"My dog scratches her face vigorously,
non-stop last night," the lady with red
eyes showed me a young Shih Tzu with
bright red cheek, ear and eye areas. "Is
she suffering from an allergy?" Her friend
had brought her in to Toa Payoh Vets on
this fine Saturday morning, May 12, 2012.
I was present from 9 am as I was
conducting a "trust and audit" process on
Dr Jason Teo. This is part of effective
management of a licensee to ensure a high
standard of veterinary care and to rectify
errors and omissions of the practice.
"I remember your case," I
said to the lady friend as I fished out
the card assuming that the affected dog
belonged to the introducer. The referred
lady who had red eyes said: "I just want a
second opinion. For the past one and a
half weeks after treatment by Vet 1, my
dog is not getting better. She is still
very itchy and her skin is full of red
I put the dog on the
examination table and viewed the records
and medication of Vet 1.
- 5307. Itchy and crusty
ears. Scabies and ringworm in a
young female sibling Shih
Tzu of one owner
"Most likely, your dog has
scabies," I pointed to the crusted lumps
on the ear edges. "Just like your friend's
dog I treated some 4 weeks ago."
"No," the lady with the
red eyes showed me a bottle of
an anti-fungal liquid medication which
stated "for cats", an ear drop bottle and
an enzyme-based shampoo. "Vet 1 had
written in the case sheet - no
sarcoptic or demodectic mites seen. She
said my dog has malassezia inside the
ears." Vet 1 had confirmed by staining.
"It is possible that
your dog has malassezia, a yeast
infection." I said. "Negative skin
scrapings do not mean there are no
scabies. After all, your friend's dog, the
sibling of this dog, had scabies."
The following are the images I took of the
friend's case scabies 4 weeks ago. The dog
is a sibling of the presented case.
- 5309. Itchy and crusty
ears. Scabies in the sibling
of another owner, 4 weeks
ago. Now fully cured. No
images available as the
owner did not come back for
any review since the hairs
have had grown back on the
ear edges and there is no
"It is not possible as
our dogs don't meet." the lady with the
read eyes disagreed with my "instant
diagnosis" and Vet 1 had stated that her
dog does not suffer from mites due to one
or more skin scraping done.
"Scabies can be
transmitted by owners' hand. Did you touch
her dog earlier?"
"Yes," she said.
"Any kiss and hugs?"
"Yes," she laughed. All puppies usually
get kisses and hugs from lady owners.
"So your hands could have transmitted
scabies mites to your own dog. When did
you touch your friend's dog?"
"One to two months ago."
"How is the scabies dog
now?" I asked the friend who had asked me
why Dr Vanessa was not present on this
second visit. She wanted Dr Vanessa as her
puppy was vaccinated by her, she told me.
She came again in the morning, before 12
noon and Dr V worked from 12 noon to 8 pm
on weekdays and that was why she missed
I said to the friend, "Do you remember
seeing one scabies mite under the
"Yes," the friend said.
"My dog is fully cured now. I complied
with all your instructions of cleaning."
"Normally it will take 2
weeks and one injection to recover," I
"My dog recovered in 1
week as the hair grew (back on the ear
So, now I have to prove
that this lady's dog has scabies. Actually
Dr Jason was on duty on this Saturday. So
I asked Dr Jason and Mr Min to do a few
skin scrapings. "Make sure it is deeper
into the skin. There is no need to use
oil. A drop of water will do." So both
took the dog to the back room and produced
a skin scraping.
I examined the skin
scraping from Min and put the slide under
the microscope. I scanned the hairs and
cell debris. There was no scabies mites.
"I can't find any mite,"
I said to the lady owner. "I will have to
do a deeper skin scraping to look for the
mites." The lady cringed at the thought of
drawing more blood from the ear edge skin
scraping as she could feel the pain of her
young dog. She had diagnosed "allergy" as
her dog had scratched herself violently.
Dr Jason shook his head
when I told him there was no mites seen
from the ear crust. "No mites, no
scabies." Simple as that. "Perhaps, the
ear crusting could be ear trauma," I
speculated. There was evidence and I was
quite sure that the crusty ear spot was
due to the burrowing of the scabies mites.
However, no smoke without fire. No scabies
diagnosis without scabies mites. I was at
the dead end. No light at the end of the
Yet the clinical signs
of intense itchiness of the face, cheeks
and ears over one and a half weeks meant
there were some mites burrowing deep
inside the skin. The elbows and hocks were
reddish and hairless. The backside had
several ringworm like patches (see images
above). So, there was some pathogens
attacking the skin. Malassezia and
ringworm medication were given for the
past 10 days and yet there was no
improvement in the skin disease.
"Is the anti-fungal
medication bottle that states 'for
cats' safe for use in dogs?" the lady with
red eyes asked me.
"Well, the liquid
medication in the bottle is not produced
by the drug company for dogs. It is
marketed for cats. However, the dog can
take the medication if given appropriate
The problem is that this
young female dog was still scratching
intensely and was wild last night,
upsetting the lady whose red eyes could be
due to emotions rather than infections, in
Knowing that the lady
would prefer no more skin scraping, I had
second thoughts of traumatising her. The
dog is family and any deep skin scraping
would be brutal in her opinion. Yet talk
is cheap. Show and tell is the best
I reviewed the slide again instead of
doing another skin scraping. Hoping
against hope. I scanned mm by mm. And
suddenly, the Gods were kind to me. A fat
looking squarish mite was moving his six
claws under the slide! "Come and see the
scabies mite," I asked the lady with the
The owner saw it under
the higher power. I got the power to the
lower one and the mite was distinctly seen
by the lady. It was alive and punching its
So, there was proof of
No smoke with fire. No
scabies without scabies mites. I could
find only one. But that was sufficient
evidence as it is sometimes very difficult
to find them. Unless the skin scraping is
deeper as the mites burrow under the skin.
I did not do the skin scraping myself and
this case was part of the "trust and
audit" case for my staff.
Once the diagnosis was
there, the owner had confidence in the
veterinary surgeon's competence. This is a
tough world as Singaporeans are now highly
educated and well informed.
The treatment is a simple injection of
ivermectin subcutaneous. Sometimes two
injections are needed, but usually one is
sufficient if the dosage is just correct.
However, this sibling seemed to have some
systemic disease like hormonal disorder as
the whole body below the chest was
affected by skin wounds and infections.
"I need a blood test to check on the
health of this dog," I advised. The owner
consented. This may not be a simple case
of scabies and malassezia. But it may be
related to a poor immune system or
hormonal imbalance like an early stage of
"polycystic ovary syndrome (PCOS)." Many
doctors will diagnose a young lady putting
on weight as having eaten too much but she
may be suffering from PCOS.
So in this case, the dog's generalised
skin disease could be due to a poor immune
system as she had been on anti-ringworm
medication for the past one and a half
weeks with no response.
It is hard to say at this stage as more
tests for hormones can be expensive. Two
siblings. One had scabies only on the ear
edges. This one had the whole body
infested with skin disease. Why?
FOLLOW-UP ON MAY 16, 2012
I phoned the owner today, May 16, 2012 to
enquire about the female shih tzu, one year old
with only one scabies mite shown in the
microscope to her. The friend had the sibling
but its ears were the only area affected.
"A scratch or two, short while
in the morning and evening," she said. "Not like
the furious scratching earlier. Do I have to
consult you 2 weeks later?"
"No, if the hairs grow back,"
I said. "Some scabies dog need a 2nd injection 2
weeks later. Wait and see." I was glad that the
ivermectin injection had worked and the owner
had bathed the dog's skin lesions thoroughly. It
was very stressful for her to see her young dog
scratching for weeks."
Blood test was taken on May
14, 2012 as the dog had generalised chronic skin
"Normal blood test results,
except for increased liver enzymes," my
associate vet told me.
RESULTS are normal for the total white cell
count but if you analyse the profile of the cell
types, you will see that this dog has a chronic
infection as evident by increase in monocytes to
11% and eosinophils to 8%. Normally the values
are below 2%.
Total WCC 11.9 (6-17)
is normal but the monocytes and
eosinophils are higher than normal
SGPT/ALT 95 (<59)
SGOT/AST 158 (<81)
Could there be other medications given by
the owner's family members affecting the
Did the owner's mother use
medication on the skin over the past months,
affecting the liver?
Overall, this was a chronic
skin disease for a young dog. Was it ringworm
first, yeasts inside the ears and then scabies
spreading from ear edges to face and paws? Or
was there scabies in the first place? It is hard
to say. Blood tests can be useful and in this
case, there was no bacterial infection as Vet 1
had given the antibiotics. Antibiotics don't
kill scabies mites and that was why the dog kept
being itchy and worrying the lady with reddened
Skin diseases are hard to diagnose. Execute
evidence-based medicine. Always show and tell.
This provides confidence to the owner.
Unfortunately, it was not possible to find more
than one scabies mites in both of the dogs.
Other than the possibility of re-infestation, my
hypothesis is that the two dogs were treated
earlier by the breeder or pet shop operator or
animal shelter, as the two owners had
adopted them when they are over 6 months of age.
In the earlier treatment, the dosage of the
anti-mite medication was insufficient to
eliminate all the mites but sufficient to make
skin scrapings negative. This was a case
of no smoke without fire. The fire is the
"scabies mite." I was fortunate in finding only
one scabies mite in each of the two siblings.
Whether one or more, the clinical outcome of
freedom from skin scratching is what the owner
Performance counts although evidence is
BE KIND TO
DOGS & CATS --- GET EYE ULCERS TREATED
WITHIN 4 HOURS --- IF YOU DON'T WANT THEM TO BE
BLIND. More case studies, goto: