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Assessment and management of chronic otitis externa Kesser 345

Table 1 Topical steroids and their potency Brand name

10 days postoperatively [25]. Good surgical outcomes, including hearing improvement, can be achieved with a low complication rate, and a recurrence rate of approxi mately 10–20% [22,24].

Generic name

Class 1 – superpotent Cormax cream/solution, 0.05%

Clobetasol propionate

Diprolene ointment, 0.05%

Betamethasone dipropionate

Temovate cream/ointment/ solution, 0.05%

Clobetasol propionate

Treatment of chronic otitis externa The cornerstone of therapy for COE is the removal of any and all real or potential irritants, including Q-tips, water, medications, soaps, shampoos, bobby pins, fin gernails, paper clips, eyeglass arms, and so on. The vast number of medical therapies for COE only verifies its frustrating, recalcitrant nature. Trial and error may be the most helpful treatment advice. There is a large armamentarium for this disease – find a therapy that works for each patient. Topical steroid therapy has shown efficacy and can be applied in the office under binocular microscopy with a homemade Q-tip. Medium and high potency steroid preparations (creams pre ferred) that have shown efficacy include betamethasone valerate 0.1% and triamcinolone 0.1%. Unpublished data (Magit et al. ) have shown promising results with fluocinolone acetonide oil 0.01% ear drops (Derm-Otic, Hill Dermaceuticals, Sanford, FL). Patients are instructed to wash their hands and apply a small amount of the steroid cream on the end of their pinky finger and apply to the skin at the meatus twice a day. Higher potency drops and creams such as clobetasol propionate 0.05% (supplied as cream, ointment, or gel) and dexa methasone 0.1% ophthalmic drops can be used for breakthrough therapy for short periods of time weighed against the potential side effects of thinning and weak ening of the ear canal skin (Table 1). A course of oral steroids may also help cool down the refractory patient [26]. Tacrolimus (FK-506) 0.1% is a nonsteroidal immunosup pressant mainly used after allogeneic organ transplan tation. It has been shown to have efficacy in atopic dermatitis and recently in noninfectious chronic otitis externa [27] by inserting a wick containing 0.1% tacro limus into the ear canal and changing the wick every second to third day for 9–12 days. Patients with more refractory problems are queried for history of allergic disease, new soaps, detergents, sham poos, food sensitivity, and so on in an effort to identify an inciting agent. Consultation with an allergist may reveal chemical or food sensitivities that can be addressed with environmental control measures and even immunother apy/desensitization. Patients are also queried about remote fungal infections, and the finger and toenails are inspected for low-grade fungal infection. If found, treatment of the low-grade fungal infection, skin end point titration testing, immunotherapy, and the yeast free diet are recommended.

Ultravate cream/ointment, 0.05%

Halobetasol propionate

Vanos cream, 0.1%

Fluocinonide

Psorcon ointment, 0.05% Psorcon E ointment, 0.05% Class 2 – potent Diprolene cream AF, 0.05%

Diflorasone diacetate Diflorasone diacetate

Betamethasone dipropionate

Elocon ointment, 0.1% Florone ointment, 0.05% Halog ointment/cream, 0.1% Lidex cream/gel/ointment, 0.05%

Mometasone furoate Diflorasone diacetate

Halcinonide Fluocinonide

Psorcon cream, 0.05%

Diflorasone diacetate

Topicort cream/ointment, 0.25%

Desoximetasone Desoximetasone

Topicort gel, 0.05%

Class 3 – upper mid-strength Cutivate ointment, 0.005% Lidex-E cream, 0.05% Topicort LP cream, 0.05% Class 4 – mid-strength Cordran ointment, 0.05% Kenalog cream/spray, 0.1% Synalar ointment, 0.03% Westcort ointment, 0.2% Elocon cream, 0.1%

Fluticasone propionate

Fluocinonide

Desoximetasone

Flurandrenolide

Mometasone furoate Triamcinolone acetonide Fluocinolone acetonide Hydrocortisone valerate

Class 5 – lower mid-strength Cordran cream/lotion/tape, 0.05% Flurandrenolide Cutivate cream/lotion, 0.05%

Fluticasone propionate

DermAtop cream, 0.1% DesOwen lotion, 0.05%

Prednicarbate

Desonide

Locoid cream/lotion/ointment/ solution, 0.1%

Hydrocortisone

Pandel cream, 0.1%

Hydrocortisone

Synalar cream, 0.03%/0.01%

Fluocinolone acetonide Hydrocortisone valerate

Westcort cream, 0.2%

Class 6 – mild Aclovate cream/ointment, 0.05% Derma-Smoothe/FS oil, 0.01% Synalar cream/solution, 0.01% Class 7 – least potent Cetacort lotion, 0.5%/1% Cortaid cream/spray/ointment Hytone cream/lotion, 1%/2.5% Micort-HC cream, 2%/2.5% Nutracort lotion, 1%/2.5% Synacort cream, 1%/2.5% Desonate gel, 0.05%

Alclometasone dipropionate

Fluocinolone acetonide

Desonide

Fluocinolone acetonide

Hydrocortisone Hydrocortisone Hydrocortisone Hydrocortisone Hydrocortisone Hydrocortisone

Reproduced with permission from: National Psoriasis Foundation, http:// www.psoriasis.org/NetCommunity/Page.aspx?pid=469.

Other, more unconventional therapies for COE include KTP/532 laser [28], tea tree oil (although it is unclear whether this study enrolled patients with acute otitis externa or COE, and resistance was found in Pseudomonas species) [29], a conchal flap meatoplasty [30], the Canter bury technique for canalplasty [31], intradermal injection of antibiotics and steroids [32 ], and chemical peel of the ear [33 ]. Future work may target proteases known to contribute to chronic inflammatory skin conditions. Proteases matrix metalloproteinases (MMPs) and human neutrophil elas tase (HNE) were found to be significantly higher in COE

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