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Written by a Medical Acupuncture for Veterinarians Course Graduate. Author’s name available upon request. Signed release obtained from client/author/4934.

Abstract

A 25-year-old thoroughbred mare presented for chronic dermatitis and pruritus and was treated with acupuncture after failing to completely respond to conventional treatments. She responded well to one dry needling acupuncture treatment and is less pruritic.

Case Report

Angel presented for extreme pruritus and dermatitis on 4/14/16. She had raw areas from self-traumatization due to scratching. She was prescribed oral prednisolone powder and silver sulfadiazine for the raw areas. The wounds worsened and she was started on antibiotics (SMZs, Excede). Angel was tested for PPID and was positive5 with a baseline ACTH level of 38.9pg/mL so she was started on Prascend tablets. She continued to improve with antibiotics and PPID treatment, but continued to have areas of dermatitis and be pruritic. Angel was tested for allergies on 8/30/16 and the results showed that she was allergic to fescue, sage, hazlenut, candida albicans, timothy, russian thistle, birch, ryegrass, rhodotorula, alder, nigrospora, curvularia, ragweed, juniper, cedar, helminthosporium and cephalothecium. Her diet was reviewed and allergens removed from her diet. Acupuncture treatment was recommended for further management of Angel.

On the day of her first acupuncture treatment, Angel had a dull mentation but was responsive on presentation. She had multifocal areas of alopecia all over her body, with sores over both her fetlocks, and was severely pruritic. All other physical examination parameters were within normal limits. A neurologic exam was not performed. Angel’s myofascial palpation showed reactivity on the left at points ST-7, BL-10, GB-21, ST-10, BL-18, BL-21, BL-53 and BL-54, and on the right to ST-7, BL-10, LI-18, SI-9, BL-23, BL-53 and BL-54.

Angel’s acupuncture treatment consisted of the dry needling using the following points. Bai Hui was chosen as a starting point as it is innervated by the mid to caudal lumbar spinal nerves and will help treat the reactivity she demonstrated on scan to BL-53 and BL-54. BL-25 (midlumbar spinal n) and BL-26 (caudal lumbar spinal n), BL-27 (S1 spinal nerves) and BL-53 were also used bilaterally to treat the hind end trigger points.  GB-21 was not used as a starting point, even though it is usually a relatively innocuous initial point, because Angel demonstrated reactivity to it on the scan and she had not had acupuncture before. It was, however placed as local treatment for GB-21 reactivity. LI-18 was also used to treat local neck reactivity. GV-14, innervated by the cervicothoracic spinal nerves, was chosen as a regional point to neuromodulate neck and head local reactivity to myofascial palpation, as well as its usefulness for treating immunologic dysfuction. PC-9, LI-4, LI-1 on the right, and LU-11 on the right, were chosen as front end points. Her front legs, especially dorsal fetlocks were particularly affected by dermatitis, and these points were at accessible areas with unaffected skin. The rationale behind this was by neuromodulating regional areas; it might stimulate wound healing along areas innervated by these median and ulnar nerves as well.

Additionally, BL-54, LU-5, LI-1 and LU-11 on the left were tried but not tolerated well by Angel. I would have also liked to use LU-7, and SP-10 since they are indicated for skin conditions, but both these points were located over areas where dermatitis was present and I did not want to cause an infection by needling through affected areas. These would be points to consider if dermatitis in these areas resolves during follow-up treatment. Electroacupuncture would have been helpful but would likely not have been tolerated by Angel at this time as she was very antsy during her treatment. Laser acupuncture would also have been useful for helping wound healing, but that modality was not available to me at this time.

On follow up examination two weeks later, Angel was much brighter and less pruritic. Areas of dermatitis were still present, as were the wounds on the dorsal part of her fetlocks bilaterally.

Acupuncture points show neuronal innervation, as evidenced by the increased concentration of the neurotransmitter substance P at acupuncture point on histological tissue samples4. The skin as an organ system has very dense nervous innervation. Neurons come into contact with various types of cutaneous cells by axon terminals, which contain neurosecretory vesicles which have neurotransmitters in them3. Merkel cells and Langerhans cells in the skin synthesize neurotransmitters. Neuromediators, such as substance P, can modulate functions of the Langerhans cells3. In atopic dermatitis, the cutaneous concentration of substance P decreases. While Angel has not been diagnosed with atopic dermatitis, her clinical signs are similar, and stimulation of increased cutaneous substance P by dry needling at acupuncture points could help explain her clinical improvement.
Segmental acupuncture has been shown to inhibit histamine-induced pruritus1. Nonsegmental acupuncture had no effect1. On follow up, Angel was less pruritic and segmental acupuncture during treatment #1 could explain this.

Electroacupuncture helps enhance innate immunity, and helps modulate adaptive immunity2. As a follow up treatment, I would like to use electroacupuncture on Angel if she will tolerate it, as I believe it will help the immune mediated component of her dermatitis if there is one. Angel’s improvement from management with appropriate medication had plateaued and I believe the acupuncture treatment further enhanced the improvement of her dermatitis and pruritus. There are additional points I would like to needle once Angel’s dermatitis clears up. The current plan is to eliminate allergens from Angel’s feed and schedule another acupuncture appointment and continue her treatment from there.

I typically recommend acupuncture to clients for more musculoskeletal related issues, and Angel’s case was helpful to me in being able to see how acupuncture is helpful and applicable to a wide variety of cases. I will now think to recommend acupuncture more often.

 

References:

1: Rogers PA, Schoen AM, Limehouse J. Acupuncture for Immune-Mediated Disorders. Literature review and clinical applications. Problems in Veterinary Medicine. 1992. 4(1): 162-193

 

2. Kim SK, Bae H. Acupuncture and Immune Modulation. Autonomic Neuroscience: Basic and Clinical. 2010. 157: 38-41

 

3. Misery L. Atopic Dermatitis and the Nervous System. Clinic Rev Allerg Immunol. 2011. 41: 259-266

 

4. Chang WW, Weissensteiner H, Rausch WD, Chen KY, Wu LS, Lin JH. Comparison of Substance P Concentration in Acupuncture Points in Different Tissues in Dogs. The American Journal of Chinese Medicine. 1998. 26(1): 13-18.

 

5. Graves E. Equine Endocrine Diseases: The Basics. AAEP Horse Health. 2015. http://www.aaep.org/info/horse-health?publication=747