Lick Granulomas

Acral lick granulomas are a common problem in dogs. There are a number of treatments that have been advocated for this problem, mostly because none of them is consistently successful in eliminating all cases of lick granuloma.

Lick granulomas can occur secondary to allergies -- in this case, treatment for the allergy is often successful. It is a good idea to consider allergy testing in dogs with persistent lick granulomas or recurrent ones. The standard treatments for allergies are itch control medications or hyposensitizing "allergy shots". Skin testing is the most accurate way to diagnose allergies. Veterinary dermatologists frequently do this. Blood testing for allergies is considered to be less accurate but can be substituted when skin testing is hard to arrange.

Acral lick granulomas can occur secondary to injuries, underlying bone infection (this is a tricky diagnosis because the persistent licking can lead to periosteal inflammation around the bone making it seem like an infection was the cause), bacterial skin infection, parasites and other physical causes.

These lesions are thought to be due to stress or boredom in some dogs and even to be an obsessive/compulsive disorder in others.

So the first step in treatment is to do a thorough examination for an underlying cause. If one can be identified, it should be treated. If a bacterial infection is suspected antibiotics must be used for at least 6 to 8 weeks. If an underlying cause can not be found then the lick granuloma itself should be treated. There are a number of ways of doing this. Topical treatment with a combination of Synotic and Banamine has been advocated. Local anesthetic preparations like DermaCool or Relief can be helpful. Application of aversives like bitter apple or chloramphenicol ophthalmic ointment is sometimes done. Bandaging or using a sock to cover the lesion helps in some cases. A good adjunct to this type of therapy appears to be administration of hydrocodone to cut down on the irritation and/or fill the need for endorphins that the dog may be experiencing.

The psychological cases can respond to simple changes in environment (reducing stress or boredom). In more difficult cases, amitriptyline (Elavil), naltrexone (Trexane), clomipramine (Anafranil) and fluoxetine (Prozac) have been advocated. Acupuncture is reported to work well in some dogs, anecdotally.

For really desperate situations, radiation therapy, casts over the area, cryosurgery, and surgical excision have all been attempted.

This condition is frustrating and often will take several approaches to find the one that will work. Keep working with your vet to find a solution to the problem for your dog.

Mike Richards, DVM

Biting at skin in older Golden

Q: Hi Dr Mike Our oldest bitch ( Golden retriever ) suffers from nervous biting of her coat. In specific areas such as one of her back legs by the hock, and by the stifle and sometimes on her rear back. She has been to the vet and he diognosed nervousness keep it clean, and apply Hydrocortiderm. Have you any thoughts or tips on this subject ? Alick & Moira

A: Alick-

I think that I would have a hard time accepting a diagnosis of nervousness as the cause of biting at the skin without trying to rule out a number of other conditions but it is possible that your vet has already done that. If there are specific discrete sores at the spots that your golden favors chewing, usually raised up from the surrounding skin level, hairless and sometimes with a weeping surface, the diagnosis may be a "lick granuloma" and these do seem to be a condition that is induced by boredom or stress in some dogs.

Most dogs that bite at themselves do so because they are itchy. Even dogs with lick granulomas that are due to behavioral causes begin to lick or chew on the area due to itchiness or some initiating irritant. Determining why the itchiness is occurring can be very difficult, though. The possibilities include flea infestation, bacterial skin infections as a primary cause (not too uncommon in goldens), inhalant allergies (common in goldens), hypothyroidism (common in goldens), food allergies (not too common), contact allergies (not too common), parasitic mites (Sarcoptes, Demodex) and yeast skin infections. In a few dogs, there is an underlying problem not related to skin itchiness, such as joint pain in the affected region, infections in underlying tissues such as bone, organ dysfunction or some other process that the dog can't directly address so responds to by chewing in the general vicinity of the problem. Some dogs really do seem to develop chewing or licking behaviors as a form of obsessive compulsive disorder or a displacement behavior for feelings of stress or fear (nervousness).

The problem with all these possibilities is that it is hard to figure out a cost efficient and patient friendly way to sort through all of them. We usually try to do skin scrapings for mites early on (but we don't do this for most discrete lick granulomas) since the test is easy and since missing the mites makes us feel foolish ten tests later. We may test for hypothyroidism if there are other signs or a family history of problems with this condition. If there is a history of allergies, or clinical signs very suggestive of allergies, we may either refer the patient to a dermatologist for testing or consider using a short course of prednisone to see if the chewing stops when itching is controlled. Antibiotic use may be indicated if there are signs of secondary infection or if there are other signs of bacterial skin infection, such as pustules or excessive dander. Usually, after some or all of this testing and therapy, and if we think the problem is not a typical lick granuloma, we might try behavioral medications and suggest some changes in the dog's lifestyle if it seems like there may be a way to alleviate the stress or boredom.

It is hard to provide specific information without being able to do an examination but I hope this gives you a general idea of our thought process in cases like this so that you can take what seems applicable to your situation and make use of it.

Mike Richards, DVM 2/6/2001

Lick Granulomas and wound chewing

Q: Dr. Richards,

I have a 5 1/2 year old Irish Setter that has currently gone through several surgeries on his paw. In January, my vet operated and found nothing. In Late March, the paw swelled again and surgery was done again. They had suspected a "foxtail" but nothing was found. The third surgery was done due to my dog taking his stitches out-while at the vets. 8 days later, again at the vets-my dog removed his stitches. This has become a nightmare. I am now on day 8 of recovery, soaking the paw 2-3 times daily in Epsom salts but covering the paw with a sock and bootie because my Irish is an escape artist extraordinaire with the Elizabethan collars, and everything else we've tried. He's on an antibiotic Cephalexin 750mg. and Lodeine. My question is twofold:

Any ideas to help dry out the paw area (I currently use a blowdryer and sunlight when possible) and keep him away from it to allow it to heal,.

Once the stitches are out-is it likely to become a lick granuloma problem-taking me back to square one!

Biopsy report came back negative-allergic dermatitis-inflammation of the area.....

Any help would be greatly appreciated.

Frustrated Irish Setter Mom.

A: M-

If this problem is affecting a back paw you might want to try one of the newer "Bite Not" collars that are essentially a tube of plastic and foam (like a very wide collar) that prevents turning the head. Some dogs tolerate these a lot better than Elizabethean collars. A dog that really wants to get out of these collars can do it, though.

If the problem is affecting a front foot then the situation is a lot harder because even Elizabethean collars don't prevent licking at front paws and forelegs all that well if the dog is determined to get to them -- and as you have discovered, with persistence, most dogs can get the collars off.

We have been extremely frustrated by a couple of Irish Setters in our practice who have developed lick granulomas or who have persistently licked at healing wounds, keeping them irritated. We got so frustrated with one of these dogs that we put a fiberglass cast on the leg to prevent her from getting to it -- and she chewed through that after two weeks. In her case, that was long enough to allow the wound she had to heal but I have never done this again because there is a lot of potential for problems when a wound is covered over with a cast and the cast can cause sores in other areas, just compounding the problems.

If your vet has decided to allow the current sore to heal without suturing it again if it is reopened (which is an acceptable choice or even a better choice in many instances), it will help if you can keep her from licking at it all the time.

We have used local anesthetic sprays (like DermaCool TM) to try to make licking the area less fun -- no feedback from the skin and some anesthetizing of the tongue. It works for some dogs.

We have used very frequent applications of drying powders (we like Neopredef (Rx) powder for this) and that works for some dogs, too. We have used all sorts of drying powders. Desenex (TM) foot powder sometimes works pretty well for moisture between the toes and around the footpads. We have used this approach instead of mechanical drying, such as with a blow dryer, but that is mostly because I never thought about that approach.

Applying a mixture of Banamine (Rx) and Synotic (Rx) -- 3cc of Banamine in a bottle of Synotic-- works for some dogs.

We have used amitriptyline (Elavil Rx) in some dogs and have been thinking of trying clomipramine (Clomicalm Rx) but haven't done it yet. These are behavioral medications and some dogs seem to be able to leave a lick granuloma alone when they are on these medications.

There have been reports that dogs who were put on hydrocodone (Hycodan Rx) have recovered from lick granulomas. This might work because the hycodan is a narcotic and any endorphin effect that the licking is inducing would be less important to the dog with the narcotic in his system. We have tried this several times and haven't been too impressed with the results but some vets do report good success.

Using a sock to cover the wound is helpful and we have had several patients who would simply leave the wound alone as long as it was covered. This has worked for elbow hygromas and a number of foreleg wounds in our practice. I would keep trying this unless your setter is not tolerating the sock at all.

We have had several patients, especially those with allergies, who responded better to corticosteroid administration than to anything else for lick granulomas and wound chewing. The corticosteroids slow wound healing so there is a trade-off in using them. But they are an option when nothing else is working well.

Obviously, when there are so many approaches to a problem it is likely that none of them work well -- and that is definitely the case in treating lick granulomas. It is OK to combine several approaches (to use behavioral and topical medications, for instance).

I wish I had better advice but I think that you are likely to have problems with a lick granuloma forming at the wound site and that you will probably have to sort through several of these approaches to the problem to find the solution that is right for your setter. He sounds like he is going to make this challenging.

Mike Richards, DVM 5/13/1999