Editorial Type: Case Reports
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Online Publication Date: 01 Jul 2007

Organic Diseases Mimicking Acral Lick Dermatitis in Six Dogs

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Article Category: Other
Page Range: 215 – 220
DOI: 10.5326/0430215
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Acral lick dermatitis (“lick granuloma”) in dogs is often thought to have a behavioral etiology. However, other diseases may cause lesions on the distal legs, mimicking acral lick dermatitis. In this report, six dogs were presented with acral lick dermatitis-like lesions from different underlying causes—namely lymphoma, an orthopedic pin, deep pyoderma, mast cell tumor, leishmaniasis, and (presumptive) sporotrichosis.

Introduction

Acral lick dermatitis (“lick granuloma”) is a canine disease usually resulting from self-trauma directed at the distal leg.1–3 Lesions are well-circumscribed plaques, ulcers, or, less commonly, nodules that frequently have a hyperpigmented border.1,3,4 Various etiologies have been proposed, including behavioral disorders, allergy, pyoderma, trauma, or joint disease.1,2,4 Behavioral problems such as anxiety, phobia, stress, boredom, or obsessive-compulsive disorder may manifest as repetitive licking, leading to self-trauma.1,5–8 Because other underlying causes may also result in self-trauma and similar clinical presentations, this paper describes six cases of acral lick dermatitis-like lesions caused by underlying infectious, orthopedic, or neoplastic etiologies.

Case Reports

Case No. 1

A 9-year-old, male Beauceron was presented for an ulcerated nodule of 1 year’s duration. The nodule was on the medial aspect of the right carpus, which the dog frequently licked. The prior owner had died recently of acute tuberculosis. Dermatological examination showed an alopecic and ulcerated plaque with a narrow, hyperpigmented border and swelling of the adjacent digit [Figure 1]. Physical examination revealed a mild generalized lymphadenopathy. A complete blood count (CBC), serum biochemical panel, and thoracic radiography were normal. Differential diagnoses were leishmaniasis, tuberculosis, and neoplasia. A 6-mm punch skin biopsy of the lesion showed lymphoblastic lymphoma. The new owner elected to euthanize the dog.

Case No. 2

A 5-year-old, male miniature pinscher was presented for a recent wound that was diagnosed by the referring veterinarian as a lick granuloma. The dog was acquired at 4 years of age by the current owner and was otherwise in good health. The lesion covered a large area of the dorsal aspect of the left carpus, and the center was ulcerated and surrounded by a broad area of alopecia and depigmentation that resembled a scar [Figure 2]. The dog licked the lesion frequently. Although the carpal joint was detectably swollen, the dog did not limp.

Differential diagnoses included an underlying osteoarticular problem, a foreign body, and a behavioral problem. The dog was anesthetized for radiography of the left front leg, which showed a metal pin that had been inserted to repair a distal radial fracture [Figure 3]. Healing appeared to be adequate as no callus was seen, the pin had not migrated, and no evidence of osteolysis or osteomyelitis was seen. The owner was unaware of any surgery prior to acquiring the dog. Removal of the pin (a Kirschner pin) resulted in healing of the carpal skin and regrowth of hair within 2.5 months.

Case No. 3

A 6-year-old, spayed female Labrador retriever was presented with a nodular lesion on the dorsal aspect of the left carpus [Figure 4]. The lesion had been present for at least 8 months and was diagnosed by the referring veterinarian as a lick granuloma. The dog frequently licked at the lesion. Various topical treatments were ineffective. Differential diagnoses included deep pyoderma and neoplasia. A CBC and serum biochemical panel were normal, and radiographs of the lesion showed only soft-tissue swelling. Two 6-mm punch biopsies were performed for histopathology and bacterial culture. Histopathology showed acanthosis with folliculitis and furunculosis; neither dermatophytes nor Demodex spp. mites were seen. Bacterial culture of the tissue grew Staphylococcus intermedius. Based on antibiotic susceptibility testing, cephalexina (25 mg/kg per os [PO] q 8 hours) was administered for 1 month.

While improvement was seen on recheck examination, total resolution of the lesion and the licking was not noted until after 3 months of continuous antibiotic therapy [Figure 5]. At that time, the antibiotic was discontinued. Three weeks later, the owner reported that the lesion and licking had started to recur. The cephalexin was restarted at the previous dose, and when resolution of the lesion was seen at a 1-month recheck examination, the dose was reduced to 12.5 mg/kg PO q 8 to 12 hours. The dog was successfully maintained on this protocol for 2 years, at which time it was lost to follow-up.

Case No. 4

A 10-year-old, castrated male Labrador retriever was referred with a complaint of a lick granuloma of 6 months’ duration, which was unresponsive to topical treatments. The dog licked frequently at the lesion. The preliminary report of a biopsy that had been performed by the referring veterinarian 5 days prior to examination showed acanthosis and chronic granulomatous and eosinophilic dermatitis with collagenolysis. Physical examination revealed a nodular, partially ulcerated mass on the right front foot [Figure 6]. Pending final review of the biopsy, a tentative diagnosis of a deep pyoderma was made, and the dog was administered cephalexina (37.5 mg/kg PO q 12 hours) for 1 month.

Three days after the initial visit, the final report on the biopsy indicated the lesion was a grade II mast cell tumor. The owner did not return for a recheck examination until 1 month later, at which time the lesion had decreased to approximately two-thirds of its previous size and was no longer ulcerated [Figure 7]. A CBC, serum biochemical panel, and thyroid panel showed a thyroxine (T4) value of 9.2 (reference range 12.9 to 46.4 nmol/L) and a free T4 (by dialysis) value of 3.9 (reference range 10.3 to 45 pmol/L), which were consistent with a diagnosis of hypothyroidism. The owner declined chemotherapy or radiation therapy, but accepted conservative management with thyroxineb (0.02 mg/kg PO q 24 hours), prednisonec (1 mg/kg PO q 24 hours), diphenhydramined (2.5 mg/kg PO q 24 hours), and famotidinee (0.25 mg/kg PO q 24 hours). The owner also declined follow-up T4 value testing. The dog survived for an additional 6 months before the owners elected euthanasia.

Case No. 5

A 9-year-old, spayed female Beauceron was presented for a lesion of 2 years’ duration on the right carpus. The dog frequently licked the lesion. The dog lived outside with two other healthy Beaucerons in southeastern France. The lesion was diagnosed by the referring veterinarian as a lick granuloma. Multiple treatments that were both local (i.e., corticosteroid ointments and injections) and systemic (i.e., corticosteroids, antibiotics, and psychotropic agents) had been used without beneficial effect. Physical examination showed no abnormalities other than an ulcerated plaque with a lichenified, alopecic border [Figure 8] on the right carpus. The dog did not lick at the lesion in the examination room.

Differential diagnoses included demodicosis, dermatophytosis, bacterial furunculosis, leishmaniasis, foreign body, neoplasia, arthritis, and a behavioral problem. No Demodex spp. mites were seen on scraping, and radiographs showed no abnormalities of the carpal bones. Two 6-mm punch skin biopsies were taken—one from the center of the lesion, and the other from the periphery. Histopathology showed acanthosis, papillomatosis, and ulceration. The dermis had a severe cellular infiltrate primarily of macrophages, with some lymphocytes and plasma cells. Occasional macrophages contained Leishmania organisms [Figure 9]. A CBC and serum biochemical panel showed an elevated total protein of 90 g/L (reference range 50 to 75 g/L). An antileishmania immunofluorescent antibody titer was 1:400 (1:100=positive).

Treatment was started with megluminef (100 mg/kg sub-cutaneously q 24 hours) for 1 month and allopurinolg (30 mg/kg PO q 24 hours) for 4 years. The treatment markedly decreased the size of the lesion and resolved the dog’s licking. The dog became seronegative for leishmaniasis 1.5 years after starting treatment. A small lesion persisted that was thickened, alopecic, and had an area (0.3 × 0.5 cm) that intermittently ulcerated and required antibiotics. No further changes in this lesion occurred during the following 4 years, at which time the dog died of a gastric torsion.

Case No. 6

A 1.5-year-old, castrated male Labrador retriever-cross was presented for evaluation of ulcerative lesions on the dorsal right carpus. The lesions were first noted by the owner 2 months previously. The referring veterinarian administered cephalexin (unknown dosage), a corticosteroid injection, a topical corticosteroid/dimethyl sulfoxide/flunixin meglumine solution, and ketoconazole (5 mg/kg PO q 24 hours for 10 days). The owner reported that the dog had not licked at the lesion until the aforementioned topical solution had been applied.

Physical examination showed several ulcers and nodules on the dorsal aspect of the right carpus [Figure 10]. Differential diagnoses included a deep pyoderma, fungal infection, and neoplasia. Impression cytology of the ulcerative lesions showed low numbers of small, round to cigar-shaped organisms with capsules, both extracellularly and intracellularly in neutrophils and macrophages. These findings were interpreted to be consistent with Sporothrix schenckii. The owners declined the general anesthesia that was necessary to obtain skin biopsies. (The ulcerative lesions were extremely painful, and the nodules were closely associated with the cephalic vein.) The presumptive sporotrichosis was treated with ketoconazoleh (5 mg/kg PO q 12 hours for 3 months). The dog’s lesion began to resolve within the first month of treatment. A follow-up telephone conversation with the owner 1 year after initial examination revealed the dog had no lesion on its carpus and was considered healthy.

Discussion

Much of the literature regarding acral lick dermatitis deals with presumed behavioral problems owing to boredom, stress, or anxiety.5–9 A number of articles describing the use of psychotropic drugs (such as clomipramine, fluoxetine, citalopram) or of narcotic antagonists for these lesions have been published.2,10–14 Less commonly, a neurological origin for acral lick dermatitis has been reported, usually documented with either abnormal electromyography or nerve conduction velocity findings.15–17 Arecent review of neuro-pathophysiology and pruritus briefly mentioned two dogs with acral lick dermatitis-like lesions; one dog had a peripheral nerve tumor, and the other had sciatic nerve inflammation. 18 Other than these two canine cases, the authors were unable to find specific reports of acral lick dermatitis or acral lick dermatitis-like lesions attributable to nonbehavioral causes.1,3,19

The six cases of acral lick dermatitis-like lesions in this report emphasize the importance of other possible etiologies for these clinical lesions. Concurrent behavioral problems were not ruled out for these six cases; however, with the exception of aggressiveness of the miniature pinscher (case no. 2), none of the owners reported any behavioral problems. The diagnoses and/or responses to treatments also supported the nonbehavioral etiology of each case. It is important to remember that behavioral problems such as conflict and anxiety are difficult to determine without a detailed behavioral history, which was not obtained in these cases.

In spite of the diversity of underlying diseases, all dogs exhibited findings typical of acral lick dermatitis. Five of the six cases were large-breed dogs, which are predisposed to acral lick dermatitis.1,2 With the exception of case no. 6, all owners complained of the dogs licking the lesion. Although the clinical appearance of lesions varied, five of the six referring veterinarians made an initial diagnosis of “lick granuloma.” Most strikingly, all dogs had lesions affecting the distal thoracic limbs. The similarity of clinical signs to the classic presentation of behavioral-related acral lick dermatitis may have delayed the final diagnosis.

This difficulty in reaching a diagnosis is further illustrated by the nonspecific findings of 1) acanthosis in all biopsies except case no. 1, and 2) the lesions of both case nos. 3 and 4 initially responding to antibiotics. The finding of pyoderma, either secondary or primary, has been noted previously in acral lick dermatitis.1,3,4,8,20 Pyoderma may occur from the traumatic effect of the dog’s licking the lesion, pushing a stiff hair through the follicle wall, and thereby causing a furunculosis.3 Deep pyoderma apparently was the sole etiology of case no. 3, as both the lesion and the licking completely responded to antibiotic therapy. It is possible, however, that this dog had underlying atopic dermatitis or food hypersensitivity, which may have explained the relapse. Because the dog did well with a low-dose antibiotic protocol, diagnostic tests for allergic disease were not performed. Although considered controversial, low-dose antibiotics were effective in this case.21 The secondary pyoderma of case no. 4 may have been partially related to the concurrent hypothyroidism in addition to the self-trauma induced by the mast cell tumor.22

The reaction to the orthopedic pin in case no. 2 had several possible etiologies. Because of the good alignment and the lack of callus, migration, lameness, osteolysis, or osteomyelitis, discomfort was unlikely. The pin had been present at least a year, and the onset of the lesion was described as recent; thus, the mere presence of the pin may not have caused the problem. A hypersensitivity reaction to metallic orthopedic implants has been rarely documented in people.23–26 Such reactions may manifest as localized or generalized eczema, urticaria, or granuloma, and they are variably pruritic or painful. They often occur directly over the implant.23–26 Metals in contact with biological systems undergo corrosion, leading to the formation of metal ions, which activate the immune system by forming complexes with endogenous proteins.26 Upon removal of the implant, the skin lesion either resolves rapidly (within 3 weeks) or more slowly, presumably owing to the continued presence of metallic particles in the area of the implant.24,26

In case no. 5, it was uncertain whether the leishmaniasis was the primary cause of the lesion, or if it caused secondary infection of an existing lesion (directly or via metastasis from elsewhere in the body).27,28 Despite resolution of the dog’s licking and the dog’s clinical improvement and seronegative conversion, the incomplete healing of the lesion suggested either partial ineffectiveness of the treatment or another underlying cause, such as allergic skin disease.

Conclusion

Six dogs were diagnosed with lesions similar to acral lick dermatitis of nonbehavioral or medical causes. Medical etiologies may be suspected when lesions are nodular or ulcerative, cause lameness or joint swelling, occur in older dogs, or have not responded to conventional topical and/or behavioral treatments. Diagnostic tests that were helpful in finding the causes of these lesions included impression cytology, radiography, and biopsy for both bacterial culture and histopathology.

a

Cephalexin; IVAX Pharmaceuticals, Miami, FL 33137

b

Thyro-Tabs; Vet-A-Mix, Shenandoah, IA 51601

c

PredniSONE; Roxane Laboratories, Inc., Columbus, OH 43228

d

Diphenhydramine; Barr Laboratories, Inc., Pomona, NY 10913

e

Pepcid; Johnson & Johnson–Merck Consumer Pharmaceuticals, Ft. Washington, PA 19034

f

Glucantime; Rhône-Mérieux, Lyon, France

g

Zyloric; Wellcome S.A., Paris, France

h

Ketoconazole; Apotex Corporation, Toronto, Ontario, Canada

Figure 1—. Cutaneous lymphoma mimicking acral lick dermatitis on the medial right carpus in a 9-year-old, male Beauceron (case no. 1).Figure 1—. Cutaneous lymphoma mimicking acral lick dermatitis on the medial right carpus in a 9-year-old, male Beauceron (case no. 1).Figure 1—. Cutaneous lymphoma mimicking acral lick dermatitis on the medial right carpus in a 9-year-old, male Beauceron (case no. 1).
Figure 1 — Cutaneous lymphoma mimicking acral lick dermatitis on the medial right carpus in a 9-year-old, male Beauceron (case no. 1).

Citation: Journal of the American Animal Hospital Association 43, 4; 10.5326/0430215

Figure 2—. Acral lick dermatitis-like lesion on the dorsal left carpus of a 5-year-old male miniature pinscher (case no. 2), arising from the presence of an orthopedic pin in the radius.Figure 2—. Acral lick dermatitis-like lesion on the dorsal left carpus of a 5-year-old male miniature pinscher (case no. 2), arising from the presence of an orthopedic pin in the radius.Figure 2—. Acral lick dermatitis-like lesion on the dorsal left carpus of a 5-year-old male miniature pinscher (case no. 2), arising from the presence of an orthopedic pin in the radius.
Figure 2 — Acral lick dermatitis-like lesion on the dorsal left carpus of a 5-year-old male miniature pinscher (case no. 2), arising from the presence of an orthopedic pin in the radius.

Citation: Journal of the American Animal Hospital Association 43, 4; 10.5326/0430215

Figure 3—. Radiograph of the left leg of the lesion in Figure 2, showing the intramedullary Kirschner pin in the distal radius.Figure 3—. Radiograph of the left leg of the lesion in Figure 2, showing the intramedullary Kirschner pin in the distal radius.Figure 3—. Radiograph of the left leg of the lesion in Figure 2, showing the intramedullary Kirschner pin in the distal radius.
Figure 3 — Radiograph of the left leg of the lesion in Figure 2, showing the intramedullary Kirschner pin in the distal radius.

Citation: Journal of the American Animal Hospital Association 43, 4; 10.5326/0430215

Figure 4—. Deep pyoderma mimicking acral lick dermatitis on the dorsal left carpus in a 6-year-old, spayed female Labrador retriever (case no. 3).Figure 4—. Deep pyoderma mimicking acral lick dermatitis on the dorsal left carpus in a 6-year-old, spayed female Labrador retriever (case no. 3).Figure 4—. Deep pyoderma mimicking acral lick dermatitis on the dorsal left carpus in a 6-year-old, spayed female Labrador retriever (case no. 3).
Figure 4 — Deep pyoderma mimicking acral lick dermatitis on the dorsal left carpus in a 6-year-old, spayed female Labrador retriever (case no. 3).

Citation: Journal of the American Animal Hospital Association 43, 4; 10.5326/0430215

Figure 5—. Photograph of the same area illustrated in Figure 4, after 3 months of antibiotic treatment.Figure 5—. Photograph of the same area illustrated in Figure 4, after 3 months of antibiotic treatment.Figure 5—. Photograph of the same area illustrated in Figure 4, after 3 months of antibiotic treatment.
Figure 5 — Photograph of the same area illustrated in Figure 4, after 3 months of antibiotic treatment.

Citation: Journal of the American Animal Hospital Association 43, 4; 10.5326/0430215

Figure 6—. A mast cell tumor mimicking acral lick dermatitis on the dorsal right front foot of a 10-year-old, castrated male Labrador retriever (case no. 4).Figure 6—. A mast cell tumor mimicking acral lick dermatitis on the dorsal right front foot of a 10-year-old, castrated male Labrador retriever (case no. 4).Figure 6—. A mast cell tumor mimicking acral lick dermatitis on the dorsal right front foot of a 10-year-old, castrated male Labrador retriever (case no. 4).
Figure 6 — A mast cell tumor mimicking acral lick dermatitis on the dorsal right front foot of a 10-year-old, castrated male Labrador retriever (case no. 4).

Citation: Journal of the American Animal Hospital Association 43, 4; 10.5326/0430215

Figure 7—. Photograph of the same area illustrated in Figure 6, after 1 month of antibiotic treatment.Figure 7—. Photograph of the same area illustrated in Figure 6, after 1 month of antibiotic treatment.Figure 7—. Photograph of the same area illustrated in Figure 6, after 1 month of antibiotic treatment.
Figure 7 — Photograph of the same area illustrated in Figure 6, after 1 month of antibiotic treatment.

Citation: Journal of the American Animal Hospital Association 43, 4; 10.5326/0430215

Figure 8—. Acral lick dermatitis-like lesion on the dorsal right carpus of a 9-year-old, spayed female Beauceron (case no. 5) with cutaneous leishmaniasis.Figure 8—. Acral lick dermatitis-like lesion on the dorsal right carpus of a 9-year-old, spayed female Beauceron (case no. 5) with cutaneous leishmaniasis.Figure 8—. Acral lick dermatitis-like lesion on the dorsal right carpus of a 9-year-old, spayed female Beauceron (case no. 5) with cutaneous leishmaniasis.
Figure 8 — Acral lick dermatitis-like lesion on the dorsal right carpus of a 9-year-old, spayed female Beauceron (case no. 5) with cutaneous leishmaniasis.

Citation: Journal of the American Animal Hospital Association 43, 4; 10.5326/0430215

Figure 9—. Photomicrograph of the biopsy of the lesion in Figure 8, showing Leishmania spp. organisms in macrophages (arrow). (Hematoxylin and eosin stain, bar=10 μm.)Figure 9—. Photomicrograph of the biopsy of the lesion in Figure 8, showing Leishmania spp. organisms in macrophages (arrow). (Hematoxylin and eosin stain, bar=10 μm.)Figure 9—. Photomicrograph of the biopsy of the lesion in Figure 8, showing Leishmania spp. organisms in macrophages (arrow). (Hematoxylin and eosin stain, bar=10 μm.)
Figure 9 — Photomicrograph of the biopsy of the lesion in Figure 8, showing Leishmania spp. organisms in macrophages (arrow). (Hematoxylin and eosin stain, bar=10 μm.)

Citation: Journal of the American Animal Hospital Association 43, 4; 10.5326/0430215

Figure 10—. Acral lick dermatitis-like lesion on the dorsal right carpus of a 1.5-year-old, castrated male Labrador retriever-cross (case no. 6), arising at the site of infection containing organisms compatible with a diagnosis of sporotrichosis.Figure 10—. Acral lick dermatitis-like lesion on the dorsal right carpus of a 1.5-year-old, castrated male Labrador retriever-cross (case no. 6), arising at the site of infection containing organisms compatible with a diagnosis of sporotrichosis.Figure 10—. Acral lick dermatitis-like lesion on the dorsal right carpus of a 1.5-year-old, castrated male Labrador retriever-cross (case no. 6), arising at the site of infection containing organisms compatible with a diagnosis of sporotrichosis.
Figure 10 — Acral lick dermatitis-like lesion on the dorsal right carpus of a 1.5-year-old, castrated male Labrador retriever-cross (case no. 6), arising at the site of infection containing organisms compatible with a diagnosis of sporotrichosis.

Citation: Journal of the American Animal Hospital Association 43, 4; 10.5326/0430215

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    MacDonald JM, Bradley D. Acral lick dermatitis. In: Bonagura JD, ed. Kirk’s Current Veterinary Therapy XIII Small Animal Practice. Philadelphia: WB Saunders, 2000:551–555.
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Copyright: Copyright 2007 by The American Animal Hospital Association 2007
<bold> <italic toggle="yes">Figure 1</italic> </bold> —
Figure 1 —

Cutaneous lymphoma mimicking acral lick dermatitis on the medial right carpus in a 9-year-old, male Beauceron (case no. 1).

<bold> <italic toggle="yes">Figure 2</italic> </bold> —
Figure 2 —

Acral lick dermatitis-like lesion on the dorsal left carpus of a 5-year-old male miniature pinscher (case no. 2), arising from the presence of an orthopedic pin in the radius.

<bold> <italic toggle="yes">Figure 3</italic> </bold> —
Figure 3 —

Radiograph of the left leg of the lesion in Figure 2, showing the intramedullary Kirschner pin in the distal radius.

<bold> <italic toggle="yes">Figure 4</italic> </bold> —
Figure 4 —

Deep pyoderma mimicking acral lick dermatitis on the dorsal left carpus in a 6-year-old, spayed female Labrador retriever (case no. 3).

<bold> <italic toggle="yes">Figure 5</italic> </bold> —
Figure 5 —

Photograph of the same area illustrated in Figure 4, after 3 months of antibiotic treatment.

<bold> <italic toggle="yes">Figure 6</italic> </bold> —
Figure 6 —

A mast cell tumor mimicking acral lick dermatitis on the dorsal right front foot of a 10-year-old, castrated male Labrador retriever (case no. 4).

<bold> <italic toggle="yes">Figure 7</italic> </bold> —
Figure 7 —

Photograph of the same area illustrated in Figure 6, after 1 month of antibiotic treatment.

<bold> <italic toggle="yes">Figure 8</italic> </bold> —
Figure 8 —

Acral lick dermatitis-like lesion on the dorsal right carpus of a 9-year-old, spayed female Beauceron (case no. 5) with cutaneous leishmaniasis.

<bold> <italic toggle="yes">Figure 9</italic> </bold> —
Figure 9 —

Photomicrograph of the biopsy of the lesion in Figure 8, showing Leishmania spp. organisms in macrophages (arrow). (Hematoxylin and eosin stain, bar=10 μm.)

<bold> <italic toggle="yes">Figure 10</italic> </bold> —
Figure 10 —

Acral lick dermatitis-like lesion on the dorsal right carpus of a 1.5-year-old, castrated male Labrador retriever-cross (case no. 6), arising at the site of infection containing organisms compatible with a diagnosis of sporotrichosis.

Contributor Notes

Address all correspondence to Dr. White.
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