What is the treatment for lesions on the head and ears?

Treatment of Lesions on the Head and Ears

Immediate Diagnostic Approach

The treatment of head and ear lesions depends critically on distinguishing between infectious, inflammatory, traumatic, and neoplastic etiologies through targeted history and examination focusing on: duration of symptoms, associated pain or drainage, history of water exposure or hearing aid use, immunocompromised status, and presence of systemic symptoms. 1

Key Clinical Features to Identify

• Infectious lesions: Look for pustular lesions, localized tenderness, focal swelling, and otorrhea suggesting furunculosis (infected hair follicle) 1
• Inflammatory/eczematous lesions: Assess for chronic pruritus, erythema, scaling, maculopapular eruptions on the conchal bowl, or eczematous changes suggesting contact dermatitis 1, 2
• Fungal infections: Evaluate for otomycosis with mechanical debris in the external auditory canal 1
• Viral lesions: Identify vesicles on the external ear canal and posterior auricle, severe otalgia, facial paralysis suggesting herpes zoster oticus (Ramsay Hunt syndrome) 1

Treatment by Lesion Type

Contact Dermatitis (Irritant or Allergic)

For eczematous lesions of the ear canal, apply topical corticosteroids as first-line therapy to reduce inflammation and pruritus. 1, 2

• Remove the sensitizing agent immediately (common culprits: nickel in earrings affecting 10% of women with pierced ears, hearing aid materials, neomycin in 5-15% of chronic external otitis patients) 1
• Apply topical corticosteroids directly to affected areas 1, 2
• For steroid-refractory cases or when steroids are contraindicated, use calcineurin inhibitors: tacrolimus 0.1% ointment or pimecrolimus 1% cream 1, 2
• Ensure proper application: clean the ear canal first, position patient with affected ear upward, fill canal with medication, maintain position for 3-5 minutes 2
• Treatment duration: 7-10 days, extending to 2 weeks if symptoms persist 2

Critical caveat: Neomycin causes contact sensitization in 13% of normal volunteers and should be avoided in chronic cases 1

Furunculosis (Localized Otitis Externa)

Treat infected hair follicles with local heat, incision and drainage if fluctuant, and systemic antibiotics covering Staphylococcus aureus. 1

• Systemic antibiotics targeting S. aureus (the most common causative agent) are indicated 1
• Cephalexin is FDA-approved for skin and skin structure infections caused by S. aureus 3
• Surgical drainage may be necessary for large or fluctuant lesions 1

Fungal Infections (Otomycosis)

Noninvasive Aspergillus otitis externa requires thorough mechanical cleansing of the external auditory canal followed by topical antifungals or boric acid. 1

• Mechanical debridement is the critical first step 1
• Apply topical antifungal agents after cleaning 1
• For invasive aspergillosis of the ear, initiate prolonged systemic voriconazole therapy, usually combined with surgical debridement 1

Viral Infections (Herpes Zoster Oticus)

Ramsay Hunt syndrome demands prompt systemic antiviral therapy combined with systemic corticosteroids to prevent permanent facial nerve damage. 1

• Initiate antiviral therapy immediately upon recognition 1
• Add systemic steroids concurrently 1
• Monitor for facial paralysis, loss of taste, and decreased lacrimation 1

Cutaneous Aspergillosis

Because cutaneous lesions may reflect disseminated infection, treat with systemic voriconazole while evaluating for a primary focus of infection. 1

• Systemic voriconazole is the recommended antifungal 1
• Perform thorough evaluation to identify primary infection source 1
• For aspergillosis in burns or massive soft tissue wounds, surgical debridement is mandatory in addition to antifungal therapy 1

Common Pitfalls to Avoid

• Do not use irrigation in patients with suspected tympanic membrane perforation, patent tympanostomy tubes, current otitis externa, or narrow/stenotic ear canals 1
• Avoid neomycin-containing preparations in chronic external otitis due to high sensitization rates (5-15%) 1
• Do not miss referred otalgia: In patients with ear pain but no canal swelling or middle ear disease, evaluate for temporomandibular joint syndrome, dental pathology, upper aerodigestive tract cancer (especially in tobacco/alcohol users), or other head and neck pathology 1
• Recognize immunocompromised patients: Those with coagulopathy, immunosuppression, or previous head/neck radiation require modified treatment approaches and heightened vigilance for invasive infections 1

When to Refer or Escalate Care

• Suspected invasive fungal infections require infectious disease consultation and systemic antifungal therapy 1
• Herpes zoster oticus with facial paralysis needs urgent otolaryngology evaluation 1
• Persistent or refractory eczematous conditions despite topical therapy warrant dermatology referral 2
• Any concern for malignancy (especially in older patients with tobacco/alcohol history) requires complete head and neck examination with mucosal surface visualization 1