A lick granuloma occurs when a dog excessively chews at the skin, creating a thickened area of skin which often becomes ulcerated and infected.  Most lick granulomas occur on the front or hind limbs.  This problem is so frustrating to treat in dogs for several reasons.  First, there is often an underlying reason for the dog to be constantly licking one area of the skin (usually arthritis, allergies, deep infection, or obsessive compulsive behavior).  Second, if this problem is allowed to happen for any period of time, there is a chance it could become more of a behavioral problem in addition to or instead of a medical one, which becomes harder to treat.  Third, lick granulomas require long-term treatment (often several months or more) which is hard for owners to keep up with.

Underlying Causes
Lick granulomas are usually a symptom of a greater underlying problem.  Treating just the lick granuloma is not enough to rid your pet of the problem - you must address the underlying disease or the lick granuloma will be a continual problem.  The main diseases that lead to the development of lick granulomas are:

• Allergies - both food and environmental allergies cause itchiness, especially in the skin.  When these dogs chew on themselves, the skin becomes irritated and infected.  
• Arthritis - when a lick granuloma forms over a joint, especially in older dogs, this could be a symptom of underlying pain in that area caused by arthritis.  The licking is a soothing gesture that helps the dog alleviate some of the pain, much like rubbing your temples with a headache.
• Deep infection - whether there was a penetrating trauma (like a splinter), a bug bite, or a cut, sometimes the infection that results can be treated topically but still be present deep under the skin.  The dogs lick because of discomfort from the infection much like they do when arthritis is present.  There is often a draining tract associated with deep infections from penetrating trauma.
• Other causes of underlying pain - these can include bone cancers, bone infections, soft tissue tumors, hairline fractures, and others. 
  
• Obsessive compulsive disorders - Boredom, anxiety, and habitual licking can all be causes of lick granulomas.  Once medical causes have been ruled out, behavioral problems can then be addressed.  If your dog does not lick in your presence, then boredom or anxiety may be the root cause of the lick granulomas.  Behavioral and medical therapy may help.  Contrary to what most people believe, habitual licking is a less common cause of perpetual granulomas.  Even dogs who have had long-term lick granulomas (years) may be able to be treated if the right diagnosis is made and the underlying problem treated.  There are some dogs, though, that don't seem to have a reason to keep licking and then this will become a chronic management issue.

Treatment
Long-term treatment all depends on the underlying cause of the lick granuloma, but some general care for the granulomas when they become infected and ulcerated include:

• An Elizabethan collar or wrap - the key to getting these granulomas to heal is that the dog MUST stop the licking cycle.  Even though dogs don't enjoy wearing E-collars, it is a necessary evil temporarily until we can figure out the root cause of the granuloma.
• Antibiotics - from the constant licking and damaged skin, bacteria and yeast are common secondary infections in lick granulomas and need to be treated.  They actually can be the primary cause as well.  Sometimes deep cultures are needed to identify what antibiotics we should use.
• Anti-inflammatories - usually steroids are used to take away some of the inflammation and itchiness associated with lick granulomas.  This is a temporary fix but can give us a clue as to what is causing the licking (for example allergies will respond very well to steroids).
• Harmony laser treatments - the medical laser we have has worked wonders for the treatment of lick granulomas.  This laser decreases the ability of bacteria and yeast to survive, decreases swelling and pain, and speeds up wound healing.  Several treatments over a few weeks may be needed to achieve good results.
• Referral to a dermatologist - in some cases, we simply cannot resolve the lick granuloma.  In these instances we recommend taking your dog to a veterinary dermatologist.  They are board certified in skin diseases and should be able to figure out what is going on in the tough cases!
  

The bottom line is - we understand how frustrating these lick granulomas can be, and we are here to figure out a solution for you and your dog.  If you suspect your dog has a lick granuloma, please bring him or her in immediately to get checked out.  The sooner we can diagnose and begin treatment the easier treatment will be in the long run.  Please be patient - this is a process that takes a while to work!