What is the best way to treat ear fungus that is resistant to ketoconazole (Extina, Ketozole, Nizoral, Xologel)? — JILL DUNN, MSN, RN, NP-C, Elba, Ala.

To clarify, “resistant” could mean one of three things. First, it could mean that the clinician performed a culture and ran a susceptibility report indicating that the fungal causative agent was truly resistant to ketoconazole. In such a case, the report should identify the causative agent, and the susceptibility report should indicate the antifungals to which the causative agent responds.

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Second, “resistant” could mean that the clinician used ketoconazole in the past with success but the patient now says it is no longer effective. (This is a good time to culture the infection.)

If this is the case, consider topical oxiconazole (Oxistat) b.i.d. or topical naftifine (Naftin) gel once a day. Finally, “resistant” could refer to a case in which the clinician used ketoconazole and it did not work or did not work well enough to control the symptoms. In the situation described by Ms. Dunn, the issue may an incorrect diagnosis (determine whether the infection is more inflammatory than infective) or a diagnosis that is only partially correct. 

For example, the infection may be a process that has fungal and inflammatory aspects—like seborrheic dermatitis—in which case the addition of a low-dose topical steroid or anti-inflammatory cream may help make the ketoconazole more effective. Consider hydrocortisone 2% or desonide (Desonate, DesOwen, Verdeso) for one week. To avoid steroids completely, consider off-label pimecrolimus (Elidel), which is approved to treat atopic dermatitis. If none of these suggestions work, consider referring the patient to a specialist.—Abby A. Jacobson, PA-C (185-4)

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