Systemic
Systemic therapy included oral drops, tablets, capsules or intravenous
route of administration.
Antifungals
The antifungal agents included: azoles (clotrimazole, fluconazole,
miconazole, voriconazole, ketoconazole, itraconazole, luliconazole,
econazole, serticonazole, posaconazole and bifonazole), polyenes
(amphotericin B and nystatin), echinocandin (caspofungin), allylamine
(terbinafine), thiocarbamate (tolnaftate), hydroxyquinoline (clioquinol)
and griseofulvin. Azoles were chosen in a majority of studies (61%).
Clotrimazole was the commonest azole used (46%), followed by
fluconazole (15%) and miconazole (12%).
In studies where an oral antifungal was prescribed, such as in
immunosuppressed patients who were unresponsive to topical antifungals,
voriconazole was chosen frequently (36% of studies). One prospective
study documented the efficacy of oral fluconazole in immunosuppressed
patients. Amphotericin B was frequently chosen when intravenous
treatment was required.
Jimenez-Garcia L et al (16) reported 75% resolution with clotrimazole
cream compared to 45% with tolnaftate eardrops after a week of
treatment. Other studies found the efficacy of clotrimazole eardrops to
exceed 90% with little adverse effects. Kiakojuri K et al (17) noted a
reduction in the relapse rate with a prolonged course of clotrimazole
eardrops.
Clotrimazole-resistant Aspergillus spp. were encountered more frequently
among immunosuppressed patients. These organisms were found to be
susceptible to fluconazole and tolnaftate solution. Luliconazole showed
strong activity against Aspergillus niger complex in two in-vitro
studies where the minimum inhibitory concentration was the lowest
compared to other antifungals.
Antiseptics
Various antiseptics have been employed including Betadine
(povidone-iodine), Gentian Violet (methylrosanilin), iodine,
N-chlorotaurine, boric acid, Castellani’s paint, Cresylate drops,
Mercurochrome and Tincture Merthiolate. Two studies found 10% Betadine
and 1% clotrimazole to be equally effective at treating otomycosis. One
study found better results with Tincture Merthiolate compared to
clotrimazole drops. Another study showed resolution of otomycosis in
77% of cases when treated with topical 4% boric acid in alcohol.
Steroids
Steroid use was mentioned in 8 studies. Most of the steroids
(beclomethasone, betamethasone, dexamethasone and hydrocortisone) were
used in combination therapy. However, Arndal E et al (5) reported on
topical hydrocortisone cream use in some patients.
Anaesthetics
Lignocaine and tetracaine formed part of some formulations used to treat
otomycosis.
Acidifying agents
2% acetic acid was chosen in 8 out of 9 studies where acidifying agents
were employed. One study used 2% salicylic acid.
Combination therapy
Among the studies retrieved, 24 evaluated combination therapy as follows
– antifungal/antibiotic 17%, antifungal/acidifying agent 17%,
antifungal/steroid 12.5%, two antifungals 8%, antifungal/antiseptic
8%, antifungal/antibiotic/steroid 8%, antifungal/anaesthetic 8%,
acidifying agent/antiseptic 8%. One study each evaluated
antifungal/steroid/anaesthetic,
antifungal/antibiotic/steroid/antiseptic/anaesthetic and
antiseptic/steroid combinations.
Arifullah et al (15) achieved a resolution rate of 57.3% with an
antifungal and acidifying agent mixture (clotrimazole and acetic acid).
Kiakojori K et al (18) found that a mixture of miconazole and acetic
acid was not superior to topical miconazole alone. Anwar K & Gohar MS
(9) recorded a similar outcome when they substituted 1% clotrimazole
for miconazole.