VetInfo Digest February 2002
Shampoos and Conditioners
Pet Health Insurance
This month's note:
I forgot to mention a very important aspect of the physical examination last month. We try to weigh every patient, every time they come into our office. Weight gain and weight loss can both be significant clues for illness. When a patient is losing weight and the client is not making an effort to cause the weight loss it is very likely that a disease process is causing the weight loss. In older cats weight loss may accompany diabetes, hyperthyroidism, kidney failure or liver disease. In older dogs diabetes, liver disease and cancer are probably the most likely causes of unexplained weight loss. While there are other symptoms associated with all of these diseases it is often the weight loss that tips us off. Weight gain can occur with the use of certain medications, such as corticosteroids. It can be the result of hypothyroidism or hyperadrenocorticism (Cushing's disease) in dogs. Fluid accumulation from heart or liver disease can lead to increased weight and a bloated appearance. Often, weight gain is just an indication that the pet is taking in too many calories for the amount of exercise it is getting, though. The excess weight contributes to arthritis formation and increases the incidence of diabetes, respiratory problems, heart disease (not as significantly as in humans) and other disorders. Keeping track of your pet's weight is important and should be part of nearly every examination.
Bathing and Grooming Pets
Veterinarians do not get a lot of information about bathing and grooming pets during their schooling. This is probably partially due to an overall tendency for veterinary schools to ignore very basic health maintenance and partially due to a lack of scientifically validated information concerning the benefits or risks associated with various bathing and grooming practices. There are also a huge number of shampoos and conditioners on the market and it would be a major undertaking to try to evaluate the risks and benefits of all of them. Veterinary clients frequently ask questions about bathing and grooming, though. Consequently, a lot of mythical information gets passed on from veterinarians to clients and sometimes from clients back to veterinarians.
The first question that many dog owners think to ask is "how often should I bathe my dog?" I have never seen a study that really looked at bathing frequency and related it to skin disease, general skin condition or overall health of pets who did not have preexisting skin disease. However, I think that it is possible to answer this question after collecting a little information from the pet owner. My first question is usually "how frequently can you bathe your pet?" If the answer is "daily", that tells me one thing. If the answer is "once a year," that tells me another thing. Most people answer this question, "I guess I could do it about once a month, if I had to.". For the last two groups, my answer is easy to come to. I tell them it is OK to bathe their pet as often as they can. For the client who answers "daily," or "every other day," I have to go into a lot more detail about the benefits and risks of bathing pets.
Cat owners are generally less concerned about bathing, probably because cats do a lot of grooming on their own. When bathing is necessary for a cat it helps a lot to put a window screen in the tub, supported securely at one end by a block of wood or something else that gives it a slight upward angle from the tub floor. Placing the cat on the screen allows it to dig its claws into the screen, which seems to make many cats feel secure enough to take the bathing without too much complaint. Surprisingly, I think that many cats do benefit from bathing and I recommend that cat owners try to bathe their cats when they have dry skin evidenced by dander formation, when obesity prevents proper grooming of the rear end of the cat's body and when they have a strong tendency to form mats in the hair coat. More cats accept bathing readily than most people would guess. It is still wise to be prepared for your cat to resist and to avoid being bitten or scratched if that occurs. Start slowly with a warm water rinse. If the process is a total disaster at that point, you won't have to catch the cat to rinse off the shampoo you have applied. If that works well, you will probably be able to bathe your cat successfully.
I have had several clients ask me why dogs and cats seem to need to be bathed less often than people feel the need to bathe. One reason that comes to mind pretty quickly is that dogs and cats don't sweat (maybe a little from their foot pads). Without sweating, the need for bathing is reduced. Cats groom themselves, further reducing the need for bathing. Most veterinarians assume that normal cats don't need to have baths at all and as far as I can tell this is probably true. Very few dogs make it through their whole life without needing a bath at least occasionally. This does set an easy minimum standard, though. It probably does no harm if cats are not bathed at all and dogs are only bathed when they roll in something they shouldn't or come home covered with swamp mud. Bathing more frequently than this is certainly an option, just not an essential, unless there are medical problems involving the skin.
There are a number of pet and human shampoos. There are also a number of substances that aren't really shampoos that people use to wash their pets. I think that I can say with near certainty that most veterinary dermatologists abhor the use of Dawn (tm) dish detergent on pets. Clients like Dawn and other dishwashing detergents because they kills fleas fairly quickly, but they also remove skin oils about as well as they cut the grease from dirty pots and pans, which is bad for skin health. Johnson's Baby Shampoo (tm) and similar products are also generally disliked by veterinary dermatologists. These products have a pretty strong detergent action and are also suspected of removing too much of the skin's oil if used frequently.
For a long time veterinary dermatologists and much of the veterinary literature have suggested that there is enough difference in the skin and hair pH of humans and dogs that it was best not to use human shampoos. Dogs and cats have traditionally been thought to have skin pH in the range of 7.0 to 7.2 and hair pH slightly lower than this, while humans were thought to have skin pH in the 5.5 to 6.5 range and hair pH also just a little lower. More recent work suggests that there is a wide range in the skin pH in dogs and that it may be somewhat breed dependent, with the range appearing to vary somewhere between 5.5 and 7.8 in dogs. If it is important to match shampoo pH with the skin or hair pH, this would seem to indicate that there is a much wider range of possibilities, since "pH balanced" shampoos for humans would be in the lower range and pH balanced shampoos for dogs traditionally in the higher range. Most companies don't tell you the pH of their shampoos, even in their more detailed advertisements and dispensing literature. Since there isn't a standard definition for this term and since it is probably safe to apply products that are within a range of plus or minus 1 to 2 pH units of normal, this is probably not an important issue.
Personally, I think that there isn't a significant difference between pet shampoos and human shampoos, in general. I do think that there are low quality and high quality shampoos and that there is a lot of variation in which shampoos are best for an individual pet. Shampoos are designed with lots of optional characteristics. Some are meant to control "flyaway hair" and some to give more body to the hair or to have other special characteristics. If you find a shampoo that makes your pet's hair coat seem nicer, whether it is a human shampoo or a pet one, the odds are that it is safe to use without worrying about causing major damage. There are shampoos with only natural ingredients, shampoos with only plant based ingredients and many other formulations that fit specific needs of either clients or pets.
We do see pets who develop skin problems from shampoos, especially minor itchiness or dry skin. If you see these problems after bathing then switching shampoos may be helpful. Try to look at the ingredients when choosing a new product. Even minor changes in ingredients can be enough to stop irritation in some pets, such as switching from a shampoo containing ammonium lauryl sulfate to one containing sodium lauryl sulfate, or from one with sodium lauryl sulfate to one with sodium laureth sulfate. Changing categories of shampoos entirely, such as using a "natural" shampoo without these chemicals is another option. With just a few rare exceptions, pets being bathed more than once a week should have a moisturizing conditioner applied after bathing. Shampoos that claim to moisturize are not sufficient when bathing this frequently.
I feel the same way about conditioners as I do shampoos. If a human conditioner seems to be working well for your pet, it is almost certainly safe to use and it is probably similar to many of the pet conditioners. When bathing pets frequently a moisturizing conditioner should be used after bathing unless your vet tells you otherwise. I really do not know of a "best" shampoo or "best" conditioner for general use. I do think that most of my clients have found a shampoo they like for general use within the first two or three tries, though.
Therapeutic shampoos contain specific ingredients that help with skin disorders. Veterinarians tend to be much more familiar with the effects of therapeutic shampoos, although there are still a lot of possible choices even among this group. There are several basic classes of therapeutic shampoos and some ingredients have beneficial effects in more than one category. Shampoos may be antibacterial, antiseborrheic (control skin oils and greasiness), antipruritic (control itchiness) or antifungal. These categories are pretty much self-explanatory, but there are wide variations among the products that fit into these categories. Sulfur shampoos have mild effects in all categories but work better as an antiseborrheic than as antifungal or antibacterial agents. Therapeutic shampoos are generally stocked at veterinary offices and dispensed when specific problems are present.
Bacterial skin infections are common in dogs, especially as a secondary problem when allergies or seborrhea are present. Antibacterial shampoos are usually used to aid in control of skin infections and only occasionally can be used as the sole therapy. They do help a great deal in some patients, though.
Antibacterial shampoos that work well generally contain either benzoyl peroxide, chlorhexidine, ethyl lactate, or closely related medications. We prefer benzoyl peroxide shampoos at the present time for most bacterial skin infections. If there is a mixed bacterial and yeast infection we usually use chlorhexidine shampoos, though. We find that just placing a microscope slide against the skin and then examining it under the microscope will often help us to identify whether a skin condition is bacterial, mixed or yeast (one form of fungal infection). Benzoyl peroxide shampoos can be irritating and do dry the skin some. Rinsing them off very well after ten to fifteen minutes and using a moisturizing conditioner helps a great deal. Benzoyl peroxide shampoos are not highly stable and should be purchased from a well known source because this makes them difficult to manufacture. Ethyl lactate shampoo (Etiderm tm) is less irritating and less drying, so it is a good substitute for dogs with sensitive skin or for use during the winter months when the skin is more prone to dryness. Povidone iodine (Betadine Rx) has been used as an antibacterial shampoo but it is has a very short duration of effect and is probably more suited for use as a pre surgical disinfectant, which is its most common use in veterinary medicine.
Seborrhea is the abnormal accumulation of excessive skin cells and sometimes skin oils on the skin surface. This is very common in some breeds, most notably springer spaniels and cocker spaniels. It can occur in any breed as a secondary problem, though. Seborrhea is probably the leading cause of really smelly dogs with greasy or oily skin. Depending on the severity of the seborrhea it may be necessary to bathe the dog from as frequently as once daily to as infrequently as once a month or so. Again, it is helpful to use moisturizing conditioners after the use of antiseborrheic shampoos when it is possible to do this. This is the one skin condition for which shampoo therapy is actually a mainstay of treatment, not a secondary aid.
Antiseborrheic shampoos may contain sulfur in some form, salicylates, or coal tar. Sulfur shampoos and salicylates seem to be safe for both dogs and cats, except for selenium sulfite, which should not be used in cats due to the potential for selenium toxicity. These ingredients are better for pets with dry seborrhea or slight to moderate greasiness. Coal tar shampoos work better for really greasy skin conditions. Coal tars should be used as infrequently as possible in dogs and should not be used in cats at all, due to potential poisoning from phenols in the tar in cats.
We don't have a strong preference between sulfur and salicylate shampoos and we often find that the benzoyl peroxide shampoos we are using for the skin infections will also control seborrhea well enough that we can get by with it alone. We use tar shampoos very infrequently. There are some cocker spaniels that seem to require tar, or tar and sulfur shampoos, though. When tar is necessary it usually takes at least a 2% to 3% solution to make a difference. Mal-Acetic Wipes (tm, Dermapet) can be helpful for seborrhea that is patchy and are good for use on cats for seborrheic conditions when bathing isn't an option. We have noticed that there a few pets with mild seborrhea and bacterial skin infections who seem to respond to Etiderm shampoo, even though it isn't really known for its antiseborrheic qualities.
It can be helpful when treating seborrheic pets if a good quality non-medicated shampoo is used first, rinsed well and then the therapeutic shampoo is applied. When this is the case, using an soothing shampoo, such as one with oatmeal or aloe vera, can make your pet more comfortable. It is really important to leave the antiseborrheic shampoo on the pet for the recommended time period, generally at least ten minutes. Rinsing very well reduces skin irritation after use of these shampoos, as well.
Antifungal shampoos usually contain chlorhexidine, miconazole or ketoconazole. When we feel the need for chlorhexidine shampoos we usually use more concentrated shampoos containing 4% chlorhexidine. We use these for Malassezia yeast infections. Combination shampoos containing miconazole and chlorhexidine are available and it is possible to use lower levels of chlorhexidine when this combination is used. I have not used Nizoral (tm) or the veterinary (or generic) ketoconazole shampoos enough to have a good feeling for how well they work but I do know practitioners that like them a lot for yeast infections. Shampooing does not work well to control ringworm in dogs and cats. This has been borne out in several studies over the last few years. It is better to use systemic oral therapy to control ringworm, even though miconazole apparently does work against the ringworm fungi in humans when used topically.
Antipruritic (control itching) shampoos and conditioners may contain corticosteroids, pramoxine (a local anesthetic), aloe vera or oatmeal. Even though shampoos are available, I think all of these products actually work better as conditioners and all are available in this form, as well. We have not had much luck using pramoxine but I know a couple of dermatologists that like these products and feel they are successful enough to justify trying them. We see some response to Resicort (tm), a conditioner containing hydrocortisone and we stock this product for that reason. There is not much absorption of hydrocortisone through the skin in dogs so it is definitely worth trying this conditioner to reduce the overall dependence on systemic (oral or injectable) cortisones when long term use is necessary for dogs with allergies or other conditions that must be controlled rather than cured. Oatmeal shampoos and oatmeal conditioners seem to reduce itchiness for 24 to 48 hours but rarely control it totally. I use Relief (tm), an oatmeal conditioner, for my own dogs when itching is a problem. It seems to work pretty well for my dog who has atopy.
Moisturizing shampoos don't work very well. Moisturizing conditioners tend to be much better. Therefore, it is a good idea when a pet is bathed to consider the use of a moisturizing conditioner, or a therapeutic and moisturizing conditioner, if necessary. When the skin is still wet the application of a moisturizing conditioner traps the moisture and allows the skin to absorb it. Again, I personally think it is OK to use human conditioners, but there are some nice ones made for pets that work well, such as Relief Conditioner (tm) or Humilac (tm). Medicated conditioners are sometimes more effective than medicated shampoos, as the ingredients may have longer contact with the skin, so if your vet prefers a medicated conditioner there may be good reason for that. Some conditioners have patented methods of extending the action of their products. These include Novosomes (tm) and Spherulites (tm), which do appear to work and may be helpful, especially when bathing frequently is difficult.
The companies that seem to make the best therapeutic shampoos for veterinary use are Virbac (tm), Evsco (tm), Dermapet (tm) and DVM Pharmaceuticals (tm). Most veterinarians stock at least one of these brands.
This link is helpful in researching medications, including shampoos and conditioners, for pets:
http://www.hiproanimalhealth.com/catalog/usa/ . This does not appear to be a public link on this web site, so it may disappear at any time. I am not aware of any other accessible source for the Compendium of Veterinary Products (c) information online that does not require a membership fee or professional affiliation to access.
Quick Comparison for Therapeutic Shampoo Ingredients: Ingredient Antibacterial Antifungal Anti-itch Antiseborrheic Notes aloe vera Y (weak) Y (weak) Y N   benzoyl peroxide Y N Y(weak) Y (weak)   chlorhexidine Y Y N N   ethyl lactate Y N N N   miconazole N Y N N   povidone-
Y Y N N   pramoxine N N Y N   oatmeal N N Y N   salicylic acid Y N Y Y   selenium sulfide N Y N Y Not for cats sulfur Y (weak) Y(weak) Y Y   tar (coal tar) N N N Y (strong) No cats
Veterinary costs are rising dramatically as people seek more and more sophisticated care for their pets. Magnetic resonance imaging, computerized tomography, ultrasonagraphy and other forms of advanced diagnostic care were not even options for most pets until the late 1980s. Kidney transplants, open heart surgery and brain surgery were done solely in research situations until recently. These types of advanced diagnostic and surgical procedures push the envelope for financial commitment to a pet. Even more generalized care has become increasingly sophisticated and many pet owners now opt for a higher level of care for their pets than was standard even a decade ago. When I started in practice in 1979 it was often hard to get a cat owner to do routine care, much less sophisticated diagnostic procedures. Now feline only practices are common and it is not unusual for cat owners to spend more than a thousand dollars for radioactive iodine therapy or thousands of dollars on a kidney transplant. This type of care has prompted many pet owners and veterinarians to reevaluate the need for pet health insurance.
Pet insurance has been available in the United States for approximately 22 years, but it really has not caught on in a big way here. A larger percentage of pets are insured in England and Sweden seems to have the largest population of insured pets.
Percentages of dogs covered by pet insurance:
U.S. < 1%
Great Britain 10 to 14%
The exact definition of insurance can be confusing. There are organizations that imply they provide insurance that really are just member discount programs. These are usually easy to spot, because they require you to find a veterinarian who provides services to members and the discount is taken off the bill right at the veterinary office. Preferred provider organizations (PPOs) and health maintenance organizations (HMOs) or health maintenance agreements with an individual veterinary practice come closer to being actual insurance. At the present time I am not aware of a large representative of either of these types of services that exists in the U.S. The BluePaws (tm) insurance plan was a PPO but it recently suspended operations. Indemnity insurance is the only currently available option in the United States and Veterinary Pet Insurance (tm, VPI) and Pet Care (tm) (Pethealth in Canada) are the only companies providing this service. VIP is the only one providing it in all states at the current time, while Pet Care provides coverage in 35 states currently. Therefore, much of the information in this article is based on correspondence with Kent Kruse, D.V.M., who is the Chief Operating Officer for VPI.
It is helpful to understand the types of insurance that may be offered and to see the advantages and disadvantages of each, as it is certain that all of the above options will become available again at some time in the future. It is also important to make a decision about the need for pet insurance as early as possible in your pet's life, as preexisting conditions are usually excluded from coverage and obtaining coverage prior to the development of health problems is obviously preferable for pet owners who do intend to pursue advanced care for their pets.
Preferred provider organizations recruit veterinarians to participate in a plan that provides lower cost treatment for pets who are treated within the network of "preferred providers". There can be an insurance component or the organization may just offer a discounted rate for services. This type of organization does exist in the United States in the discounted price form, an example being Pet Assure (tm) <www.petassure.com >. At this time, with BluePaws insurance having suspended operations, actual insurance based on this concept is not available, to the best of my knowledge.
The biggest flaw in the preferred provider scenario for the pet owner is the restriction requiring treatment through veterinarians who are preferred providers. This limits the pet owner's choice of veterinarians. In human medicine this seems to cause the most controversy with policyholders since it often seems desirable to seek help from a physician who is not a member of the group. This is especially difficult in emergency situations. From the veterinarian's standpoint this type of insurance makes almost no sense from a long term view. Veterinarians negotiate away part of their profits, which are historically low compared to other health professionals, in exchange for an increase in volume of pets treated. It is hard to provide excellent service at a lower profit margin, especially when it entails seeing more patients just to break even and greatly increased numbers to see an actual profit. It didn't take too long in human medicine to see that compromises in health care have to be made to maintain profitability when the PPO concept becomes prevalent in an area. I am hopeful that veterinarians will avoid this scenario and I would encourage pet owners to avoid it, as well. It may be attractive in the short term, but seeing how a person's medical care often gets relegated to decisions made solely on profitability should be enough warning to make most people avoid this type of insurance for veterinary medicine.
Health maintenance contracts are most commonly available through individual veterinarians. I am not aware of an organization offering true health maintenance insurance in the U.S. However, some individual veterinary practices offer health maintenance contracts and some of them come very close to providing comprehensive coverage, at least for procedures that the practice performs. It is more common for veterinary practices to cover routine care in prepackaged "health maintenance" agreements than for them to cover all veterinary services that might occur, however. If you opt for an individual practice's health maintenance agreement make sure that you know what is covered. I think that the health plans that cover routine care seem to work pretty well and often are a benefit to the pet, as they make it more likely that comprehensive care is offered. These types of policies can be bad in the long term for a veterinary hospital, if they are not well managed, though. Most services in veterinary hospitals have less than a 25 to 30% profit margin and discounts in this range may be difficult for a hospital to absorb over time. If you are paying for comprehensive care it may be up to you to be sure that you actually get it.
Indemnity insurance is the concept behind the most widely available pet insurance in the United States. This insurance is the type that is sold by Veterinary Pet Insurance (tm) <www.petinsurance.com> and Pet Care < www.rdpetinsurance.com >. Indemnity insurance is actually a form of property insurance, similar to car insurance or boat insurance. It assumes that pets are property, which is the legal view of pets in the U.S. at this time. The pet owner pays an insurance premium which "indemnifies" them against a certain amount of risk. If the pet becomes ill, they pay the per-incident deductible and the percentage of the bill that the contract calls for and the insurance company pays the balance.
When using Veterinary Pet Insurance's plans, the usual arrangement is for the veterinary client to pay the veterinarian and then to be reimbursed by VPI after the paperwork is filed. Some veterinary hospitals may accept direct payment by the insurance company. Be sure to ask how your veterinary practice handles insurance based transactions.
Indemnity insurance offers several advantages for the pet owner and the veterinarian. From the pet owner's perspective this type of coverage offers the ability to seek veterinary care from any veterinarian, including any veterinary specialist, without worrying about finding someone who participates in the health care company's plan. For the veterinary practice, this insurance does not require discounting of fees or make it necessary to accept a relationship with a client based on their membership in a club or preferred provider organization. Fees are not set by the insurance company and no discounting of fees is necessary. This type of insurance has worked well for dentists, allowing the profession to maintain good customer relations and to provide more advanced services over time.
There are some drawbacks to veterinary insurance that have to be considered. In breeds with a high rate of genetically linked disease or congenital predisposition to disease, it is very important to find out what conditions are excluded. Hip replacement may not be covered in breeds that are very prone to hip dysplasia, for instance.
It is best to specifically ask what congenital or hereditary disorders are excluded specifically for the breed of puppy that you own. It may be even better to call and ask about exclusions for each breed that you are considering seriously when making decisions about purchasing a puppy.
Perhaps the biggest stumbling block for veterinary clients considering pet health insurance is ownership of more than one pet. When a client owns one pet and clearly wishes to provide the best possible care, insurance is an attractive option. When a client owns multiple pets, the cost of insurance becomes more of an obstacle. Veterinary Pet Insurance offers discounts of 5% to 10% (over four pets) for multiple pet owners, but this is not enough of a discount to make it really easy to insure multiple pets. On the other hand, if pet insurance is to be reasonably priced for one pet there can't be so much profit that giving bigger discounts than this make sense. They base their fees on the probability of a single pet having health problems during its lifetime. If you own multiple pets, that doesn't make it less likely that any one pet will require extensive care. It just isn't possible for an insurance company to discount its fees a great deal, unless they aren't providing realistic fees to begin with.
For many years the consumer advocate groups in the U.S. tended to be against purchasing pet health insurance as a way to cushion the financial consequences of poor health in a pet. Their logic was quite simple. Veterinary clients have the right to authorize euthanasia, which means that no one ever has to go into debt over a pet's medical care involuntarily. Viewed from this perspective alone, it is hard to justify pet insurance. As pets have become a more important part of the family unit over the last few years, this attitude has softened somewhat, though. At this time, financial advisors seem to be more inclined to say that pet insurance makes sense for pet owners who know that they will spend whatever it takes to make their pets well. I think that they are thinking of one or two pet households, for the most part. For folks in this category, and every veterinary practice has some, pet health insurance may avert a financial crisis. For people with multiple pets who have good self discipline, it may make more sense to set up a savings account specifically for emergency and extensive care costs for pets. By doing this and by providing good quality routine care it may be possible to effectively self insure and cover most problems. This is a good theory only for people who can manage to save for emergencies. If you can't do this, insurance may make sense even if you have five to ten pets.
Many veterinarians have traditionally opposed pet health insurance. Some veterinarians fear that if a client is dissatisfied with the insurance company in any way, they will blame the veterinarian for making the recommendation to buy insurance. This is inevitably going to happen once in a while. In some cases the client will feel that the veterinarian should make up for any shortcomings, which is usually an unrealistic expectation. Another reason veterinarians may oppose insurance is that they have watched the medical profession lose control of patient care and even lose a great deal of their income potential, as insurance companies have increasingly dictated standards of care. This problem is not likely to occur with indemnity insurance since the contract for care is between the client and the insurance company directly.
There is another reason that veterinarians are reluctant to recommend insurance. Most veterinarians have dealt with numerous clients who start out taking really good care of their pets but who gradually over time give up the effort. I think that most veterinarians believe that this occurs because the pet owner decided that good quality preventative care was too expensive. It is likely that this group might also apply the same logic to pet insurance, except that the pet might not even get the routine care in the beginning due to the insurance cost. As more clients purchase pet insurance it will be possible to see if this sort of trend develops and if it is offset by people who allow better care for illnesses and injuries since they are covered by the insurance. I believe that will be the case. Hopefully, as veterinary insurance catches on and becomes more common, veterinarians will feel more comfortable recommending it.
The VetInfo Digest is published by TierCom, Inc., P.O. Box 476, Cobbs Creek, VA 23035. The opinions expressed in this newsletter are those of Michael Richards, DVM., author. Please send e-mail for Dr. Richards to email@example.com
Copyright 2002, TierCom, Inc.
This page was last edited 06/15/04
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