Hydrocortisone 1% / Miconazole 2% ointment

BACKGROUND: Erythemato-ceruminous otitis externa (ECOE) is frequently seen in dogs affected with an allergic skin disease, with recurrent secondary bacteria and yeast overgrowths (detected on cytological examination). OBJECTIVES: The objective of the study was to compare the efficacy and safety of an ear spray containing only hydrocortisone aceponate glucocorticoid diester (HCA) to a control product (CTRL), an approved otic formulation containing prednisolone-miconazole-polymyxin combination, in dogs with ECOE. ANIMALS: In total, 97 and 104 dogs with ECOE were respectively randomly assigned to the tested ear treatment product group (HCA) or the commercially available ear treatment control product group (CTRL). MATERIALS AND METHODS: Dogs were treated for 7-14 days, as needed. At Day (D)0, D7, D14, D28 and D42, Otitis Index Score-3, hearing test, pruritus and pain visual analogue scales, and cytological scores were graded. The overall response to treatment also was assessed. RESULTS: All clinical parameters decreased rapidly and in a similar way without any significant difference at any time between treatment groups. A good-to-excellent response to treatment was seen in >90% of dogs of both groups as early as D14. The treatment was considered safe in all dogs. CONCLUSIONS AND CLINICAL RELEVANCE: A 7- to 14-day ear topical application of HCA alone to dogs with ECOE accompanied with bacterial and/or fungal (yeast) overgrowth was safe and led to no statistical difference in improvement of clinical scores relative to the CTRL combination. Based on these results, it may be necessary to reconsider the routine use of antimicrobial drugs such as antibiotics and antifungals as a first-line treatment for ECOE that is likely to have been caused by an allergic reaction.

Abstract licence: CC BY-NC-ND

Hailey-Hailey disease (HHD), or familial benign chronic pemphigus, is a rare autosomal dominant disorder characterized by recurrent vesicles and erosions in intertriginous areas. Topical corticosteroids are the primary treatment, but their potential systemic side effects are often overlooked. Prolonged use on compromised skin can lead to excessive absorption, increasing the risk of iatrogenic Cushing's syndrome and adrenal insufficiency. Here, we report the case of a 50-year-old woman with HHD who had been using topical clobetasol or betamethasone for over 10 years, reaching doses up to 50 g/day. She developed Cushingoid features, metabolic abnormalities, and suppression of the hypothalamic-pituitary-adrenal (HPA) axis. After tapering off topical corticosteroids, she developed adrenal insufficiency and associated withdrawal symptoms. Following the initiation of hydrocortisone replacement therapy, psychiatric symptoms, impaired glucose tolerance, and osteoporotic fractures emerged, suggesting exacerbation of iatrogenic Cushing's syndrome. This case highlights the risk of systemic complications from chronic topical corticosteroid use, particularly in high-absorption areas. Gradual dose reduction, close endocrine monitoring, and individualized tapering strategies are essential to prevent severe outcomes. Clinicians should be aware of potential adrenal suppression and consider endocrine evaluation in patients receiving prolonged, high-dose topical corticosteroid therapy.

Abstract licence: CC BY-NC-ND

An 8-month-old intact female shorthair domestic cat was referred to the National Chung Hsing University Veterinary Medical Teaching Hospital for uncontrolled chronic otitis in both ears. The affected ears revealed purulent discharge, erosion with bleeding and brownish-black proliferative tissue in the opening of both ear canals. Cytological examination of the discharge revealed the presence of gram-positive coccoid bacteria. We carried out histopathological examinations of biopsies obtained from friable and proliferative tissues of both ears. Based on the clinical and histopathological characteristics, proliferative and necrotizing otitis externa (PNOE) was diagnosed. Treatment was initiated with a combination of twice-daily application of 0.1% tacrolimus ointment and a once-daily otic lotion containing hydrocortisone aceponate, miconazole nitrate and gentamicin sulfate following the administration of once-daily anti-bacterial flush which contains tromethamine, edetate disodium dehydrate (EDTA) buffered to pH 8 with tromethamine hydrochloride and deionized water. The antibiotic ear lotion was withdrawn in the absence of purulent discharge in both ears after 11 weeks. Most proliferative lesions resolved after 17 weeks, and we tapered the dosage of 0.1% tacrolimus from once daily to once weekly during the year follow-up period. However, in our case, partial remission of PNOE was observed with the application of a combination of 0.1% tacrolimus ointment and a commercial ear lotion. The cat was healthy and had a good quality of life. To our knowledge, this is the first report of PNOE in a cat in Taiwan.

Abstract licence: CC BY

Dupilumab treatment of atopic dermatitis may lead to the development of dupilumab-associated facial erythema [1]. There have been reports of its treatment with itraconazole [2], fluconazole [3] and ivermectin [4], with the hypothesis being that dupilumab may unmask an underlying hypersensitivity to Malassezia [5]. Literature review revealed one case series of three patients with atopic dermatitis who developed acral erythema during dupilumab treatment, one of whom improved with itraconazole [6]. Herein we describe a case of persistent palmar erythema improving with low-dose fluconazole. A 31-year-old male with severe whole body atopic dermatitis was treated with dupilumab 300 mg every 2 weeks. After 12 months of treatment, despite overall improvement in his atopic dermatitis, his palms started to become erythematous, scaly and dermatitic, with associated painful fissures and severe pruritus (Figure 1). This critically affected his life because he was a guitarist by occupation. On detailed history-taking, he had no exposures to suggest irritant or allergic contact dermatitis; hence patch testing was thought to be of limited utility. There was mixed growth on bacterial culture, and fungal culture was negative, noting some Malassezia species are slow-growing in culture [7]. Although alternative diagnoses were considered, clinically, the appearance was not consistent with psoriasis or dyshidrotic eczema. He had mild facial erythema. There was limited improvement with topical corticosteroids, including clobetasol propionate 0.05% ointment and betamethasone dipropionate 0.05% ointment under occlusion with damp cotton gloves. However, he did note some improvement after commencement of miconazole 2% cream. We subsequently trialled clotrimazole 1%/hydrocortisone 1% cream and miconazole 2%/hydrocortisone 1% cream, but he reverted to miconazole 2% cream without topical corticosteroid as this gave the most improvement. At this time, Malassezia-specific immunoglobulin E (IgE) serum level was elevated to 1.2 kU/L (normal < 0.35 kU/L). While elevation of Malassezia-specific IgE level is not exclusive to atopic dermatitis, in dupilumab-treated atopic dermatitis patients, it has been found to be associated with the development of dupilumab-associated facial erythema [8]. Given his mild partial response with topical antifungal without topical corticosteroid, he was commenced on oral antifungal, fluconazole 50 mg daily, initially for 4 weeks duration. After 4 weeks, he reported via telehealth review good improvement in the condition of his hands, followed by rapid worsening on cessation of fluconazole; hence, it was restarted. At 9 weeks, his palms were markedly less erythematous and scaly, with fewer fissures. He also had a reduction in facial erythema. At 26 weeks, his palms were slightly more scaly following a few weeks of non-adherence. He restarted and has continued fluconazole 50 mg daily for the past 8 months. He maintained stable improvement of his hand dermatitis without any adverse events, and was able to return to his occupation as a guitarist. This case suggests low-dose fluconazole may be useful for the side effect of dupilumab-associated palmar erythema, akin to its reported efficacy in the treatment of dupilumab-associated facial erythema. Notably, this patient had an elevated Malassezia-specific IgE level. Fluconazole may exhibit its effect by reducing skin colonisation with Malassezia, as well as by having inherent anti-inflammatory properties [7]. In considering this potential treatment option, it is worth noting that low-dose fluconazole is well-tolerated long-term, and remains a more affordable option than itraconazole in the Australian context. Open access publishing facilitated by The University of Sydney, as part of the Wiley - The University of Sydney agreement via the Council of Australasian University Librarians. The authors have nothing to report. The authors obtained the patient's consent to publish this case. The authors declare no conflicts of interest. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Abstract licence: CC BY-NC-ND

BACKGROUND: Recurrent otitis (RO) is characterized by inflammatory or infectious processes in dogs with allergic skin diseases, accompanied by recurrent secondary bacterial and fungal infections. Dogs underwent a combined therapeutic approach for RO, assessing the effect of long-term management during the Stabilization Phase (SP) using a suspension containing ciprofloxacin, clotrimazole, and betamethasone, followed by management in the Proactive Phase (PP) with topical hydrocortisone aceponate (HCA) administration. A total of 45 dogs were evaluated, totaling 90 ears. All animals had a clinical history of bilateral RO with an erythematous-ceruminous clinical presentation, as indicated by the anamnesis, clinical, cytological, and otoscopic evaluations, with three or more relapse episodes of otitis per year. RESULTS: The SP management reduced bacterial infections and led to an increase in yeast occurrence. There was a decrease in severe otitis cases, while the incidence of moderate scores-Otitis Index Score-3 (OTIS-3) (3 and 4) increased, indicating the persistence of RO with significant changes. In the PP, the topical HCA solution demonstrated efficacy, showing a marked reduction in cytology and clinical assessment over 90 days, with no signs of recurrence or otitis persistence throughout the remaining period. The PP, using HCA, promoted improvement in cytological and clinical outcomes, with most dogs showing no recurrence of otitis. CONCLUSIONS: The likely favorable safety profile of HCA, its local anti-inflammatory effects, and its ability to avoid systemic side effects make it a promising therapeutic option for the long-term management of RO in dogs.

Abstract licence: CC BY-NC-ND

BACKGROUND: Effective management of otitis externa (OE) requires addressing all contributing factors to prevent chronicity and recurrence. Evidence on the long-term efficacy of topical corticosteroids in preventing recurrence and secondary infections remains limited. OBJECTIVES: This retrospective noncontrolled study evaluated the efficacy of hydrocortisone aceponate (HCA) in resolving non-infectious chronic or recurrent (CR)-OE with or without proliferative changes, and preventing recurrence of acute episodes and secondary infections. ANIMALS: A total of 63 owned dogs (115 ears) with unilateral or bilateral non-infectious CR-OE were included. Most ears were enrolled after resolving infectious otitis, as persistent inflammation or recurrence required further management. MATERIALS AND METHODS: Clinical records from two dermatology referral centres (February 2022-July 2023) were reviewed. Dogs were included if they had recurrent otitis for over a year (≥ 1 year) or chronic otitis (≥ 1 month). Otitis severity was assessed using the Otitis Index Score (OTIS3) scale, and by grading stenosis and hyperplasia severity. Enrolled patients received HCA 0.584 mg/mL at weight-adjusted doses. A reactive phase continued until OTIS3 < 2, followed by a proactive phase with regimens adapted to otitis severity. Concurrent treatments were recorded. RESULTS: Recurrence was not observed in 79.1% of ears (mean follow-up 202.6 days). Among 24 relapsed ears, 29.17% recurred after treatment discontinuation. Higher recurrence was associated with stopping therapy (p < 0.001) and recent bacterial otitis (p = 0.015). No adverse effects were noted. CONCLUSIONS AND CLINICAL RELEVANCE: The use of HCA appears to be an effective and safe option for reactive and proactive management of non-infectious CRC-OE, reducing recurrences and improving patient and owner quality-of-life.

Abstract licence: CC BY-NC