Managing Difficult Canine Atopic Dermatitis Cases: Why Multimodal Therapy Works Better

A Labrador Retriever with chronic canine atopic dermatitis (CAD) has been receiving oclacitinib for over a year. The itching is better than before, but flare-ups still occur every few months. Each episode is managed with additional antibiotics, ear medications, or corticosteroids before the cycle begins again. 

Is the medication failing? 

Not necessarily. 

CAD is a complex disease involving immune dysregulation, skin barrier dysfunction, microbial imbalance, and environmental allergens. No single treatment addresses all these factors. The most successful long-term outcomes are often achieved not by finding a "stronger" drug but by combining complementary therapies that target different aspects of the disease¹. 

Why One Therapy Has Its Limits 

Each of the commonly used therapies in CAD has a specific role. 

• Oclacitinib rapidly controls pruritus by inhibiting Janus kinase (JAK)-mediated cytokine signalling. 

• Lokivetmab specifically targets interleukin-31 (IL-31), one of the primary drivers of itch. 

• Ciclosporin suppresses T-cell activation and is useful for long-term immunomodulation. 

• Glucocorticoids remain valuable for managing acute flare-ups but require careful use because of their long-term adverse effects¹. 

These medications are highly effective at reducing inflammation and pruritus, but none can repair a damaged skin barrier, eliminate secondary infections, or prevent future allergen exposure. That is why multimodal therapy has become the cornerstone of modern CAD management. 

Repair the Skin Barrier 

A defective skin barrier allows allergens, microbes, and irritants to penetrate the skin more easily, fuelling chronic inflammation and recurrent flare-ups¹. 

Barrier repair should therefore be an ongoing part of treatment, even when pruritus is well controlled. 

Useful strategies include: 

• Therapeutic bathing. 

• Moisturising shampoos and conditioners. 

• Topical barrier repair products. 

• Regular ear care in dogs prone to recurrent otitis. 

Maintaining skin integrity can reduce allergen penetration and help decrease the frequency of disease exacerbations. 

Nutrition: More Than Supportive Care 

Nutrition is increasingly recognised as an active component of CAD management rather than simply supportive care. 

Therapeutic diets enriched with omega-3 fatty acids (EPA and DHA), antioxidants, and polyphenol-rich ingredients have been shown to improve skin lesion severity and reduce owner-assessed pruritus when used alongside standard medical therapy². 

Omega-3 fatty acids help modulate inflammatory pathways, while antioxidants reduce oxidative stress that contributes to skin damage. Polyphenols may further support immune regulation and skin health, making dietary intervention an important complement to pharmacological treatment. 

Looking Beyond Calories: Hidden Nutritional Deficiencies 

Recent evidence suggests that chronic inflammation in CAD may interfere with the body's ability to absorb and utilise essential micronutrients, even when dogs consume balanced commercial diets³. 

Functional deficiencies in nutrients such as iron, zinc, and certain vitamins may develop because inflammation alters nutrient transport and availability. Reduced iron availability, in particular, has been associated with ongoing immune activation and impaired tissue repair.³ 

Although nutritional assessment is not yet routine in every dermatology case, these findings highlight the importance of considering nutritional status in dogs with persistent or recurrent disease. 

Don't Forget Allergen-Specific Immunotherapy 

While medications control clinical signs, allergen-specific immunotherapy (ASIT) remains the only treatment that aims to modify the underlying allergic response. 

ASIT may reduce disease severity and medication dependence over time, particularly in carefully selected patients with confirmed environmental allergies¹. Because improvement is gradual, owners should be counselled that benefits often take several months to become apparent. 

Every Difficult Case Needs Regular Reassessment 

Treatment plans should not remain static. 

Regular follow-up allows veterinarians to evaluate: 

• Pruritus severity. 

• Skin lesion progression. 

• Secondary infections. 

• Medication response. 

• Adverse effects. 

• Nutritional management. 

• Owner compliance. 

Objective scoring systems such as the Canine Atopic Dermatitis Extent and Severity Index (CADESI) and owner-reported pruritus scores can help monitor disease progression and guide treatment adjustments². 

Building Your Multimodal Treatment Plan 

For many dogs with chronic or recurrent CAD, successful management involves combining several complementary strategies rather than relying on a single intervention. 

A practical multimodal approach may include: 

• Anti-pruritic or immunomodulatory medication. 

• Prompt treatment of bacterial and yeast infections. 

• Therapeutic skin barrier care. 

• Strict parasite prevention. 

• Nutritional support with therapeutic diets. 

• Allergen-specific immunotherapy where appropriate. 

• Regular monitoring and client education. 

Tailoring this combination to the individual patient allows veterinarians to address the multiple factors driving chronic inflammation rather than focusing solely on itch control. 

The Clinical Take-Home 

There is rarely a single solution for difficult canine atopic dermatitis. While modern medications have transformed disease management, they are most effective when integrated into a broader treatment strategy that includes skin barrier repair, nutritional optimisation, infection control, parasite prevention, and allergen-specific immunotherapy where indicated. By adopting a multimodal approach, veterinarians can reduce flare frequency, minimise medication dependence, and deliver more consistent long-term control for dogs living with this lifelong disease. 

References (Vancouver) 

1. Santoro D, Marsella R, Pucheu-Haston CM, Eisenschenk MNC, Nuttall T, Bizikova P. Current knowledge on canine atopic dermatitis: pathogenesis, diagnosis and treatment. Vet Sci. 2022;9(7):330. doi:10.3390/vetsci9070330. Available from: https://www.mdpi.com/2306-7381/9/7/330 

2. de Santiago MS, Arribas JL, Llamas YM, Becvarova I, Meyer H. Randomized, double-blind, placebo-controlled clinical trial measuring the effect of a dietetic food on dermatologic scoring and pruritus in dogs with atopic dermatitis. BMC veterinary research. 2021 Nov 19;17(1):354. https://doi.org/10.1186/s12917-021-03063-w 

3. Frizzo-Ramos J, et al. Lymph-targeted nutritional supplementation improves clinical outcomes and reduces medication requirements in dogs with canine atopic dermatitis: a randomized, double-blind, placebo-controlled pilot study. Front Vet Sci. 2025. Available from: https://doi.org/10.3389/fvets.2025.1657869