Current Vet

In this episode, Dr. Lottie chats with Dr. Ashley Bourgeois to discuss everything about veterinary dermatology from itchy dogs, why allergy testing isn’t used as a definitive diagnostic test, how we can help ourselves to become more confident with dermatology and what Ashley can’t live without in the clinic. 

Ashley is a board certified veterinary dermatology with over a decade’s experience in treating pets’ skin complaints. She hosts ‘The Derm Vet’ podcast (go and listen for EVERYTHING on veterinary dermatology!), she runs her business which helps vets worldwide become more confident in treating skin conditions and she’s a seasoned speaker having done previous talks at VMX and many other conferences. Ashley is truly a wonderwoman and the best person to give insights into the derm world!

Where to find Ashley:

Find us on TikTok & Instagram: @veterinaryvista

Timeline:
00:00 Intro
01:14 Dermatology 101
09:24 Derm Workups
22:59 Common Derm Missteps
29:25 What are Allergies?
40:40 Setting Owner Expectations
44:52 Life Outside the Clinic
48:39 Getting into Derm
51:11 Final Questions
59:34 Outro

Current Vet is an educational podcast intended for veterinary students, veterinary professionals, and individuals with an interest in veterinary medicine.

All content provided in this podcast and its associated materials is for educational and informational purposes only. It is not intended as, and must not be considered a substitute for, professional veterinary advice, diagnosis, or treatment.

Any clinical cases discussed in this podcast are fictional, and are designed to reflect typical or likely clinical scenarios for educational purposes. They do not represent specific real-life cases, clients, or animals.

While every effort is made to ensure accuracy and alignment with current evidence at the time of publication, veterinary medicine is a rapidly evolving field, and recommendations may change over time.

Creators and Guests

Host
Dr. Lottie Wilkinson
Creator and host of the Current Vet podcast

What is Current Vet?

The podcast that makes veterinary medicine simple.

In each episode, Dr. Lottie breaks down clinical conditions, cases, and concepts across species, focusing on pathophysiology, decision-making, diagnostics, and what actually matters in practice. It’s the kind of context that makes your knowledge finally click.

Every month, we’ll also have honest conversations with guests about the incredible variety of veterinary medicine, what you can do with a vet degree and how to think bigger about your career.

Whether you’re cramming for exams or looking for a soundtrack for your dog walk, Current Vet will make veterinary medicine simple

Hello, hello, and welcome to a brand new episode of Current VET. If you're new here, this is the podcast that makes veterinary medicine simple. I'm your host, Dr. Lottie, and today we're talking about a topic that is central to veterinary medicine. It's definitely something I think a lot of GP clinicians can feel a little bit uncomfortable with, and that is dermatology.

So dermatology covers everything from simple infections to ectoparasites, autoimmune conditions, neoplasias. But for all of these different conditions, a lot of the clinical signs can be very similar, so making that diagnosis can be quite confusing. To help us untangle the topic, we have Dr. Ashley Bourgeois here with us.

Ashley is a board-certified veterinary dermatologist, and some of you may know her online as the DermVet. She's also the host of the DermVet podcast, so I'm very excited to chat to a seasoned host and also bust some dermatology myths for you all. So Ashley, welcome to Current VET.

Thank you so much for having me, and congrats on having another veterinary podcast out in the world.

Thank you. So in my experience, I think dermatology is one of those areas of vet med that people are a little bit scared of. Clinical signs can be really similar for a lot of different conditions, but the diagnostic process can be really drawn out, especially for things, you know, like a food trial or allergy testing.

And I think it's also one of those areas where owners may not think it's that significant of a problem. If their pets are just a bit itchy, they may not be fully committed to a full workup and the whole process that we as vets want to go through. So what are those things that vets should know about dermatology, the, the basics to make it a bit less scary?

Yeah, I mean, I think you hit on a lot of the really important points. A lot of these conditions can look very similar, right? They can be itchy, inflamed, lead to secondary infections. So a lot of times when I'm teaching veterinarians I say, "Take a step back, you know, start with the basics." Uh, some people when they come to see us are ready to completely jump in.

The most important thing to me as a clinician when that pet comes to see me is comfort. So yes, I wanna jump into why it's happening, in diet trials, and allergy testing, and all sorts of things, but the most important thing in that moment of time if they're coming to see me and their pet is uncomfortable, inflamed, hairless, is to just reestablish comfort.

Because something we take for granted is that human-animal bond. And having ... And I have an allergic dog who wants to jump onto my lap right now, and she is frustrating when she is sloughing and itchy, and I'm a dermatologist who's literally educated in this. So we really have to be empathetic to our owners.

So it's okay to plant the seed. Yeah. And I do that a lot with my owners, right? Like, "Hey, let's just get them feeling better. The next time I see you we're gonna start talking about what an allergic workup looks like." But we have to just take a step back, 'cause I think we get overwhelmed with dermatology when we try to cram it all in to one 30-minute appointment slot.

Yeah.

Yeah, definitely. How do you approach making owners feel more comfortable about this diagnosis, and how are you explaining your thought process and what you would like to do going forward to them in a way that's understandable? Because I think dermatology has this whole new vocabulary that comes with it, and even as a vet student, you know, learning that was- Really tricky 'cause it's, it's so different from the way you explain a lot of other conditions.

There are so many different lesions and different ways of describing, you know, papules, macules, pustules, all of those types of things. So how are w- you approaching that process as a vet, and then also with owners to make them feel comfortable?

So it, for me, it's really important to not get bogged down in medical vocabulary with an owner.
So how I teach and, like, when I do my lecturing and my podcasting kind of teach vets, the way I explain things, the terminology I use is completely different than w- how I explain things to owners, and I think that's really important. I'm not sure I have ever said papule or macule in front of an owner, right?

Unless they're medical and they're interested, but it's probably just not something that, like, I'm gonna get a deer in the headlight look, right? Like, that's, that's not what they're there for. They're gonna be very confused. So I, I hardly ever call it atopic dermatitis in front of an owner. I will sometimes, um, or if I do, I say both.

In the clinic for owners, I'm a huge whiteboard person, especially for initial exams. So we have whiteboards in all of our clinic- Yeah ... our, our clinic exam rooms. And so if I'm breaking down, you know, the three types of allergies, flea, food, environmental, if I'm gonna talk about environmental allergies, sometimes I'll write environmental allergies, and in parentheses I'll put atopic dermatitis.

The only reason I sometimes do that is to differentiate for owners the way they're thinking about environmental allergies with people. Like, people do get atopic dermatitis and atopic eczema, but if you say environmental allergies to a, a person, like a, just a person not medically trained, and when they think of people- Yeah

we don't think of skin, right? We think of, "Oh, I sneeze, my eyes water, um, I cough- Yeah ... I get congested." So I'll tell owners environmental allergies, you know, in people we tend to think more respiratory signs, conjunctivitis, but in dogs they actually show as dermatologic signs. But beyond that, I don't usually use that terminology unless they're a medically trained person, because it's just not necessary, and I already have a lot to cover.

Uh, when I'm explaining things to veterinarians, that's much different, and it does take time. I mean, I've been a dermatologist, you know, a board of dermatologist for over a decade. Like, now those things come natural to me, but it did take a lot of time of ... I used to have a little, in my residency, like, a little terminology sheet next to me, right?

Like, what is, how do you define a nodule versus a mass, things like that. So it, it really comes down to practice.

And can you explain a couple of the- Key things that vets should know for approaching these cases and for recognizing these different things, the top clinical signs and, and lesions that we should be aware of.
Yeah. I would say don't get too, like, you know, beyond getting through vet school and your exams and things like that, when you get into the real world, I wouldn't get bogged down by knowing every little dermatologic terminology. And maybe other dermatologists would say different. I'm a very real world person.

Um, so I, I wouldn't get too caught up personally in, like, memorizing exactly the difference between, like, a papule, a macule, things like that. I would say the big things that you should feel comfortable with are the things you're gonna see on a daily basis that are more common. Yeah. So erythema, you know, that would
I use erythema all day long, right, in the clinic, so that's just redness. Yeah. Alopecia, you know, alopecia would be hair loss. Hypotrichosis can kinda be, like, partial hair loss. Pustule would be- Yeah ... another one that you should feel really comfortable with, which just think of a pimple. Basically, a pustule is a pimple.
Yeah. Um, crusting, scaling, I would probably say that those are the more common things, mostly because you're mostly in the, in the clinic gonna see allergies, right? You're gonna see food allergy, flea allergy- Yeah ... atopic dermatitis. In cats it's called feline atopic skin syndrome. Sorry, it's another term, but that's what it is.

Um, and then you're gonna have variations of that. Then of course you get other things, right? We see pyoderma from endocrinopathies. We see, you mentioned cutaneous neoplasia. We don't see it, like, every day like we do allergies, but we do see it. And then of course autoimmune diseases. But if you can get those basics down, infection, allergies, when starting, things start to look weird, you know, then you kind of know the path you need to go on, biopsy versus referral.

Yeah. No, thank you. Can you also just, mostly for me as well as listeners, but, uh, tell us the difference between scaling and crusting? 'Cause I think things like erythema, it's a bit more obvious, but yeah, what, what's the difference between those two lesions?

So scaling's not gonna be like the firm stuff you see with crusting.

Like, crusting is gonna be like the honey colored, more firm, like if you think if you're scratching yourself and then as it's healing it kinda gets a crust over it, or if you burn yourself and then- Yeah. Okay ... it heals and you get a crust. Serious material that's gotten hard, maybe infection. That's why I'm most huge advocate of cytology 'cause you can get autoimmune diseases that crust and there's no infection there.
Scaling's gonna be more that dandruff. So if you think of dandruff, essentially that is scaling.

Okay, so you talked about at what point we're going to be doing diagnostics ourselves and then potentially referral. What should we be doing in terms of a workup in GP and then- When should we be referring? When is it too much to handle at GP, basically?

So the first thing I will say, and I can't say I speak for every dermatologist, but I think I speak for a lot, there is like no too early to refer.

So sometimes I think that a lot of veter- like veterinarians think like it's not bad enough to re- I am thrilled to have a, you know, a two-year-old golden retriever that responds great to apoquil, but the owner would really like to think of long-term, you know, therapy and desensitization. I, like that's like my dream, right?

Like I see train wrecks all day. I'm super happy to see the proactive owner. Now, I know in a ge- in a general sense most owners are not gonna jump to it that early in the game, but we do get some of them. When I think, yes, you really should be ... So what should you feel comfortable with in general practice?

I think there's general practitioners who are amazing dermatologists, and the reality is, you know, I think there's 350 or 400 of us, and that includes everybody, those who are clinically practicing versus retired, you know, versus industry. So I know that there are areas where you can't refer to a dermatologist or you'll have owners who are not willing to go to a dermatologist.

So the things I think- Yeah ... are very important to recognize would obviously be recognizing typical chewing the paws, ear infections, getting a good history, and history doesn't mean it takes an hour to get the history, but just getting comfortable how to guide those questions when you are seeing if there is an underlying potential allergic component versus something else.

If I had a 12-year-old dog come in to see me and they're red and scaly and losing hair, one of the most important questions I will ask first is have they had issues in the past? It's not very common, not impossible, but not very common for dogs to all of a sudden get allergies when they're 12. So a lot of times if I find out they're red, scaly, itchy, they've never had skin issues before, I'm usually thinking either we have an infection from an endocrinopathy, right?

We've developed Cushing's and we're getting infection. We've developed hypothyroidism and we're getting infection. Or we've got cancer, and we've got something like cutaneous lymphoma. That's very different than a red- Yeah ... scaly dog that comes in and they've just kind of waxed and waned allergies their entire life.

So getting comfortable with those basic things is really important. I'd say, you know, the minimum database, cytology we do all day long. Of course, skin scraping we don't see quite as much anymore because of isoxazolines, but they still happen. You know, those and like DTM, fungal PCRs- Are really simple to do in the clinic.

And then I think it really comes down to what your comfort level is. Every general practitioner is gonna be completely different in how comfortable they feel managing allergies. But I, the plea I would have is take allergies seriously. Sometimes I think we have a tendency, right, to see, like, well, oh, another skin case.
I'm just gi- giving this drug. Like, when they start flaring every time they come off the drug, I would say that's a great time to refer, or you really need to spend some time having a conversation with that owner. Sometimes I think because allergies- Yeah ... are so common and they're not, not life-threatening, that we feel comfortable just to be like, "Oh, well, here you go again.

Here you go." And we don't change anything, and they start not responding to stuff- Yeah ... 'cause they get infected. But allergies are a lifelong progressive disease, um, so it is really important that we take it seriously.

And just 'cause it's common doesn't mean it's normal. Right. And that sometimes I've heard too, like, well, they, they're so upset and their, you know, their dog just has allergies.

Like, most owners don't sign up to get a pet with a lifelong disease, right? That flares occasionally. Yeah, yeah. That can be very difficult. That's why we keep getting new allergy medications. I still have patients, I'm, like, waiting- Yeah ... for the next drug to come out 'cause they haven't responded to what we have.
Um, so- Yeah ... you know, it is a really frustrating disease to manage and deal with.

So you're talking about those features that you're asking for in a history. What are the things that we should really be asking for, or things if an owner mentions that, that is a big red flag for you? Well,

I would definitely say licking paws for dogs is the big one, right?

Because a lot of owners, they'll come in and say their ear is infected, and if you don't dive deeper into why it's infected, it'll just keep coming back. So many times owners come to me for a really bad ear infection and, you know, I'm getting my history, I'm getting my swabs of the ear, and then I start asking questions to differentiate why that's happening.

And very commonly I'll say, "Well, have they, do they tend to lick their paws? Do they chew their paws? Do they keep you up at night because they're licking their paws?" Oftentimes owners will say, "Well, they've always licked their paws, but I think it's just 'cause they're bored." You know, that, things like that where they think, well, that's just a thing they do, they lick their paws.

And of course, we're not gonna panic any time a dog just barely licks their paws, but oftentimes when you dig deeper it is, "Well, yeah, I'm not sleeping, but I think it's just 'cause they're bored." And that's not very common, especially if you do give a medication- Yeah ... like steroids or a JAK inhibitor and that behavior stops, then there probably is an allergic reason.

That would be a very typical for, one for us. If you wanna think of something that's not allergies that you should pick up on, it would be mucus membrane involvement. So it's gonna be very, very uncommon- To have the nasal planum become depigmented and crusty because of allergies. Sometimes you get like secondary bacterial mucocutaneous pyoderma things.

But in general, if you start to see that the mucus membranes are affected, that's when you should have things like autoimmune or neoplasia on your list. Cats are a different story. Cats are really weird with their eosinophilic granulomas. You know they can get them. 'Cause every ... Yeah. Yeah, so with cats, I guess, you know, always an asterisk.

Uh, but cats are a bit of a different story. But from the typical thing you're gonna see of a lot of allergic dogs in the clinic, like if all of a sudden the mucus membranes are involved, you should at least have a red flag up that probably something else is going on.

I see. I wanna jump onto that because I think eosinophilic granuloma in cats is, again, one of those topics that when you're at vet school you're like...

Weird?

It's the same, but there are all these different presentations of it. So can you just give us a really quick like what are the different ways that eosinophilic granuloma can present in cats and just like your number one differentiator for, for those different things? Because, yeah, I think it's something that students and, uh, and GP vets can really struggle with.

So the first thing to realize about eosinophilic ... So it's EGC in a s- eosinophilic granuloma complex, and the biggest thing that I wanna start off by saying is it is another clinical presentation. It's not a diagnosis. Sometimes we have a tendency like, "Well, I biopsy sometimes, right? Like there's a mouth lesion.

We should make sure. We'll biopsy it." 'Cause they can get squames and other things in the mouth. Yeah. So, you know, say we get back eosinophilic granuloma, then people wanna put that as a diagnosis. That is almost the equivalent of being like, you know, they have erythema. Like it's just a clinical presentation.

It's not a diagnosis. There's three kind of presentations that fall within that complex, and some cats will have all of them. Some, you know, most cats will have one or two of them. The eosinophilic plaques, those are usually areas they can lick on their body. So we see a lot of that on belly, on trunks, on limbs, but they're kind of more flat and firm, erythematous.

There's usually debris. They can even be necrotic, but they're usually on the trunk and on areas of the body that they can actually lick and go for. Uh, so that's number one, eosinophilic plaque. Number two would be eosinophilic granuloma. Those can really occur anywhere, but we tend to think about them like in the mouth.

I've seen them like on a chin. So they literally look like mass-like effects. So you can see them on the hard palate, the soft palate. I've seen, I biopsied one on the toe of a cat. So they can kind of occur anywhere. They can occur in dogs, but it's not as common. I maybe have had like two dogs in the last f- like couple years that have had that.

I've had tons of cats. The third presentation, ulcer or you'll also heard called rodent ulcer. I like to call it rodent ulcer- Yeah ... 'cause indolent ulcer makes me think of the bad ulcers in the eyeball and- Eyeballs freak me out, so I like to say rodent ulcer. And that tends to be like on, on the lips, but especially like right on these upper lips where the canines are.

They can be very subtle, so I'm a huge advocate in cats if you're able to, to an oral exam. If the cat is a no thank you to oral exam, I at least try to take my two fingers and lift the lips up a little bit just to look right here. You'll be surprised how many will have very faint rodent ulcers that the owner just didn't notice.

But I've also seen crazy severe ones where like the whole top lip is gone and it's eating away to the nose. So those are the three presentations of eosinophilic granuloma complex. The main differentiation is allergies, and it can be from any of the allergies. So I've had granulomas from food allergic cats.

I've had plenty, uh, tons of eosinophilic plaques from flea allergic cats. Um, and then of course atopic cats. So any- Sure ... you're basically going down an allergy workup if you know an eosinophilic granuloma's there.

Okay. Great. Thank you. I think that really helped me as well. You also said about a minimum database-

Mm-hmm

that you're doing as part of your workup, and that's gonna be cytology, s- skin scraping, all of those kind of things. Is there a set of diagnostics that you are definitely doing in your workups that you would do for every case?

So cytology is the only big one that I would say I do in almost every case, unless there's no lesions.
Um, right? Sometimes they come in, they're like, "Oh, they lick their paws," but they're currently on cytopoint and doing fine. But again, I just wanna start the process of figuring out why. If there's lesions, I almost always cytology. Now, I ... Minimum database is great, but I'm also an advocate for the client's pocketbook, so I do not scrape every case.

I do not fungal test every case. But I've also only done skin for, you know, I'm going on 11 years of being boarded and then my residency, so I'm almost at 14 years of just doing skin and ears. So I ha- I'm to the point of experience where I just feel really comfortable saying, "That's probably on Demodex."

Um, so but as someone who's maybe not as comfortable, right? 'Cause either you're a newer grad, totally do the tests you need to do if you don't feel confident in that. But I just think once you get experience, you'll get to the point where you don't feel like you need to scrape, pluck, smear, right? It's a great saying.

I think it's wonderful when you're just starting. Maybe if you're not, you're pretty sure it doesn't have it, but you just wanna make sure. Like, whether or not you wanna do things like little free diagnostics that don't cost your clinic money, I think is very clinic independent, right? Yeah. Like, we let our resident do that if he's not feeling comfortable, but that's very clinic to clinic dependent.

But for me, I'm only doing this now, like I can feel pretty confident that I don't need to charge them- For I don't need to do a scrape 'cause I know it's not that. But when you're starting, you will probably do more diagnostics because you're not quite to that point, and that's where experience really just comes into hand.
The basic minimum database would be the scrape, pluck, smear. Skin scrape to make sure it's not mites. Um, uh, pluck, you could do things like trichograms or pluck hairs, right, for a fungal culture DTM. And then smear being cytology. Of course, there's lots of different ways to do cytology. My day-to-day, I'm doing cytology all day long.

You know, and then maybe an occasional fungal test or an occasional skin scrape.

Is there ever a time when hematology, biochemistry, those kind of blood workups are even useful, or i- is that just not something you ever really reach for? Oh, we

do l- we do lots of blood tests. Most of our blood testing is to monitor our drugs, right?

So I see the worst of the worst, so I have cases that have to live on steroids. Even if they're on, you know, cyclosporine, JAK inhibitors, we're probably to some degree monitoring those, right? Just depending on the drug and the case and previous lab work they've had. So we do tons of lab work monitoring.

For a diag- as a diagnostic test versus monitoring, I'd say the biggest reason that we're doing tests are to look for endocrinopathies. So to look for things like they're hypothyroid, and that's why they're getting a pyoderma. I wanna rule out basic signs of Cushing's. Like, I'm gonna ... Like, to see if they're concentrating their urine, I'm going to look for ALP elevations.

And then the other, I guess, one would be if they are older and we're really worried something bad's going on, right? Like, so think of a cat with paraneoplastic alopecia. Like, if they come in and I'm like, "You've been losing weight and you've ... but and you've got a shiny bald belly," like, whoa, I'm actually worried you have, like, cancer, not allergies.

So of course we might do a lab panel just to see, you know, are their liver values through the roof? Are their pancreatic values through the roof?

Are there any things that you see that are really common mistakes that GP vets are making in derm cases that we should definitely be aware of?

So, a- and just because they're common mistakes doesn't mean there's judgment. I wanna start with that. I had a, a cl- clinic, one of my local clinicians who I love very much and is a wonderful clinician, when I was talking about a case yesterday that actually I was sending back to them because there was a neutropenia that- I, I didn't know why it was happening.

I was like, "Eek, not me." So, um, and they're completely wonderful. And the, you know, they, we were chatting about things. We're like, "Well, you know, a lot of times we'll send them to you guys." And then, and you know, it's like we say the same thing, and you're the third time to say it, and then they listen. I'm like, "I get it."

Like, to- listen, I've been a vet student, I've been a resident. I absolutely know that happens. So I do ... We all know that happens. We all know as long as you put in the record, right? Yeah. They declined this or we talked about this. And when the client comes in, they're like, "Oh, they never mentioned it." And I see five times you wrote in the, the record, "Discussed allergies."

Like, we all know that happens.

Yeah.

But things that we do see that are just, like, missteps. You know, with allergies, it's, it's mostly getting into the workup, whether you're not, you're comfortable with that or not. So if you are gonna put them through a diet trial, you should have your handouts or your staff educated to explain what that looks like, right?

Not just saying, "Well, avoid grains and over-the-counter foods." That's not a diet trial. We still see that written in records sometimes. Or just switch them to a fish diet over the counter. That's not a diet trial, right? You have to do a prescription-based diet that's strict or a home-cooked diet if they don't wanna do prescription-based.

But there's several studies that show over-the-counter diets can have other residues in the food that's not on the label. That does not make over-the-counter diets bad. They're just not meant to be a diagnostic food. Um, so that's probably a big one. I'd say the other one that's more on the common thing that we see are flea combing, not finding fleas, and saying it's not a flea allergy.

So I see that a lot in my allergic cat patients, that it'll, they'll be completely itchy and then it'll say, like, "Flea comb, don't see fleas." And then no- not flea allergy. You don't have to see fleas to have flea allergy. In fact, if you're seeing fleas and flea dirt, it's the tip of the iceberg. And yes, indoor cats.

Yeah. I've, I literally diagnosed a flea allergic cat that was a sole cat in the household. It was, like, on the sixth or seventh story of an apartment in Los Angeles when I was practicing in California. Yeah. I mean, fleas are just sna- sneaky little buggers, right? They, they can ride an elevator just like the rest of us on a dog that's also there.

Yeah, anywhere. Anywhere. So that's- Yeah ... that's probably another big one is just indoor cats and not thinking that flea allergy can be the cause. And listen, that's an easy win in cats- Yeah ... with how limited we are with the stuff we have. The other thing I would probably say, and I think this is, this is hard for me too, is the multiple allergies.

So you put them on flea control, they're not instantly better, and then we're like, "Well, you know, take them off flea control." So many dogs and cats are flea and environmentally allergic, you know, food and environmentally allergic. Yeah. So that would be another one that's probably overlooked, and that's even hard for us as clinicians 'cause that's a lot of puzzle piece putting together.

Yeah. What are the most extreme cases that you've seen as a referral center and as a specialist?
I mean, the most dramatic ones probably are the horrific, like autoimmune and neoplastic ones. I mean, we see terrible allergies, don't get me wrong. I've had dogs mutilating themselves in the room. I've cat- have cats completely tearing themselves apart.

I've had dogs and cats who come in with, like, no hair 'cause they're so infected, and allergies can look really, really bad. But of course, then you get- Yeah ... the, you know, epitheliotropic lymphoma where their nose is essentially ulcerative and depigmented and falling off. Their ... I've had a complete mouthful of ulcers from n- neoplasia.

There's all, like l- completely red, inflamed, losing hair, plaque, scaling. And I have seen the- Yeah ... autoimmune cases, like erythema multiforme, pemphigus foliaceus. But, you know, that's why the workup and the diagnostic is really important. Even if it is a cancer case and they are not gonna be referred to an oncologist, and maybe there is a poor prognosis for how advanced they are, just having- Yeah

a diagnosis for the owner, right? So they know what to expect, so they're not just in limbo of not knowing what's going on with their pet. So maybe we put them on high-dose steroids for a couple of weeks to provide some quality of life, and we know that the quality of life will be shortened if they're not gonna do chemo and things like that.

Yeah. Like, you can still really help these, these owners and these patients through that by giving them, you know, information and, and guide them through it.

Yeah. How much of the time would you say for these cases that you see do you get a definitive diagnosis that you can explain to the owner? I

mean, almost always.

We do get weird biopsies- Okay ... right, where, like, even the pathologist is like, "It could go this way or this way." Like, we get that, too. Going back to missteps, I would say that's another big one is if you're going to biopsy, either just doing... Like, if you don't feel confident in where to biopsy, who to send it to, how many, definitely refer them.

Nothing breaks my heart more- Right ... than having to tell someone we need to repeat a biopsy 'cause, you know, for a diagnostic test that's not cheap, and then we're waiting longer- Yeah ... to get that information. So I've seen several cases where just one site was taken- Mm ... but the pet's completely affected. We send, we don't send it to a dermatopathologist because skin is very complicated.

It's the external organ of the body. It gets exposed to lots of things. It can do lots of different, you know, inflammatory patterns. So I would- Yeah ... say that usually we can get there. The question is, well, you know, does the owner have the finances and the bandwidth to do it? 'Cause even if you get a biopsy that is kind of like super inflamed, you know, could be crazy allergies or even could be early cancer.

We've gotten those before. Yeah. Usually you can do PAR testing, immunohistochemistry. You know, there's so many cool advancements they have in diagnostics, but it just depends on how committed the owner is because those things can definitely add up.

So allergy dogs are something that- Everyone, I think, in vet med sees a lot.

And you've mentioned, you know, environmental causes, food causes, ectoparasites. Can you start by explaining what allergies actually are, and then we can go on and talk about the differences in these different causes?

I think the most basic way to think about allergies, and how I often start out by talking to owners about it, is it is the body inappropriately reacting to something, whether it is a flea bite, right?

So let's even take fleas, right? Fleas are itchy, but usually it's because there's a bunch of them. That's different than, say, a flea allergic dog. So a lot of times if we diagnose a flea allergic dog, the first thing the owner will say when we're like, "We really think you should start flea prevention," and that includes both the animals in the house, right, so you can limit exposure to the one who's allergic.

The first thing the owner will say is, "But my other dog's not itchy." So and I'll say, like, flea infestation is much different than a just flea allergy. Like flea allergy- Yeah ... plenty of dogs and cats get flea exposure. Like, they're on a walk, you know, there's, like, a couple in the house you never see. I know it grows to think about, but it's true for many of us.

They get a little exposure, but they're not itchy. That's different than a dog who has a flea allergy, and that minimal exposure really catapults our immune system, right? It overreacts to it essentially. So I also will explain it to people, like, think of two people sitting in a field and they both get stung by bees.

Now, you get stung by a bee, you, you might notice it and be like, "Oh," you know, you're annoyed by it. Maybe it hurts a little. Your immune system's acting very different than, say, like, a person, you know, who has to carry an EpiPen around, right? 'Cause if they get that sting- Yeah ... like, their body literally can go into anaphylaxis.

So immunologically a bit different, but I think it's helpful for owners just to think about. Like, it is a body overreacting to something that usually a pet who doesn't have allergies would not have that same reaction.
Perfect. And then let's come on to the different causes. So is there any way of telling the difference from, I guess, a first consult between allergies caused by, for example, food or from those environmental causes?
So honestly, those two you can't really tell apart just by looking at a pet. Flea allergy, right, you can get a bit of a hint because it's usually, like, dorsal lumbar sacral region. But food and flea, or food and environmental can be identical if you just show me two pictures of dogs. The biggest thing is gonna be the history, right?
So the history, has it ever have been seasonal? So if the dog comes in, it's like only summer they get these issues, and the rest of the year they're fine. It's not like they're rotating foods or anything like that. Then if they're getting the same food and they get several months- Where they're fine, it's not gonna be a food allergy.

The issue is we get a lot of non-seasonal atopics because we do live in a world where allergies for people and our pets are progressing, right? With genetics and with even take hygiene hypothesis, right? Dogs used to live on the farm and just roll around in dirt 30 years ago, and now they're not exposed to as much stuff and, you know, the world is seeing worse and worse allergies.

So we get a lot of non-seasonal dogs. So if they're not strictly seasonal, I'd say GI signs are usually helpful for food allergic dogs, right? Like they have always had soft stools, mucusy stools. They have more than three bowel movements per day can be abnormal. But many food allergic dogs have completely normal GI.
So there's lots of things- Yeah ... that can give you a hint of it. Like they've always had cow pie stools. I'm probably pretty concern- and right, it's non-seasonal. I'm probably pretty concerned that they're, they've got food allergy. But the other thing to recognize, as many studies show us, 30% of atopic dogs concurrently have a food allergy.

So you can also have, what, a third of dogs that could have both. So sometimes, like I'll know they have environmental allergies based on they're worse in the summer and things like that, but I'm also wondering- Yeah ... if there's like a low grade food allergy that's been sitting there also causing some of these recurrent issues too.

So then you have to go through the diagnostic steps just like we do.

Okay. And is there a diagnostic test for you that is best when it comes to allergies?

There are zero diagnostic tests for environmental allergy. Zero. We have to go through the history and the rule outs just like you guys do. Our allergy test, when I intradermal, do an intradermal allergy test for a dog, it is not a diagnostic test.

I allergy test, I already know that dog or cat has environmental allergies because either the history or I have done all the rule outs. So there is zero diagnostic test for environmental allergies. Food allergy, your diagnostic test is a good diet trial. So that is the hard thing. Like you could allergy test a normal dog and you might get positives on that test.

So the only reason we do that test- Right ... is because we have ruled it out. That's why a lot of people don't like derm, and I totally get it. We all want the quick snap test that says, "You've got no food allergy," or, "You do." And there is really great- Yeah ... research happening, so maybe there is a world that happens.

But we have to do all these annoying ... Listen, I would love to not do a diet trial. I'm not a fan of doing diet trials either. Yeah. But, you know, I also don't wanna spend, you know, several hundred dollars to over a thousand dollars to allergy test a dog who doesn't need it. So that's why we are very big- Yeah

advocates of jumping into the history and then doing the rule outs. Sure.

Can you give us a really quick walkthrough of the intradermal skin test? I allergy

test dogs and cats all the time, but I'm not doing it to find out if they have environmental allergies because- Sure ... of the fact that you could do a normal dog and they could have positives, right?

The only reason that we allergy test is if you have owners committed to doing immunotherapy, and the reason we're allergy testing them is to find out what should go into that formula because every formula is custom for that pet. Sure.

And the process is that you're injecting a tiny bit- Mm-hmm ... of each allergen into the skin and seeing if there's a reaction, essentially.

Yeah. So

there's lots of different ways, and it's not a standardized thing by any means. So we, most all of us are gonna inject histamine and saline 'cause those serve as our positive and our negative controls, right? You put histamine in anyone's skin, like, it should show you what a good posi- as long as they're not on steroids or anything like that, it should show you, like, what a good positive is for them.

Why that's important is dogs and cats can be very different in how they show us their allergy test. Some of them swell up nice and bright and red and b- and big, and they're easier to read. Some of them don't get red, but they get really firm and turgid so then I'll know that's what, uh- Okay ... four, that's our high.
So we rank them from zero, no reaction, which is what our saline should be, to four, which is what our histamine should be. So then we inject all the various pollens, dust mites, molds. We inject the things that are more common in that environment. So it's not that we are all testing for the exact same things.
Where I live in the Pacific Northwest of the United States, like, my pollens are gonna be much different than where I grew ... I grew up more in the Midwest. So you're using regional panels to really inject small amounts into the skin and see how it reacts. And then when you know how it reacts- Yeah ... we sit down and look at their history, and then we formulate what we feel like gives us our best chance to desensitize that pet.

Okay. And it's just giving you that extra kind of context, I guess, to put in with the clinical picture, and then you can go ahead with, like you say, immunotherapy or it just kind of guides your management approach more than anything. Yeah.

I honestly pretty much have them ... For me, they're almost always dedicated to immunotherapy to do allergy testing.

I have had- Okay ... one case ever, and it was, like, 12 years ago, that could truly avoid stuff. I know that it happens, but it's rare. So the only time I've had that happen was, like, over 10 years ago in California. We had a lot of horse, and so we tested for horse dander as part of our test, and that was the only thing that popped up on this dog's test.

And then come to find out they put the dog in a horse stall as, like, its kennel when they left. And they started to realize that was exactly when the dog would get worse. Beyond that- Right ... of the thousands of pets I've allergy tested, I have hardly ever had something I can avoid. So we pretty much- Okay

have them committed, in the idea in their head they're going to do immunotherapy when we do that test. Because if they're ragweed- Okay ... grass allergic, dust mite allergic, like, you just cannot fully control they'll never see those things.

Sure. Sure. Okay. So it's just something that you, you use before you do immunotherapy to target that treatment.

Yep. It's

ex- it allows us to customize what we feel like is gonna be the best option to desensitize them, and desensitization is giving- Sure ... small amounts over time to essentially teach the immune system to tolerate it. It's not a fast therapy.

Yeah.

It can take several months, up to a year, maybe even a little bit longer to see how well they do.
And it's, it's great that some of these ... Some patients will totally come off medications. I've had that happen, and they'll just- Great ... be on immunotherapy, and that's awesome. Many of them, it helps, but they still need help along the way. So they're better, but spring's always a little tough, and we still need, you know, a monoclonal antibody- Yeah

or a JAK inhibitor. They still always need something every day, but instead of getting a Piderma five times a year, they get one they can manage topically. So it, it ... We have to be- Yeah ... very upfront with owners of what success looks like. But the literature really shows about 70% of patients have some form of success.
Sometimes it's just that they don't keep getting worse. So we forget that atopic dermatitis, feline atopic skin syndrome are progressive diseases. They tend to get worse as they get older. So if many pets ... And that's why I say I would love to see all these patients younger, right? So they don't get worse.

Yeah.

But we have many owners who will come in and say like, "Oh, he's not being so bad," and now it's happening all the time. Or I've had owners where we're desensitizing them, we're like a year and a half in, it's time for them to refill, and they're like, "You know what? I don't think I've seen any difference with this."
And it's very safe, but it- Yeah ... you know, it's another expense. And so I'll tell the owners, "No problem." Like, you know, maybe they truly have failed, 'cause we do get 30% that fail. So we'll stop it, but just let me know if things get worse. And oftentimes what happens is they called me within a few weeks to a month saying, "Whoa, never mind, it was helping."

Right? Maybe it just at least stopped their progression. So, and that's something that takes time to really explain to owners and, and we're really passionate about making sure owners understand that so they know what to expect.

So what are your top tips or things that you always do to best communicate the workups, the treatment plans? Like, there's things that can be incredibly long processes. Like you said, they can be expensive. They can be frustrating if owners aren't seeing the obvious changes and it's more about the stabilization than the, like, clinical improvement.

How can we communicate that with owners and set realistic expectations?

I think in dermatology you have to be very comfortable knowing that you need to adjust your allergy discussion based on the owner in front of you, right? So like sometimes I have owners come in and it is their third pet with me, and so I, you know, I can go deep 'cause they know, right?

I have some owners- Yeah ... that come in and, like, they, a- like the word allergy is the first they've ever heard of it, and they're already overwhelmed- Yeah ... to comparely pay for like our exam fee. So then we might need to take a step back. Yeah. So I'm a big advocate for educating, but also you may have to repeat yourself or you need to learn to read body language or see if they're engaged when you're going
Right? If I'm in an allergy spiel and I look and they just like look like, "Whoa, what the heck?" Like- Glazed over ... halfway through, we're probably taking a step back and saying, "Okay, today here's what we're doing. This conversation we'll reserve for next time." And some people you don't know, 'cause I've had people who are in, right?

Like as soon as I go they get it, clicks, got it. Yep, I wanna ... My ... I'd say the other thing that's helpful is ask them what their goal is. So I got an owner yesterday in the clinic that it's the second time seeing this dog, doing way better, right? It had a really bad pododermatitis. It's doing way better. Her, her primary goal is least amount of drugs possible.

So our primary goal will be to allergy test that dog as soon as they get it off. We had to use steroids, so have to get off steroids. But like we're not hesitating to allergy test that dog 'cause that is her primary goal. Yeah. Right? Some people come in and they say, "This dog is 10, it's been struggling with allergies its whole life.

My primary goal is comfort," and they may not want to allergy test them. Yeah. So sometimes to know where to guide your conversation it can also be helpful to say, "What ... You know, here's the basic information. What is your goal?" And then when you know what their goal is, then you can maybe tailor what you're gonna say to that and not overwhelm them.

And are there ways of improving ... If we've got something like our flea example where treating the environment is a really central part to treating the animal, are there ways that we can improve owner compliance with treatments just in the way we're talking to them in our consults to convince them that, that it's something more important than maybe they realized originally?

So sometimes it just takes a lot of time, right? Like I've had people I've had to repeat that conversation even though it's in my discharge. I know I've covered it like three or four times because maybe they forgot, maybe life got busy, maybe they didn't think it was that big of a deal. I really like to focus on the fact that flea prevention is

The good ones are great. Not many of them truly repel, right? Like, they're ... You're not ... I like to say they're not a force field around the animal. They are a quick speed of kill, and you're trying to control everyone in that environment so that the one who's allergic is getting less and less exposure. So compliance is a really tough one.

I think that because we do now have the isoxazolines who are pretty much good at all ectoparasites, focusing on ectoparasite control rather than just saying flea can be really helpful because essentially you are probably controlling most things that are ectoparasites, right? Like by- lice, cryla tiella, mites, things like that.

So the other thing to bring up is just- Yeah ... that you're really controlling all these things that can be hard to see and difficult, and the fact that if we miss that aspect, we're gonna probably keep getting infections. And I'm more worried about methicillin-resistant staph than I am about flea prevention side effects, which is very minimal in most of these cases.

How do you look after yourself and your mental health, your wellbeing while working in vet med, which is, you know, a notoriously quite challenging career, both like kinda mentally, emotionally, all of the different aspects. What are things that you're doing to make sure that you're well?

So let me start off by saying that I am a dermatologist, so of all the specialties, right, we have frustrating things we deal with, and we're talking to people that are frustrated all day long.

So I don't wanna negate that there are difficulties, but we're also usually off by 5:00 or 5:30 and not much dies for us. So let's just like call that what it is as a dermatologist. I think of the Grey's Anatomy episode where they go up and see derm, and they're just like, "Oh my gosh, like they're all so relaxed."

I mean, we're stressed. Don't get me wrong, but it's different. Yeah. Um, you know, for me it is ... And I do a lot of things outside the clinic, but for ... And I have two young kids and, you know, a husband I also need to make sure gets my attention. But I would say the big things really for me is I have other passions, too.
So I'm super passionate, right? I do a ton of stuff in the vet field outside of being in the clinic, and very involved in our company and, and progressing that. But for me, it is movement, so I've always been a big workout, weightlifting person, but I just do it in our garage because that's the time I have.

I've gotten into Pilates- Yeah ... in the last year 'cause as you get older, your back ... Yeah. Nice. As you get older, your backs start to suck. So as we're down on the floor a lot, and I do have two young kids I wanna keep up with, right, like that, that has been really important for me. But honestly, I think we just take for granted going for a walk.

Um, we wanna make it like- Yeah ... I have to hit the gym for an hour, and I have days I cannot do that. I love to walk my dog. It sounds so easy and corny. I'm a music person. I throw on music, and I walk my dog if I am frustrated, and that helps a lot. I also have hobbies that make me happy. So we, our family likes to ski.
We are currently in ski season, and we're gearing up to really ... We only live an hour from the mountain, so our kids are six and eight, and they're learning to ski now, and that is a huge, big thing in our family. And then I'm just also literally tonight for the second time gonna go practice white water kayaking.

So I'm a huge- Wow. Yeah. It's in a pool. It's, it's January here so we're not on the river right now. Oh. So I learned to roll last, last month, so I'm kind of a- Nice ... not a person that likes to be busy, but nature and movement make me happy. So things that ... I want a sport that I can do ... I love to hike. I want a sport I can do more in the summer, and so that's the one.

And one of our techs actually is really good and is a president of, like, the little kayak area here, so she's gotten me into it. So yeah, so that's what makes me happy, nature and movement, and that's how I stay sane. Yeah. But I think you find what works for you. That doesn't mean that's for everybody. Some people need to- Yeah

binge-watch a TV show. Great. Like, that's totally fine. I also think what makes me somewhat sane is realizing it's okay to change and fluctuate what you need. You know, when you have kids, you might decide part-time is what you need, and that doesn't mean you can't, when they get older, eventually go to full-time.

You know, you might need to- Yeah ... fluctuate. Maybe you need to go to industry for a while. Like, the cool thing about vet med is there's so many different paths you can go on, and it's okay if you need to- Yeah ... change and adjust that based on what fits for your life at that time.

I mean, Pacific Northwest, you're in, like, the prime area for hiking, kayaking, like, all of those kind of things.
I mean, it's the main reason we moved here almost 10 years ago. Um, you know, I pretty much like outdoors, and we have got wineries and breweries. Yeah. Everyone's very chill here. I mean, being in an area that we love and are, are surrounded by active people has been super good for us.

So for anyone not wanting to learn more about dermatology or specialize further in the area, where should they start?

So I mean, honestly, for the most part, even spending time in general practice, you're gonna get a lot of exposure to derm, right? So even if you're not sure and just ex- Yeah ... ex- exploring, we are very fortunate that, uh, fortunate or unfortunate depending on which practice you're at and how much they love derm, that you're gonna see a ton of skin and ears just being in a general practice.

Um, so you can just get a feel of do you like looking at cytology? Do you like having those discussions with owners? Do you get excited when derm cases come in, right? Like, I fell in love with derm very early. Yeah. And I would just be super excited any time a skin case came in when I was in vet school. Um, so you start to pick up on that because it is such a common thing.

Um, and then of course going to the na- the annual derm meeting. We're a very quirky, pretty accepting bunch, so it's pretty easy to go in there, um, and just see all the different people, and then many of us will have people who will shadow through if they're interested. So I did a ton of externing- Yeah

when I was a student. On my off blocks I would go extern at different universities, different practices, and I just really loved it. Um, so it is one you can get a ton of exposure to see if you like it or not just being in general practice. But of course, there's d- derm dermatologists all throughout- So you could always see if you can spend a day or two with one of them.

Are there any habits that if you do realize that you're interested in dermatology that you should get into to become more confident in approaching those cases?

So I would say getting comfortable with cytology, and there's such easy ways to do that. So I al- when I teach on cytology I always say, like when you

That and otoscopy. So practice on patients that are sedate, practice on patients that are anesthetized, right? Like you're gonna do it in a neuter, just do cytology. Sometimes you're shocked the things you'll find- Yeah ... like they actually do have infections. But learn how to get samples between the toes, learn how that just feels like when that patient is not jumping around or you're in front of the owner and you're more nervous.

Like just- Yeah ... it's almost like walking to me now, right? 'Cause I just do it so often. So practice on patients that are not the Cujo Frenchie that are trying to, you know, bite you. Yeah. Um, just practice when they're still, and then as that gets better and better and you get that kind of motion down, then you'll feel comfortable doing that in front of clients.

Yeah. Perfect. Thank you so much. I wanna finish before we wrap up with some quickfire questions, and then I've got two final questions that I ask every, uh, guest as well. So what is one misconception about dermatology that you want to correct?

Oh, that is a good one. I would say a misconception about dermatology is probably that it is easy, even though I just made the joke ear-

Which I think people in the clinic probably don't think it's easy, right? Even though I made the joke- Yeah ... of like our, our quality of life being maybe, like, better that we're not working overnights, that we don't have on-calls and things like that. Um, I mean, we are very much dealing with chronic cases that are flaring that we're frustrated with, with the

Like, I get cases, I'm like, they come in and they're not doing better, and I'm like, I'm, like, frustrated- Yeah ... right? Because it's just hard. Um, I mean, I ha- I, and I'll be honest with owners too, I had one yesterday, it's a very difficult dog that just ... I'm like the third dermatologist. It flares randomly and, you know, we're do- we've done all the things right and it's still struggling, and I'll be like, "Man, this is tough even for me."
So just being honest with owners- Yeah ... I think is helpful. Um, but yeah, I'd probably just say, like, that it's easy. Um, it's just different hard, right? Like we, we're dealing with things we can't just fix. Um- Yeah ... you know, they're gonna see us their whole lives in 95% of the time. So it is just a different form of hard.
I always like to tell our staff, even when we have a busy day or we've had a lot of frustrating clients or cases, or we're run down, I like to say, like, "We always make it to 5:00, and usually nothing dies." But I'm, like, a annoyingly optimistic person.

No, that's good. What is one thing you can't make it through a day in the clinic without?

Oh, my microscope. I mean, that's never ... Like microscope and slides. I mean, even if I have cases that like most of them have been doing great, like they're great rechecks, there's usually something, right? Like they're doing great, but they're kind of shaking their head a little bit and we might still check the ears.
Yeah. So definitely, um, you know, besides my patients and clients, and of course my staff, my technicians are like my life- Yeah ... and my world, and we would be completely lost without us. We have a lot of very chatty, uh ... We're a fun clinic. We have a lot of very chatty doctors, and I'm the chattiest, and they have to keep me in line.

But beyond them, which is a given, and our s- our front staff, um, probably definitely my microscope.

If you weren't a dermatologist, what would you be doing?

I've actually thought about this a bit. So we're saying still in like vet med?

Or not even in

vet med. Oh, or not. Anything. Yeah. So I've kind of like thought about this a couple

So I think there's two main things I'd be if I wasn't in vet med. So if I wasn't in vet med, the two things that I would probably love to be would either be like an ad- adventure travel like writer type person. I love to travel. I'm always up for doing something adventurous. Um, I, I, I'm pretty much the person that like if you're like, "I wanna do this," I'm like, "Great, let's find a way."

Yeah.

That and like concerts are like my happy place. Nice. I love concerts. Um, but I love to travel, so probably that, or the other one would probably be a talk show host. Nice. That probably comes off of being in the podcast- Yeah ... world for now six years, but I am just, I lo- I'm very curious person. So I really love to find more out about people and how they think, um, and learn stuff I don't know.

Yeah. But I do that best through learning from people who are experts in that or have lived it. I'm not great at learning other ways. I'm very great at learning through conversation. Yeah. Um, so that's probably like the two things I'd consider.

Nice. What is one thing that vets can start doing today to get better at dermatology?

I would say if you are in a practice and you have a person, right, there's always like whenever you're in a practice, you always know the one or two things certain people are good at, right? Yeah. Like you'll have the person who loves surgery. You have the person who loves this. Like if you find either a doctor or even I'd say a technician, right?

Some techs are amazing at derm. Yeah. Like they're really comfortable looking under the microscope. They're really comfortable getting slides. They're really comfortable having those hard conversations with owners when you discharge. Cling onto them. Like really like say, "I love this. If you see something cool under the microscope, let me know.

You know, if you, uh, have a cool biopsy, can I help with part of it?" I mean, that's how I was in vet school- Yeah ... a lot, was basically like, "Let me know, um, and I wanna be a part of it." Besides saying simple like of course do more cytology in practice and all those things. But if you have someone who's really passionate about any aspect of derm- Like, cling onto them and let them know that you want to learn from them.

Yeah. And a final quickfire question is what is one habit in GP that you would ban forever if you could?
Oh, man. I don't wanna get, like, roasted. I mean, it's simple, but this is true. I used to say I wish ... where I live in the Pacific Northwest now there's a couple areas that it's not as big of a deal, but for most of us I used to say I wish we could ban seeing any dog or cat who's not on constant flea control.

Like, it, it sounds so simple, but you'll be shocked how many patients come to us and they're not on flea control. Yeah. Um, and it's just ... it is a lot of time to wait and a lot of money to spend to have a dermatologist say, "I think you're flea allergic." Yeah. And even if they're not flea allergic, right, it's like a breath of fresh air if I say, "Are you consistent with your flea control?"

"Yes." "You have two cats at home. Are they on good flea control?" "Yes." I can just cross it off the list and move on. Yeah. 'Cause even if going down, back to that multiple allergy thing, right? Like, they're atopic and they're flea allergic. Like, if I know you have put them on good flea control and they're on it, like, it's just time I don't have to spend on something simple when I could really dive into the stuff that is probably the main issue.

Yeah. So a lot of times vets will think it's that we want a diet trial done. To be honest, I don't care too much about that because it ... unless you're gonna do it right. Like, I'd rather you not do a diet trial if you're not gonna take the time to go over how you do it. But man, if they could all be on a good isoxazoline I'd be so happy.

Perfect. Okay, great, and let's finish with two questions for all guests. So if you were a new grad again tomorrow, is there anything you would do differently?

I would probably say the thing I would do differently is ... and I did a lot of living in the moment, um, but I would say I wouldn't worry so much about the future.

Um, I am very much a future thinker. I knew I wanted to do, do 'em really easy, so I didn't ... like, really early, so I didn't have that big concern. But I would say a lot of times I was already worried about, like, what- Yeah ... programs would be available when it was time for me to, you know, go, well, if I wanna do my internship, like, which ones do I wanna go to?

Like, I was already thinking about that my second or third year. So when I got out as a new grad, like, I probably would've said, like, I did my internship at Purdue and it was wonderful. I would've been like, "Just worry about this right now. You don't ... you can't even predict what's gonna come in the next six months over what program's next."

Yeah. So, like, just, just don't worry about that and live in the now. Um, it's a beauty and a curse to be so forward-thinking, but sometimes- Yeah ... it's easy ... it's better just to say, "I'm really gonna absorb and focus on what I'm in right now."

And if you could give one piece of advice to all students, vet students and new grads, what would it be?

It's okay if your path changes I think that we, and I say this as someone who pretty much stayed on the path, but some things have changed, right? I didn't know I'd make a podcast. I didn't know I'd love lecturing. But I think we get really stuck on, "I'm going to be this." If I don't have, right, we go to school for so long, and then by the time you're out, you're ready just to say like, "But I wanna do this."

And like, you can wanna do that, but it's okay in five years- Yeah ... if that needs to change. Um, because we do sometimes get stuck on, well, I'm, I'm a part-time GP, but I'm a full-time industry person. I'm this. Like, the reality is I have many friends who've changed their paths multiple times based on what their passion was, based on trying something- Yeah

and it didn't work. So that's okay. So just know that this is a job where you dar- very much can change your path if you need to.

Thank you so much, Ashley. This has been a really great episode. I know it will be perfect for students trying to learn derm or new grads dipping their toe into the water a little bit more, or practicing vets who may be, like, struggling with cases.

So thank you so much for your time and sharing all your amazing knowledge. If you want to learn more from Ashley, she shares a lot of dermatology and education content through the Derm Vets online, as well as on her podcast, which has hundreds of episodes covering different conditions, different topics in dermatology

So if you wanna dive deeper into those different conditions, that is the perfect place to start. Thank you to everyone for listening. If you enjoyed this episode, give us a follow wherever you get your podcasts. Share the episode with a friend or colleague, and find us on TikTok and Instagram at Vet New Vista to let us know what you want to hear next.

Thank you so much, Ashley. I've really loved having this conversation. Great. Thank you so much. Appreciate it. Thank you. I'll see you next time.