What is the treatment for a fungal infection behind the ears?

Treatment of Fungal Infection Behind the Ears

For fungal infections behind the ears (retroauricular area), topical azole antifungals such as clotrimazole cream or miconazole cream applied 2-3 times daily for 2-4 weeks are the most effective first-line treatment, with the affected area kept clean and dry. 1

First-Line Topical Treatment

• Topical azole antifungals (clotrimazole, miconazole) are highly effective for candidal skin infections and should be applied directly to the affected area behind the ears 1
• The Infectious Diseases Society of America recommends topical azoles and polyenes as effective treatments for candidal skin infections 1
• Keeping the affected area dry is critical for treatment success, as moisture promotes fungal growth 1

Treatment Duration and Monitoring

• Treatment should continue for 2-4 weeks even if symptoms resolve earlier to prevent recurrence 1
• Clinical resolution typically occurs within 1-2 weeks, but completing the full course is essential 2, 3
• If symptoms persist beyond 2 weeks of appropriate topical therapy, consider systemic antifungal treatment 1

When to Escalate to Systemic Therapy

For moderate to severe infections or treatment failures, oral fluconazole 100-200 mg daily for 7-14 days is recommended 1

• Systemic therapy is indicated when:
  • Topical treatment fails after 2-4 weeks 1
  • The infection is extensive or severe 1
  • The patient is immunocompromised 1

Special Considerations for Immunocompromised Patients

• HIV-positive or immunocompromised patients require more aggressive initial therapy and may need suppressive therapy with fluconazole 100-200 mg three times weekly for recurrent infections 1
• These patients are at higher risk for azole-refractory infections, especially with prior azole exposure 1

Common Pitfalls to Avoid

• Do not discontinue treatment when symptoms improve—complete the full course to prevent recurrence 1
• Ensure the area remains dry throughout treatment; moisture behind the ears from hair, sweat, or hygiene practices can undermine therapy 1
• Fungal cultures are generally not necessary for simple skin infections, as they rarely change management 1
• Azole-refractory infections are more common in patients with previous azole use, so consider alternative agents if there is treatment failure 1

Alternative Topical Agents

• Nystatin cream can be used as an alternative polyene antifungal for candidal skin infections 1
• Other azoles such as miconazole or econazole are equally effective alternatives to clotrimazole 4, 3