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Welcome to the official podcast of the World Small Animal Veterinary Association, where we bring you conversations with leading veterinary experts from around the globe. Each season spotlights one WSAVA committee, sharing their knowledge, research, and insights through short, accessible interviews.
Every fortnight, we speak with two experts on a shared theme, offering concise, engaging discussions designed to spark curiosity and guide you toward WSAVA’s extensive library of educational resources, webinars, and events. Hosted by WSAVA President Jim Berry, the podcast delivers focused conversations that connect you with the latest thinking in small animal medicine worldwide.
You can find more educational resources from WSAVA here: https://wsava.org/education/
Jim Berry: Welcome to the WSAVA podcast. Today we look at the link between nutrition and dermatology, focusing on the microbiome and its impact on atopy. Consider this, how often is a skin condition actually a reflection of what is happening in the gut? Our interviewer, Cat Henstridge, speaks first with Galia Sheinberg and later with Meagan Painter.
Jim Berry: Let's listen in.
Cat Henstridge: Galia, thank you so much for joining us today on the WSAVA Nutrition Podcast. So we are gonna talk today about the impact of nutrition on skin disease because I'm a first opinion clinician in small animal practise and I see an awful lot of skin disease and allergic dogs, atopic dogs, but just generally sensitive dogs in my practice, I think the numbers are going up and often we are using medications to soothe these dogs, but nutrition can play a big role in supporting sensitive skin and sensitive dogs. So how important do you find it in your clinical practice?
Galia Sheinberg: Nutrition is very important for skin. So I think it's important to differentiate the part of nutrition being important for skin and coat, and nutrition driving all skin disease, which I think it's a misconception that a lot of clinicians might have and a lot of our clients might have, because a lot of the allergic skin disease is not related to food, and it's not driven by food. When you have a dog that has skin disease, the first thing that most people think about is the food causing the problem? Allergic skin disease is huge as a clinician. Only 30% of allergic dogs will have allergies driven by food, and the rest of them are
going to be environmental.
Galia Sheinberg: So the second part of the question is, can we help dogs that have allergic skin disease with supplements or with diet? And the answer is yes, but those nutrients can help in a smaller way that I think that it's perceived. I don't think that we can cure the allergic skin disease only with supplements and diet.
Cat Henstridge: Most clients that come to me with an itchy dog have tried to change the food 'cause we can control what goes in dog's mouths and if we have got a dog who's got a genuine food allergy and nothing else, then yes, there's loads of diets we can reach for. But I do think that's really interesting that in your practise you're now seeing dogs having skin disease caused by nutritional deficiencies. So when it comes to supporting those sensitive dogs through nutrition, not necessarily curing obviously, but supporting, what are the key nutrients for you that you are looking for in diets?
Galia Sheinberg: So if we go to science-based evidence, the strongest support is for the Omega supplementation where there are more studies.
Galia Sheinberg: So I think that the first thing that clients will reach for is fatty acid or omega supplementation. So there is a stronger evidence based on using those products. But then the question of what type of product you use comes to play. Because there's a lot of products that are not controlled in the way of what they contain, how much Omega, if they have contamination or other ingredients that are not listed on the label.
Galia Sheinberg: And there's so much things that are available directly to clients through direct purchase. So I think that thinking about Omega, using high quality scientific proven products is very important. I think that there's like a general idea of using an EPA and DHA products that go between 50 to 220 milligrammes per kilo would be like general recommendation and a ratio that is about 10 to 1 between Omega-6 and Omega-3 fatty acids.
Cat Henstridge: There's an awful lot of smaller companies creating these things now. How do you prefer your clients with skin disease to get the omegas? Are you recommending that they supplement or are you using diets with them already in there?
Galia Sheinberg: I'm not a huge supplement user, and I think now I'm fighting a current because our clients are coming in already using a lot of supplements, so I usually try to scale them back depending on what we're doing.
Galia Sheinberg: My personal opinion, I prefer to use derm diets, so we're talking about vitamin D and zinc and vitamin A, which are very important for skin function. Those are important ingredients that derm diets might include in an adequate or supplemented amount. If I can make things easier using a commercial derm focused diet, I would always prefer to do that. If my client prefers to use a supplement, then I will add it and in some cases where I see a clear benefit of using a supplement, then I will recommend it, but it's very individualised and that's the way I generally try to approach this.
Cat Henstridge: Yeah, I think that point about how much clients are often already doing is really true, and something that I often have to remember in my practice is that it's all well and good us giving clients a list of medicines to give and supplements and jobs to do, and feeling really smug that we're managing these cases really well, but we're actually giving them an enormous amount of responsibility. So yeah, to be able to take that off the table and say, everything you need for skin health is in this particular food, and therefore you don't have to try to get extra tablets into them or spend more money on supplements, I think is a really valid point. And you mentioned omega threes, you mentioned some vitamins. What about the macronutrients? Is there anything that you particularly look for in terms of carbohydrates, fats or protein, or is there anything that you avoid on that wider scale?
Galia Sheinberg: In terms of macronutrients, it's important to emphasise that most commercial diets are complete and balanced in terms of nutrition. Home prepared diets, if they're balanced by a certified nutritionist, they're gonna be well done. But the next question is if they're gonna be well prepared because it's hard to prepare a diet at home and do it well.
Galia Sheinberg: Normally these diets have eight or nine ingredients and they're difficult to prepare. If we are talking home prepared or commercial, I think we are going to go very different directions. Generally, I believe that macro nutrients in commercial diets are complete and balanced, and it's going to be rare for a reputable company to do a diet that is deficient in nutrients. So I'm generally not worried about macronutrients in most of my patients, but patients come in with diets containing only protein, no carbs, no additional fats, no vitamins, no minerals. So there's that area where clients are using diets that are not complete and balanced, and that will create disease.
Galia Sheinberg: So it's important to keep that in mind. Where are the recommendations coming from?
Cat Henstridge: As long as your clients are feeding a complete and balanced, ideally commercially prepared diets, you're not too worried if it's got grains in or not. So you're not too worried if it's based on red meat or white fish, as long as it's complete and balanced.
Cat Henstridge: But your point about now seeing in your practice nutritional deficiencies created by food that previously were unheard of because we had managed to move to complete and balanced diets. I'd love you to tell us about that. What are you seeing? What are those clinical signs? It's entirely possible that vets like me are seeing this, but maybe not realising.
Galia Sheinberg: I've seen, personally seen, dogs that have zinc deficiency, that it's not driven by a breed specific disease such as the husky disease that we see. We have seen dogs that are, have zinc deficient diets and are showing signs of seborrhea, dogs that have vitamin A deficiency with very low vitamin diets. Dogs that have fatty acid deficiency because they're being fed only protein diets that are not supplemented.
Galia Sheinberg: When we're taking a clinical history, we're careful to talk about diets. If the dog is on a commercial, complete and balanced diet, our focus might shift to food allergies. But when they're using diets that they buy from a source that is a locally prepared fresh food, then we go into more questions. If they know how they're balancing the diet, if they know what nutrients the diet have, if they have a label for the food that they're feeding, and then we might want to take a look at that.
Galia Sheinberg: I do have to be very clear, i'm a dermatologist, i'm not a nutritionist, so there's limitations to my knowledge regarding nutrition. But we want to make sure that the diets are complete and well balanced, but there's a lot of diets being prepared by unknown people, unknown companies. I think that those diets by what we have seen published when they're analysed, published home prepared diets available to clients have been analysed, they are missing key nutrients and they are missing minerals and they are missing essential fatty acids. Those diets seem to me to be more prone to create some skin disease and the skin disease might not be overly obvious. It could be mild seborrhea or dry skin, or maybe the coat is not as luscious and beautiful as the owner would like it to be.
Galia Sheinberg: And it's funny because, dermatology, we focus now everybody thinks about allergic skin disease, but some owners come in because the coat of the dog is not as it used to be or what they're expecting. The cosmetic part of dermatology can also be important and we shouldn't undermine that part. The cosmetic aspect can be important for our clients, so good nutrition will reflect on healthy skin and beautiful coat, and there's nothing wrong with focusing on that.
Cat Henstridge: You were talking about nutritional deficiencies created by diet. Is there any testing we can do to look for the deficiencies or is it just about the clinical signs and then shifting the food?
Galia Sheinberg: Generally it's clinical signs. We're seeing overt skin disease. We can do biopsies that will support the diagnosis. Let's say a zinc deficiency will have certain histopathology things that we can look for. Vitamin A deficiency, which is mostly also genetic and metabolically driven, not food driven, will show certain things in a biopsy.
Galia Sheinberg: We normally don't do specific testing. We look for clinical signs. We look at the diet and we'll try to find deficiencies in the diet. There's more obscure things like protein deficiency, where you will see thiamin deficiency and changes in black coats that turn orange. But those are things that we rarely see nowadays.
Galia Sheinberg: The clinician has to have a open mind and look at the diet, and look at the clinical symptoms and have in their radar the possibility of a weird diet causing skin disease. And again, it's not something that you will see very commonly because nutrition is resilient and dogs will take a long time to get disease from a poor diet.
Galia Sheinberg: I remember when I started practising , we would see those puppies being supplemented calcium and have bone disease. I'm talking way back when I do general practice medicine, but it still happens and it has to be on our radar because of the new tendencies and owners following recommendations from people who are influencers and have a very strong opinion or a voice, but not necessarily the knowledge, the science behind the recommendation.
Cat Henstridge: Yeah, that's so interesting and the orange coated cats, I still see those, particularly in older cats, those dark coat, those black coats starting to go that brown colour, and it was only in the past few years, I've realised that that wasn't a normal ageing change and that was potentially nutritionally related.
Galia Sheinberg: Yeah, it can be related to kidney disease and things that we commonly see on older cats. There's other metabolic reasons for coat changes in older animals because the coat does change. Age does changes the coat, the consistency and the aspect of the coats. But if you think that there's something else, always looking at the diet as a source of a problem is very important.
Galia Sheinberg: And there's something else I would like to add. The probiotic world where a lot of our clients are coming in and saying, Hey, I know that my dog is on this medication because of the itch, but I heard or read that a probiotic can fix the problem, and this is something we are facing as clinicians every day, but let's go to the scientific evidence on probiotics.
Galia Sheinberg: It's a mixed bag. There's a couple of studies that support the use of some probiotics for some skin health issues, but the quality of the probiotic is very important, and most probiotic needs to be refrigerators to have a clinical value or the otherwise, they're more like prebiotics. A lot of my clients believe now that probiotics will fix every single disease, and they're using it for every single thing their dog has. So we have to address that, make them understand that if they're spending money on a probiotic or a supplement, that they have to put it in the balance because this comes from the same purse where they do have to use other therapeutic for their dogs. So have that conversation and see what they're doing, addition to your recommendations, and then look for the value in each single product that they're using and go into looking at the company that's providing those supplements or those probiotics and see if there's anything that's worth spending money there on. You will not get every single client to listen to you. They will listen to other recommendation, their friends and social media. Again, probiotics could have a potential value, there's not a lot of strong evidence published using probiotics for skin health. In the future, we might have more because there's research being done regarding the microbiome and probiotics, but there's a lot of misinformation and we're still very far from understanding the complete role of the microbiome and the probiotics on general health and skin health in particular.
Cat Henstridge: Yes, I completely agree. I think particularly when it comes to skin and allergies and sensitive skin, there is an awful lot of information and misinformation that our clients are receiving from lots of different sources that aren't the veterinary practice. And I can understand that because when you've got an animal who is itchy and sensitive, and you're watching them struggle, you do want to do everything you can. So just to wrap up from a nutritional standpoint for skin disease, what would be your brief top tips for vets in practice to advise their owners? What's that headline news that we should be giving them?
Galia Sheinberg: First of all, I would say that food is important for a healthy skin and coat, but it's not always a primary driver of skin disease. That's one of the beliefs we have to address when we're talking to clients. Second, make sure what type of diet our client is using on their pet that they're using something that is safe, complete and balanced, and it's not representing a new risk for our patient. Third, if there's specific health issues that we want to address using the diet, then to select an appropriate diet that will help that specific condition. Most commonly, that would be allergic disease when we're doing a diet trial to diagnose food allergies, and that's a very specific timeline and it's something that we should do and then finish and be able to have information based on the diagnostic diet and be very careful who you recommend that diet to. Other health issues related to diets could be supplemented or helped using additional ingredients or supplements. Mostly Omega-3 and 6 would be the main product to use.
Galia Sheinberg: I would generally recommend using it from a veterinary product company that is reputable and that does control on their ingredients, or just make sure that whatever they're using is safe and effective and not use many other supplements that are not necessary unless indicated by their health condition in particular.
Cat Henstridge: That is perfect. Thank you so much, Galia, for joining us on this podcast. I really appreciate your time and your knowledge. It's been fantastic, and I think our listeners really are gonna go away with some practical tips on how to help those clients and their itchy or sensitive pets.
Jim Berry: After Galia Sheinberg, Cat Henstridge is joined by Meagan Painter to discuss the practical impact of the microbiome on skin health.
Cat Henstridge: Megan, thank you so much for joining us on the WSAVA Nutrition Committee Podcast. I'm absolutely delighted to have you. What we're going to talk about today is the gut microbiome and its alleged impact on skin health and particularly atopic dermatitis in dogs, because I see this talked about a lot online, how if you can fix the guts, you can fix the skin.
Cat Henstridge: And so I'm really interested in speaking to an expert on the subject to see if those rumours are actually true. So just before we start, could you just briefly let us know about canine atopic dermatitis? How prevalent is it in our patients and why is it sometimes so challenging to manage?
Meagan Painter: We're all seeing allergy in our practices and canine atopic dermatitis is a very complex immunologic problem that has a genetic predisposition.
Meagan Painter: So dogs are born with atopic dermatitis tendencies, and then with time they start to show their symptoms. It is a diagnosis of exclusion where we have no perfect diagnostic test to help us in the clinic to make a diagnosis efficiently. It is variable in terms of its presentation. It's quite common in dogs in general and so atopic dermatitis has to be thought of as a complex problem. And when we think of the gut and when we're talking about the gut, and now we're into this conversation, what happens online is that the problem is being boiled down into something simple. Just fix the gut or just address the yeast. And what we know about atopic dermatitis is that it is not that simple.
Cat Henstridge: I can understand the owner's need to do something and to think that food might be an easy fix. Diet can support skin conditions with certain ingredients like our omega threes and picking less allergic proteins, or even choosing a hydrolysed diet. What I really wanted to focus on today was this concept of the microbiome of the guts having this influence on the health and potentially even the microbiome of the skin and this encouragement we're seeing of our clients to feed particular diets or particular probiotics in order for one to influence the other. Is there any evidence for that? What's your feeling? Do you use that in practice or not? Where do you go with this?
Meagan Painter: It's really only a 10 year discovery in veterinary medicine, that we've been having the very basics of these conversations. I can't say that there's no evidence to support us looking more at this. At this time, the evidence is very limited to say that probiotics in their current state help dogs with allergies.
Cat Henstridge: What's the principle behind it? Are we thinking that certain microbes produced byproducts that have a direct health impact on the skin, or a positive impact on the immune system itself? The gut biome feeds into the immune system. Do we have any evidence of other potential mode of action?
Meagan Painter: Some strains are correlated with more anti-inflammatory effects compared to other strains. The question is, if we give more of a certain strain, are we going to have more of that anti-inflammatory effect? And this is so hard to study in a vacuum. And so having three dogs that we enrol and say, we found that this strain was higher in this group of dogs and lower in this group of dogs, therefore it must mean we can intervene here, is really just the beginning of our understanding. I just don't think we're ready yet to start marketing these products or to be relaying to owners that this is the solution. With atopic dermatitis because it is a complex problem and because we have so many tools in our toolkit, there's two real issues that I like to talk about.
Meagan Painter: One is the fatigue of owners, not only financial fatigue, but caregiver burden of doing 27 things versus three things. Often owners come to me and feel like they have nothing left to give, you know, I can't possibly do more. They bring in bags of medicine, shampoos, sprays, food, and the probiotics and this chew and the dog still has a problem and doesn't even have a solid working diagnosis of what their root cause is.
Meagan Painter: So I think that it's important to really look at what exactly we're recommending in the clinic because we don't want to impact that caregiver burden more. I think we have to really be careful about the evidence. I talk about evidence-based medicine and at this time there just isn't evidence to recommend this.
Meagan Painter: I'm not saying that there won't be, and I think there probably will be useful information that comes of all of this work around the gut skin axis and how we can use this to help dogs with their inflammation, but we're just not at a point yet where that should be mainstream. We're in the driver's seat.
Meagan Painter: I think veterinarians feel like we're over here in the passenger seat and the supplement companies are driving, and we really need to feel confident reversing that and owning our position in canine healthcare to say, we are doctors and this is what we understand. Managing inflammation is important and other ways that we can do that is key, but are probiotics necessarily the way to do that at this time?
Meagan Painter: Hard to say.
Cat Henstridge: Inflammation in the skin is gonna have a knock on negative effect of the gut health because everything is connected and so if you're interested in a healthy gut, a healthy gut may well help the healthy skin, but we're on more solid ground if we go the other way. If the gut is healthy and the immune system there is healthy, you can see how that would have a positive impact on skin health. I think that's a brilliant way of framing that actually, of go the other way around because then you keep the owner on board, you get this skin healed through more conventional methods and more evidence-based methods, but hopefully having that positive effect. Do you see dogs in your clinic where owners have tried to use diet or probiotics or medication avoidance with this sort of focus on the more holistic, natural approach, and how successful is that?
Meagan Painter: I think that one thing I'll say is that the influence of diet and food on the GI tract in dogs is so variable and it is something I love to drill in to for all of my patients, having a working diagnosis of allergy is where you start. Is this even an allergic dog? It's yes or no, or am I unsure? And then from there, asking the question like this of what percentage of the problem is driven by food is a really nice way to put it. Because I think we've been, again, in this fixed mindset of sterile, infected, inflamed, not inflamed. These very black and white categories for managing a complex problem. And I don't think that serves us or our patients at all. And so when I think of what percentage of the problem is from food, the question that I wanna know is if I feed a diet that seems to be agreeable to the dog, where the stool is of good quality, the dog is not having GI signs, what impact does that have globally on the patient?
Meagan Painter: Am I able to reduce the amount of medication they're on? Are their clinical symptoms of allergy better? Are we in a place where this dog is at least somewhat better. Better, but not perfect is usually what I'll say. Or potentially their symptoms have resolved. And so I do think looking at the role that food plays in a diagnostic manner is something I love to teach vets how to do.
Meagan Painter: I had lectured with another dermatologist a couple years ago, and he believes that a hundred percent of atopic dogs have a food influence. I won't go that far, but most dogs or at least half of the dogs that I see are better but not perfect. Certainly 20 25% of the patients I see are as perfect as it's gonna get from dietary influence.
Meagan Painter: That's really fun because now you get to a point where you can treat a dog with a diet that is sustainable, something that the patient eats and likes and their stool is normal and they're not having symptoms of their allergy, and the owners are quite happy because now of course, you're treating the problem from the root cause and you're not masking it with medication.
Meagan Painter: But then we start to get into the better but not perfect and still need intervention. And in those categories, you wanna look at how you're treating the patient with medication and what their inflammation access really is. Where do they fall on the line and severity, and what do they really need when it comes to medical management?
Meagan Painter: Not all dogs are going to need everything. Not all dogs are gonna need prednisone and cyclosporine or something like a cytopoint, and so you have to look at that multimodal management for every patient.
Cat Henstridge: I think that's it in a nutshell, but I'm interested in what diets are you picking? Are you picking hydrolysed diets, skin support diets? What do you find most successful?
Meagan Painter: I use hydrolysed diets for my diagnostic diet trials. I use the term diagnostic diet trial now to really drive home the point that it's a diagnostic test. I find that the hydrolysed foods are going to reduce the issues with cross-contamination due to the fact that their prescription made products and they're going to have one ingredient per the manufacturer.
Meagan Painter: We don't have to worry about cross-contamination of external ingredients, certainly as much, if at all, hopefully.
Cat Henstridge: I wonder whether if we get them on a diet which calms everything down, that then shifts that biome population to a more healthy one, good gut bacteria feeding back into that positive impact on the immune system and it's less reactive overall.
Meagan Painter: I would bet there's no doubt of that. I think that, yes, when you start to see an improvement in stool quality and you start to see a reduction in other GI signs, borborygmi, nausea, vomiting, regurgitation, et cetera, then I think that you have to assume that there's less inflammation and therefore you would assume that there's a positive impact on the global microbiome.
Cat Henstridge: So just as a takeaway, if a veterinarian is faced with an owner saying, I've heard I should fix the gut to fix the skin, what would your strap line be for that scenario, for the vet?
Meagan Painter: You wanna just remember that the owner is another human being who's just out there doing their best. I think sometimes we want to feel like they're the enemy or they don't respect our credibility, but you're doing that too for your own healthcare and some degree to some problem you're trying to solve.
Meagan Painter: That's all they're doing is trying to solve problems. So I'd like to talk to people as if they're my friend or someone who I can relate to to say I've heard that too, and I get the marketing just as much. Here's the best information that I can give you, is that this is an area of interest and we are very interested in using different methods to help dogs with allergies.
Meagan Painter: Keep it basic, different methods to help dogs with allergies, medications, or different diets, different approaches to bathing and managing their skin sprays, mousses, et cetera. But one thing I want to be really clear about is that there is an industry that knows that you're frustrated and they're making a lot of money on that, and that's something that if you're feeling like you wanna purchase a supplement, I really want you to run that by me, because I can give you the rundown on what's really in that product or what's on the label, because not always is the marketing going to match what the product actually claims it can do. Just reach out to me, use me as a resource, because I know it's very confusing. That sometimes can help people. But really to just be honest that you're not just trying to push drugs, that you wanna help dogs with allergies in lots of different ways.
Meagan Painter: I think that's where it comes from, is people feel like if I go to the vet, they're just gonna give me antibiotics again and that might be true in your practise and you might want to check that and why are we doing that? What are we doing for managing these cases? And looking at it from an inflammation first perspective is one of the things that I teach to talk about how can I reduce inflammation in my patient before I then have to treat their infections, which are secondary to that. And so being on their side and saying, I understand, I focus on inflammation. I wanna manage that in a safe way. Help owners understand that you're on their side, you care about the dog that you want the dog's longevity and safety, et cetera, top of mind is important.
Cat Henstridge: I think that's a lovely message actually, to acknowledge what they're trying to do, and there are ways in which they can achieve that, but maybe not with the probiotic, but what goes in the dog's mouth we can use to support skin health, maybe not quite so direct way as is currently being claimed.
Meagan Painter: I think the one other thing that I think is really important to say is for the owner who has financial frustration, I think we have to be really direct and say, when you come in here and you're frustrated with the cost of care, the cost of rechecks, and you're using these supplements, I want to relay that you're wasting your money on this monthly product, and to be very upfront about this, there is no evidence that this product is going to help your dog other than the evidence provided by this internet-based company.
Meagan Painter: I don't care if you wanna spend $65 a month on these chews for your dog. But I want you to make that decision, whatever you do with your money is your choice, but I want you to realise that I'm not necessarily endorsing that as a product that could help, and I don't want that to get wrapped up into the caregiver burden, the financial burden of taking care of an allergic dog, because that is very real.
Meagan Painter: Allergic dogs have a lifelong condition that we're gonna be at for the long haul here and I'm all for trying new things, but I want to, I wanna really focus on what the evidence shows so that we don't waste precious resources.
Cat Henstridge: Yes, go with the evidence first and so currently, probiotics to manipulate a gut biome to therefore positively impacts on atopic dermatitis in dogs, the evidence just is not there yet. We should definitely be focusing on a more evidence-based approach for our patients and supporting owners to do the right thing and the best thing, but also in the most economical and sensible way. Thank you so much, Meagan. I really appreciate your insights on this.
Cat Henstridge: I think this is gonna be a really practical episode that vets are gonna be able to take back to clinical practise and put to really good use. So thank you so much. I really appreciate your insights on this.
Jim Berry: Thanks for joining us on the WSAVA podcast where we are transforming care, one episode at a time.
Jim Berry: We hope today's discussion was helpful, wherever you are in the world. You'll find further resources in the show notes and we look forward to sharing our next conversation with you soon.