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犬肢端舔舐性皮炎的诊断和治疗（2） Diagnosis and Treatment of Canine Acral Lick Dermatitis 作者:Amy K. Shumaker, DVM
翻译：刘宏锋 校对：刘欣
治疗 TREATMENT
成功地治疗和预防ALD的复发，取决于解决原发和长期存在的因素：识别和解决或控制潜在诱因、治疗感染和打破瘙痒循环。如果这3个因素没有得到解决，不复发是不可能的。重要的是要向客户强调，解决问题需要时间，而且在找到正确的治疗方法(或组合)之前，经常会尝试不同的方法。 Successful treatment and prevention of recurrence of ALD is contingent on addressing the primary and perpetuating factors: identification and resolution or control of the underlying trigger, treating infection, and breaking the itch-lick cycle. If these 3 factors are not addressed, resolution without recurrence is not likely. It is important to stress to clients that resolution will take time, and frequently different therapies are attempted before the right one (or combination) is found. 打破瘙痒和舔舐的循环 Breaking the Itch-Lick Cycle
防止舔舐肢端位点是解决问题的另一个重要步骤。如果允许犬继续舔舐伤口，即使原发因素和潜在感染得到了适当的处理，伤口也不太可能愈合。身体上的约束需要根据犬和主人的情况进行调整。伊丽莎白项圈通常是有效的，但许多犬仍然可以接近这些项圈周围的病变，许多客户发现它们很笨重，在较长的治疗周期中不愿意在他们的犬身上保持较长时间。防咬项圈（BiteNot collars ）有效且更容易被犬和主人接受，但许多犬仍然可以舔舐到边缘区域。袜子和靴子对一些犬来说是有效的屏障，但也有一些犬擅长弄掉它们。可以在 www.dogleggs.com上找到一种更耐用的包装，可以根据犬的尺寸定制。通常选择一种 身体约束手段可能需要反复试验。一旦病变得到解决，在有人监管犬时，可以短时间内移除所有身体约束，如果没有观察到舔舐，则可以慢慢增加不受约束的时间。 Preventing access to the acral lick site is another essential step in resolution. Healing is unlikely to occur if the dog is permitted to continue to lick the site even if the primary factor and underlying infection are appropriately addressed. Physical restraint needs to be tailored to the dog and the owner. Elizabethan collars are often effective, but many dogs can still access the lesion around these collars and many clients find them cumbersome and are reluctant to maintain them on their dog for the extended period of time needed for resolution of the lesion. BiteNot collars may be effective in preventing access to some lesions and are much more acceptable to the dog and owners, but many dogs can still get around to access the lesion. Socks and booties are effective barriers for some dogs, but others are adept at removing them. A more durable wrap that can be custom made for the dog based
on measurements can be found on www.dogleggs.com. Often selection of a means of physical restraint may take trial and error. Once the lesion is resolved, the selected form of physical restraint can be removed for short periods initially while
supervising the dog, slowly increasing the time without the restraint if no licking is observed. 外用药也可以有效地阻止一些舔舐行为。某些喷雾剂，如苦苹果，可能让某些犬很讨厌。在肉芽肿上或周围按1:2的比例涂抹HEET和苦味苹果的混合物，每日最多使用3次，在其他方面也取得了成功。HEET是一种含有辣椒素成分的搽剂。辣椒素，一种辣椒提取物，含有镇痛作用，已被证明在减少人类神经性疼痛、神经性瘙痒以及瘙痒方面是有效的。有宠主观察到辣椒素可以减少患犬的瘙痒，但调查人员没有发现明显改善;研究人员建议进行进一步研究。 Topicals can also be effective at deterring some of the licking behavior. Certain sprays, such as bitter apple, may be noxious enough to some dogs. A mixture of
HEET with bitter apple in a 1:2 ratio applied on or around the granuloma up to 3 times daily has been used with success in others.18 HEET is a liniment containing capsaicin as one of its active ingredients. Capsaicin, a chili pepper extract, contains analgesic properties and has been shown to be effective in reducing neuropathic pain19,20 as well as neuropathic pruritus21 and pruritus22 in humans. Capsaicin was observed by owners to reduce pruritus in affected dogs, but no significant improvement was noted by investigators; further studies were recommended by the investigators.23 口服类固醇和局部类固醇也可以帮助减少患部的炎症和瘙痒。Synotic (氟辛诺酮与二甲基亚砜[DMSO])是一种特别有效的外用制剂，因为DMSO有助于增加氟辛诺酮通过增厚组织的穿透。其他产品，如耳肤灵和耳特净，也可能是有效的局部药物，因为它们含有类固醇和抗生素的组合，这可能有助于更好的治疗继发性感染，但同时需要全身抗生素治疗。由于并发感染的可能性，通常不建议使用局部注射类固醇，但一旦感染得到充分处理，就可以考虑使用它们。 Oral steroids and topical steroids can also be helpful at reducing the inflammation
and pruritus associated with these lesions. Synotic (fluocinolone with dimethyl sulfoxide [DMSO]) can be an especially effective topical agent because the DMSO aids
in increasing the penetration of the fluocinolone through the thickened tissue. Other products, such as Tresaderm and Otomax, may also be effective topicals because they contain a combination of steroid and antibiotics, which may help further treat secondary infection, although this should not replace systemic antibiotic therapy. Intralesional injectable steroids are generally discouraged because of the likelihood of concurrent infection, but they may be considered once infection has been adequately addressed. 感染 Infection
由于大多数ALD的病变是继发性感染，因此全身抗菌治疗至关重要。可能需要6至8周或更长时间的疗程(有时数月)才能解决感染。如果最初选择经验性治疗(如头孢菌素)，尽管有适当的剂量和疗程，但反应较差，则应根据前面讨论的培养(组织培养更理想)选择治疗。 Because most ALD lesions are secondarily infected, systemic antimicrobial therapy is vital. Prolonged courses of 6 to 8 weeks or longer (occasionally several months) may be required to resolve infections. If empiric treatment is initially selected (eg, cephalosporins) with poor response despite appropriate dose and treatment course, then therapy should be selected based on culture (ideally tissue culture) as previously discussed. 过敏性疾病 Allergic Disorders 大多数情况下，原发性诱因可能是潜在的过敏。应使用商业处方或家庭烹饪的日粮进行食物排除试验。在过去，食物排除试验进行6周到12周;然而，这种疾病应该在激发日粮之前完全解决，才能更好地确定是否是食物过敏导致了这种行为。在排除性日粮试验中，继发性感染或永久性因素往往没有得到适当的治疗/解决或处理，这可能误导兽医将食物过敏排除出原发病。对于慢性病变，在开始日粮激发之前，可能需要几个月的时间才能解决，从使用合理的抗生素治疗感染，到使用口服和/或局部类固醇治疗炎症，以及打破瘙痒-舔舐循环。如果根据病史(季节性加重)排除了食物过敏的可能性，或者没有怀疑有食物过敏，那么就有必要对环境过敏进行检查和治疗。治疗方案包括过敏原检测和脱敏治疗(见Ralf S. Mueller的文章，本刊关于过敏原免疫治疗的最新进展)、服用爱波克(奥拉替尼)或阿托皮卡(环孢菌素)。基于过敏原检测 (皮内或血清学) 的特异性脱敏治疗，可能是控制潜在异位性皮炎的有效手段，应被视为一种可行的治疗手段;然而，这种疗法需要时间来显示效果(几个月到一年)，所以这应该作为一个长期的治疗和辅助治疗，可能需要直到效果被注意到。使用奥拉替尼或环孢菌素治疗应在感染得到适当处理后进行。口服类固醇可以作为长期治疗的考虑因素，但由于潜在的副作用，在采取这一选择之前，应尝试其他治疗方法，并应就长期副作用对宠主进行适当的科普。 The primary trigger in most cases is likely an underlying allergy. An elimination diet trial with a commercial prescription or home-cooked diet should be performed. In the past, elimination diet trials are performed from 6 to 12 weeks; however, the disease should be completely resolved before challenging the diet to best ascertain whether a food allergy is driving the behavior. Too often secondary infections or perpetuating factors are not appropriately treated/resolved or addressed during an elimination diet trial, potentially misleading the veterinarian into ruling out a food allergy as the primary disease. With chronic lesions, resolution may take several months between treating the infection with an appropriate course of antibiotics, and inflammation with oral and/or topical steroids, as well as breaking the itch-lick cycle, before a dietary challenge can be instituted. If a food allergy has been ruled out or is not suspected based on history (seasonal exacerbations), then work-up and treatment of environmental allergies is warranted. Treatment options include allergen testing and immunotherapy (see Ralf S. Mueller’s article, Update on Allergen Immunotherapy, in this issue), Apoquel (oclacitinib), or Atopica (cyclosporine). Allergen-specific immunotherapy based on testing (intradermal or serology) may be an effective means of controlling underlying atopic dermatitis and should be considered as a viable means of treatment; however, this therapy takes time to show benefit (several months to a year), so this should be used as a long-term treatment and adjunctive therapies may be needed until benefit is noted. Institution of therapy with oclacitinib or cyclosporine should be performed after infections have been appropriately addressed. Oral steroids could be a consideration for longterm therapy, but, because of potential adverse side effects, the other therapies should be attempted before resorting to this option, and owners should be appropriately educated regarding long-term side effects. 骨科疾病 Orthopedic
如果发现潜在的骨科问题，应采取适当的措施来减轻疼痛(如使用非甾体类抗炎药物)或纠正潜在的问题。 If an underlying orthopedic issue is discovered, appropriate measures should be taken to reduce pain (eg, with nonsteroidal antiinflammatory drugs) or to correct the underlying problem.
激光消融
Laser Ablation
激光在兽医学中的应用越来越广泛。CO2激光是一种有效的切割组织、止血和有效切除增生组织或肿瘤的仪器。CO2激光具有许多优点，包括封闭小于0.5 mm的小血管，封闭淋巴血管和神经末梢，汽化组织(包括肿瘤细胞)和细菌，从而对治疗区域进行消毒。此外，与传统手术相比，CO2激光术后疼痛更少。然而，激光手术在手术过程中是疼痛的，病人需要全身麻醉或局部麻醉，这取决于病变的大小、位置和类型。 Lasers are becoming increasingly used in veterinary medicine. The CO2 laser is an efficient instrument at incising tissue and providing hemostasis as well as effectively ablating proliferative tissue or tumors. CO2 lasers have many advantages, including sealing small blood vessels less than 0.5 mm, sealing lymph vessels and nerve endings, and vaporizing tissue (including tumor cells) and bacteria, thus sterilizing the treated area.24 In addition, there is less postoperative pain with CO2 lasers compared with traditional surgery; however, laser surgery is painful at the time of procedure, and patients need general or local anesthesia depending on the size, location, and type of lesion. 对于ALD，一旦潜在诱因得到解决，感染得到解决，如果病变持续存在，激光消融应该被视为一种治疗选择。激光消融不是一线治疗，没有解决感染和触发因素前使用，病变可能会复发。除了前面提到的激光消融的好处，在ALD病变的情况下，它还可以用于去除深部化脓性肉芽肿以及封闭神经末梢，有可能减少引起瘙痒的一些感觉神经感觉。注意，CO2激光器只能穿透0.3 mm左右的深度，因此，当烧蚀较大的ALD病灶时，可能需要分期进行手术，因为烧蚀到满意的深度需要时间。另一种方法是先用激光切除病灶，然后切除剩余的组织。 For ALD, laser ablation should be considered as a treatment option once potential
underlying triggers have been addressed, infections resolved, and if the lesion is persisting. Laser ablation should not be considered a first-line therapy without addressing infection and triggers because the lesion will likely recur. In addition to the benefits of laser ablation mentioned earlier, in the case of ALD lesions, it can also be useful for removal of deep pyogranulomatous tracts25 as well as sealing nerve endings, potentially decreasing some of the sensory nerve sensation triggering the pruritus. Note that the CO2 laser only penetrates to a depth of about 0.3 mm; therefore, when ablating a large ALD lesion, the procedure may need to be staged because ablation to a satisfactory depth takes time. Alternatively, the lesion can first be debulked with the laser, then the remaining tissue ablated.26 成功的激光手术需要技术、激光物理知识和对激光安全性的理解。继续教育会议经常举办讲习班。此外，还有在线课程，包括由美国激光研究俱乐部或美国医学激光应用研究所提供的课程。 Successful laser surgery requires skill, knowledge of the physics of laser, and understanding laser safety. There are often workshops provided at continuing education meetings. In addition, there are online courses, including those provided by the American Laser Study Club or the American Institute of Medical Laser Applications. 外科手术 Surgery
传统的外科手术切除可能困难，并有并发症。由于大多数病变位于屈曲区，术后关节运动引起的开裂引起了人们的关注。此外，病变的大小常常妨碍手术切除，因为由于位置的限制，伤口可能无法闭合。对于那些足够小到可以手术切除的病变，仍然有人担心，如果在手术干预前潜在的触发因素没有得到适当的处理，舔舐行为可能会在术后持续。 Traditional surgical excision may be difficult and have complications. Because most
lesions overlie flexural regions, concern for dehiscence postoperatively from joint motion exists. In addition, the size of the lesion often precludes surgical excision because wound closure may not be possible because of limitations of location. For those lesions that are small enough for surgical excision, there is still concern that the licking behavior may persist postoperatively if the underlying trigger has not been appropriately addressed before surgical intervention. 冷冻手术 Cryosurgery
冷冻手术，也被称为冷冻疗法，也被报道为一种治疗选择，尽管据作者所知没有关于ALD使用的发表报告，也没有被作者用作ALD的治疗。低温剂，通常是液氮，被用来将组织冷却到零度以下，通过两种不同的机制引起组织损伤。首先，冷冻组织会破坏靶区内的血管和毛细血管，导致缺血坏死，从而导致组织缺血。第二，通过冰晶的形成，诱导渗透细胞的损伤和细胞膜的破坏，实现细胞的额外损伤。当组织冷却时，细胞间形成冰晶，形成渗透梯度，将水从细胞中抽出。随着持续冷却，晶体在细胞内形成，可能导致细胞破裂。细胞外的晶体随着组织的融化而融化，形成渗透梯度，将水拉回细胞，导致细胞膨胀和破裂。两到三个冻融循环通常用于治疗兽医学中的皮肤或皮下肿瘤，因为组织损伤的数量随着冻融循环的增加而增加。 Cryosurgery, also known as cryotherapy, has also been reported as a treatment option, although to the author’s knowledge there are no published reports on use with
ALD, and it has not been used as a treatment of ALD by this author. A cryogen, typically liquid nitrogen, is used to cool tissue to subzero temperatures, inducing tissue damage by 2 different mechanisms.27 First, freezing of the tissue induces tissue ischemia by damaging blood vessels and capillaries within the target zone, resulting in ischemic necrosis. Second, additional cellular damage is achieved by formation of ice crystals, inducing osmotic cell injury and cellular membrane disruption. Ice crystals form between the cells as the tissue is cooled, creating an osmotic gradient, pulling water out of the cells. With continued cooling, crystals form within the cell, possibly resulting in cellular rupture. Crystals outside the cells melt as the tissue thaws, creating an osmotic gradient, pulling water back into the cell, resulting in swelling and rupturing of the cell. Two to 3 freeze-thaw cycles are typically used to treat cutaneous or subcutaneous tumors in veterinary medicine because the amount of tissue damage increases with each freeze-thaw cycle.28 冷冻手术作为一种治疗方案对许多病变具有吸引力，因为大多数病变只需要局部麻醉。然而，在焦虑的动物或那些疼痛的病变，如ALD，可能需要轻度镇静。此外，病变的大小和厚度可能是一个限制因素，因为治疗后的组织往往只能有效地冷动到一定的深度。因此，较大的、增厚的ALD病灶可能需要在以前的治疗中得到充分的愈合后予以消退。角质是一种不良导体，可能影响冻结深度。因此，如果正在治疗的ALD病变是过度角化的，那么在进行冷冻手术前减积，可以提高治疗的效果。 Cryosurgery holds appeal as a treatment option for many lesions because it only requires local anesthesia for most lesions. However, in anxious animals or those with painful lesions, such as with ALD, light sedation may be required. In addition, the size and thickness of the lesion may be a limiting factor because the treated tissue can often only be effectively cooled to a certain depth. Therefore, large, thickened ALD lesions are likely to need to be retreated following adequate healing from the prior treatment. Keratin is a poor conductor and could affect the depth of freeze27; therefore, if the ALD lesion being treated is hyperkeratotic, debulking before performing cryosurgery may improve response to treatment. 放射治疗 Radiation Therapy
放射治疗已被用于治疗ALD，人们怀疑X射线照射破坏了病变区域的神经末梢，打破了瘙痒周期。放射治疗已显示出一些令人满意的结果。在一项研究中，据报道，约50%的犬肢端瘙痒性肉芽肿治愈而无复发。但是，后期没有随访。在另一项研究中，13例患者中有11例疗效良好，然而，有5只犬在原部位复发，3只犬在其他部位出现新的病灶。大多数犬的治疗效果令人满意。本研究中复发率或出现新病变，强调了在采取某些治疗方式之前，确定和治疗潜在诱因的必要性。 Radiation therapy has been used as a treatment of ALD, and it is suspected that the
X-ray irradiation destroys nerve endings in the affected area, breaking the itch-lick cycle. Treatment with radiation therapy has been shown to have some satisfactory results. In one study, it was reported that about 50% of dogs with acropruritic granulomas healed without recurrence; however, follow-up time was not provided.29 In another study, 11 of 13 cases had good results; however, there was recurrence at the site in 5 dogs with new lesions developing at other sites in 3 dogs.30 Healing was satisfactory in most dogs. The frequency of recurrence or development of new lesions that occurred in this study emphasizes the necessity of identifying and addressing underlying triggers before undertaking certain treatment modalities. 针灸 Acupuncture
针灸包括沿着经络将针插入特定的穴位。一种能量和气理论上是沿着这些经脉运动的。针的放置和随后的刺激可以改变气。有研究表明，针灸可以通过与疼痛类似的神经通路缓解瘙痒。人体研究表明，针灸可以有效地减少瘙痒。针灸包括刺激三角神经纤维。受刺激的间神经元在脊髓背角被激活，产生脑，并抑制背角的c纤维活动。节段性针刺的效果可能是在c纤维疼痛产生的部位附近针刺，并控制由同一节段脊髓提供的区域。瘙痒和疼痛都是通过C纤维传播的。然而，目前还不清楚它们是沿着相同的纤维还是不同的纤维传播，目前认为瘙痒是沿着不同的C纤维传播的。 Acupuncture involves insertion of needles along meridians into specific acupoints. A form of energy, qi, is theorized to travel along these meridians. Placement of needles and subsequent stimulation can alter qi. It has been suggested that pruritus may be alleviated by acupuncture along a similar neural pathway to that of pain.31 Human studies suggest that acupuncture can be effective at reducing pruritus.32,33 Acupuncture involves stimulation of A delta nerve fibers. The stimulated interneurons are activated in the dorsal horn of the spinal cord, producing encephalons, and inhibiting C-fiber activity in the dorsal horn. Segmental acupuncture may have an effect by needling close to the area where C-fiber pain originates and manipulating areas supplied by the same segment of the spinal cord.31 Pruritus and pain are both transmitted along C fibers; however, it is unclear whether they travel along the same or different fibers, and it is currently thought that pruritus travels along different C fibers.34 人们认为ALD是一种沿着病变下方的针灸经络流动的能量或气的障碍。对病灶局部、近端、远端选择针刺穴位，有利于清除梗阻。然而，针不应该直接插入病变。“Surrounding the dragon” 是一种针灸技术，针被插入ALD病变边缘的周围，定向向内。另一项研究显示，在针刺大肠经络第4、第6、第11点(IC-4、IC-6、IC-11)和小肠第4点(IT-6)的3个穴位后，持续3个月的舔舐瘙痒病变消退。 It is thought that ALD is an obstruction of the flow of energy, or qi, along the acupuncture channel or meridian underlying the lesion. Acupuncture treatment
points selected locally, proximally, and distally to the lesion can facilitate the clearing of the obstruction; however, needles should not be placed directly into the lesion.31 “Surrounding the dragon” is an acupuncture technique whereby the needles are inserted surrounding the border of the ALD lesion, directed inward. Another study showed resolution of an acral lick lesion present for 3 months after 3 acupuncture treatments with needles placed at 4 points: the fourth, sixth, and eleventh point of the meridian of large intestine (IC-4, IC-6, and IC-11) and the fourth point of the small intestine (IT-6).35 行为学和精神性的 Behavioral/Psychogenic
如果确定行为是一个潜在的主要因素或作为一个次要因素，那么就需要行为矫正和/或心理药理学治疗。环境可能需要改变和丰富，以允许犬更多的运动和社会互动。应该鼓励运动和玩耍。因为惩罚可能会增加患有强迫障碍的犬的焦虑和恐惧，这不是一个推荐的治疗方法。此外，惩罚(责骂、训斥、殴打、用身体阻止犬舔舐)可能会无意中强化这种行为，使其成为寻求注意力的行为。或者，想要的行为可以通过持续忽视不想要的行为来实施消极惩罚(当犬从事不想要的行为——舔时走开;)。 If it is determined that behavior is an underlying primary factor or is contributing as a secondary factor, then behavioral modification and/or psychopharmacologic
treatment will be needed. Environment may need to be altered and enriched
as to allow more exercise and social interaction of the dog. Exercise and play activity should be encouraged. Because punishment may increase the anxiety
and fear often present in dogs with compulsive disorders, this is not a recommended approach to treatment.15 In addition, punishment (scolding, reprimanding,
hitting, physically stopping the dog from licking) may inadvertently reinforce the
behavior as attention-seeking behavior. Alternatively, wanted behaviors could be
enforced by applying negative punishment by ignoring the unwanted behaviors
consistently (walking away when the dog engages in the unwanted behavior; ie,
licking).15 除了行为矫正，可能还需要心理药理学干预。在许多情况下，治疗只是暂时的，直到犬对环境中的行为改变作出反应。另一些则需要长期药物治疗。 In addition to behavioral modification, psychopharmacologic interventions may
be required. In many cases, therapy is only temporary until the dog responds to
behavioral modifications in the environment. Others require long-term drug
therapy. 几项研究表明，犬接受选择性血清素再摄取抑制剂(SSRIs)治疗ALD的情况有所改善。研究人员注意到，SSRI类药物的治疗效果有所改善，其剂量与治疗人类强迫症的剂量相似。这表明，在那些患有ALD的犬身上，可能与5-羟色胺系统有关。中缝背核中含有5-羟色胺神经元，为参与复杂情绪反应调节的前脑结构提供了大部分5-羟色胺。血清素能系统参与许多不同的过程，包括痛觉、攻击性、睡眠、性行为、激素分泌、体温调节、运动活动和食物摄入，尽管它通常不包括自我理毛。然而，一项针对猫的研究发现，中缝背核的血清素子系统可以通过啃咬或梳理毛发来选择性地激活。这一发现可能支持ALD犬的类似系统被不当激活。氟西汀是研究最广泛、最有效、目前应用于ALD的SSRI药物。 Several studies have shown improvement in dogs placed on selective serotonin reuptake inhibitors (SSRIs) for treatment of ALD.12–14 Improvement was noted with
SSRIs at doses similar to that used to treat humans with OCD, which suggests that,
in those dogs with a psychogenic component to their ALD, the serotonin system is
likely involved. The dorsal raphe nucleus contains serotonin neurons that provide
most of the serotonergic input to forebrain structures involved in complex emotional
response regulation to stress.36 The serotonergic system is involved in numerous
diverse processes, including pain perception, aggression, sleep, sexual behavior, hormone secretion, thermoregulation, motor activity, and food intake, although it is not generally involved in self-grooming.14 However, a study in cats identified a serotonin subsystem within the dorsal raphe that is selectively activated by chewing or grooming. This finding may support a similar system in dogs that becomes inappropriately activated in ALD.14 The most commonly studied, efficacious, and currently used SSRI for ALD is fluoxetine.13–15 除SSIS类药物外的药物治疗也被证明对ALD的治疗具有不同的疗效，这表明可能涉及1种以上的神经递质或5-羟色胺以外的因素。氯米帕明是一种三环类抗抑郁药(TCA)，在安慰剂对照研究中被证明是有效的。TCAs同时阻断血清素和去甲肾上腺素的重吸收，而SSRIs更具体，只阻断血清素的重吸收。因此，SSRIs通常副作用较少。一项研究显示，麻醉性拮抗剂纳曲酮能改善63%患犬的病变，一旦停止治疗，病情就会反弹。麻醉拮抗剂治疗刻板行为的确切作用机制尚不清楚，然而，麻醉性拮抗剂通过与阿片类受体结合来拮抗内源性阿片的作用。多巴胺能系统参与了刻板行为，与内源性阿片相互作用，因此这可能解释了纳曲酮对患犬的治疗效果有所改善。 Pharmacotherapeutic drugs other than SSRIs have also been shown to be efficacious with various responses for treatment of ALD, indicating that more than 1 neurotransmitter or factors other than serotonin may be involved. Clomipramine, a tricyclic antidepressant (TCA), has been shown to be effective in placebocontrolled studies.37 TCAs block reuptake of both serotonin and norepinephrine, whereas SSRIs are more specific, blocking only reuptake of serotonin; therefore, SSRIs are generally associated with fewer adverse side effects. Naltrexone, a narcotic antagonist, was shown to improve lesions in 63% of affected dogs in one study, with regression once the treatment was discontinued.38 The exact mechanism of action of narcotic antagonists for treatment of stereotypical behaviors is unknown; however, narcotic antagonists antagonize the effects of endogenous opioids via binding to opioid receptors.39 The dopaminergic system has been implicated in stereotypical behaviors, with interaction between this system and endogenous opioids, thus this may explain the improvement in affected dogs treated with naltrexone. 对于那些表现出心理因素可能是其主要诱因的犬，为了在行为改变和药物干预之间制定最佳治疗方案，可能需要咨询兽医行为学家。 In those dogs showing a psychogenic component as their likely primary trigger, a consult with a veterinary behaviorist may be warranted for development of the best
treatment plan between behavioral modifications and pharmacologic interventions.
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发表于 2019-7-14 00:08:51
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