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Unfortunately the bacteria in "canine acne" can be deep within the hair follicles and pores and topical creams are not as effective. You should look at the lesions like teenage boy cystic acne in humans. It can be large swellings and painful. I would strongly recommend calling your vet and asking for oral antibiotics(since your vet has seen the lesions, you shouldn't need an appt. just the meds)...your dog should be on them, my favorite is Cephalexin...for THREE WEEKS!!! Once the skin is looking great, then you can apply topical creams to lessen the skin bacteria, and use oral antibiotics if it gets real bad again. Hopefully she will mature out of the severe form.
Good Luck and let me know if you need further help.
Okay...on to the next thing...
Failure to respond to oral and topical antibiotics...did they give her cortizone or steroidal therapy? Fungal?Dr.V
Okay, this is kind of hard to explain by typing...but I will try...and remember I haven't seen your dog, I am giving you my opinion from your description.
Canine acne is kind of a rush diagnosis and is not as well documented as feline acne...and in dermatology not so much like human med, but we try to use words that people understand ...and acne everyone gets.
The true diagnosis (if I can say this on assumption) is acutally called Muzzle Folliculitis and Furunculosis (depending on how deep the inflammation is). The initial lesions are hairless bumps of varying size and location and on histopathology look as there are thickened follicules and plugged areas, BUT no bacteria so usually nonresponsive to antibiotics. Then they enlarge alittle more and can ulcerate with a clear/reddish discharge very little pus and this time if bacteria then enters...sometimes antibiotics can help improve at this stage.
Okay...next step many of the "unknown" causes they think excessive trauma to chin and muzzle like face rubbing, chewing on balls and such should be lessened. The topicals can help but used in moderation. The recommendation on deep and difficult cases (which you can consider yourself if she is not responding and getting worse) is the use of Steroids to help lessen the inflammation (NOT INFECTION). The treatment I will use is a topical called SYNOTIC which has an antibioitic coupled with an anti-inflammatory, very strong. I will use steroids coupled with an oral antibiotic for about two weeks and the wean them off both. Then once the lesions are gone I have owners switch to creams both antibacterial and steroidal to prevent development.
HOPE THIS HELPS>
The playing with the shepherd is one of those "trauma" things that can lead to follicular damage...it is up to you how, if at all you limit playing. Remember the pus is more secondary with bacteria. The discharge now is typical.
Your welcome...good luck.