What is the best course of action for a patient with dry, cracked skin in the left ear, accompanied by bleeding, who has not responded to treatment with mometasone (mometasone furoate) or CeraVe (ceramide-based moisturizer)?

Escalate to Higher-Potency Topical Corticosteroid and Consider Alternative Diagnoses

Given the failure of mometasone (a medium-high potency steroid) and emollient therapy, you should escalate to a super-high potency topical corticosteroid such as clobetasol propionate 0.05% applied once daily for up to 2 weeks, while simultaneously ruling out fungal infection, contact dermatitis, and other inflammatory ear canal conditions that may require different management. 1

Immediate Diagnostic Considerations

The lack of response to mometasone suggests this is not simple eczematous dermatitis. You must consider:

• Fungal infection (otomycosis): Common after prolonged topical therapy, presents with thickened debris and pruritus. Aspergillus appears as white plug with black dots; Candida shows white debris with hyphae. 2 Topical antibiotics are contraindicated in fungal infections as they promote further overgrowth. 2

• Contact dermatitis: The patient may be allergic to ingredients in CeraVe or mometasone itself (4% of cases involve steroid allergy). 3 Consider patch testing if recurrent or refractory. 4

• Seborrheic dermatitis or psoriasis of the ear canal: These erythematous-squamous disorders commonly affect the external auditory canal and may not respond adequately to standard corticosteroids alone. 3

Recommended Treatment Algorithm

Step 1: Clean and Assess (Mandatory First Step)

• Perform aural toilet: Gently clean the ear canal with body-temperature saline solution using cotton-tipped applicator or gentle suction under visualization. 2 Remove all inflammatory debris, crusts, and obstructing material to allow proper medication delivery. 2

• Examine the tympanic membrane: Verify it is intact before prescribing any ototoxic preparations. 2

Step 2: Escalate Corticosteroid Potency

• Apply clobetasol propionate 0.05% ointment (super-high potency, Class I) once daily to the affected ear canal skin for maximum 2 weeks. 1 Ointment formulation provides superior potency for thick, cracked skin. 1

• Reassess after 2 weeks: If no improvement occurs, this confirms the diagnosis is not purely inflammatory dermatitis and requires alternative management. 5, 1

Step 3: Consider Alternative or Adjunctive Therapy

If fungal infection is suspected based on appearance or lack of steroid response:

• Prescribe tacrolimus 0.1% + clotrimazole 1% in otic oil applied twice daily for 1 month. 3 This combination showed 95.2% patient satisfaction and high efficacy for erythematous-squamous ear canal disorders including seborrheic dermatitis, psoriasis, and chronic external otitis. 3

• Clean the ear canal with saline-soaked swab before each application. 3

If bacterial superinfection is present (increased pain, purulent discharge):

• Add topical antibiotic drops (non-ototoxic if tympanic membrane integrity uncertain): fluoroquinolone otic drops. 2

• Consider oral antibiotics if severe inflammation prevents adequate topical delivery. 2

Step 4: Address Barrier Dysfunction

• Continue aggressive emollient therapy: Apply urea- or glycerin-based moisturizers to the external ear at least once daily. 4 Avoid alcohol-containing products. 5, 4

• For bleeding fissures: Apply propylene glycol 50% in water for 30 minutes under occlusive dressing at night, followed by hydrocolloid dressing. 4

Critical Safety Considerations

• Avoid bilateral cautery or aggressive manipulation in patients with diabetes or immunocompromise, as this may predispose to necrotizing otitis externa. 2

• Limit super-high potency steroid duration to 2 weeks maximum to prevent skin atrophy and systemic absorption. 1

• Do not use ear candling: This is contraindicated and ineffective. 2

Mandatory Dermatology/ENT Referral Indications

Refer immediately if: 1

• No improvement after 2 weeks of appropriate higher-potency topical steroid
• Severe symptoms limiting self-care activities
• Suspicion of necrotizing otitis externa (elderly, diabetic, immunocompromised with granulation tissue at bony-cartilaginous junction, facial nerve involvement) 2
• Uncertainty about diagnosis or need for specialized equipment (otologic microscope, suction) 2

Common Pitfalls to Avoid

• Assuming all ear dermatitis is eczema: Fungal infection, psoriasis, seborrheic dermatitis, and contact allergy are common mimics requiring different treatment. 2, 3

• Continuing ineffective therapy: If mometasone failed, repeating the same approach wastes time. Escalate or change strategy. 5, 1

• Neglecting aural toilet: Debris and crusts prevent medication penetration and perpetuate inflammation. 2

• Using ototoxic drops with uncertain tympanic membrane status: Always visualize the tympanic membrane or use non-ototoxic preparations. 2