Sei sulla pagina 1di 8

DOI: 10.1111/j.1365-3164.2008.00662.x

Pathogenesis of canine interdigital palmar and plantar comedones and follicular cysts, and their response to laser surgery

Blackwell Publishing Ltd

David D. Duclos*, Ann M. Hargis† , , § and Patrick W. Hanley§

*Animal Skin and Allergy Clinic, Lynnwood, Washington, USA †DermatoDiagnostics, Edmonds, Washington, USA ‡Phoenix Central Laboratory, Everett, Washington, USA §Department of Comparative Medicine, School of Medicine, University of Washington, Seattle, Washington, USA Correspondence: Ann M. Hargis, E-mail: hargisann@comcast.net

What is known about the topic of this paper

• Dermatitis with development of nodular lesions and draining sinuses in interdigital skin in dogs is painful, often recurrent, and can be difficult to properly diagnose and manage clinically and surgically.

• There are different causes of interdigital dermatitis and the role of follicular cysts is controversial.

What this paper adds to the field of veterinary dermatology

• This paper describes in dogs a previously unrecognized syndrome consisting of multiple comedones and follicular cysts in palmar or plantar (ventral) interdigital skin that:

(i) result in sinus tracts that open and drain on the dorsal interdigital skin surface giving the false impression that lesions develop dorsally, and (ii) describes a laser surgical procedure that can cure the syndrome.

Abstract

This study documents the presence of comedones and follicular cysts of palmar and plantar interdigital skin as an underlying cause of recurrent dermatitis, and describes the use of a carbon dioxide laser to surgically remove lesions. The 28 dogs included in the study had:

(i) recurrent lameness, pain, and nodules, or draining sinuses in the dorsal interdigital skin, (ii) failed to respond to antibiotic therapy, and (iii) were negative for Demodex mites and dermatophytes. All 28 had laser surgery; nine dogs had two surgical procedures and two dogs had three surgical procedures for lesion recurrence. Fifteen dogs had skin samples collected for histopathology. Clinical features in ventral inter- digital skin included alopecia, callus-like thickening, and comedones. Histological features included hyper- keratosis, acanthosis, comedones and follicular cysts, furunculosis, draining sinuses, and scarring. Surface trauma to the ventral interdigital skin appeared to contribute to lesion development. Laser surgery allowed removal of multiple layers of cysts and adja- cent hair follicles and the tracking and removal of

sinuses. One dog was euthanized for orthopaedic lameness 1 month after laser surgery, but post-surgical follow-up (1.0–8.0 years – mean 3 years) from the remaining 27 dogs revealed that laser therapy of affected skin and adjacent hair follicles resulted in resolution of interdigital lesions in 25. Two dogs con- tinued to develop interdigital cysts.

Accepted 14 February 2008

Introduction

Interdigital dermatitis (pododermatitis, pedal folliculitis and furunculosis, interdigital furunculosis) in dogs is a multifaceted disease that is often recurrent and difficult to

diagnose and treat. Causes are varied and include exogenous foreign bodies, contact irritants, hypersensitivity reactions, parasitism (demodicosis, hookworm dermatitis, Pelodera sp. dermatitis), infections with yeast, fungi, and bacteria, and disorders associated with immunosuppression. 1,2

A variety of types of trauma are thought to contribute

including external contact with irregular or rough surfaces such as vegetation or gravel, and self-trauma from licking

associated with allergic skin disease. 2 It has also been speculated that trauma to interdigital skin caused by short, bristly hairs rubbing against the skin of apposed interdigital webs can play a role. 2 In addition, chronic friction, as seen

in callus pyoderma may contribute to obstruction and

subsequent rupture of follicles, especially in dogs with

abnormal foot conformation. 2 Recently, a form of lympho- plasmacytic pododermatitis that responded to immuno- suppressive therapy has been reported. 3 It has been stated that the cause of interdigital dermatitis (pododermatitis) is often undetermined, but in no cases are the resulting lesions cysts. 1 In contrast, the presence of follicular cysts associated with interdigital dermatitis has been documented

in some dogs. 2 Clinical lesions include erythema, oedema,

nodules, pustules, ulcers, haemorrhagic bullae, haemorrhagic draining tracts, and scarring from recurrent episodes. 1,2 Histological lesions vary with the cause. Perifolliculitis, folliculitis, and furunculosis, draining tracts, and scarring are reported. Treatment includes eliminating specific

aetiological agents when present, soaking paws in antiseptic solutions, long-term antibiotic therapy, and surgical debridement. 1 In severe cases, podoplasty has been advocated. 4 Herein, the clinical and histological lesions and a proposed pathogenesis for a subtype of canine recurrent interdigital dermatitis believed to be secondary to the formation of

134

© 2008 The Authors. Journal compilation © 2008 ESVD and ACVD. 19; 134–141

multiple comedones and follicular cysts in the palmar or plantar (ventral) interdigital skin are described. These comedones and follicular cysts are present in multiple layers of the ventral interdigital skin. Each is prone to rupture and, because multiple comedones and cysts are present, their periodic rupture leads to repeated episodes of pyogranulomatous dermatitis and fistulous tracts. These tracts migrate to and drain onto the dorsal interdigital space, leading to the misinterpretation that the lesions develop in the dorsal interdigital skin. Failure to recognize the ventral origin of the cysts and remove them leads to frequent failure of therapy and repeated episodes of lesion recurrence. A laser surgical procedure that can cure or improve lesions is also described.

Materials and methods

Selection of affected dogs

The dogs were evaluated at the Animal Skin and Allergy Clinic between 1997 and 2006, and were included in the study on the basis of: (i) recurrent lameness, pain, and nodules, or draining sinuses in interdigital skin associated with multiple ventral comedones and follicular cysts; (ii) failure to respond to a 30-day course of oral cefalexin (Ranbaxy Pharmaceuticals, Inc., Jacksonville, FL, USA) 30 mg/kg/bid and oral rifampicin (Rifadin®, Hoechst Marion Roussel, Inc., Kansas City, MO, USA) 5–10 mg/kg/sid; and (iii) undergoing laser surgery for the lesions. Dogs with interdigital dermatitis from other causes such as antibiotic-responsive bacterial infection, demodectic mite infestation or fungal infection were not included. All dogs were given a dermato- logical evaluation including a complete physical examination, skin scrapings for parasites, hair examination for fungal spores and hyphae, and cytological examination for microorganisms, and were reported to have normal thyroid function by referring veterinarians. Statistical analyses were performed because it appeared that there might be a breed, age, sex, body weight, paw, and interdigital web predisposition. Demographic and clinical characteristics were evaluated between Labrador retrievers and other breeds affected, and for dogs with and without post-surgical recurrence of disease. Demographic characteristics included the age at onset of disease, body weight (kg), and sex. Clinical characteristics included the number of affected paws and the location of affected interdigital webs (4/5, 3/4, and 2/3). Statistical association was assessed by chi-squared analysis for categorical variables and t-test analysis for continuous variables using Stata 9.0 (Statcorp. College Station, TX, USA). 5 Significance was determined if the P-value was < 0.05.

Biopsy and surgical procedures

Dogs were initially anaesthetized with propofol (PropoFlo®, Abbott Laboratories, North Chicago, IL, USA) 5.5 mg/kg given intravenously and titrated against the patient response, and anaesthesia was thereafter maintained by isoflurane (Aerrane®, Baxter, Thousand Oaks, CA, USA) inhalation. Interdigital skin was clipped and prepared for a sterile surgical procedure, and the affected areas were covered with a sterile drape. Skin samples were collected from the ventral interdigital skin of 15 of the 28 dogs via punch or incisional sampling either before or during the laser surgical procedure. Between one and four samples were collected from lesional skin in each of the 15 dogs. Skin from one dog was sampled during three separate laser surgical procedures; nine had biopsy samples collected from one paw, and six had biopsy samples collected from two paws. The skin samples were taken from areas with a variety of clinical lesion appearances to investigate underlying causes and perpetuating factors. In addition to affected tissue, samples were taken from clinically normal ventral interdigital skin (one from a Saint Bernard and two from a Labrador retriever). Blood was blotted from the skin samples, which were then placed in 10% neutral- buffered formalin, and processed by standard techniques to paraffin wax. Sections (4–6 mm) were stained with haematoxylin and eosin.

© 2008 The Authors. Journal compilation © 2008 ESVD and ACVD.

Palmar and plantar interdigital follicular cysts

Carbon dioxide (CO 2 ) laser surgery methods

A Luxar LX 20 SP Novapulse® 20-watt laser system (Aesculight Inc, Woodinville, WA, USA) with a pre-sterilized NovaScan scanning hand- piece was used. An Acu-Evac® filtration particulate and smoke evacuator (Acuderm Inc, Ft. Lauderdale, FL, USA) was used to remove aerosolized tissue and debris. The CO 2 laser is named from the medium used to generate the laser beam. When CO 2 gas contained in a vacuum tube is energized, it emits a beam of light in the near infrared spectrum (10 600 nm). This beam, is concentrated by lenses and mirrors through the end of the handpiece, is highly absorbed by water, and quickly vaporizes tissues with high water content (e.g. cells comprising cutaneous soft tissue) into carbonized debris. 6 Tissues or substances with low water content such as keratin need more laser energy to achieve ablation and hence are more slowly removed by the CO 2 laser. The initial laser setting for removal of surface tissue, comedones, and follicular cysts was continuous wave (CW) at 8–10 watts of power. Depending on the number of cysts, the duration of the CW mode was approximately 5–20 min. The remainder of the surgical procedure was performed with reduced laser settings (super pulse mode at 4–5 watts) necessary to prevent unwanted destruction of normal tissue. Depending on the severity of lesions, the duration of SP mode was approximately 5–10 min. The total procedure lasts about 30–45 min per foot. The scanner head was slowly passed over the surface of the surgical site ablating to a depth of approximately 0.3 mm of tissue with each pass. Ablated tissue and debris were removed with sterile saline by irrigation or on gauze pads. After final thorough irrigation, the wound was packed with mupirocin 2% ointment (Taro Pharmaceuticals Inc., Brampton, Ontario, Canada), and a compression bandage was applied. The treated site was allowed to heal via granulation tissue.

Post-operative care

The dogs were treated with oral cefalexin (30 mg/kg/bid), and topical mupirocin 2% ointment, at the time of bandage changes; both pro- cedures were continued until the surgical wounds healed. Some dogs required pain management and were given oral deracoxib (Deramaxx® Novartis Animal Health, Greensboro, NC, USA) at 1– 2 mg/kg/day as needed during the first 7–14 days. Most required bandaging for 4–5 weeks, and a few for 6 weeks. During the first 2 weeks after surgery, the bandages were changed at least every 3– 4 days while over the next 2–4 weeks a weekly change was usually adequate. Waterproof coverings, including empty intravenous fluid bags or commercial dog boots, were used to keep the bandaged paws dry. The clients were instructed to keep their dog in a restricted area to prevent activity and trauma to the interdigital skin. Information on post-operative outcome was obtained during office visits for band- age changes and assessment for healing and clinical improvement, and via telephone calls to owners.

Results

The breeds and sexes of the 28 affected dogs are listed in Table 1. They had a mean weight of 45 kg (range 15.3–74.6), and a mean age at lesion onset of 2.9 years (range 1– 9 years). The mean duration of clinical signs before laser surgery was 2.4 years (range 0.5–7 years). Clinical lesions included nodules (Fig. 1) or draining sinuses in dorsal interdigital skin. Dorsal lesions were not always visible unless the hair was clipped. The ventral interdigital skin opposite the dorsal lesions contained an area of alopecic, thickened, firm, callus-like skin with multiple comedones (Fig. 2). Four affected dogs (three Labrador retrievers and one Labrador retriever husky crossbred) had thick, hard, rough tissue overlying the area of alopecia and comedones, and had broadening of the digital pads. This and the callus-like thickenings suggested that either weight bearing was occurring in the haired skin adjacent to the digital pads or that there was frictional trauma between haired skin and another pad (Fig. 3). Punch biopsy

135

Duclos et al.

Table 1. Demographic characteristics of dogs with interdigital cysts

 

n (28)

%

Age at onset (years) 3

21

75.0

>

3

7

25.0

Body weight (kg)

 
 

< 30

2

7.1

30–50

16

57.1

>

50

10

35.7

Sex

 

Male

19

67.9

Female

9

32.1

Neutered

 
 

Yes

20

71.4

No

8

28.6

Breed

Labrador retriever

13

46.4

Other breeds*

15

53.6

*Labrador mix (2) Irish setter (2), Saint Bernard (2), Malamute and Malamute crossbred (2), and one each Shepherd mix, Bull mastiff, Great Pyrenees (Pyrenean mountain dog), Rottweiler, Doberman pinscher, Brittany spaniel, and English bulldog.

Doberman pinscher, Brittany spaniel, and English bulldog. Figure 1. Nodular area on dorsal interdigital skin between

Figure 1. Nodular area on dorsal interdigital skin between digits 4 and 5. Note the swelling and erythema, and inflammation about to rupture through the skin surface (arrow).

about to rupture through the skin surface (arrow). Figure 2. Alopecia and comedones (arrows) in ventral

Figure 2. Alopecia and comedones (arrows) in ventral interdigital skin revealing expression of follicular contents (arrowheads) caused by pressure from the dorsal surface.

sampling (Fig. 4) or laser surgery revealed the presence of comedones and follicular cysts beneath the thick, alopecic, callus-like skin. Prior to referral, different veterinarians treated the dogs with a variety of systemic and/or topical therapeutic regimes (e.g. antibiotics, steroids, sometimes surgical lancing, soaking paws in antiseptic solutions, and

136

lancing, soaking paws in antiseptic solutions, and 136 Figure 3. Thick, hard, rough tissue (arrows) overlying

Figure 3. Thick, hard, rough tissue (arrows) overlying the area of alopecia and comedones in ventral interdigital skin adjacent to digital pad. In this dog the thickened area rubbed against the metacarpal pad. Note the adjacent digital pad (arrowheads).

metacarpal pad. Note the adjacent digital pad (arrowheads). Figure 4. An example of a large follicular

Figure 4. An example of a large follicular cyst below the thickened skin. Note the cyst contents (arrow) and the follicular wall (arrowheads).

bandaging paws) without resolution of lesions. The lesions were considered to be ‘refractory’ to therapy. The dose, duration, and frequency of specific medications given varied with the referring veterinarian and were not always available. In addition, prior to inclusion, a 30-day course of an oral cephalexin 30 mg/kg/bid and rifampicin 5–10 mg/kg/sid was given to all 28 dogs, and none responded to the antibiotic therapy. The majority of the 28 dogs (26) had cysts involving at least one front paw, and 14 had cysts affecting both front paws (Table 2). In contrast only seven had cysts affecting at least one rear paw, and six had cysts affecting both rear paws. Twenty-six had lesions in the haired interdigital skin of the palmar or plantar (ventral) surface (Table 2). One had cysts at the haired skin paw pad junction only, and another had lesions in the haired ventral interdigital skin and at the haired skin paw pad junction. Twenty-six dogs had lesions between digits 4 and 5 (Table 2), indicating that the ventral interdigital webs of the lateral digits of the front paws were the areas most often affected. For interdigital lesions, no significant differences were identified with regard to age at onset of lesions, body weight (kg), sex, number of affected paws, or location of affected interdigital webs between Labrador retrievers and other breeds. No significant differences were identified with regard to age at onset, body weight (kg) or affected paws or toe webs between dogs that had a recurrence of disease and those that did not.

© 2008 The Authors. Journal compilation © 2008 ESVD and ACVD.

Table 2. Locations of interdigital cysts in dogs

 

n (28)

%

Feet affected One front foot (left or right) Both front Both rear All feet Other* At least one front foot† At least one rear foot† Sites affected Ventral haired skin Haired skin and footpad junction Both ventral haired interdigital skin, and haired skin and footpad junction Interdigital webs affected‡ Lateral (4th/5th digital space) Central (3rd/4th digital space) Medial (2nd/3rd digital space)

7

25.0

14

50.0

2

7.1

2

7.1

3

10.7

26

93.0

7

25.0

26

92.9

1

3.6

1

3.6

26

92.9

7

25.0

3

10.7

*Represents either a dog that had both rear feet and one front foot affected or a dog that had both front feet and one rear foot affected. †Five dogs are listed twice because they had both a front and a hind foot affected. Each category (front vs. hind) is a percentage of the 28 dogs. ‡Dogs could have multiple webs affected. Each interdigital web space is a percentage of the 28 dogs.

Each interdigital web space is a percentage of the 28 dogs. Figure 5. Ventral interdigital skin

Figure 5. Ventral interdigital skin with the surface ablated by the laser. Note the lack of haemorrhage. The follicular walls (arrowheads) border expressed follicular content (arrows).

Other health or skin problems in dogs with interdigital dermatitis included atopic dermatitis (seven dogs) and orthopaedic lameness (two dogs). Nineteen had no other problems.

Laser surgical procedure Surgery on the paws always began on the ventral surface. The CO 2 laser ablated the tissue, sterilized the surface, and sealed the small capillaries, which helped to prevent haemorrhage and improved visualization of the surgical site (Fig. 5). The CO 2 laser energy quickly ablated tissue with high water content (e.g. soft parenchymal tissues bordering cysts), leaving tissue with low water content (e.g. keratin) unaltered. This differential in speed of ablation helped identify the comedones and cysts in the tissue during surgery (see Fig. 5). Digital pressure on the dorsal interdigital space helped to expose and stabilize the affected tissue, improved visualization of the ventral surgical site, and helped to express the contents of the follicular

© 2008 The Authors. Journal compilation © 2008 ESVD and ACVD.

Palmar and plantar interdigital follicular cysts

and ACVD. Palmar and plantar interdigital follicular cysts Figure 6. Ventral interdigital skin with superficial

Figure 6. Ventral interdigital skin with superficial tissue ablated by the laser. Abscesses (large arrows) were identified after layers of comedones and cysts were removed by laser surgery. Note the contents (small arrow) expressed from a follicular cyst at the edge of the surgical field.

comedones and cysts. As the follicular contents were released, frequent cleaning of the surface with sterile saline (on gauze sponges and by irrigation) was required to remove debris and keratin, and maintain good visualization of the surgical field. Multiple layers of comedones and cysts became visible as the layers of tissue were gradually ablated. Typically, once one level of comedones and cysts was removed the tissue became more normal in appearance; however, continued laser ablation revealed additional levels of come- dones, cysts, and sometimes small abscesses (Fig. 6). In most dogs there was at least one and sometimes multiple haemorrhagic, draining sinuses between the last layer of cysts and the dorsal interdigital skin. Placement of a sterile cotton-tipped applicator in the opening of the haemorrhagic sinus on the dorsal surface and applying pressure with this applicator helped identify the location of the draining sinus in the surgical field on the ventral surface, enabling the laser to be directed dorsally towards the sinus (applicator). This pressure occasionally caused the expression of keratin from the cysts in the palmar or plantar skin, thereby providing an additional visual aid for cyst location. Great care was used when surgery approached large digital vessels and nerves to avoid damaging them. In some dogs, the laser surgery extended completely through the interdigital skin to open on the dorsal interdigital surface. In an attempt to prevent future development of come- dones and cysts in follicles adjacent to the surgical site, hair follicles in normal skin approximately 5 mm around all sides of the affected area (lateral, proximal, distal, and dorsal) were also ablated.

Skin sample evaluations The skin samples varied in size from 4 mm to 2.5 cm, but most were small and not representative of the entire surgical field. The samples were selected to evaluate specific features in the surgical site. Histological lesions of the palmar or plantar (ventral) interdigital skin included moderate to extensive compact hyperkeratosis and acanthosis of epidermal and follicular infundibular epithelium (Fig. 7). Multiple follicles were cystically dilated, often extensively. Thirteen of the dogs sampled had follicular cysts and two

137

Duclos et al.

Duclos et al. Figure 7. Photomicrograph of ventral interdigital skin. Note compact hyperkeratosis (arrowheads) covering

Figure 7. Photomicrograph of ventral interdigital skin. Note compact hyperkeratosis (arrowheads) covering acanthotic epidermis. Follicular cysts are present (arrows). Haematoxylin and eosin. Low magnification.

others had draining tracts containing hair or keratin. The number of cysts in one histological section varied from 1 to 14, but it was not always possible to determine with certainty if cysts were interconnected outside the plane of the section. Two dogs had coccoid bacteria and five dogs had Malassezia sp. in the cysts. Fourteen of the dogs with interdigital lesions had furunculosis. The released follicular contents were associated with a granulomatous inflam- matory response. In some dogs with chronic lesions, hair shafts were embedded in areas of scarring. Five dogs with interdigital lesions had histologically visible tracts from areas of furunculosis to other areas of the skin sample. Two skin samples from clinically normal ventral interdigital skin had no significant lesions. In the remaining sample, the epidermis was moderately acanthotic and covered by compact stratum corneum. In this sample, there was mild follicular hyperkeratosis and dilation, with small numbers of periadnexal lymphocytes, plasma cells, a few neutrophils and histiocytes. One small focus of granulomatous furunculosis was identified, compatible with a subclinical lesion.

Post-surgical outcome Twenty-five of 27 dogs with the palmar/plantar interdigital comedo and follicular cyst syndrome were cured by laser surgery (follow up time 1–8 years; mean 3 years). The 28th dog was euthanized for orthopaedic lameness 1 month after laser surgery preventing acquisition of long- term follow-up information. Seventeen dogs required one laser surgical procedure, nine required two procedures and two required three procedures. Two of the dogs con- tinued to develop interdigital cysts after lesion ablation; repeat surgery has been recommended for one, but as the cysts in the other dog were mild additional surgery was not considered necessary. In addition, three dogs developed ventral interdigital cysts on a previously unaffected paw.

Discussion

The pathogenesis of interdigital follicular cysts in the dogs appeared to result from external surface trauma to the

138

haired skin of the palmar and plantar webs causing epidermal and follicular infundibular hyperkeratosis and acanthosis, plugging or narrowing of the follicular ostia, and retention of follicular contents (Fig. 8). Since the compound hair follicles of dogs can have 15 or more secondary follicles entering and exiting one compound follicle unit, 7 the narrowing or plugging of one follicular ostium could lead to the formation of multiple cysts. Dilated cysts are prone to rupture, which creates a foreign body inflammatory response and often a secondary bacterial infection. The presence of the released follicular contents causes an endogenous foreign body reaction and is the probable reason why lesions fail to completely respond to antibiotic therapy. Exudate from ruptured follicles can coalesce and lead to the formation of draining sinuses. However, because both the palmar and plantar interdigital skin is thickened by hyperkeratosis, acanthosis and scarring, it is unlikely that a draining sinus could easily penetrate this dense tissue and open on these thickened surfaces. Instead, as discovered during the laser surgical procedure, the draining sinuses extend towards the more normal less inflamed and scarred tissue of the dorsal interdigital space. Support for this hypothesis comes not only from the clinical and histological lesions and surgical dissection in the present study, but also from comparison of the interdigital lesions to calluses that develop in interdigital skin and at other sites, and from other studies that describe development of interdigital lesions in dogs and measure forces affecting digital pads and limbs. 8,9 For example, trauma was proposed as a cause of interdigital dermatitis and cysts in an epidemiological study of 732 laboratory beagles in which the interdigital lesions were described as raised, firm areas located in the dorsal aspect of the interdigital space. The prevalence of interdigital lesions in beagles was greater in the front than the hind paws, 8 and in those beagles with a large body condition score. The lesions developed more commonly in beagles exposed to one type of suspended cage flooring (flat bar coated flooring), which may have increased contact of the ventral interdigital skin with the coated bars, as the number of affected beagles increased as the time of exposure to this flooring increased. 8 These findings provided support for the role of surface trauma to the bottom of the paws in larger/heavier beagles as a contributory factor in the development of raised, firm dorsal interdigital lesions. However, as this was an epidemiological study, there was no accompanying histopathological description, which prevents the identification of the nature of the lesions and knowledge of the presence or absence of follicular cysts. In addition, vertical forces affecting paw pads have been studied during walking in greyhounds and Labrador retrievers, 9 in both of which the vertical forces in the fore limb were greater than those in the hind limb. 9 Digital pads 3 and 4 were identified as the major weight-bearing pads, but digital pad 5 and the metacarpal and metatarsal pads also carried a substantial amount of the load. These findings indicate that more weight bearing occurs on the front than on the hind paws of dogs, and that the digital pads 3, 4, and 5 bear more weight than digital pad 2. This may help explain the results in the current study where front paws were more commonly affected than hind paws; where the interdigital webs between pads 3/4 and 4/5 were more

© 2008 The Authors. Journal compilation © 2008 ESVD and ACVD.

Palmar and plantar interdigital follicular cysts

Palmar and plantar interdigital follicular cysts Figure 8. Schematic illustration of the proposed process of lesion

Figure 8. Schematic illustration of the proposed process of lesion development. The ventral interdigital skin becomes hyperkeratotic and acan- thotic, and primary and secondary follicles become dilated with keratin. Hairs on this surface are lost as the lesions become more severe, and the interdigital skin thickens. Follicles can rupture causing an inflammatory response and the development of draining tracts that migrate dorsally and open within the dorsal interdigital space.

commonly affected than that between pads 2/3; and where affected dogs were also heavy large breeds. The study of vertical forces affecting paw pads in greyhounds and Labrador retrievers also revealed a breed difference in paw conformation. 9 Greyhounds had long, narrow paws with little distance between the digital pads. In contrast, the Labradors had wide-based paws with greater distance between pads. 9 This latter characteristic suggests the possibility that weight bearing, especially in a heavy dog, might be more likely to be distributed to haired interdigital skin adjacent to digital pads. Interestingly, the four dogs with the thick, firm, rough tissue covering callus-like areas in interdigital skin in the present study were Labrador retrievers (three dogs) and a Labrador retriever husky crossbred. Finally, callus formation with dermatitis (callus pyoderma) of the skin over the sternum, elbow, or hock joints has clinical, histological, and aetiological similarities to the cases of chronic interdigital dermatitis and follicular cyst forma- tion in the dogs in the current study. 2 Clinically, calluses are alopecic thickened areas of skin subject to repeated pressure or frictional trauma. 2 Histologically, they frequently contain dilated hair follicles filled with keratin (e.g. come- dones and follicular cysts). 2 These dilated follicles can rupture causing furunculosis, a foreign body response to the released follicular contents and a secondary bacterial infection. Fistulas may develop in some cases. It has also been suggested that friction or other trauma to interdigital

© 2008 The Authors. Journal compilation © 2008 ESVD and ACVD.

skin may promote formation of keratin-filled follicles that can rupture as seen in callus pyoderma. 2 Thus the studies of interdigital lesions in laboratory beagles, studies of vertical forces on paw pads of dogs, and similarities to callus formation in interdigital skin and at other sites help provide evidence for weight bearing and interdigital trauma as contributing causes for lesions in the dogs in the present study. Laser surgery was a useful method for resolving lesions because it was effective in 25 of 28 dogs in which follow- up of at least 1 year was available. As the laser cauterizes the small capillaries and prevents bleeding, it facilitates differentiation between affected and normal tissue. In super pulse mode it allows removal of minute amounts of tissue with each pass, thereby avoiding unnecessary damage to the surrounding tissue and making the laser an ideal surgical tool for this condition. Moreover, the CO 2 laser ablation procedure facilitates removal not only of the follicular comedones and cysts, but also the adjacent hair follicles, which may help prevent recurrences. Even so nine dogs required two laser surgical procedures, two required three procedures, and two of the dogs continued to develop interdigital cysts. The reason why interdigital cysts in the palmar or plantar skin recurred in some dogs but not others is unclear. No other contributory disease process was identified. The most likely explanation is development of comedones and follicular cysts in remaining hair follicles near the surgical

139

Duclos et al.

site or between other digits due to continued external trauma. The capacity to develop ventral cysts in other digits was demonstrated in three dogs in the present study where such cysts developed in a previously unaffected paw. Because there are many causes of interdigital dermatitis that can successfully be treated medically or with less extensive surgical procedures, prior to contemplating laser surgery, it is necessary to evaluate and exclude those cases that are not due to the ventrally developing comedo and follicular cyst syndrome. Clinical evaluation of the palmar and plantar interdigital skin for alopecia, come- dones, and callus-like lesions; thorough dermatological evaluation for other aetiological factors (bacterial, para- sitic, yeast, fungal infections, exogenous foreign bodies, inflammation associated with allergies, etc.); an appropriate antibiotic trial; and/or skin sampling of ventral interdigital areas should enable identification of dogs with interdigital cyst syndrome. Also, as presenting signs in dogs with the comedo and follicular cyst associated interdigital dermatitis include pain manifested as lameness and sometimes licking, it is also important to exclude dogs in which lameness is due to involvement of other tissues such as the bones or joints. In this study, one dog with the interdigital cyst syndrome also had orthopaedic lameness involving the elbow joint. This dog was euthanatized 1 month after laser surgery of interdigital skin when it was realized that a significant proportion of the lameness was orthopaedic in origin; although the interdigital lesions had healed, the dog remained lame and in pain. In summary, the results reveal that the ventral interdigital skin in some dogs develops follicular cysts, which can rupture, cause inflammation and bacterial infection, and form fistulas that drain onto the dorsal interdigital surface. The lesions appear to arise from external trauma to the ventral interdigital skin. Most lesions can be successfully treated by laser surgery, but affected dogs should be

clearly identified as having the palmar plantar interdigital cyst syndrome before having this invasive laser surgery performed.

Acknowledgements

The authors acknowledge H. Denny Liggitt for pathology consultations, and Benjamin J. Weigler and Ronald F. DiGiacomo for statistical consultations.

References

1. Scott DW, Miller Jr. WH, Griffin CE. Muller and Kirk’s Small Animal Dermatology, 6th edn. Philadelphia, PA: W.B. Saunders, 2001:

304–6.

2. Gross TL, Ihrke PJ, Walder EJ, Affolter VK. Skin Diseases of the Dog and Cat Clinical and Histopathologic Diagnosis, 2nd edn. Ames, IA: Blackwell Science Ltd, 2005: 184–5, 431–5.

3. Breathnach RM, Baker KP, Quinn PJ et al. Clinical, Immunological and histopathological findings in a subpopulation of dogs with pododermatitis. Veterinary Dermatology 2005; 16: 364–72.

4. Swaim SF, Lee AH, MacDonald JM et al. Fusion podoplasty for the treatment of chronic fibrosing interdigital pyoderma in the dog. Journal of the American Animal Hospital Association 1991; 27:

264–74.

5. Moore DS, McCabe GP. Introduction to the Practice of Statistics, 5th edn. New York: W.H. Freeman, 2005: 581–609.

6. Peavy GM. Lasers and laser–tissue interaction. Veterinary Clinics of North America Small Animal Practice 2002; 32: 517–34.

7. Calhoun ML, Stinson AW. Integument. In: Dellmann HD, Brown EM, eds. Textbook of Veterinary Histology. Philadelphia, PA: Lea & Febiger, 1987: 382–415.

8. Kovacs MS, McKiernan S, Potter DM et al. An epidemiological study of interdigital cysts in a research beagle colony. Contemporary Topics in Laboratory Animal Science 2005; 44: 17–21.

9. Besancon MF, Conzemius MG, Evans RB et al. Distribution of vertical forces in the pads of greyhounds and Labrador retrievers during walking. American Journal of Veterinary Research 2004; 65:

1497–501.

Résumé Cette étude rapporte la présence de comédons et de kystes folliculaires au niveau de la peau palmaire et plantaire interdigitée comme une cause de dermatose récidivante, et décrit l’utlilisation d’un laser au dioxyde de carbone pour éliminer surgicalement les lésions. Les 28 chiens inclus dans cette étude avaient: 1) une boiterie récurrente douloureuse et des nodules ou des fistules au niveau interdigité, 2) une absence de réponse à l’antibiothérapie et 3) absence de Demodex et de dermatophytes. les 28 chiens ont eu une chirurgie au laser, neuf ont eu deux chirurgies et deux trois chirurgies à cause de récidives. Un examen histopathologique a été réalisé pour 15 chiens. Les signes cliniques en zone interdigitée ventrale incluaient alopécie, épaississement et comédons. Les signes histopathologiques regroupaient une hyperkératose, une acanthose, la formation de comédons et de kystes folliculaires, une furonculose, des fistules et une fibrose. Des traumatismes de surface à la peau interdigitée semblaient aggraver les lésions. Le laser a permis l’élimination de nombreuses couches kystiques et l’élimination des follicules adjacents et des fistules. Un chien a été euthanasié pour boiterie un mois après le laser, mais une résolution a été observée chez 25 cas après un suivi de (1.0 à 8.0 ans – moyenne 3 ans). Deux chiens ont présenté des récidives.

Resumen Este estudio demuestra la presencia de comedones y quistes foliculares en la piel intedigital palmar y plantar como causa de dermatitis recurrente y describe el uso de láser de dióxido de carbono para

retirar las lesiones quirúrgicamente. Los 28 perros incluidos en el estudio tenían: 1) cojera recurrente, dolor

y nódulos o senos de drenaje en la piel interdigital dorsal, 2) no respondieron a tratamiento con antibióticos,

y 3) fueron negativos para Demodex y dermatofitos. Todos los perros se trataron con cirugía de láser; nueve perros tuvieron dos procedimientos quirúrgicos y dos perros tuvieron tres debido a lesiones recurrentes. Se tomaron muestras de piel para histopatología de quince perros. Las características clínicas en la piel interdigital ventral incluyeron alopecia, engrosamiento tipo callosidad y formación de comedones. Las características histopatológicas incluyeron hiperqueratosis, acantosis, formación de quistes y comedones, furunculosis, senos de drenaje y cicatrización. Trauma superficial en la piel interdigital ventral parecía

140

© 2008 The Authors. Journal compilation © 2008 ESVD and ACVD.

Palmar and plantar interdigital follicular cysts

contribuir al desarrollo de las lesiones. La cirugía con láser permitió retirar niveles múltiples de quistes y los folículos adjacentes así como la localización y extirpación de los senos de drenaje. Un perro fue eutanasiado debido a cojera ortopédica un mes después de la cirugía con láser, pero el seguimiento post-operatorio (1–8 años, media 3 años) del resto de los 27 perros indicó que el tratamiento con láser de la piel afectada y los folículos adjacentes produjo resolución de las lesiones interdigitales en 25 perros. Dos perros continuaron desarrollado quistes interdigitales.

Zusammenfassung In dieser Studie wird das Auftreten von Komedonen und follikulären Zysten der palmaren und plantaren Zwischenzehenhaut als zugrunde liegende Ursache einer wiederkehrenden Dermatitis dokumentiert. Die Verwendung eines Kohlendioxidlasers zur chirurgischen Entfernung dieser Veränderungen wird beschrieben. Die 28 Hunde, die in die Studie aufgenommen wurden, hatten: 1) rezidivierende Lahmheit, Schmerz und Knoten oder abfließende Sinusse in der dorsalen Zwischenzehenhaut, 2) reagierten nicht auf Antibiose und 3) waren negativ für Demodexmilben und Dermatophyten. Bei allen 28 Hunden wurde Laserchirurgie durchgeführt; neun Hunde hatten zwei und zwei Hunde hatten drei chirurgische Interventionen aufgrund von erneutem Auftreten der Läsionen. Bei fünfzehn Hunden wurden Hautproben für eine histopathologische Untersuchung genommen. Der klinische Befund der ventralen interdigitalen Haut bestand aus Alopezie, kallusartiger Verdickung und Komedonenbildung. Der histologische Befund bestand aus Hyperkeratose, Akanthose, Komedonen und follikulärer Zystenbildung, Furunkulose, abfließenden Sinussen und Narbenbildung. Ein oberflächliches Trauma der ventralen Zwischenzehenhaut schien zur Entstehung der Läsionen beizutragen. Die Laserchirurgie ermöglichte das Entfernen von Zysten in zahlreichen Schichten und der angrenzenden Haarfollikel und das Auffinden und die Entfernung der Sinusse. Ein Hund wurde einen Monat nach der Laserchirurgie aufgrund von orthopädischer Lahmheit eingeschläfert, aber die Kontrolluntersuchung nach der Chirurgie (1.0 bis 8.0 Jahre – Durchschnitt 3 Jahre) der übrigen 27 Hunde zeigte, dass die Laserchirurgie der betroffenen Haut und der angrenzenden Haarfollikel bei 25 Hunden in einer Heilung der interdigitalen Veränderungen resultierte. Zwei Hunde entwickelten weiterhin interdigitale Zysten.

© 2008 The Authors. Journal compilation © 2008 ESVD and ACVD.

141