Therapy decision tree for canine atopic dermatitis

This tree was created with the help and expertise of Dr. William Oldenhoff, DVM, DACVD, and Dr. Shannon Palermo, VMD, DACVIM. Originally published by Clinicians Brief.








Is patient experiencing an acute disease flare?



Initiate treatment for acute flare of atopic dermatitis

  • Perform cytology to evaluate for secondary infections and initiate anti-inflammatory/antipruritic therapy
  • Confirm current use of effective ectoparasite prevention

See Chronic Control of Canine Atopic Dermatitis, next section.

Bacterial or yeast infection present?



Use topical antimicrobial or antifungal therapies (eg, topical chlorhexidine and ketoconazole [KETOCHLOR® (chlorhexidine gluconate, ketoconazole) Medicated Shampoo])

  • If severe or more generalized infection is present, consider systemic therapies, ideally based on culture and susceptibility testing


Utilize short-term topical or systemic anti-inflammatory therapies, such as

  • GENESIS® Topical Spray (0.015% triamcinolone acetonide), a topical
    glucocorticoid spray
    • Ideal for localized skin lesions1,2
    • Avoids overuse of topical antimicrobials and systemic corticosteroids
    • Duration and frequency of use should be based on individual patient’s clinical presentation and response. Application should continue until complete remission of signs2
  • Prednisone or methylprednisolone
    • Rapid efficacy
    • Systemic adverse effects are common
    • Consider avoiding if infection is present
  • Oclacitinib
    • Used twice daily for ≤14 days to rapidly improve lesions and pruritus with minimal adverse effects3
  • Cyclosporine
    • Addresses inflammation/immune response to relieve pruritus and reduces skin lesions in 4 weeks4
    • Consider giving with other antipruritic/anti-inflammatory therapy

Determine if long-term control may be required based on response to therapy and persistence and severity of clinical signs

See Chronic Control of Canine Atopic Dermatitis, next section.





Confirm any inciting flare factors have been avoided or removed

  • Diet trial if clinical signs are nonseasonal and presentation is consistent with possible adverse food reaction
  • Effective year-round flea and tick prevention
  • Secondary bacterial/fungal infections and any concurrent conditions (eg, endocrine disease) appropriately treated

Atopic dermatitis is a multifactorial disease process, requiring a multimodal treatment approach to achieve optimal results

  • Breaking the cycle of inflammation will decrease not only pruritus but potentially otitis, secondary infections, and other clinical signs
  • Use of topical therapies to treat occasional flare-ups and long-term use of systemic therapies may be required for treatment success2
  • Consider immunotherapy to address the underlying cause of atopic dermatitis (eg, hypersensitivity)

Evaluate patient’s individual needs and client’s budget and compliance to select appropriate long-term therapy

See Proactive Therapy, next section


  • Sole treatment for environmentalinduced atopic dermatitis that has the potential to eliminate need for other therapies
  • Available in both subcutaneous and sublingual forms
  • In a study, within 12 months, ≈50% of dogs had improved clinical signs, and 80% had a decrease in need for anti-inflammatory/antipruritic medications5




  • Once-daily maintenance therapy
  • Rapid reduction in pruritus in as few as 24 hours3
  • Has a short half-life (out of system within 20 hours), requiring daily use in most patients
  • Generally well-tolerated
  • Immunomodulatory; therefore, may have some anti-inflammatory effect
  • May require additional therapies such as cyclosporine and/or a pulse treatment with a topical steroid for adequate control of clinical signs

Canine atopic dermatitis therapeutic injection

  • Caninized monoclonal antibody against interlukin-31
  • Can reduce pruritus and associated inflammation but has less anti-inflammatory effect overall
  • Well-tolerated and can be used in combination with other therapies


  • Maintains long-term beneficial effects in most patients with only 1 dose every other day or twice weekly6
  • Anti-inflammatory effects may reduce the incidence of not only pruritus but also other clinical signs of atopy7
  • New liquid formulation (CYCLAVANCE™ [cyclosporine oral solution] USP MODIFIED) allows for precise, simple dosing
    • Avoids variance in dosing as compared with capsule formulation
    • May be better accepted by patients than capsules2,8

Topical steroids

  • Application of a topical glucocorticoid spray performed twice weekly on 2 consecutive days on the areas of previous skin lesions has been shown to delay the recurrence of lesions at these sites without causing skin atrophy2

Emollient shampoo therapy

  • A weekly bath with an emollient shampoo containing lipids, antiseptics, and complex sugars (ALLERMYL® [piroctone olamine] Medicated Shampoo) can help remove allergens and reduce itching and lesions
  • Baths should include allowing the shampoo to remain on the animal for 5-10 minutes before rinsing
  • In a controlled trial, 25% of dogs given a weekly bath with 10-minute application of shampoo (ALLERMYL®) experienced a 50% reduction in pruritus scores within 24 hours9



  1. Deboer DJ, Schafer JH, Salsbury CS, et al. Multiple-center study of reduced-concentration triamcinolone topical solution for the treatment of dogs with known or suspected allergic pruritus. Am J Vet Res. 2002;63(3):408-413.
  2. Olivry T, DeBoer DJ, Favrot C, et al. Treatment of canine atopic dermatitis: 2015 updated guidelines from the International Committee on Allergic Diseases of Animals (ICADA). BMC Vet Res. 2015;11:210.
  3. Cosgrove SB, Wren JA, Cleaver DM, et al. Efficacy and safety of oclacitinib for the control of pruritus and associated skin lesions in dogs with canine allergic dermatitis. Vet Dermatol. 2013;24(5):479–e114.
  4. Steffan J, Parks C, Seewald W, North American Veterinary Dermatology Cyclosporine Study Group. Clinical trial evaluating the efficacy and safety of cyclosporine in dogs with atopic dermatitis. J Am Vet Med Assoc. 2005;226(11): 1855–1863.
  5. Olivry T, DeBoer DJ, Favrot C, et al. Treatment of canine atopic dermatitis: 2010 clinical practice guidelines from the International Task Force on Canine Atopic Dermatitis. Vet Dermatol. 2010;21(3):233–248.
  6. Steffan J, Favrot C, Mueller R. A systematic review and meta-analysis of the efficacy and safety of cyclosporin for the treatment of atopic dermatitis in dogs. Vet Dermatol. 2006;17(1):3–16.
  7. Forsythe P, Paterson S. Ciclosporin 10 years on: indications and efficacy. Vet Rec. 2014;174(Suppl 2):13-21.
  8. Navarro C, Crastes N, Benizeau E, McGahie D. Voluntary acceptance and consumption of two oral ciclosporin formulations in dogs: two randomised, controlled studies. Ir Vet J. 2015;68(1):3.
  9. Löflath A, von Voigts-Rhetz A, Jaeger K, Schmid M, Kuechenhoff H, Mueller RS. The efficacy of a commercial shampoo and whirlpooling in the treatment of canine pruritus - a double-blinded, randomized, placebo-controlled
    study.Vet Dermatol. 2007;18(6):427-431.

GENESIS® Topical Spray (0.015% triamcinolone acetate): For use on dogs only. Wear gloves when applying the product. The use of this product on dogs less than eight pounds, less than one year of age, breeding, pregnant, or lactating has not been evaluated. Adverse events of polyuria and polyphagia have been reported in <6% of dogs receiving treatment. For full prescribing information, contact Virbac at 1-800-338-3659 or download here.


CYCLAVANCE™ (cyclosporine oral solution): For use in dogs only. Wear gloves during and wash hands after administration. Gastrointestinal problems and gingival hyperplasia may occur at the initial recommended dose of CYCLAVANCE oral solution. CYCLAVANCE oral solution should be used with caution: 1) in cases with diabetes mellitus as it may cause elevated levels of serum glucose; 2) in dogs with renal insufficiency since the effect of cyclosporine use on dogs with compromised renal function has not been studied; 3) in simultaneous administration with drugs that suppress the P-450 enzyme system, such as azoles (e.g. ketoconazole), that may lead to increased plasma levels of cyclosporine. Killed vaccines are recommended for dogs receiving CYCLAVANCE oral solution because the impact of cyclosporine on the immune response to modified live vaccines has not been evaluated. For full prescribing information, contact Virbac at 1-800-338-3659 or download here


© 2021 Virbac Corporation. All Rights Reserved. CYCLAVANCE, GENESIS, ALLERMYL, and KETOCHLOR are registered trademarks of the Virbac Group of companies.

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Virbac Dermatology Products for Dogs

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ALLERMYL® (Piroctone Olamine) Medicated Shampoo  CYCLAVANCE™ (cyclosporine oral solution) USP MODIFIED  GENESIS® Topical Spray (0.015% triamcinolone acetonide) KETOCHLOR® (Chlorhexidine Gluconate, Ketoconazole) Medicated Shampoo