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.