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Acral Lick Granuloma... A Dermatology Nightmare

Everyone who has had a dog with a lick granuloma will tell the same story. The skin lesion started as a tiny sore spot on the skin and the dog kept licking at it.  Applying medications didn't seem to help much and the darn thing kept spreading outward while thickening.  It often would be wet and oozing from the dog licking and chewing incessantly at it.  Finally a trip to the veterinarian revealed a name for this patch of thickened, scarred and irritated skin: ACRAL LICK GRANULOMA!   "Well, OK", the owner would say, "so what do we do about it?"

The problem is that we veterinarians cannot give the owner a specific recipe for a cure for acral lick granuloma.  The skin is so deeply affected that even down to the base layer of the skin there can be found under the microscope little pockets of bacteria, broken hair follicles, plugged and scarred oil glands and dilated and inflamed capillaries.  And if these skin lesions are removed surgically, the dog simply licks at the sutures or incision line after the surgery heals, thus creating a brand new granuloma right where the original one was!

The photos above to the left and right are of an Airedale with a classic case of Lick Granuloma.  (Click on the photos to see a larger version in a new window.)  The dog is perfectly healthy, is on an excellent diet, does not suffer from allergies but does have slight separation anxiety when his owner leaves for work.  In this case the "cause" of the licking specifically at the affected area of skin may be self stimulation to help allay the anxiety of separation from the owner.  The skin lesions will heal slightly, almost seem like they are going to heal, and overnight (or during the day while left alone) the lick granuloma is activated, licked raw from continuous passes of the tongue.  Also with this dog, when one of the attempts to break the cycle of licking involved wrapping the lower leg with a cast to keep the dog away from the lesion, he began to make a new one in the same location on the opposite leg!  Now there are TWO LICK GRANULOMAS! (See the photo on the right.) 

CAUSES:

There are numerous theories and one may apply for one dog and an entirely different theory may be correct for another.  Take your pick...
1.)   Many dermatologists think that boredom is a major underlying factor in some cases of Acral Lick Granuloma.  The dog's licking activity helps pass the time.
2.)   Some believe that allergic inhalant dermatitis creates stress in the skin resulting in inflammation and pruritus (itching) which triggers the dog's propensity to lick at any convenient area. 
3.)   A foreign body such as a thistle spine, splinter or bee sting might start up a reaction in the skin which leads to drawing the dog's attention to the spot.
4.)   Bone or joint pain can draw the dog's attention to the wrist or ankle area and in an attempt to alleviate the discomfort the dog licks over the top of the joint.
5.)   Psychological stimuli such as separation anxiety, a new pet or child in the home, or neighbor dogs invading the dog's "territory" can create psychological stress.  Self stimulation such as picking out an area to concentrate on and licking for extended periods of time are a way for the dog to relieve the "stress".
6.)   Hypothyroidism has played a role in some cases of Acral Lick Granuloma.   Especially in Black Labs with lick granulomas it would be a good idea to have the Thyroid Gland function checked.  Thyroid medication may just be what the dog needs to have those skin lesions resolve.

TREATMENTS:

NOTE:  Lick granulomas and laser surgery...The use of laser surgical instrumentation is fast becoming a useful tool to assist in treatment of lick granulomas in dogs.  The laser instrument ablates (removes) the tissue by vaporizing the surface layers.  As the laser light energy passes over the diseased tissue it is essentially vaporized, nerve tissue is sealed so that little sensation is perceived by the patient, and bleeding from the surgical area is minimal.  Your veterinarian may have laser surgery or may refer you to a veterinarian who does so that a consultation specific for your dog's problem can be arranged.

Numerous methods have been tried in an effort to stimulate healing and resolution of acral lick granulomas in dogs. Some therapy is directed at attempts to keep the dog away from the skin lesion in order to allow it to heal.  The truth is that no single method works very well.  Such things as bandaging the entire leg (the dog will lick just above any wrap or cast that is placed over the lesion) and applying nasty tasting materials such as Bitter Apple or Tabasco sauce, usually to no avail.  Barbed wire wrapped in plaster casts doesn't work.  Putting an Elizabethan collar on doesn't work well because as soon as it is removed the licking starts again and the dog will activate the lesion all over again.  The bottom line is that these chronic, infected, ulcerated skin lesions are often the result of a psychological compulsion to lick and chew at this target area. 

Obsessive and compulsive disorders do occur in dogs and these lick granulomas can therefore persist for years and years.  Psychogenic and anti-anxiety drugs have been tried, too.  Very occasionally such medications as Prozac or Xanax might make a slight difference...but not enough dogs respond well to these to be able to call psychoactive medications a cure. Cortisone injections into and under the granuloma quiet them down, alleviate pruritus (itchiness) and shrink them...for a while; then the dog starts licking again and the lesion becomes as big as ever.  Deadening cutaneous nerves has been tried, even Cobra venom was professed to have a cure rate of 90% way back in the early 1970s, but these methods have proven to be unsatisfactory.

We've got a real dermatology nightmare here!  Something makes the dog compulsively attracted to the granuloma and they often will start licking at a different place if the dog is prevented from licking at the original lesion!  Look at the photo above on the right and you can see the second lesion on the opposite leg that this dog started when he was put into a cast to inhibit the licking at the first lesion.

So...what does on do about this nightmare?  Long term antibiotics seem to be the best helper...as long as three to six months may be required for significant improvement.  Cortisone topical creams rubbed into the lesion daily can help.  Topical medications that have multiple antibiotic/cortisone ingredients can help.  This is one disorder where the veterinarian preaches control or management of the skin problem since a cure is not now known.  Any little thorn, splinter, tick bite, scratch or infection over the carpal areas in the front legs and over the area lower down from the tarsus in the rear legs can lead in a short time to an Acral Lick Granuloma.  So keep a close eye on these problem spots and at the first sign of persistent licking at one particular site, get veterinary help as soon as possible.

Many types of dermatological problems are avoided if the dog or cat is consuming an optimum diet... see the Important Topics department in ThePetCenter.com for lots of nutritional information about nutrition for dogs and cats.  In some cases, adding a supplement such as DermCaps, a popular Omega Fatty Acid supplement with a number of beneficial ingredients, is the key factor in avoiding repeated episodes of Hot Spots and other skin afflictions.  If your dog or cat seems to lack good coat and skin health, consider upgrading the diet to a meat-based ingredient formula and adding a supplement such as omega fatty acids can make a very real difference.

LICK GRANULOMA IN A DOG... A CASE PRESENTATION:

BEFORE THERAPY	AFTER THERAPY
Click to see closeup view	Click to see closeup view
Three months ago acral lick granulomas on Nikki, my Rhodesian Ridgeback bitch, were very distressing and I was rather desperate to help her. I decided to take her to Dr. Daniel Morris who is head of Dermatology at the Veterinary Hospital of the University of Pennsylvania.  Dr. Morris examined Nikki and she has been placed on 2000 mg of Cephalexin (biopsy showed deep follicular infection, not *MRSA) for 5 weeks now, and steroids. The steroids were started at 20mg day and is now now on a tapering off schedule. We plan on continuing antibiotics for 12 weeks and the steroids will be reduced to the lowest dose without reoccurrence of itchiness or licking. She was also recently started on hyposensitization shots based on her Heska Company allergy testing results.      She's had the best couple of weeks in a very long time. Less pruritic, more energy, overall happier, and as you can see from the attached pictures, some healing is taking place. We expect to keep the lick granulomas under control but understand that a total cure may not be possible.  I will keep ThePetCenter.com updated regarding her progress.      Donna Knitter RRT, CPFT, CVT
* The term MRSA or methicillin resistant Staphylococcus aureus is used to describe those examples of this organism that are resistant to commonly used antibiotics. Methicillin was an antibiotic used many years ago to treat patients with Staphylococcus aureus infections. It is now no longer used except as a means of identifying this particular type of antibiotic resistance.