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Discussion on Shoe boil and Surpass use/contraindications

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Brandi Reinert
Member
Username: Brandi

Post Number: 68
Registered: 11-2004
Posted on Tuesday, Oct 4, 2005 - 1:25 am:   Edit PostPrint Post

Dr. O.,

I have a 22-yo gelding with a recurring shoe boil. His first flare up was about 7 or 8 years ago, baseball sized reaction, we treated with initial draining by needle, maybe an injection of an antibiotic, then hosing/massage/dmso, and the addition of a shoe boil boot to his wardrobe, any other details are fuzzy at this point. It resolved and resorbed after a couple of months. 2nd flare up was Jan 2, 2003, grapefruit sized swelling, would not respond to treatment and eventually (w/in a couple weeks) ruptured. We tried a lugol's iodine procedure wherein the cavity was cleaned out and a gauze "rope" was soaked in lugols and packed into the cavity, left for 3 days and then removed. The idea being that the lugols would dry up or kill the serum producing cells that are so troublesome in this sort of situation. It didn't work, and we had an open, draining wound for almost exactly a year before it finally closed. 6 months of that year were spent regularly flushing the cavity with various disinfectant solutions to keep it clean, and periodic flushing after that as needed. By Jan 2004 it was scabbed over and no longer producing fluid. Just yesterday morning it blew up again, grapefruit sized and aggressive. Today the vet at the clinic I use (we drained with a giant needle and added antibiotic) suggested using Surpass to reduce the inflammation. However we also decided to use a DMSO/Dexamethazone compound. I told my vet that this horse is on 1 gm bute per day for arthritis. The Surpass contraindications list both dex and bute (or any other nsaid), and my vet recited these, but felt it was okay. Here are my 2 dollar questions:
Do you have an opinion on the combination of these medications? This vet didn't seem at all concerned, and I've called the maker of Surpass, but not sure I'll get a callback or a practical answer (I expect nothing other than CYA legalese).
Do you have other ideas about treating shoe boils like this? My regular vet jokes that I know more about treating them than most vets, but I just can't imagine that there's not some more innovative or better treatment out there. Anyone else with more or better experience, please share, I'll take any help or ideas I can get.
Thanks.
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Robert N. Oglesby DVM
Moderator
Username: Dro

Post Number: 13849
Registered: 1-1997
Posted on Tuesday, Oct 4, 2005 - 1:15 pm:   Edit PostPrint Post

The problem is not that there is no good treatment for such trauma but that just treating it does not prevent future trauma. It is the recurring trauma that results in a chronic problem.

Hmmmm...I tend to agree with your vet that it PROBABLY is not toxic but disagree with him that with the current mix of antiinflammatories that it is indicated. It looks like you have plenty of antiinflammatory therapy and the only suggestion I have would be to use 1 gm bute twice daily.

Generally each acute episode is worse than the last as the tissues involved become increasingly scarred in and less capable of repair. You could follow your past courses and wait to see if it will resolve and if it opens treat. Or you could be proactive here, open the boil aggressively, debride out the necrotic, bruised, and scarred in tissues. Then very carefully close the wound being sure that dead space is closed as you work your way out. Drains may be indicated and absolute stall rest required for this to heal primarily first intention. Also a neck cradle may be required to keep the horse from tearing at it with his teeth. Of course this is only good until the next hit.
DrO
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Helen Gkikakis
Member
Username: Lilou

Post Number: 3
Registered: 2-2005
Posted on Tuesday, Oct 4, 2005 - 3:32 pm:   Edit PostPrint Post

Brandi, I hope you can figure this out, and your horse will feel better. However, even though I am Greek (from Greece that is), this all sounds TOO Greek to me! What is a shoe Boil?
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Brandi Reinert
Member
Username: Brandi

Post Number: 69
Registered: 11-2004
Posted on Wednesday, Oct 5, 2005 - 2:06 am:   Edit PostPrint Post

Helen, thanks for the well-wishes, and perfect timing on your question, I just took pics of it so you can see firsthand what a shoeboil is.
upShoeboilday3
It is an acute bursitis of the elbow, in my understanding caused by pressure from the shoes due to a horse lying down excessively, or in a particular manner, often because of pain. This photo is day 3 of treatment and 1/3 the size of the day 1 condition--it was literally the size of a LARGE grapefruit on day 1, and it is almost exactly baseball sized now, though it appears smaller in this photo.

Dr. O., Thanks for the feedback. Your comment about opening it is very enticing and I've inquired about it before, but the vets say I would have to stall-tie him for 6 weeks so he couldn't lie down on it. At 22 and full of arthritis from his neck to his hocks, that immobility would probably kill him. But I'm inventing in my mind a vest of sorts made out of closed-cell foam that extends down the leg just past it and is thick enough, with a hole in the elbow so the site would be completely protected. There has been a discussion on this site before that involved using a donut shaped foam or pad mounted inside a blanket for a horse with a hip injury, I'm thinking along the same lines but attached to a shoulder slinky shaped thing with a leg. Too bad I'm not very handy. But Cashel Company might be willing to help...
But to be clear, so I don't expend resources trying to invent something that won't solve the problem, is the idea to keep him from lying down or to keep him still and not move the joint hardly at all, if we were to open it up, and close it up surgically?
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Robert N. Oglesby DVM
Moderator
Username: Dro

Post Number: 13851
Registered: 1-1997
Posted on Wednesday, Oct 5, 2005 - 7:05 am:   Edit PostPrint Post

Oh I see, I did not read between the lines well enough and the clues were there: he develops this from lying down and not from injury during work. I pictured a heavy shod gaited horse with a lot of action striking the elbow with his shoes and that changes things.

While I don't think it would take 6 weeks, yes the horse would have to be kept from lying on it while it healed and you KNOW he is going to do this again. Nix the surgery but still think if you can come up with such apparel it would be beneficial for an uncomplicated healing and further exacerbation of the problem.
DrO
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Kim Fotter
Member
Username: Fpony

Post Number: 377
Registered: 9-1999
Posted on Wednesday, Oct 5, 2005 - 7:53 am:   Edit PostPrint Post

What about a neoprene slipper when he is in his stall so that his shoe doesn't irritate the elbow? Might be easier than trying to get a sling on his shoulder.Cashel might already have something like that. A neoprene sleeve might stay on the elbow like an athlete with a sleeve over the knee with a patella cut out. then you could adhere padding to the sleeve to make that donut shape? Kim
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Brandi Reinert
Member
Username: Brandi

Post Number: 70
Registered: 11-2004
Posted on Wednesday, Oct 5, 2005 - 3:10 pm:   Edit PostPrint Post

Thanks Dr. O., and I didn't even know a horse could get one the way you described, so I thought it was obvious...just when you think you know something....

I also spoke with the vet from IDEXX, the makers of Surpass. I stand corrected, as this guy shared a wealth of information and recommendations. He said he regularly treats horses with Surpass who are on 1 gm bute per day and he sees no problem with that at all. He recommended 24-48 hours between applications of the Surpass and the DMSO/Dex mix, he said the DMSO will destroy the lipids that carry the diclofenac into the system, so you would get a very rapid uptake of meds dumped into the system that would then get processed out of the system readily. In essence you would be wasting your money because the lipids provide a timed-release effect. This Dr. also felt that a chronic shoe boil with lots of scar tissue would be respond very well with Surpass, as opposed to a first-time acute, mostly fluid filled one. I'll let you know.

Kim, thanks for the idea on the slipper, he already wears a foamy rubber donut around his pastern every single night (for the past 3 years), which prevents the shoe from contacting the elbow, and you're right, Cashel does make the slipper you mentioned. I've seen it in their catalog, but the donut seems way easier and I can't see how the slipper would be any more effective--it seems like there's a lot less padding. How he got another flare up wearing the donunt I don't have an explanation for. But I love the idea about the knee brace you describe. Not sure one would stay up, you can see he's pretty muscle-y in the forearm but it's worth a try.
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Brandi Reinert
Member
Username: Brandi

Post Number: 71
Registered: 11-2004
Posted on Thursday, Oct 13, 2005 - 9:54 pm:   Edit PostPrint Post

Dr. O.,
I've been treating this shoeboil, which opened up just a day or so after my last post. The DMSO/Dex was very hard on the skin, so I did switch to the Surpass, and I think it's helping, but I'm not sure anything will be able to make it go down any faster than slow Father Time. 2 or 3 times a day I water-massage it to stimulate blood flow (he really hates cold water, so I'm using warm), dry it, flush the inside of the cavity (which is 90% filled with fibrous tissue) with either dilute betadine or dilute chlorhex, then I apply the surpass all around the outside and add Swat directly to the open/draining area. Do you think this is a reasonable protocol? What do you think of flushing with hydrogen peroxide? Alcohol? I'm looking for something to dry up the inside. I've also thought about using a syringe to inject some of the surpass right into the cavity and trying to devise a way to keep it in there. At the end of 6 hours it has weeped tons of translucent yellow or blood-tinged fluid all down his leg, usually with some pus near the opening. The Swat doesn't last long enough, and I can't get any wraps to stay on...I've considered shoving some roll gauze in there after I've cleaned it. I really want to find some way to hurry this along, I don't want another 11 1/2 months of this like the last time. Anyone have any experience? (by the way Dr. O, you might want to move this discussion to diseases of the upper foot, but I wanted to keep the history with this question, so I posted here.)
Thanks,
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Michelle Boake
Member
Username: Rein

Post Number: 3
Registered: 1-2004
Posted on Friday, Oct 14, 2005 - 1:13 am:   Edit PostPrint Post

Hi Brandi,

I also have a mare that gets this.(Glad you put the picture, as I didn't really know what a shoe boil was either. I guess I always called it "capped elbow") Anyway, I've used "Shriener's Herbal Spray". First I'll clean it out with colloidal silver, then spray Schriener's on.

On our old stud with sores on other parts of his body I sewed sheep skin to his sheet. I had good results from that.

Good Luck,
Michelle
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Robert N. Oglesby DVM
Moderator
Username: Dro

Post Number: 13905
Registered: 1-1997
Posted on Friday, Oct 14, 2005 - 6:56 am:   Edit PostPrint Post

Brandi, follow our directions in the article Equine Diseases » Skin Diseases » Wounds / Burns » Long Term Deep Wound Care to promote rapid healing. The article addresses all your questions directly except for the Surpass.

I am uncertain that a topical NSAID has a place around an open wound. If you have active inflammation going on I would be using oral bute instead.
DrO
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Kathy
New Member
Username: harley13

Post Number: 1
Registered: 7-2008
Posted on Tuesday, Jul 22, 2008 - 9:15 pm:   Edit PostPrint Post

Brandi, I have a Percheron Draft horse that had the same thing happen minus the rupture. I had the vet out and she drained it and now it has gone down but it seems to have moved to the out side of his leg and is very hard. Just when I thought I was out of the woods he got another one on the other leg now. I am using the donuts on both legs and I haven't ridden him in almost 4months from this. My vets don't seem to have any more suggestions either. Both sides are very hard and slightly crusty on the outside. My question is when do I need to worry about this thing rupturing? And should i be hosing it down etc? My vets tell me leave the donuts on and leave them alone. Not good enough if you ask me.
Thanks,
Kathy
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Kathy
New Member
Username: harley13

Post Number: 2
Registered: 7-2008
Posted on Tuesday, Jul 22, 2008 - 9:30 pm:   Edit PostPrint Post

Hi Kathy again,
What is the progression on these shoe boil things? Get large but stay mushy then start to go down but get very hard? Does them moving in different places on the elbow suggest they are going away or are they just damaging the tissue in the new area?
Kathy
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Robert N. Oglesby DVM
Moderator
Username: dro

Post Number: 21128
Registered: 1-1997
Posted on Thursday, Jul 31, 2008 - 6:49 am:   Edit PostPrint Post

Hello Kathy,
If they are not open your veterinarians are pretty close to right: topical treatment often softens the skin and may complicate the issue by creating ulcers. The progress of these things depends on how long they go on being irritated. If the irritation is removed it is possible for these to nearly disappear as the acute firmness is consist of granulation tissue but with chronic injury the granulation tissue becomes scar.
DrO
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M. Lynn
New Member
Username: mlynn

Post Number: 4
Registered: 10-2004
Posted on Saturday, Jul 25, 2009 - 9:50 am:   Edit PostPrint Post

Has anyone heard of using antihistamines for treating "shoe boils"?
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Sara Wolff
Member
Username: mrose

Post Number: 5207
Registered: 1-2000
Posted on Saturday, Jul 25, 2009 - 10:11 am:   Edit PostPrint Post

I've never had a horse with shoe boils, but my understanding is that they are a type of trauma, not an allergic reaction and I think antihistamines are for allergies. I'm sure Dr.O. or someone else with more knowledge will comment.
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dieliz
Member
Username: dsibley

Post Number: 169
Registered: 11-2005
Posted on Sunday, Jul 26, 2009 - 7:01 am:   Edit PostPrint Post

Baron, my Appendix, developed a shoe boil just after we had completed treatment on one of my boarder's horses. (I think he saw a way to make me spend more money on him!!) Spencer, the boarder, ruptured and had to have a drain inserted. He was treated with antibiotics to flush the wound, bute, and stall rest while the wound was open.

Baron's is about the size of a golf ball. It never ruptured, no heat, no soreness. My vet said that, especially with all his other problems, we should just leave it. I totally agree; I don't show him, am lucky to ride him, and if that's the worst thing that happens to him this year, I can live with it.

I would use a 'boil boot' to keep it from getting worse, but he lives in the lean-to outside, and also has this uncanny ability to remove any foreign object on his body and send it swimming in the water tank....
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Brandi Reinert
Member
Username: brandi

Post Number: 115
Registered: 11-2004
Posted on Sunday, Jul 26, 2009 - 4:10 pm:   Edit PostPrint Post

I was the one who originated this post back in 05, and with the recent activity, I thought I would give y'all an update on what we've done for Moon. In January of 06, after 3 more months (after the original year) of an open, oozing wound that wouldn't heal or close or stop producing fluid, I had a wonderful surgeon who used a laser to remove all the scarred tissue. It was hideous for the first few days (picture below but only for those with strong stomachs) but the benefit of the laser is that it that the cauterized tissue requires very little aftercare and tightens up rapidly. It was nicely healed within 2 months with very little aftercare - nothing more than cleaning it. Of course Moon still wears the boil boot (round foamy donut thing) every single night. We were super pleased with the solution. We got another flare-up in Dec 07, which was disappointing to say the least, but we quickly went after it again with the laser and it healed up just as well the second time. I'm on another almost 2-year run of no problems at all. I know that it could happen again (winter time is when it always recurs), but the laser treatment is the way to go for me. I spend so much time and money on flushing, and meds, and annoying the crap out of my horse that this solution, for a couple hundred bucks, is totally the right way to go, and makes me and my horse so much happier.

This has been a great choice for Moon, where flare-ups are more on the rare side, and expecially because his always open up and drain chronically for months and months - for that condition this is a perfect solution in my mind. Moon still has a small chronic scabby area on the point of his elbow, but it's completely benign - I simply peel the stuck shavings off of it now and again, and if it is too pink or has any blood I put a dab of ointment on to keep any flies at bay, and forget about it. Cosmetically it's just a callus looking area, no loose floppy skin or any remaining swelling (hard or soft).

By the way, the first time we had this done I went to my regular clinic where this surgeon did some work, but the second time he just came and did it right in my barn, so if you have the right contacts, it's important to realize this is not a "big deal, fancy" procedure. It's easier than removing sarcoids, etc, as there's more leeway with boundaries and edges.

I hope this can help someone along the way. Here's the post-laser pic:
Moon Shoe Boil post-laser 12/07
I'll add a current one if I can think to snap a photo today so you can see how great it looks. Good luck to anyone who is dealing with these annoying problems.
Brandi
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Robert N. Oglesby DVM
Moderator
Username: dro

Post Number: 23498
Registered: 1-1997
Posted on Monday, Jul 27, 2009 - 8:18 am:   Edit PostPrint Post

Thank you so much for keeping us up to date Brandi. Would it be possible to post a image of the current appearance when cleaned up so folks can get a better idea of what you are describing.
DrO
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M. Lynn
New Member
Username: mlynn

Post Number: 5
Registered: 10-2004
Posted on Monday, Jul 27, 2009 - 8:48 pm:   Edit PostPrint Post

Can you put a shoe boil boot on a horse that is out 24/7? His is very fit and active but is 22 and don't want to risk a bad trip.
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Brandi
Member
Username: brandi

Post Number: 116
Registered: 11-2004
Posted on Wednesday, Jul 29, 2009 - 2:30 am:   Edit PostPrint Post

Okay here you go, sorry this took me so long. The current pics of Moon's healed shoe boil after being lasered off in Dec 07. There is a bit of saggy tissue on the inside, but from the side view it looks near-perfect - I'll include that view next

Moon Shoe Boil Healed
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Brandi
Member
Username: brandi

Post Number: 117
Registered: 11-2004
Posted on Wednesday, Jul 29, 2009 - 2:37 am:   Edit PostPrint Post

Here's the side view - compare this to the picture in the first post.
Moon Shoe Boil Healed Side view

If anyone wants a picture of the shoe boil boot, just ask.

As for turnout - I would worry about interference, injury or tripping, somewhat - and I feel awful when I forget to take off Moon's before he goes out to pasture for the day (I space it about once a year). Balance would be my first concern, though my horse isn't overly active, he is older, so I don't want to cause him any trouble.
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Brandi
Member
Username: brandi

Post Number: 118
Registered: 11-2004
Posted on Wednesday, Jul 29, 2009 - 2:41 am:   Edit PostPrint Post

oops - I meant compare this last pic to the 1st picture in the thread, but it's not exactly in the first post. sorry.
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Robert N. Oglesby DVM
Moderator
Username: dro

Post Number: 23512
Registered: 1-1997
Posted on Wednesday, Jul 29, 2009 - 7:27 am:   Edit PostPrint Post

Great job helping folks Brandi. With your permission I wish to import these images into the article on Shoe Boils and Elbow Hygromas. If I would impose on you further:
1) Can you tell us in more detail how you cared for the wound?
2) And most important to what do you attribute the prevention of recurrence of the boil?
DrO
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Ann
Member
Username: dres

Post Number: 2435
Registered: 10-2000
Posted on Wednesday, Jul 29, 2009 - 9:25 am:   Edit PostPrint Post

Yes, Brandi, please post a pic of the boot on him.. And may i ask if Dr. Tom Y did the lazer..? I know he has done a few around here on other issues..

On the first day God created horses, on the second day he painted them with spots..
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Brandi
Member
Username: brandi

Post Number: 119
Registered: 11-2004
Posted on Wednesday, Jul 29, 2009 - 11:52 am:   Edit PostPrint Post

Dr. O - of course you may use them in any way. For his care immediately following treatment, I did nothing but hose the junk out of it. I tried to tape some gauze to it at first to keep out shavings, etc, but of course it never worked. Literally all I did was hose it clean as needed - which was every day in the beginning. Once it was primarily closed, I put dynamite wound balm on for my peace of mind, but I'm not sure it made any big difference - it might now, if I put it on every other day for a couple of weeks, it might heal that area up just a touch more, who knows. To answer your second question I feel that the most important thing I can do to prevent recurrence is to keep the boot on when he's in his stall at night (he's turned out all day), and keep him bedded deeply - which is of the utmost importance when it is cold outside. This horse in particular gets cold easily (he's always laid in fresh warm poo on cold nights **Yay!** and never any other time of the year), and I feel that he really "tucks in" his feet at this time, pressing his shoe on this area, or in some way putting more pressure on it - so deep bedding helps him not only cushion it, but provides him with some important insulation. His last recurrence was after a cold night on particularly thin bedding (yes, I feel very guilty).
I hope this is helpful.
Ann, I'm sorry I cannot answer your question, I was sworn to secrecy because this particular person doesn't want a barrage of shoe boil procedures - he likes the more interesting and complicated stuff. And since he takes VERY, VERY good care of my herd, I must honor his request. BTW, nice to hear from you!
Here's the boot.
Moon Boil Boot
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Brandi
Member
Username: brandi

Post Number: 122
Registered: 11-2004
Posted on Friday, Jul 31, 2009 - 9:07 pm:   Edit PostPrint Post

Dr. O - after re-reading your updated article, I thought I should clarify something. When it comes to the laser removal of the boil, I feel it was a GREAT solution for me and my horse because he did have all that scar tissue formation inside the bursa, and obviously we had tried nearly everything else (not opening it up, lugol's iodine packing, prolonged flushing and various other treatments over the course of about 4 years - 1 of which involved this boil being open and draining for nearly 10 months!).
I certainly would not reach first for a laser on a first-time occurrence, so I wanted to make that point clear to anyone who might be reading this post.
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