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Putnam North Animal Hospital
Lick Granuloma (Acral Lick Dermatitis)
The Basics
Lick granulomas, also known as a acral lick dermatitis, are a self-induced traumatic skin lesion. They are mainly is a problem of dogs, rarely cats. The dog will continually lick at one area of the leg, producing hair loss, irritation, and thickening of the skin. They will typical appear as a raised, red, hairless areas or a skin lump found over the front surface of one limb. Occasionally, there may be sores on more than one limb. The most common locations to find the sores are over or near the wrist (carpus) of the front limb or just below or above the ankle (hock) on the rear limb. Breeds most likely to develop lick granulomas include the Doberman Pinscher, Great Dane, Labrador Retriever, Irish Setter, Golden Retriever, and German Shepherd, but any breed of dog can be affected. Males are affected twice as often as females. The condition may appear at any age; however, most dogs are over 5 years of age when presented for treatment. Although there are several conditions that cause discomfort of the skin and persistent licking, in many dogs with lick granulomas, no underlying problem can be found. In these cases, lick granulomas is considered a psychogenic disease; that is, it is caused by a behavioral disorder. For example, sometimes excessive licking or chewing can result from boredom or can be used as attention-seeking behavior. Sometimes anxiety is the stimulus for stereotypic behaviors like repetitive licking. Stereotypic behaviors are excessive, repetitive behaviors engaged in to relieve psychological distress such as boredom or anxiety.

Diagnosis
Several other skin conditions may appear similar to lick granulomas. These include skin tumors, other granulomas (masses due to chronic inflammation), and deep bacterial or fungal infections. In addition, several conditions that cause pain or itching can be involved in the development of lick granulomas, since dogs will lick areas where they feel tingling or discomfort. Depending upon the appearance of the skin lesion and your pet’s history, we may need to run several tests to check for similar conditions and underlying disorders, including skin scrapings, bacterial or fungal cultures, and skin biopsies. In some cases, x-rays may be warranted to look for joint or bone disease, such as arthritis, or bone infections that can cause pain and therefore cause a dog to lick over the painful area incessantly. A history of trauma or surgery in the area might indicate possible nerve damage as a source of discomfort. A variety of conditions that cause itching can contribute to the development of lick granulomas; these include allergies, skin infections, and skin parasites. If no underlying disease can be found, then by exclusion, psychogenic factors are assumed to be the cause of the dog’s constant licking.

Therefore, the first step in evaluating a dog thought to have a lick granuloma is to perform basic tests to assess for other contributory medical and skin conditions. Once a lick granuloma is confirmed and any possible medical factors have been addressed, a behavioral component can be evaluated as a possible source for the problem. At this point we will try to identify and correct or manage the psychological/behavioral trigger that is leading to the incessant licking.

Treatment
Lick granulomas can be challenging to treat. Medications may help, either for direct application, or as oral tablets or capsules. Often the visible skin lesion is only the surface of the problem, and the root cause is psychological or behavioral. Therefore, the frustration of dealing with a dog that is compulsively licking needs to be met with an understanding that some sort of underlying trigger may exist and that dealing with that trigger is critical to solving the problem. Response to treatment depends upon correction of the underlying cause. Many cases require long-term care at home and adjustment of treatments when the lesion reappears. It is worth remembering that stressful changes in your pet’s life may precipitate reoccurrence of the problem.

There are many approaches to treating lick granulomas, and some trial and error is usually needed to find the best treatment for an individual dog. Since deep bacterial infections of the skin are usually present as well, oral antibiotics are usually given for 1 – 2 weeks or more. The affected skin area can be treated directly with topical medications, sometimes including antibiotics, steroids to reduce inflammation, other anti-inflammatory drugs or even antihistamines. Bitter-tasting topical solutions are sometimes applied to discourage licking. Most treatments that are applied to the lesion are aimed at altering the sensation in the skin by reducing irritation and inflammation or relieving pain. Rarely, removal of the lesion with conventional surgery, laser surgery, or cryosurgery is also advocated. Some degree of relief can also sometimes be brought about by frequently bandaging the leg and/or placing an Elizabethan collar on the dog to break the cycle of licking-itching.

Behavioral components of the condition also need to be addressed. Boredom can be alleviated by increasing playtime, introducing another animal as a playmate, reducing confinement time, or keeping the pet occupied with toys such as those with openings for treats (e.g., Kong-type toys). Several behavioral modification training techniques can be used. Stressful conditions should be eliminated, when possible. Antidepressant and antianxiety drugs may also be helpful in some dogs.

DOs
Be diligent and persistent with treatment. Hair regrowth and reduced compulsion to lick happen very slowly (weeks to months).
Minimize stressful situations that can contribute to anxiety in the pet.
Increase the pets exercise and playtime to help alleviate boredom.
Follow behavior modification treatment plans.
Use medications as prescribed.

DON’Ts
Avoid blaming or acting exasperated with a dog with a lick granuloma. Unfortunately, compulsive licking can truly be exasperating, but yelling at or punishing dogs for doing this simply does not register with them and often can make them more compulsive, which worsens the problem. In other words, harsh words and punishment for licking behaviors tend to be totally counterproductive.
Don’t assume that the problem is entirely in the skin, or entirely in the dog’s mind. Oftentimes, a combination of behavioral factors and skin factors is to blame for lick granulomas.

Signs to Watch For
Persistent licking or chewing at one area on the foot or leg.
Hair loss, irritated skin, and eventually a raised, completely hairless, shiny, reddened area of skin.

Routine Follow-Up
Because determining the best treatment of lick granulomas often requires trial and error, several visits may be necessary to determine the optimal combination of treatments for your dog.
Once the right treatment is found, the visits become much less frequent—generally just routine checkups.