Drug Therapy for Ear Disorders

adult ear drop admin

pull ear back & up

child ear drop admin

pull ear back and down

Conditions of the Ear

• Cerumen impaction ​

• Removal may be by irrigation, suction, or instrumentation​

• Gentle irrigation should be used with lowest pressure, directing stream behind the obstruction. Glycerin, mineral oil

Otitis Externa

• “swimmer’s ear”

• Staphylococcus or Pseudomonas

• Aspergillus (type of mold)

• Treatment:

  • Initially antibiotic ear drops

• Hallmark signs:

  • Pinna pain (pain in the outer part of the ear)

  • Otorrhea (discharge from the ear)

Neomycin-polymyxin B-hydrocortisone (Cortisporin Otic)

• Each component has its own MOA

• Patient teaching

  • Burning stinging OTOTOXICITY

• Safe in children but only for bacterial infections >2 years

• Treatment is for 7-10 days

Ofloxacin ear drops

• May be given if the tympanic membrane has ruptured

• 1 gtt QID for 7 – 10 days

Malignant Otitis Externa

• Fulminant infection (extremely severe and rapidly progressing infection)

  • Osteomyelitis of the skull

• Symptoms:

  • Deep seated pain

  • Malodorous otorrhea (foul-smelling discharge from the ear.)

• Treatment

  • Fluoroquinolones

    • Ciprofloxacin

Acute Otitis Media

• Seen in children

• Exposure to smoke, pacifiers, recent URI

• Presentation

  • Pulling at ears, fever, clinical exam

  • Otalgia (ear pain)

• Pathogens:

  • S pneumonia, H influenzae, M catarrhalis

• Teaching

Amoxicillin ear antibiotic

• Beta Lactam

• Children

  • Weight based 90/mg/kg/day, comes 200 or 400 mg/ml, given BID

  • 10 kg child - how much to you give?

• mostly GI

• Alternative: Azithromycin, Cephalosporins

ear patient teaching

• Treat the symptoms – pain and fever

  • Analgesics / Antipyretics

    • Acetaminophen

    • NSAIDS

      • Older than 9 months

    • ASPIRIN in children

• Home environment

• Administer medication

• Ear plugs while swimming/ OTC swimmer’s ear

Dermatitis

• Inflammation of the skin

• Atopic AKA eczema

  • Pruritus, erythema, vesicle rashes

• Contact

  • Pruritis, erythema, blisters, vesicles

• Seborrheic

  • Scaly, flaky, pruritus

• Drug Induced

  • Depends on the cause

Urticaria

• Treated with antihistamines

• aka hives

Psoriasis

• chronic due to increased T lymphocytes

• scaly, silver plaques on the outside of joints

Rosacea

• Chronic

• Erythema, telangiectasis (small, visible blood vessels that appear close to the surface of the skin), rhinophyma (thickening of the skin on the nose, leading to a bulbous, enlarged appearance)

Bacterial infections

• Cellulitis

• Folliculitis

• Impetigo

Fungal infections

• Candidiasis

• Tinea

Viral infections

• Verrucae (warts caused by HPV)

• Herpes

Ulcerations

• Ulcerations

  • Pressure sores

• Venous Stasis ulcers

  • Due to impaired circulation

Acne

• Increased in androgens

• Medication

• Stress

• Comedones

• Acne Vulgaris

Goals of Acne Treatment

• Relieve symptoms

• Eradicate or improve lesions

• Promote healing & repair

• Restore Skin integrity

• Prevent recurrence

• Goals can be more specific according to what is being treated

Antibacterial Agents

• Most caused by Staphylococcus & Streptococcus

• Topical

  • Fewer side effects

  • Most are OTC

  • Bacitracin

  • Mupirocin (Impetigo)

  • Metronidazole (Rosacea)

  • Gentamycin (Bacterial)

  • Erythromycin (Acne)

• Oral:

  • Cephalosporins

    • Staph

  • Sulfa

    • Bactrim

      • Staph

      • MRSA

  • Clindamycin

    • Cellulitis

Polymyxin B Sulfate

• Effective against gram-negative

• Total daily dose applied to denuded wounds should Not exceed 200 mg to reduce risk of neuro or nephrotoxicity

• Combined with Bacitracin & Neomycin (triple antibiotic)

Mupirocin (Bactroban)

• Rx only

• Most gram (+) bacteria including MRSA

• Intranasal use may be associated with irritation of the mucous membranes

Antifungal

• Most are available OTC

  • Prescription are

• Extremely to eradicate

  • Tinea

    • Butenafine (Lotrimin)

    • Clotrimazole (tinea & candidiasis)

    • Ketoconazole (tinea & candidiasis)

• Candidiasis

  • Nystatin (thrush)

  • Fluconazole (RX)

Antivirals

• Some topicals are available

• Acyclovir

Topical Glucocorticoids

• Relieve inflammation & itching

• Many are OTC

• Absorption is greater through inflamed skin

  • Locally can ↑ risk of infection

  • Long-term use leads to atrophy

Benzoyl peroxide

topical

Clearasil, Fostex

• Keratolytic effect- loosens dry skin and causes shedding of the outer layer of the epidermis, reduces inflammation​

• Suppresses sebum production -> Suppresses growth of P. Acnes (antibacterial effect), through release of active oxygen​

• Watch for local irritation- burning, blistering, scaling, swelling​

Clindamycin and Erythromycin

• Suppress P. acnes and decrease inflammation​

• Monotherapy leads to resistance, should be combined with benzoyl peroxide​

acne antibiotics- systemic

• Doxycycline (Vibramycin)-po, Minocycline-po, Tetracycline-po​

• Small doses over long period of time​

acne tx Oral contraceptives ​

• contain ethinyl estradiol and norgestimate​

• Suppress sebum production and reduce skin oiliness​

• Not given to men due to breast enlargement and decrease in body hair that may occur​

Retinoids

• Closely related to Vitamin A

• MOA: decreases the size of the sebaceous gland, decreases comedone formation

• 12 week course

Isotretinoin (Accutaine)- Teratogenicity*

• PREGNANCY TEST

• Common adverse effects include dryness and itching of the skin and mucous membranes, nosebleeds (80%), inflammation of lips (90%), sensitivity to ultraviolet light (100%)*

Keratolytic Agents

Promote shedding of the layers of the skin

Salicylic acid​

• Indications:

  • Dandruff, seborrheic dermatitis, acne, psoriasis​

  • Systemic toxicity- tinnitus, hyperpnea, psychological disturbances​

Sulfur

• Promotes peeling and drying​

• Indications :

  • Acne, dandruff, psoriasis, seborrheic dermatitis​

  • Comes in lotions, gels and shampoos​

• Benzoyl peroxide

Immunomodulators

• Tacrolimus (Protopic) & pimecrolimus (Elidel)

• Macrolide immunosuppressants

Psoriasis Systemic meds

• Adalimumab (Humira)​

• Alefacept (Amevive)​

• Cyclosporine (Neoral, Sandimmune)​

• Etanercept (Enbrel)​

• Infliximab (Remicade)​

• Methotrexate (Rheumatrex, Trexall)​

• Ustekinumab (Stelara)​

• BBW: Cause severe infections, malignancies and toxicities

Acitretin (Soriatane)

• effective in the treatment of psoriasis, especially pustular forms.​

• Adverse effects :

  • ↑cholesterol/triglyderides

  • Tetratogenic

  • Cannot donate blood for three years

• Given orally & weight based

Nursing Considerations

• Apply sparingly. Some preparations come with applicators, some should be applied while wearing protective gloves, and others dropped onto the skin with no direct contact.​

• do not use with open wounds or broken skin, which could lead to systemic absorption and toxic effects.​

• Avoid contact with the eyes, which could be injured by the drug.​

• do not use with occlusive dressings, which could increase the risk of systemic absorption.​

• Provide comfort measures to help to tolerate drug effects such as pain or itching.