Canine Mange — Essentials

Key Takeaways

Canine mange is a skin disease caused by microscopic mites that burrow into or live on a dog’s skin, causing intense itching, hair loss, and skin irritation

Two primary types exist: sarcoptic mange (highly contagious to humans and other animals) and demodectic mange (not contagious, caused by immune system compromise)

Early veterinary diagnosis through skin scrapings is crucial, as mange symptoms can mimic other skin conditions

Treatment requires prescription medications, medicated baths, and environmental cleaning - home remedies alone are insufficient

Prevention involves regular parasite preventatives, maintaining good hygiene, and supporting your dog’s immune system through proper nutrition

The impact of mange extends beyond simple skin irritation. As female mites burrow through the dog’s skin or establish colonies in hair follicles, they trigger inflammatory responses that can compromise skin health and create openings for additional pathogens. While some mites naturally exist on healthy dogs without causing problems, mange develops when mite populations explode due to factors like weakened immune systems, poor nutrition, or exposure to heavily infested animals. Some dogs can act as asymptomatic carriers, harboring mites without showing clinical signs but still capable of spreading the infestation to other animals.

A normal immune system helps keep mite populations under control, preventing the development of mange.

Understanding mange requires recognizing that not all mites behave identically. Some species live on the skin surface, others penetrate deeper layers, and certain types specifically target ear canals. This diversity means that effective treatment depends on accurate identification of the specific mite species involved.

Types of Mange in Dogs

Veterinary medicine recognizes four primary types of mange affecting dogs: sarcoptic mange, demodectic mange, cheyletiellosis, and otodectic mange. These conditions differ significantly in their contagiousness, target populations, and treatment requirements. While sarcoptic and demodectic mange represent the most clinically significant forms, understanding all types helps dog owners recognize symptoms early and seek appropriate veterinary care. Different types of mange can present with the same symptoms, such as hair loss and skin lesions, so veterinary diagnosis is essential to distinguish mange from other skin conditions.

The distinction between contagious and non-contagious forms proves particularly important for multi-pet households. Sarcoptic mange, caused by the sarcoptic mite Sarcoptes scabiei var canis, spreads rapidly between animals and to humans, requiring immediate isolation and comprehensive treatment protocols. Conversely, demodectic mange typically affects dogs with compromised immune systems and poses no transmission risk to healthy pets or people.

Sarcoptic Mange (Canine Scabies)

Sarcoptic mange, caused by the mite Sarcoptes scabiei var canis (these are scabiei mites responsible for canine scabies), represents the most contagious form of mange affecting dogs. These sarcoptic mites complete their entire life cycle on the host animal in 17-21 days, during which female mites burrow into the stratum corneum (outermost skin layer) of the host's skin to create tunnels where they deposit eggs. The eggs hatch after about 10 days to 8 weeks, continuing the infestation cycle.

The burrowing behavior of female mites triggers intense allergic reactions in most dogs, resulting in the characteristic severe itching associated with canine scabies. These microscopic mites prefer areas with thinner skin, commonly targeting the ventral abdomen, ear margins, chest, and limbs during initial infestations. Sarcoptic mange symptoms typically appear between 10 days and 8 weeks after exposure, often manifesting on the ears, legs, chest, and belly.

Sarcoptic mange is highly contagious to other dogs, cats, and humans through direct contact. The mites can survive in the environment for several days on contaminated bedding, grooming tools, or surfaces, making indirect transmission possible though less common. In severe cases, affected dogs develop crusty skin, oozing sores, and significant hair loss that can progress to involve the entire body if treatment is delayed.

Demodectic Mange (Red Mange)

Demodectic mange results from overpopulation of Demodex canis mites, which normally inhabit hair follicles and sebaceous glands as part of the natural skin flora in most dogs. Unlike sarcoptic mites, demodex mites typically cause no symptoms in animals with normal immune systems, living commensally without triggering inflammatory responses.

While Demodex canis affects dogs, a related species, Demodex cati, is responsible for similar skin disease in cats.

Three distinct forms of demodectic mange occur based on the affected dog’s age and immune status:

Localized demodectic mange primarily affects puppies under 18 months, presenting as small patches of hair loss around the face, forelimbs, or trunk. This form often resolves spontaneously as the puppy’s immune system matures, requiring no specific treatment in many cases.

Juvenile generalized demodectic mange involves widespread skin lesions in young dogs and often indicates inherited immune deficiencies. These cases require aggressive treatment and careful monitoring, as the condition may persist into adulthood.

Adult generalized demodectic mange typically develops in dogs with compromised immune systems due to underlying diseases, medications, or stress. This form suggests serious underlying health problems requiring comprehensive veterinary evaluation.

Demodectic mites transfer from mother to puppy during the first few days of nursing through direct contact. However, the condition is not contagious between adult dogs or to humans, as healthy immune systems prevent mite overpopulation.

Cheyletiellosis (Walking Dandruff)

Cheyletiellosis, commonly called walking dandruff, is caused by Cheyletiella mites that live on the epidermis surface rather than burrowing into deeper skin layers. These relatively large mites are sometimes visible to the naked eye, creating the characteristic “salt-and-pepper” appearance as they move through surface scales and debris.

The mites complete their 3-week life cycle entirely on the host, though female mites can survive off-host for up to 10 days under favorable conditions. This survival ability makes cheyletiellosis highly contagious between cats, dogs, rabbits, and humans, particularly in environments with multiple animals.

Affected animals typically develop excessive scaling, mild itching, and the distinctive moving dandruff appearance along their back and neck regions. While less severe than sarcoptic or demodectic mange, cheyletiellosis requires prompt treatment to prevent spread to other pets and family members.

Otodectic Mange (Ear Mites)

Otodectic mange, caused by Otodectes cynotis mites, specifically targets the ear canals where these parasites feed on wax, oils, and cellular debris. While more common in cats, ear mites also affect dogs, particularly those in multi-pet households or shelter environments.

Infected dogs typically exhibit intense head shaking, excessive ear scratching, and production of dark brown, coffee-ground-like cerumen (ear wax). Intense scratching is a hallmark symptom of ear mite infestations, often leading dogs to rub their heads against furniture or walls. The constant scratching and head shaking can lead to hematomas (blood-filled swellings) in the ear flaps and, in severe cases, tympanic membrane perforation.

Ear mites spread easily through direct contact between animals and can cause secondary bacterial infections if the scratching damages ear canal tissues. Prompt veterinary treatment prevents complications and provides relief from the intense itching these mites generate.

Direct contact transmission occurs most commonly in settings where dogs interact closely with infested animals. Dog parks, boarding facilities, grooming salons, and animal shelters represent high-risk environments where sarcoptic mites and other contagious forms can spread rapidly between animals. Even brief contact with an infested dog may be sufficient for transmission, particularly with sarcoptic mange.

Indirect transmission happens when mites survive on contaminated objects for extended periods. Bedding, toys, grooming tools, and even clothing can harbor viable mites that transfer to healthy dogs. Sarcoptic mites survive in the environment for several days, while some species like Cheyletiella can persist for up to 10 days under optimal conditions.

Mother-to-puppy transmission represents the primary route for demodectic mange, occurring during the first few days of nursing when puppies acquire demodex mites through direct skin contact. This natural transfer typically causes no problems in healthy puppies, but those with genetic immune deficiencies may develop clinical disease.

Environmental factors influence transmission risk significantly. Crowded conditions, poor hygiene, stress, and inadequate nutrition all increase susceptibility to mange infestations. Wild mammals can also serve as reservoirs for certain mite species, potentially introducing mange to domestic dogs in rural or suburban areas.

Clinical Signs and Symptoms

Early recognition of mange symptoms enables prompt veterinary intervention and prevents progression to severe, debilitating infestations. The clinical presentation varies considerably based on the mite species, infestation severity, and the affected dog’s immune status.

Early stage symptoms typically begin with localized areas of intense itching and small patches of hair loss. Dogs may exhibit increased scratching, licking, or chewing at affected areas, often focusing on specific body regions depending on the mange type. Red bumps, scaling, and mild skin thickening may develop in these initial areas.

Progressive symptoms emerge as mite populations expand and inflammatory responses intensify. Widespread alopecia (hair loss) develops, often following characteristic patterns specific to each mange type. The dog’s skin becomes increasingly inflamed, developing papulocrustous eruptions, thick crusts, and areas of damaged skin vulnerable to secondary infections.

The intense pruritus (severe itching) associated with mange leads to self-trauma as dogs scratch, bite, and rub affected areas. This scratching behavior often causes more skin damage than the mites themselves, creating wounds that provide entry points for bacteria and yeast organisms.

Location-specific patterns help veterinarians differentiate between mange types:

Sarcoptic mange typically begins on the ventral abdomen, ear margins, elbows, and hocks

Demodectic mange often starts around the eyes, muzzle, and forelimbs in localized forms

Cheyletiellosis primarily affects the dorsal neck and back regions

Otodectic mange localizes to the ear canals and surrounding areas

Secondary complications frequently develop in untreated cases, including deep pyoderma (bacterial skin infections), yeast infections, seborrhea (excessive oil production), and systemic illness in severe infestations. These complications often require additional treatment beyond simple mite elimination.

Physical examination focuses on identifying characteristic lesion patterns, distribution of hair loss, and the degree of pruritus exhibited by the patient. Veterinarians assess the overall body condition, examine lymph nodes for enlargement, and evaluate for signs of secondary infections that commonly accompany mange infestations.

Deep and superficial skin scrapings represent the primary diagnostic method for most mange types. The veterinarian uses a scalpel blade to scrape affected skin areas, collecting cellular debris, scales, and hopefully mites or eggs for microscopic examination. Deep scrapings prove essential for detecting demodectic mites residing in hair follicles, while superficial scrapings work better for surface-dwelling species.

Hair plucking methods specifically target follicular mites by extracting hair shafts with attached roots where demodex mites typically reside. This technique often proves more sensitive than skin scrapings for detecting low-level demodectic infestations, particularly in early or resolving cases.

Acetate tape preparations help identify surface-dwelling mites like Cheyletiella by pressing clear tape against affected skin areas and examining the collected material under magnification. This non-invasive method works well for detecting walking dandruff and other superficial parasites.

Additional diagnostic methods may include cytological examination of skin samples to identify secondary bacterial or yeast infections, fecal flotation tests (since dogs may ingest mites during grooming), and specialized PCR tests for detecting mite DNA in difficult cases.

The challenge of negative skin scrapings occurs frequently, particularly with sarcoptic mange where mite numbers may be extremely low. In these situations, veterinarians often recommend therapeutic trials using anti-mite medications to determine if symptoms improve with treatment, effectively using treatment response as a diagnostic tool.

Treatment Options for Canine Mange

Effective mange treatment requires veterinary-supervised protocols tailored to the specific mite species, infestation severity, and individual dog’s health status. Modern treatment approaches combine targeted anti-parasitic medications with supportive care to eliminate mites, control symptoms, and prevent complications. Treatment options include both topical medications and oral forms, depending on the type and severity of mange.

Treatment success depends on several factors including early intervention, accurate species identification, consistent medication administration, and addressing any underlying immune suppression. Oral forms of parasite preventives are a convenient and effective option for many dog owners. In multi-pet households, all animals typically require treatment regardless of symptom presence, particularly for highly contagious forms like sarcoptic mange.

The duration of treatment varies considerably, with most protocols requiring 6-8 weeks of consistent therapy followed by follow-up skin scrapings to confirm mite elimination. Premature discontinuation of treatment often leads to relapse and may contribute to treatment resistance.

Topical Treatments

Lime sulfur dips remain highly effective against multiple mite species and represent one of the safest options for young puppies, pregnant dogs, and animals with medication sensitivities. The 2-4% solution is applied weekly for 6-8 weeks, covering the entire body regardless of lesion location. While the sulfur odor proves unpleasant and temporary skin yellowing occurs, these dips effectively penetrate skin layers to reach burrowing mites.

Medicated shampoos containing benzoyl peroxide or chlorhexidine help remove crusts, scales, and debris while providing antimicrobial activity against secondary infections. These shampoos are typically used 2-3 times weekly as adjunctive therapy rather than primary mite treatment.

Spot-on treatments including selamectin, moxidectin, and fipronil offer convenient application for sarcoptic mange treatment. These medications absorb through the skin to provide systemic anti-parasitic activity with minimal handling stress for severely pruritic dogs.

Proper application techniques prove crucial for topical treatment success. The entire body requires treatment regardless of lesion distribution, as mites may be present in clinically normal areas. Owners must wear gloves during application and ensure complete coverage while avoiding eye and mucous membrane contact.

Systemic Medications

Macrocyclic lactones including ivermectin, milbemycin oxime, and moxidectin provide potent anti-mite activity through oral or injectable administration. These medications require careful dosing based on body weight and breed considerations, as certain dog breeds (particularly Collies and related breeds) show increased sensitivity to these compounds.

Ivermectin protocols typically involve daily oral administration for 4-6 weeks, with dosing adjusted based on the mange type being treated. Regular monitoring ensures treatment effectiveness while watching for potential neurological side effects in sensitive breeds.

Isoxazolines represent newer treatment options with excellent safety profiles and broad-spectrum activity against mites and other parasites. Fluralaner, sarolaner, afoxolaner, and lotilaner provide convenient monthly or longer-lasting protection while effectively treating existing infestations.

Popular oral medications like Bravecto, Simparica Trio, NexGard, and Interceptor often contain these active ingredients, making them suitable for both treatment and prevention protocols. The convenience of these formulations improves owner compliance compared to traditional daily dosing regimens.

Treatment monitoring involves regular skin scrapings to assess mite reduction and eventual elimination. Most protocols require negative skin scrapings on two consecutive examinations before discontinuing treatment, ensuring complete parasite clearance.

Supportive Care

Antibiotic therapy addresses secondary bacterial skin infections that commonly accompany mange infestations. Deep pyoderma often requires 4-6 weeks of systemic antibiotic treatment with agents like cephalexin, clindamycin, or fluoroquinolones based on culture and sensitivity results when available.

Antifungal medications combat yeast overgrowth that frequently develops in damaged, inflamed skin. Topical antifungal shampoos or systemic medications like ketoconazole help restore normal skin flora balance during recovery.

Anti-inflammatory support requires careful consideration, as corticosteroids should be avoided in demodectic mange cases due to their immune-suppressing effects. Non-steroidal anti-inflammatory medications or topical preparations may provide symptomatic relief while allowing immune system recovery.

Nutritional support plays a crucial role in recovery, particularly for dogs with compromised immune systems. High-quality diets rich in omega fatty acids, antioxidants, and essential nutrients support skin healing and immune function restoration. Maintaining a dog's health through proper nutrition and preventive care is essential for both recovery and prevention of future mange episodes.

Thorough cleaning protocols should begin immediately upon diagnosis. All bedding, toys, collars, and washable items require hot water washing at temperatures exceeding 60°C (140°F) followed by high-heat drying cycles. The heat effectively kills mites and eggs that may be present on these items.

Environmental disinfection involves vacuuming all carpeted areas, upholstered furniture, and car interiors where the infected dog has spent time. Vacuum bags should be immediately disposed of, and steam cleaning provides additional mite elimination for heavily contaminated areas.

Certain seasonal parasites, such as harvest mites (the larval stage of Trombiculidae mites), can also cause pruritic skin conditions in dogs and require similar environmental control measures to prevent infestations and related health issues.

Quarantine protocols become necessary for highly contagious forms like sarcoptic mange. Infected dogs should be isolated from other pets and family members until treatment shows effectiveness, typically requiring 2-3 weeks of consistent therapy before transmission risk decreases significantly.

Preventive strategies focus on maintaining optimal health and avoiding high-risk exposure situations. Regular use of monthly preventative medications that include anti-parasitic activity helps protect against mange and other external parasites. Products containing isoxazolines provide broad-spectrum protection when used consistently.

Stress reduction and optimal nutrition support immune system function, particularly important for preventing demodectic mange in susceptible dogs. Avoiding overcrowded conditions, maintaining good hygiene, and providing proper veterinary care help minimize infection risks.

Long-Term Effects of Untreated Mange

Untreated mange in dogs can have devastating and lasting impacts on both skin health and overall well-being. When conditions like sarcoptic mange (canine scabies) or demodectic mange are left unchecked, the relentless activity of microscopic mites leads to a cascade of worsening symptoms and complications.

For dogs suffering from sarcoptic mange, the highly contagious nature of this skin disease means that not only does the infested dog endure intense itching, hair loss, and inflamed skin, but the risk of spreading the condition to other dogs—and even humans—remains high. As female mites burrow into the dog’s skin to lay eggs, the life cycle continues unabated, resulting in persistent and severe itching, crusty skin, and oozing sores. Over time, the constant scratching and trauma can cause damaged skin, making it vulnerable to secondary bacterial and yeast infections. These secondary infections can become chronic, leading to deep skin disease that is much harder to treat and can even threaten the dog’s life in extreme cases.

Demodectic mange, caused by demodex mites that normally reside in hair follicles, can also become a serious problem if the dog’s immune system is weakened. In these cases, demodectic mites multiply unchecked, resulting in red mange—a condition marked by widespread hair loss, inflamed and thickened skin, and recurring skin infections. Dogs with compromised immune systems are especially at risk for severe cases, where the skin disease becomes chronic and debilitating. Without intervention, the affected dog may develop extensive areas of hair loss, crusty lesions, and even systemic illness due to ongoing secondary infections.

One of the challenges in managing mange in dogs is that vets diagnose mange primarily through skin scrapings, but negative skin scrapings do not always rule out the disease—especially in sarcoptic mange, where mite numbers can be very low. This can delay diagnosis and allow the life cycle of the mites to continue, worsening the dog’s condition. In some cases, a therapeutic trial with topical treatments, oral medications, or medicated baths may be necessary to confirm the diagnosis and begin to treat mange effectively.

If mange is not treated, the long-term effects can include chronic skin infections, permanent hair loss, thickened or scarred skin, and a severely diminished quality of life. In extreme cases, untreated mange can lead to life-threatening complications, especially if the dog develops widespread secondary infections or if the immune system is unable to recover. The suffering caused by intense itching, pain from oozing sores, and the stress of chronic illness can be overwhelming for both the dog and its owner.

Preventing these severe outcomes requires prompt veterinary care at the first sign of mange in dogs. Early intervention with appropriate topical treatments, oral medications, and supportive care can halt the progression of the disease, restore skin health, and prevent the spread of highly contagious forms like sarcoptic mange to other dogs and humans. Isolating the infested dog, thoroughly cleaning its environment, and following your veterinarian’s recommendations for treatment and prevention are essential steps to protect your pet and others.

In summary, the long-term effects of untreated mange are serious and potentially life-threatening. By recognizing the signs early and seeking veterinary care, dog owners can ensure their pets avoid the chronic pain, infections, and complications associated with this skin disease, and help them return to a healthy, comfortable life.

Recovery and Prognosis

The recovery timeline for mange varies significantly based on the specific mite species, treatment protocol used, and individual dog’s health status. Most cases show improvement within 2-4 weeks of starting appropriate treatment, with complete resolution typically occurring over 6-12 weeks.

Treatment monitoring requires regular veterinary examinations and follow-up skin scrapings to assess progress. Successful treatment is confirmed by negative skin scrapings on two consecutive examinations performed 2-4 weeks apart. This verification ensures complete mite elimination before discontinuing therapy.

Factors affecting recovery include the dog’s age, immune system status, presence of underlying diseases, and owner compliance with treatment protocols. Young, healthy dogs generally respond more rapidly than elderly or immunocompromised animals. Concurrent diseases like diabetes, cancer, or other immune-suppressing conditions may prolong recovery times.

Hair regrowth and skin healing follow predictable patterns during recovery. Initial improvement involves reduced itching and inflammation, followed by gradual hair regrowth over 4-8 weeks. Complete coat restoration may take several months, particularly in severe cases with extensive hair loss.

Monitoring for complications includes watching for treatment resistance, allergic reactions to medications, or development of secondary infections during therapy. Some cases may require treatment protocol adjustments or alternative medication choices if initial responses prove inadequate.

Long-term management becomes necessary for chronic demodectic mange cases, particularly adult-onset generalized forms associated with underlying immune suppression. These cases may require lifelong monitoring and periodic treatment adjustments based on disease activity and underlying condition management.

Zoonotic Risks and Human Health

Sarcoptic mange poses genuine transmission risks to humans, though the resulting human scabies typically remains temporary and self-limiting when the source animal receives appropriate treatment. Understanding these zoonotic risks helps families take appropriate precautions while caring for infected pets.

Human transmission occurs through direct contact with infected dogs, particularly during grooming, cuddling, or medical care activities. The sarcoptic mites can temporarily establish on human skin, causing itching, small red bumps, and mild skin irritation that typically resolves within a few weeks even without specific treatment.

Protective measures should include wearing disposable gloves when handling infected animals, washing hands thoroughly after any contact, and avoiding prolonged skin-to-skin contact until treatment shows effectiveness. Family members should monitor for symptoms and consult healthcare providers if persistent skin irritation develops.

Non-contagious forms including demodectic mange, cheyletiellosis (though this can cause temporary irritation), and ear mites pose minimal risk to human health. These mite species are host-specific and cannot establish permanent infestations on human skin.

When to seek medical care includes situations where family members develop persistent itching, skin rashes, or other dermatological symptoms after exposure to infected pets. Healthcare providers can assess symptoms and provide appropriate treatment if human scabies has developed.

The temporary nature of human infections from dog mites provides reassurance for families, though proper precautions remain important during the treatment period.

Recovery and Prognosis

Recovery expectations for canine mange depend largely on early intervention, appropriate treatment selection, and consistent follow-through with veterinary recommendations. The overall prognosis remains excellent for most cases when proper treatment protocols are implemented promptly.

Typical recovery timelines span 6-12 weeks for complete resolution, though initial improvement often becomes apparent within the first 2-3 weeks of treatment. Severe cases with extensive secondary infections may require longer treatment periods and more intensive supportive care.

Follow-up skin scrapings serve as the definitive measure of treatment success, with negative results on consecutive examinations confirming mite elimination. Most veterinarians recommend continuing treatment for 2-4 weeks beyond the first negative scraping to ensure complete parasite clearance.

Hair regrowth patterns follow predictable sequences, beginning with fine, soft hair that gradually develops normal texture and pigmentation over several months. Areas with severe skin damage may show permanent changes in hair quality or distribution, though most dogs achieve excellent cosmetic results.

Prognosis variations depend on several factors:

Localized demodectic mange in puppies: Excellent prognosis with frequent spontaneous resolution

Sarcoptic mange: Excellent prognosis with proper treatment and environmental management

Generalized demodectic mange: Good to guarded prognosis depending on underlying immune status

Adult-onset demodectic mange: Variable prognosis based on underlying disease management

Long-term considerations may include genetic counseling for dogs with inherited immune deficiencies, ongoing monitoring for immunocompromised animals, and lifetime prevention strategies for dogs at increased risk of reinfection.

FAQ

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Can mange kill a dog if left untreated?

While mange itself rarely proves fatal, severe untreated cases can lead to life-threatening complications including systemic bacterial infections, severe dehydration, and extreme debilitation. The intense itching and self-trauma associated with mange can create extensive wounds that become infected, potentially leading to sepsis in extreme cases. Early treatment prevents these serious complications and ensures a full recovery.

How long can mange mites survive in the environment without a host?

Survival times vary significantly by mite species. Sarcoptic mites typically survive 2-6 days in the environment under favorable conditions, while Cheyletiella mites can persist up to 10 days off the host. Demodex mites have very limited environmental survival, usually dying within hours of leaving hair follicles. Temperature, humidity, and surface type all influence survival duration, with cooler, more humid conditions generally extending mite viability.

Is it safe to use home remedies like apple cider vinegar or coconut oil for mange treatment?

Home remedies alone are insufficient for treating mange and may delay proper veterinary care, allowing the condition to worsen. While some natural products may provide mild symptom relief, they cannot eliminate mite populations or address secondary infections that commonly develop. Prescription medications specifically designed for mite elimination are necessary for effective treatment, and attempting home treatment can lead to treatment resistance and prolonged suffering.

Can indoor dogs get mange, and how would they be exposed?

Indoor dogs can contract mange through several routes including contact with infected animals during walks, visits to grooming facilities or veterinary clinics, or exposure to contaminated items brought into the home. Demodectic mange can develop in indoor dogs due to immune system compromise from illness, stress, or genetics rather than external exposure. Even minimal outdoor exposure or contact with other animals can provide transmission opportunities for highly contagious forms like sarcoptic mange.

What’s the difference between mange and other common skin conditions like allergies or hot spots?

Mange typically presents with progressive hair loss in characteristic patterns, intense itching that develops suddenly, and the presence of mites or eggs on skin scrapings. Allergies usually cause seasonal or food-related symptoms with less dramatic hair loss, while hot spots appear as localized, moist, infected areas rather than the dry, crusted lesions typical of mange. Definitive diagnosis requires veterinary examination and skin scraping analysis, as visual symptoms alone can be misleading and multiple conditions may coexist.