Suspected Calcinosis Cutis in my pug, Angel

[PugLife]

Hi to all. I suspect that my beautiful 10-year-old fawn pug, Angel, has iatrogenic cushings from long-term prednisone use, along with calcinosis cutis. We are headed to the dermatologist today and I'm hoping she will be able to either confirm this, and if not, diagnose and treat whatever may be going on with Angel's skin. Our regular vet has not been much help as we have worked to diagnose and treat her skin issue.

A little background info - Angel has mast cell tumors. She had surgery to remove three of them in September of 2017, and the aftermath was horrendous. She nearly died and was in the emergency vet hospital for several days on oxygen and getting a blood transfusion. Awful.

Since then, she's been mostly healthy, with the exception of having more mast cell tumors pop up from time to time. We refuse to operate on her again, and so the vet recommended putting her on Benadryl and Prednisone to keep the tumors down. We started the Prednisone in June of 2018. Over time, we had dropped her down to a very low dose (5 mg/day), and she seemed to be doing well on that. (She weighed 16 pounds at that time, by the way.)

Recently, she developed another small tumor on her leg, so we upped her Prednisone to 10 mg/day. Around that time, I noticed some scabbing and oozing in the middle of her back. I took her to the vet, and when he clipped back her fur, we could see that she had a large amount of red, broken, oozing skin along a large section of her spine. They took some surface smear slides to see if this was mast cell related. The results came back with no mast cells, but positive for bacterial infection. The vet gave her an antibiotic shot, a shot of Dexamethasone and Benadryl (just in case it was mast cell-related), and gave us Entederm ointment and Dermabenss shampoo to use on her. After a day or so, her back started to look much, much worse. It was oozing a lot and looked redder, and sort of raised and puckered. And it looked like the red/scabby/scaly area was spreading both forwards and backwards. So I took her back to the vet. This time, they did fine needle aspirations to again look for mast cells, since it seemed like the skin was just getting angrier. Again, they found no mast cells. They sent us off with an oral antibiotic (Zeniquin) and a different ointment (Mupirocin). I asked the vet if we should stop her prednisone so her skin could heal, and they told me no.

A couple of days ago, I found another new crusted spot under her fur towards her head. These antibiotic treatments just do not seem to be doing anything good for this. I've been researching like crazy, and I started reading about calcinosis cutis. It seems to fit in this case - she has developed a hard, scaly, crusty plaque all along her back, and none of the antibiotics are helping it. With her long-term Prednisone use and the Dexamethasone shot, I can't help but think that she has developed calcinosis cutis.

Here are the other symptoms she has that seem to fit with the Cushings diagnosis:

Increased drinking and urinating
Accidents in the house
Pot belly
Lethargy
Muscle weakness in her back legs


She is a pug and very into food and eating, so it's difficult to tell if her extreme appetite is due to Cushings. However, I should note that she has gained a couple of pounds without us changing anything in her diet or exercise. Also, the muscle weakness, lethargy, drinking, and urinating have gotten way worse since the Dexamethasone shot.

Additionally, here are some abnormalities in the bloodwork that the original vet did:

CREA 0.4 mg/dL - LOW - (Reference range 0.5 - 1.8)
ALT 193U/L - HIGH - (Reference range 10 - 125)
ALKP 237 U/L - HIGH - (Reference range 23 - 212)
AMYL 265 U/L - LOW - (Reference range 500 - 1500)
TT4 0.9 ug/DL - LOW - (Reference range 1.0 - 4.0)
RBC 4.99 M/uL or 2.14 M/uL - LOW - (Reference range 5.50 - 8.50)
HCT 34.8% or 15.2% - LOW - (Reference range 37.0 - 55.0)
HGB 11.5 or 11.2g/DL - LOW - (Reference range 12.0 - 18.0)
MCH 23.0 or 52.4 pg - Normal or HIGH - (Reference range 18.5 - 30.0)
WBC 12.70 or 18.16 K/uL - Normal or HIGH - (Reference range 5.50 - 16.90)
NEU 8.78 or 13.87 K/uL - Normal or HIGH - (Reference range 2.00 - 12.00)
MONO 2.36 or 2.69 K/uL - HIGH - (Reference range 0.30 - 2.00)
PLT 575 or 201 K/uL - HIGH - (Reference range 175 - 500)


The vet re-ran the CBC because the numbers looked so off, and he thought that there must have been some issue with the sample, like it coagulated or something. So that's why those tests have two values listed. The values that I listed first are what appeared in the second CBC test.

Despite the vet's assurance that the Prednisone isn't the problem, I decided to wean Angel off of it, and we should be done with that by the end of this week. I will be asking tons of questions at the dermatologist today, but I wanted to post here to find out if anyone has experience with the reversal of these Cushings symptoms after weaning off Prednisone. I also wanted to post as a PSA in case anyone out there stumbles across this in the future, so that they will know that even at low doses, long-term use of Prednisone can potentially cause issues like this. I will upload photos of Angel's skin as well here in a moment, and I will update later with details from the dermatologist and how her treatment progresses.

Thanks very much to this community for having a place to discuss this issue. I think it's very needed!

[PugLife]

I can't figure out the photo uploading right now. I'll link to the images on Imgur for now, and try to figure out how to resize them later so that I can upload them to an album here.

After being clipped and cleaned at the vet: https://i.imgur.com/tQqYGxU.jpg

Two days later: https://i.imgur.com/0eZP1BU.jpg

A couple more days later: https://imgur.com/0UNE8wH.jpg

Later still. You can really see how it's spreading towards her head here: https://i.imgur.com/KaojCLO.jpg

Getting extremely crusty: https://i.imgur.com/CEuJoUi.jpg

After a bath to remove some crusts: https://i.imgur.com/Dji6lxV.jpg

Today: https://i.imgur.com/zvflZRf.jpg

[labblab]

Welcome to you and your sweet little Angel! Yep, those photos do indeed look like CC to me. Along with all the other symptoms and test results you’ve described, Iatrogenic Cushing’s definitely seems likely. The good news is that, from the Cushing’s standpoint, you should indeed see symptom improvement once the prednisone is discontinued. However, as severely as her skin is affected, I’m thinking it may take a fair amount of time for that to clear. The dermatologist should be a helpful guide in that respect.

One cautionary note, though — I’d specifically confirm an appropriate prednisone taper with the dermatologist. If you try to wean too abruptly, you can create a whole other set of problems. During these eight months of prednisone supplementation, Angel’s adrenal glands may have shut down their natural production of cortisol, leaving her now with an inadequate supply if the taper proceeds too quickly. So do check to make sure that you’re following a prescribed protocol. And definitely do keep us updated!

Marianne

[PugLife]

Welcome to you and your sweet little Angel! Yep, those photos do indeed look like CC to me. Along with all the other symptoms and test results youÂ’ve described, Iatrogenic CushingÂ’s definitely seems likely. The good news is that, from the CushingÂ’s standpoint, you should indeed see symptom improvement once the prednisone is discontinued. However, as severely as her skin is affected, IÂ’m thinking it may take a fair amount of time for that to clear. The dermatologist should be a helpful guide in that respect.

One cautionary note, though — I’d specifically confirm an appropriate prednisone taper with the dermatologist. If you try to wean too abruptly, you can create a whole other set of problems. During these eight months of prednisone supplementation, Angel’s adrenal glands may have shut down their natural production of cortisol, leaving her now with an inadequate supply if the taper proceeds too quickly. So do check to make sure that you’re following a prescribed protocol. And definitely do keep us updated!

Marianne

Thanks for the welcome, Marianne!

The dermatologist agreed that this appears to be calcinosis cutis. We opted not to do a biopsy yet, both to spare her the procedure and to save the funds, as it was going to cost around $500, and we're still going to need funds to take her back to an oncologist to figure out a new treatment for her mast cell tumors since she can no longer have steroids. The dermatologist was about 90% certain even without biopsy, so we'll work off of this diagnosis for now, but we can always biopsy later if we need to confirm. He took some slides to look for infection and did not see any sign of infection at this stage, so it appears that the previous treatments have at least curtailed the infection for now.

You make a very good point about tapering off the prednisone. Both the dermatologist and the original vet suggested a similar tapering schedule, and on that schedule, she should take her last dose in two days. And you are right about things taking a long while to heal after the prednisone is out of her system. The dermatologist said the same thing, and said it might be up to 6 months or more before things are resolved. He said that all of the calcium that's currently in her skin will be pushing its way out, which will cause more redness, oozing, and possibility of infection, and things will likely look worse before they look better. I can already see a few more red oozy patches under her fur going towards her head. I'm not quite sure how we will be able to put her collar on her for walks if this goes all the way to her head. Maybe if we place a gauze pad between the collar and her skin, or perhaps cut off the arm of an old t-shirt and put that around her neck under the collar?

Since this will be a long process, he prescribed a different topical antibiotic, silver sulfadiazine cream. He noted that long-term use of Mupirocin tends to create resistant bacteria, so even though that has been helpful for the infection, we're stopping that now. We started the silver sulfadiazine this morning, and unfortunately, it's looking like it's more difficult to apply evenly over the crusts and plaques on her back. I asked about DMSO gel since I've heard about it both here and on Pug Village, and they are ordering that for me and it should be in by Friday. We will be applying the silver sulfadiazine in the morning and the DMSO gel at night, and he suggested bathing her once per week. If anyone has suggestions for the best shampoo to use, please let me know. The DermaBenSs that the original vet prescribed seems too harsh and makes her skin red.

I also asked about oral minocycline and/or aluminum-based antacids. Those were both suggested to me by a member of Pug Village as ways to help her body bind and remove the excess calcium. The dermatologist didn't like the idea of the minocycline as it's an antibiotic, and he didn't want her to have to take an antibiotic for 6 months. He wasn't sure about the aluminum-based antacids, so he's supposed to be researching that and get back to me later. Does anyone here have experience using either of these drugs to help calcinosis cutis heal faster? Or any links to research on it?

I'm going to be scouring this site to review how others have helped heal their pup's calcinosis cutis, but if anyone would be up for posting their treatment regimen here, what worked and what didn't, etc., I'd greatly appreciate it. I will also post pictures as Angel's skin progresses. And I will update on the resolution of her other symptoms, too. My plan is to watch them closely, and take her in for another set of bloodwork in a few months to see if things are going back to normal with the steroids out of her system.

[labblab]

I’m afraid I only have a moment to type right now, but if you’re a Facebooker, here’s a link to a Facebook group that is dedicated to CC. I’m not a Facebooker myself, but I understand this is quite an active group.

https://m.facebook.com/groups/988564191285009/

Also, here’s a link to a thread about CC that appears on our “Everything Else” forum. You may find some helpful info there, although there’s undoubtedly a lot more info spread around on individual members’ threads.

https://www.k9cushings.com/forum/showthread.php?8909-Calcinosis-Cutis-treatment-thread

As far as shampoo, it might be a good idea to check with the dermatologist in order to make sure you’re not getting something with an ingredient that would conflict with your other topicals. However, I’ve been very pleased with a couple of different Douxo products. I’ve been using their chlorhexidine shampoo on my non-Cushing’s Lab who has suffered from recurrent staph infections, and I used their seborrhea formula on another dog. They have multiple formulas for different purposes, and I’ve been impressed with the overall quality of their products. But again, you may want to check with the dermatologist first.

Gotta run for now, but I’ll try to return later.
Marianne

[PugLife]

I’m afraid I only have a moment to type right now, but if you’re a Facebooker, here’s a link to a Facebook group that is dedicated to CC. I’m not a Facebooker myself, but I understand this is quite an active group.

https://m.facebook.com/groups/988564191285009/

Also, here’s a link to a thread about CC that appears on our “Everything Else” forum. You may find some helpful info there, although there’s undoubtedly a lot more info spread around on individual members’ threads.

https://www.k9cushings.com/forum/showthread.php?8909-Calcinosis-Cutis-treatment-thread

As far as shampoo, it might be a good idea to check with the dermatologist in order to make sure you’re not getting something with an ingredient that would conflict with your other topicals. However, I’ve been very pleased with a couple of different Douxo products. I’ve been using their chlorhexidine shampoo on my non-Cushing’s Lab who has suffered from recurrent staph infections, and I used their seborrhea formula on another dog. They have multiple formulas for different purposes, and I’ve been impressed with the overall quality of their products. But again, you may want to check with the dermatologist first.

Gotta run for now, but I’ll try to return later.
Marianne

Thank you so much, Marianne! The Facebook group is great, I've been reading posts there and gaining so much knowledge and support.

I keep discovering more lesions coming up every day. It feels discouraging in the moment, but then I remember that the dermatologist told me this would happen and that all of the deposits must work their way out of her skin. Poor girl.

[PugLife]

Just thought I'd check in with an update on Angel. She has been off Prednisone for about a week and a half. However, just as the dermatologist predicted, things have continued to worsen with her skin. She now has lesions from the top of her head nearly to her tail, and down the sides of her face. I can also feel several little bumps coming up through the skin over her shoulders spreading towards her sides. I've even found some redness and suspicious looking patches in her armpit; those have me particularly worried as they don't look like the calcinosis lesions, and I'm concerned they might be mast cell tumors. She won't let me get much of a look at them (can you blame her??), so I'll need to wait until my husband gets home tonight to get a good peek.

She deals fairly well with most of this, but the lesions on her face are really itching her, and she's attempting to rub them on everything. I had to break down and put her in the "cone of shame," which is tricky because it rests against the lesions on her neck, further irritating them. I cut off the arm of an old tshirt and slipped it over her head under the cone, and that helps a little bit, but not much. *sigh* I wish I had a better update. We are continuing with the treatments the vet prescribed and just praying that we are nearing the end of the "things get worse" phase so that she can start feeling better.

[Joan2517]

Awww, the poor girl. I fell so badly for her.

[PugLife]

Thanks, Joan - I feel so badly for her, too!

I took Angel back to the dermatologist last week because I was concerned that she had an infection. Sure enough, she did, so she's now back on Zeniquin to help with that. The dermatologist also clarified that what he meant when he said it would get worse was that the existing lesions would probably look worse before they looked better. He did NOT mean that she could be expected to have so many new lesions. But since she is still getting new lesions after 3 weeks off Prednisone, he suspects that she might have endogenous Cushings rather than iatrogenic Cushings. He wants us to wait until she's been off Prednisone for four weeks, then run an ACTH stim test. I wish we could run the test sooner; it's an incredibly frustrating and helpless feeling to watch her skin deteriorate day by day.

[Squirt's Mom]

Her derm vet may well be correct concerning the Iatrogenic VS conventional Cushing's. However CC is caused by calcium deposits under the skin and those deposit must work their way up and thru the skin to the outside, causing new lesions as they do. Even if she does have true Cushing's and starts treatment you can expect new lesions to form as the CC heals. This is sadly a condition that gets much worse before it gets better....but it CAN get better so don't get discouraged.

Hugs,
Leslie

[PugLife]

The results are back from Angel's ACTH stimulation test, and the dermatologist says they are negative for Cushings. Here are the results:

* CORTISOL SAMPLE 1 - 1.6 (Range 1.0 - 5.0 ug/dL)
* CORTISOL SAMPLE 2 - 11.6 (Range 8.0 - 17.0 ug/dL)

The samples were taken one hour apart.

So it looks like she really is still just dealing with fallout from the Prednisone use. I'm so relieved to hear that she doesn't have Cushings, but I'm wondering how much longer it will be before we will stop seeing new calcinosis lesions, and see a lessening in her extreme drinking and peeing. If anyone has any experience with this and can chime in with how long it took for new lesions to stop forming after you stopped steroid/Prednisone use, I'd really appreciate it. Angel has now been off of Prednisone for just over 4 weeks.