painful area incessantly. A history of trauma or surgery in the area might indicate possible nerve damage as a source of discomfort.
A variety of conditions that cause itching can contribute to the
development of acral lick dermatitis; these include allergies, skin
infections, and skin parasites (fleas, mange, etc.). If no underlying
disease can be found, then by exclusion, psychogenic factors are
assumed to be the cause of the dog’s constant licking.
Therefore the first step in evaluating a dog thought to have
acral lick dermatitis is to perform basic tests to assess for other
contributory medical and skin conditions (above). Once acral lick
dermatitis is confirmed to be the problem, a very valuable form
of evaluation is consultation with a veterinary behaviorist. These
are veterinarians who specialize in assessment and treatment of
behavioral disorders such as acral lick dermatitis. While animal
behaviorists are sometimes derided, they are specialty-trained
veterinarians whose focus of practice is entirely animal behavior,
and their input and recommendations can be lifesaving. The American Association of Veterinary Behaviorists is a nonprofit veterinary medical association. It regroups the specialty-trained veterinarians around the world who are experts in behavioral problems of dogs and cats (see “For the Public” → “Find a Board Certified Veterinary Behaviorist” at www.dacvb.org). Your veterinarian should be able to refer you to one of these Diplomates in your area, or by telephone, to better identify and correct the psychological/behavioral trigger that is leading to the incessant licking.
LIVING WITH THE DIAGNOSIS
Acral lick dermatitis can be challenging to treat. Medications may
help, either for direct application or, in the case of behavior-modifying medications, as oral tablets. Often the visible skin lesion is only the surface of the problem, and the root cause is psychological or behavioral. Therefore, the frustration of dealing with a dog that is compulsively licking needs to be met with an understanding that some sort of underlying trigger may exist and that dealing with that trigger is critical to solving the problem. Response to treatment depends upon correction of the underlying cause. Many cases require long-term care at home and adjustment of treatments when the lesion reappears. It is worth remembering that stressful changes in your pet’s life may precipitate reoccurrence of the problem.
TREATMENT
There are many approaches to treating acral lick dermatitis, and
some trial and error is usually needed to find the best treatment for
an individual dog. Since deep bacterial infections of the skin usually
are present as well (secondary problem due to the damage of licking),
antibiotic pills are usually given for several weeks. The affected skin
area can be treated directly with a variety of medications, including
topical treatments and injections. Bitter-tasting topical solutions are sometimes applied to discourage licking. Most treatments that are applied to the lesion are aimed at altering the sensation in the skin.
Agents used include corticosteroids, dimethyl sulfoxide (DMSO),
capsaicin, antiinflammatory drugs, and antihistamines. Additional
treatments aimed at reducing itching or painful sensations include
acupuncture, laser surgery, or cryosurgery. Removal of the lesion
with conventional surgery, laser surgery, or cryosurgery is also
advocated by some veterinarians. Some degree of relief can also
sometimes be brought about by frequently bandaging the leg and/
or placing an Elizabethan collar on the dog to break the cycle of
licking-itching.
Behavioral components of the condition also need to be
addressed. Boredom can be alleviated by increasing playtime,
introducing another animal as a playmate, reducing confinement time, or keeping the pet occupied with toys such as those with openings for treats (e.g., Kong-type toys). Several behavioral modification training techniques can be used. Stressful conditions should be eliminated, when possible. Antidepressant and antianxiety drugs may also be helpful in some dogs, and these can be prescribed by your veterinarian or a veterinarian specialized in behavioral medicine.
DOs
• Be diligent and persistent with treatment. Hair regrowth and
reduced compulsion to lick happen very slowly (weeks to months).
DON’Ts
• Avoid blaming or acting exasperated with a dog with acral
lick dermatitis. Unfortunately, compulsive licking can truly be
exasperating, but yelling at or punishing dogs for doing this
simply does not register with them and often can make them
more compulsive, which worsens the problem. In other words,
harsh words and punishment for licking behaviors tend to be
totally counterproductive.
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