Journal of Feline Medicine and Surgery (2013) 15, 598–604
CLINICAL REVIEW
DERMATOPHYTOSIS IN CATS
ABCD guidelines on prevention
and management
Tadeusz Frymus, Tim Gruffydd-Jones, Maria Grazia Pennisi, Diane Addie,
Sándor Belák, Corine Boucraut-Baralon, Herman Egberink, Katrin Hartmann,
Margaret J Hosie, Albert Lloret, Hans Lutz, Fulvio Marsilio, Karin Möstl,
Alan D Radford, Etienne Thiry, Uwe Truyen and Marian C Horzinek
Overview: Dermatophytosis, usually caused by
Microsporum canis, is the most common fungal
infection in cats worldwide, and one of the most
important infectious skin diseases in this species.
Many adult cats are asymptomatic carriers.
Severe clinical signs are seen mostly in kittens
or immunosuppressed adults. Poor hygiene is a
predisposing factor, and the disease may be
endemic in shelters or catteries. Humans may be
easily infected and develop a similar skin disease.
Infection: Infectious arthrospores produced by
dermatophytes may survive in the environment for
about a year. They are transmitted through contact
with sick cats or healthy carriers, but also on dust
particles, brushes, clothes and other fomites.
Disease signs: Circular alopecia, desquamation
and sometimes an erythematous margin around
central healing (‘ringworm’) are typical. In many cats
this is a self-limiting disease with hair loss and scaling
only. In immunosuppressed animals, the outcome
may be a multifocal or generalised skin disease.
Diagnosis: Wood’s lamp examination and
microscopic detection of arthrospores on hairs are
simple methods to confirm M canis infection, but
their sensitivity is relatively low. The gold standard
for detection is culture on Sabouraud agar of hairs
and scales collected from new lesions.
Disease management: In shelters and catteries
eradication is difficult. Essential is a combination
of systemic and topical treatments, maintained for
several weeks. For systemic therapy itraconazole
is the drug of choice, terbinafine an alternative.
Recommended topical treatment is repeated body
rinse with an enilconazole solution or miconazole
with or without chlorhexidine. In catteries/shelters
medication must be accompanied by intensive
decontamination of the environment.
Vaccination: Few efficacy studies on anti-M canis
vaccines (prophylactic or therapeutic) for cats have
been published, and a safe and efficient vaccine is
not available.
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JFMS CLINICAL PRACTICE
Agent properties
In contrast to single-celled yeasts, dermatophytes (‘skin plants’) are
complex fungi growing as hyphae and forming a mycelium. About
40 species belonging to the genera Microsporum, Trichophyton and
Epidermophyton are considered as dermatophytes. Over 90% of feline
dermatophytosis cases worldwide are caused by Microsporum canis.1
Others are caused by M gypseum, T mentagrophytes, T quinckeanum,
T verrucosum or other agents. With the exception of M gypseum, all of
these agents produce proteolytic and keratolytic enzymes that enable
them to utilise keratin as the sole source of nutrition after colonisation
of the dead, keratinised portion of epidermal tissue (mostly stratum
corneum and hairs, sometimes nails).
Dermatophytes produce arthrospores, which are highly resistant,
surviving in a dry environment for 12 months or more [EBM grade
III].2 In a humid environment, however, arthrospores are short-lived.
High temperatures (100°C) destroy them quickly. Arthrospores adhere
very strongly to keratin.
Depending on the source of infection and reservoirs, dermatophyte
species are classified into zoophilic, sylvatic, geophilic and anthropophilic fungi.
Epidemiology
Dermatophytosis is worldwide the most common fungal infection of
cats and one of the most important infectious skin diseases in this
species. It may be transmitted to other animal species, and is also an
important zoonosis.
M canis is a typical zoophilic dermatophyte.
It was generally thought that subclinical
Zoonosis
M canis is the causative
infections are very common in cats, espeagent of ringworm.
cially in longhaired animals over 2 years of
age. However, in many groups the prevalence is relatively low. Therefore, M canis
European Advisory Board
on Cat Diseases
www.abcd-vets.org
Corresponding author: Tadeusz Frymus
Email: tadeusz_frymus@sggw.pl
DOI: 10.1177/1098612X13489222
©
Published
by
SAGE
on
behalf of ISFM and AAFP 2013
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R E V I E W / ABCD guidelines on dermatophytosis
should not be considered part of the normal
fungal flora of cats and its isolation from a
healthy animal indicates either subclinical
infection or fomite carriage.1
Arthrospores are transmitted through contact with sick or subclinically infected animals, mainly cats, but also dogs or other
species. In sick animals, the infected hair
shafts are fragile and hair fragments containing arthrospores are very efficient in spreading infection. In addition, uninfected cats can
passively transport arthrospores on their hair,
thereby acting as a source of infection. Risk
factors include: introducing new animals into
a cattery, cat shows, shelters, mating, etc.
Indirect contact is very important too;
transmission may occur via contaminated
collars, brushes, toys, environments, etc.
Arthrospores are easily spread on dust particles, even to rooms without access for cats.
Outdoor cats, especially in rural areas, can
be exposed by digging to M gypseum, a
geophilic fungus living in soil. Cats may be
infected with T mentagrophytes or T quinckeanum through contact with small rodents,
and with T verrucosum through contact with
cattle.
Pathogenesis
EBM grades
The ranking system
for grading the level
of evidence of
various statements
within this article is
described on
page 533 of this
Special Issue.
Dermatophytes
(‘skin plants’)
are complex
fungi growing
as hyphae and
forming a
mycelium. Over
90% of feline
dermatophytosis
cases
worldwide are
caused by
Microsporum
canis.
immunodeficiency virus (FIV) and feline
leukaemia virus (FeLV) on the prevalence of
fungal infection has been investigated. The
higher prevalence of M canis in FIV-infected
animals compared with normal cats reported
in one survey3 was not observed by another
group.4 It has been suggested that any association may be related to differences in the environment rather than to the retroviral status of
the cats.5
The incubation period of ringworm caused
by M canis is 1–3 weeks. During this time,
hyphae grow along the hair shafts through the
stratum corneum to the follicles where they
produce spores that form a thick layer around
the hair shafts. As dermatophytes are susceptible to high temperatures, they cannot
colonise deeper parts of the skin or the follicle
itself. Therefore, the hair grows normally but
breaks easily near the skin surface, resulting
in hair loss. Several metabolic products of the
fungus may induce an inflammatory response
in the skin, and may be observed mainly
around the infected area, forming sometimes
ring-like lesions with central areas of healing
and papules on the periphery (‘ringworm’).
In many immunocompetent cats living in
hygienic conditions these lesions are limited
(eg, to the head) and disappear after several
weeks. In immunosuppressed animals, the
outcome may be a multifocal or generalised
skin disease with secondary bacterial infections. On rare occasions, a marked inflammatory reaction to hyphae induces a nodular
granulomatous reaction involving dermis and
draining on the skin surface. These so-called
pseudomycetomas are more often seen in
Persian cats, sometimes concurrently with
classical lesions.
The pathogenesis of other dermatophyte
infections is similar to that described above.
Healthy skin acts as an effective barrier
against fungal invasion. The increased rate of
regeneration of epidermal cells in response
to the dermatophyte, with the consequent
removal of fungus from the skin surface, is
another protective mechanism. As dermatophytes cannot penetrate healthy skin, many
cats are merely passive carriers of the
arthrospores or remain subclinically infected.
Whether such an infection will lead to
clinical disease depends on many factors.
Predisposing factors to disease include: a
young age (first 2 years of life), immunosupImmunity
pression (including immunosuppressive
treatment), other diseases, nutritional deficits
Naturally occurring ringworm is rarely recur(especially proteins and vitamin A), high temrent, suggesting an effective and long-lasting
perature and high humidity.1
immunity. Experimental studies confirm that
animals express increased resistance to subseVery important for the facilitation of infecquent challenge by the homologous fungus.
tion is any kind of skin trauma resulting from
Reinfections may occur, but require a much
increased moisture, injury by ectoparasites or
greater number of spores,
scratches due to pruritus, playing
and usually these subseor aggressive behaviour, clipping,
quent infections are cleared
etc. In general, poor hygiene is a
European Advisory Board on Cat Diseases
more rapidly.1 It has been
predisposing factor. In overThe European Advisory Board on Cat Diseases (ABCD) is a body
suggested that for the develcrowded feline groups, social
of experts in immunology, vaccinology and clinical feline medicine
that issues guidelines on prevention and management of feline
opment of full immunity, the
stress may play an important
infectious diseases in Europe, for the benefit of the health and
infection must run its entire
role. This can make eradication
welfare of cats. The guidelines are based on current scientific
natural
course, as in cats
of ringworm very difficult in
knowledge of the diseases and available vaccines concerned.
whose infection was aborted
catteries or shelters infected
with antifungal treatment the
with M canis.
The latest version of the dermatophytosis
in cats guidelines is available at www.abcd-vets.org
delayed type hypersensitivity
The potential immunosupreactions were often weaker.6
pressive effect of feline
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JFMS CLINICAL PRACTICE
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Figure 2 Circular alopecia caused by M canis infection.
Courtesy of Tadeusz Frymus
Figure 1 In some cats, especially immunocompetent adults,
the only sign of dermatophytosis may be scaling. Courtesy of
Tadeusz Frymus
Although dermatophyte infection is
confined to the superficial keratinised
tissues, a humoral and cellular immune
response is induced. Prominent activation
of T helper type 2 (Th2) cells and the corresponding cytokine profile leads to antibody formation followed by chronic
disease, whereas activation of Th1 cells
stimulates a cell-mediated response characterised by interferon-γ, and interleukins
12 and 2, and leads to recovery.1,7 Such
cats are protected against reinfection.8 The
role of the humoral response in dermatophytosis is unclear, although antibodies
could have a fungistatic effect by means
of opsonisation and complement activation.9
Clinical signs
In many cats, dermatophytes cause a mild,
self-limiting infection with hair loss and scaling (Figure 1).
The typical presentation of ringworm in cats
is regular and circular alopecia (Figure 2), with
hair breakage, desquamation and sometimes
an erythematous margin and central healing.1,10 The lesions are sometimes very small,
but occasionally may have a diameter of 4–6
cm. Lesions may be single or multiple, and are
localised mostly on the head (Figure 3) but also
on any part of the body, including the distal
parts of the legs and the tail. Young cats, in particular, display lesions localised at first to the
bridge of the nose and then extending to the
temples, the external sides of the pinnae and
auricular margins (Figure 4). Multiple lesions
may coalesce. Pruritus is variable, generally
mild to moderate, and usually no fever or loss
of appetite is observed.1,10
In some cats, dermatophytosis can present
as a papulocrustous dermatitis (‘miliary dermatitis’) affecting mainly the dorsal trunk.
In immunosuppressed cats, extensive lesions
with secondary bacterial involvement are some-
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JFMS CLINICAL PRACTICE
Figure 3 On many
occasions dermatophytosis
lesions start on the head.
Courtesy of International Cat
Care (formerly Feline Advisory
Bureau)
As dermatophytosis can
produce
lesions similar
to many feline
skin diseases,
it should be
considered in
cats with any
cutaneous
condition.
times associated with chronic ringworm.
Such patients demonstrate atypical, large
alopecic areas, erythema, pruritus, exudation
and crusts (Figure 5). At this stage, dermatophytosis may mimic other dermatological
conditions. Typical signs may be still visible
at the margins of the lesions.
A rare outcome is onyxis and perionyxis
and, exceptionally, nodular granulomatous
dermatitis (pseudomycetoma) with single
or multiple cutaneous nodules, firm and
not painful on palpation.11 Fistulisation
of these nodules is possible. Pseudomycetoma occurring as abdominal masses
may be a rare complication of laparotomy
in animals with cutaneous dermatophytosis.12
Diagnosis
As dermatophytosis can produce lesions similar to many feline skin diseases, it should be
considered in all cats with any cutaneous
condition. If possible, dermatophyte diagnosis
should be undertaken before any treatment.
An inexpensive and simple screening tool
for M canis infection is the Wood’s lamp examination. However, it is not very sensitive: only
about 50% of M canis strains fluoresce and
other dermatophytes do not fluoresce at all.13
Furthermore, debris, scale, lint and topical
medications (eg, tetracycline) can produce
false-positive results. Thus, Wood’s lamp findings should be confirmed by other methods.
Direct microscopic examination is another
simple and rapid method to detect dermatophytes on hairs or scales. It is recommended to
pluck hairs for this purpose under Wood’s
lamp illumination, or from the edge of a lesion.
The sample should be cleared with 10–20%
potassium hydroxide solution before examination. There are a number of techniques to
improve the visualisation of fungal elements
on the hair shafts.1 Hairs or hair fragments
with hyphae and arthrospores are thicker, with
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R E V I E W / ABCD guidelines on dermatophytosis
Figure 4 External sides
of the pinnae may also
be affected by
dermatophytosis. Courtesy
of Tadeusz Frymus
Figure 5 In some
a rough and irregular surface. However, direct
microscopic examination may give falsepositive results, especially if saprophytic fungal spores are present or debris is interpreted
as fungal elements. Also, the sensitivity of this
technique is relatively poor and has been
assessed as 59%.14 Higher sensitivity (76%) has
been achieved by fluorescence microscopy
with calcafluor white – a special fluorescent
stain that binds strongly to structures containing cellulose and chitin.13
Culture on Sabouraud dextrose agar or other
media is the gold standard for the detection of
dermatophytes. This method is very sensitive
and can determine the species. Samples (hairs,
scales) should be collected from the margin of
new lesions after gently swabbing with alcohol
to reduce contamination. If a subclinical infection or passive carriage is suspected, brushing
for 5 mins with a sterile brush is the best
method for collecting sample material. A brand
new toothbrush is mycologically sterile.1
Several in-house dermatophyte test media
(DTM) based on colour change are available
commercially. However, few attempts have
been made to evaluate the performance of such
media with veterinary samples.10 Therefore,
suspect colonies must be examined microscopically to confirm the presence of a fungus.1
Polymerase chain reaction has been proposed for the detection of M canis sequences
in suspected material from animals.15
cats, particularly
immunocompromised
ones, the outcome of
dermatophytosis may be a
multifocal or generalised
skin disease. Courtesy of
International Cat Care (formerly
Feline Advisory Bureau)
Disease management
In immunocompetent cats, isolated lesions disappear spontaneously after 1–3 months and
may not require medication. However, treatment of such cases will reduce the disease
course as well as the risk for other animals and
humans, and contamination of the environment.
Topical treatment is generally less effective
in cats compared with humans due to poor
penetration of the medicines through the hair
coat, lack of tolerance of this treatment by
many cats and the possible existence of unnoticed small lesions (Figure 6). Thus,
therapeutic measures should include a combination of systemic and topical treatment,
maintained for at least 10 weeks. Generally,
cats should be treated not only until the
lesions completely disappear, but until the
dermatophyte can no longer be cultured from
the hairs on at least two sequential brushings
1–3 weeks apart.
In catteries and shelters, dermatophyte
infection is very difficult, time-consuming and
expensive to eradicate. Good compliance by
the owner is therefore essential. A treatment
programme is necessary, together with complete separation of infected and uninfected
animals and intensive decontamination of the
environment. This will necessitate interruption of breeding programmes and shows. All
animals in the cattery should be treated. A far
less preferable alternative is to divide the cats
into groups and treat according to infection
status. Special hygiene measures should be
taken when handling infected animals in
order to prevent infection of humans (gloves,
disinfection of cat scratches or any other
injury).
M canis should not be considered part of
the normal fungal flora of cats. Its isolation
from a healthy animal indicates either subclinical
infection or fomite carriage.
Figure 6 Some dermatophytosis lesions may become visible
only after clipping. Courtesy of Tadeusz Frymus
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Topical therapy
In cats with a limited number of lesions, hairs
should be clipped away from the periphery of
lesions incorporating a wide margin. Clipping
should be gentle to avoid spreading the infection due to microtrauma. Spot treatment of
lesions may be of limited efficacy; instead,
whole body shampooing, dipping or rinsing
is recommended. In patients with generalised
disease, longhaired cats and for cattery decontamination, clipping the entire cat is useful to
make topical therapy application easier and to
allow for better penetration of the drug. This
approach also limits the spread of the spores
into the environment, to people and to other
animals. The entire hair coat, including
whiskers, should be gently clipped and all
infected hairs should be wrapped and
disinfected before disposal. Chemical or heat
sterilisation of instruments is essential. Cats
should not be clipped in veterinary clinics to
avoid environmental contamination. The best
place for clipping is in the cat’s own household, where the environment is already
contaminated.
Topical antifungal drugs differ widely in
their efficacy. One of the most effective procedures is a whole body treatment with a 0.2%
enilconazole solution performed twice weekly.1 Local or general side effects are very seldom reported provided that grooming is
prevented (Elizabethan collar) until the cat is
dry.16 Very effective is also 2% miconazole
with or without 2% chlorhexidine as a twice
weekly body rinse or shampoo.1 In the USA,
lime-sulphur solution is commonly used.
Systemic therapy
Itraconazole
Though relatively expensive, itraconazole is
currently the preferred drug in feline dermatophytosis and is licensed for this indication.1 It is comparable (or superior) in efficacy
to ketoconazole or griseofulvin and is much
better tolerated by cats. The only adverse reaction occasionally reported is anorexia. The
embryotoxicity and teratogenicity of itraconazole also seems to be lower than that of ketoconazole. Nevertheless, its administration in
pregnancy is not recommended. Use in kittens
as young as 6 weeks is possible.
Most veterinary dermatologists will use
itraconazole as so-called pulse therapy, which
is also suggested by the manufacturer. This
protocol is effective and also reduces the cost
of treatment. A pulse administration of
5 mg/kg/day for 1 week, every 2 weeks for
6 weeks has been suggested.17 Another study
demonstrated that there were sufficient levels
of itraconazole in the plasma and the fur of cats
with ringworm that had been given three
cycles of treatment consisting of 1 week with
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JFMS CLINICAL PRACTICE
treatment (5 mg/kg) and 1 week without. A
25–30% reduction in levels was observed after
the week without treatment, but the concentrations were still high enough even 2 weeks after
the last administration [EBM grade IV].18 These
data illustrate that such a treatment schedule
(3 x 7 days of dosing) provides actual coverage
of at least 7 weeks.
Terbinafine
An alternative is terbinafine administered
orally 30–40 mg/kg once daily.1,11 It seems
also suitable for pulse therapy. After administration lasting 14 days, terbinafine persisted in
the hair of cats at inhibitory concentrations for
5.3 weeks [EBM grade III].19 Occasional vomiting and intensive facial pruritus has been
observed as side effects.
Generally,
cats should
be treated
until the
dermatophyte
can no longer
be cultured
from hairs on
at least two
sequential
brushings 1–3
weeks apart.
Ketoconazole
Ketoconazole has been used orally at 2.5–5
mg/kg twice daily. However, cats are relatively susceptible to side effects with this drug,
which include liver toxicity, anorexia, vomiting, diarrhoea and suppression of steroid
hormone synthesis. Ketoconazole is also
contraindicated in pregnant animals.
Griseofulvin
In some countries, griseofulvin is still used.
However, it is not now generally recommended as more safe and effective preparations are
available. It is administered orally for at
least 4–6 weeks at 25–50 mg/kg q12–24h.
Griseofulvin is poorly soluble in water and
micronised formulation as well as administration with fatty meals enhance absorption.
Adverse reactions include anorexia, vomiting,
diarrhoea and bone marrow suppression,
particularly in Siamese, Himalayan and
Abyssinian cats. The use of griseofulvin is
contraindicated in kittens younger than 6
weeks of age and in pregnant animals as the
compound is teratogenic, particularly during
the first weeks of gestation. There are a few
reports suggesting that FIV infection predisposes cats to griseofulvin-induced bone marrow suppression. Therefore, cats should be
tested for this infection prior to therapy. If
griseofulvin is chosen, a complete blood count
should be carried out monthly to detect possible bone marrow suppression.
Lufenuron
Lufenuron is a chitin synthesis inhibitor, used
for the prevention of flea infestations in dogs
and cats. As chitin is also a component of the
fungal cell wall, some antifungal activity had
been anticipated. However, studies in cats
have not demonstrated antifungal effect and
lufenuron is not recommended for the treatment of dermatophytosis.1
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R E V I E W / ABCD guidelines on dermatophytosis
Va c c i n a t i o n
Not
recommended
Very few efficacy studies on anti-M canis vaccines (prophylactic or therapeutic) for cats have been
The
ABCD
does
not
performed and published. Although considerable success has been achieved in prophylactic or
recommend dermatophytosis
therapeutic use of anti-dermatophyte vaccines in cattle and fur-bearing animals, a safe and efficient
vaccination.
vaccine for cats is still not available.10,22
A killed M canis cell wall vaccine induced both humoral and cell-mediated immunity in experimental
cats; however, these responses did not protect cats against challenge.23 Similarly, M canis antigens
combined with a live Trichophyton vaccine did not induce protective immunity against topical challenge
with M canis.24 A commercial vaccine consisting of killed M canis components in adjuvant was licensed
in the USA for treatment of cats rather than prevention. However, in experimental cats, this vaccine did not
prevent the establishment of a challenge infection and also did not provide a more rapid cure of an established infection in vaccinated
cats compared with unvaccinated controls.24 The product was withdrawn from the market. Some other studies to develop
dermatophytosis vaccines have been reviewed elsewhere.22
Other options
In cattle and fur-bearing animals, immunotherapy with anti-dermatophyte vaccines is
believed to reduce the lesions and to accelerate their disappearance. Although M canis
vaccines have been marketed for treatment of
affected cats, controlled studies demonstrating efficacy of this procedure in cats are hard
to find. Results of a placebo-controlled
double-blind study performed on 55 cats with
severe dermatophytosis caused by M canis or
T mentagrophytes have been published.20 An
inactivated vaccine containing antigens of M
canis, M canis var distortum, M canis var obesum, M gypseum and T mentagrophytes was
given three times intramuscularly to sick ani-
mals. A trend of improvement in all cats following therapeutic vaccination was observed,
although this improvement was not significantly different from that seen in the placebotreated cats.
Environmental decontamination
Thorough vacuuming and mechanical cleaning is essential to remove infective material
(no visible hairs should be present), especially
in households with one or a few cats where
disinfection is impractical and unnecessary.
However, in catteries or shelters, disinfection
is very important. Most disinfectants labelled
as ‘antifungal’ are fungicidal against mycelial
KEY POINTS
< Dermatophytosis, caused usually by M canis, is the most common fungal infection in cats and one of
the most important infectious skin diseases in this species.
< M canis produces arthrospores that may remain infective for about a year and are easily transmitted by direct
contact or by fomites to cats, other animal species and humans.
< Many cats are infected subclinically or are fomite carriers of the arthrospores.
< Dermatophytosis may be endemic in groups of cats, especially in poor environmental conditions, and the
eradication of the disease is very difficult in such cases.
< Circular alopecia, desquamation and sometimes an erythematous margin around central healing (‘ringworm’) are
typical lesions of this chronic skin disease.
< In many cats it is a self-limiting disease with hair loss and scaling only. In young animals and immunosuppressed
adults, the outcome may be a multifocal or generalised skin disease.
< The gold standard for the detection of dermatophytes is culture on Sabouraud agar. Wood’s lamp examination
and microscopic detection of arthrospores on hairs are much less sensitive.
< In severe cases systemic and topical therapy must be combined and maintained for several weeks. In catteries
and shelters, medication must be accompanied by intensive decontamination of the environment.
< For systemic therapy itraconazole is the drug of choice.
< Recommended topical treatment is repeated body rinsing with an enilconazole solution or miconazole
with or without chlorhexidine.
< As a safe and efficient vaccine for cats is still not available, the ABCD does not recommend
vaccination.
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forms of the dermatophyte or macroconidia
but not against arthrospores. Most efficient
against arthrospores are 1:33 lime-sulphur,
0.2% enilconazole, and 1:10 to 1:100 household chlorine bleach.1 All surfaces should
be cleaned with one of these solutions. An
enilconazole smoke fumigant formulation is
available in many European countries.
Detailed decontamination procedures, as
well as the management of infected catteries
and shelters during treatment, are described
elsewhere.1,21
Funding
The authors received no specific grant from any funding agency in
the public, commercial or not-for-profit sectors for the preparation
of this article. The ABCD is supported by Merial, but is a
scientifically independent body.
Conflict of interest
The authors do not have any potential conflicts of interest to
declare.
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