Malassezia otitis externa.

RE: Malassezia otitis externa.

Leana Watermeyer — Fri, 02 Jul 2021 12:46:40 GMT

Yes

RE: Malassezia otitis externa.

Leana Watermeyer — Fri, 02 Jul 2021 12:46:23 GMT

In selected cases where they have a usually resistant bacterial otitis externa. In the tropics it is humid for about 8m of the year so it doesn't take much to get a Malassezia blowout so we normally add it. I suspect a lot of these dogs have underlying atopy.

RE: Malassezia otitis externa.

Delia Richter — Fri, 02 Jul 2021 08:01:27 GMT

Is that 1ml of enilconazole to 1 bottle (76ml) of cortavance?

RE: Malassezia otitis externa.

Anthony Todd — Thu, 01 Jul 2021 22:31:25 GMT

[quote userid="11162" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29901/malassezia-otitis-externa/231037#231037"]For the chronic cases we use Cortavance spray with 1ml Enilconazole (Imaverol) [/quote]

Sounds like corticosteroids might be helpful have you tried them alone?

RE: Malassezia otitis externa.

Leana Watermeyer — Thu, 01 Jul 2021 18:13:52 GMT

I live in the tropics - we see Malassezia ears most days. For the chronic cases we use Cortavance spray with 1ml Enilconazole (Imaverol) added if you can get this in the UK. This is off label. Apply 1ml once daily in the ear(s)for 3 weeks then on 2 consecutive days each week probably lifelong. To our dismay Cortavance has been on back order for months so now we use ear cleaner with 5ml 5mg Dexamethasone & 1ml Enilconaxoke added. The bottle of ear cleaner is 100ml.

RE: Malassezia otitis externa.

Anthony Todd — Wed, 30 Jun 2021 05:24:37 GMT

I still can't understand why all my simple Malazzesia ears just got better with Csteroids alone, either topically or systemically, if "severe".

just because something is found doesn't mean it is a pathogen per se.

PS As Pred has a blood level for around 5 days [confirmed by response and duration of] why is pred often, or usually, given daily??

RE: Malassezia otitis externa.

Delia Richter — Tue, 29 Jun 2021 20:57:26 GMT

Oh and I tell the owner it is like having eczema down the ear - people seem to be able to relate to that.

RE: Malassezia otitis externa.

Delia Richter — Tue, 29 Jun 2021 20:53:36 GMT

Hi, sorry I'm late to the party...!

So these guys usually have Canine Atopic Dermatitis, so a primary dodgy skin barrier, with secondary allergy/inflammation and Malassezia yeast overgrowth / dysbiosis.

Double check the feet, especially in between the pads of the front feet. Look for inflamed greasy skin here and get impression smears. Also double check the back foot on the same side as the affected ear - some dogs have yeasty toes just where they stick their back toenails into the ear and give it a good scratch. Have a look around the butt, and ask the owner if he scoots.

He's young, so it's definitely worth doing some work up (food trial etc) but you're right, before anything else you have to get on top of that yeast.

Is the dog still comfortable having his ear treated, or is he now ear phobic? How good are the owners at treating the ears, and what is their commitment like? I usually tell these owners that I am their new best friend, because they are going to be seeing me loads over the next couple months until things are sorted.

When you are using the ear treament does the problem ever fully resolve?

So if the dog is still happy having ear treatments and isn't already ear phobic:

Prednisolone at 0.5 - 1mg / kg sid (yup, high anti-inflammatory dose) until the ear is not inflamed and is comfortable, maybe as long as 10 - 14 days, but may only take a few days.

Personally I take a smear, confirm yeast in house, then clean the ear with a gentle squalene containing fluid like Otoact / Vetsoothe Clear (which is not clear but milky). I then place an Osurnia as my tipple of choice. I get them back in 1 week to see me, so there is continuity. I do repeat the cytology and the cleaning of the ear and place the second osurnia at that 1 week recheck. I decide whether to continue prednisolone at that point as well. I think if the ears are that chronic, and if side effects aren't a problem you might want to continue the prednisolone.

I then get them back 2 weeks later, again to see me. I repeat cytology, and cleaning. Each time I clean the ears in front of the owner I make sure they see what I am doing - fill the ear canal, massage the ear base, wipe away all the crap that floats to the top, let the dog shake his head.

At this stage you'll have one of a few scenarios:

1) Amazingly perfect ear!! Don't be fooled, start topical steroid at this point. I usually use Cortavance (when available) or Elocon (Mometasone) if it's not available. To start with I get the owner to use it daily, with cleaning with Otoact once or twice a week. Start your allergy work up.

2) Inflamed but not 'infected' ear - again steroid topically daily, and cleaning. Start allergy work-up.

3) Still some yeast on your cytology, and/or some ceruminous discharge. Some inflammation. I use a topical steroid eod, and on the other days get the o to put canesten down the ear. I show them the trick to get the canesten into a syringe. Clean ear once or twice a week, depending on amount of discharge.

4) Still inflamed and yeasty - cortavance eod, and canesten eod, with more frequent cleaning.

Recheck 2 weeks.

You will probably need months of topical steroid / anti-yeast treatment, as there will be chronic changes to the ear canal lining.

Keep getting these guys back for rechecks really frequently.

Over time if things are under control slowly drop the frequency of the topical meds, you should be able to after a few months get down to say once a week topical steroid, and stop the canesten.

I tend to avoid the ear cleaners that are a bit acid or stingy even though they do discourage yeast, as these ears are quite often sore and the skin barrier is trying to deal with enough as it is.

Once your yeast is under control, start your allergy work-up.

Hope this helps.

Cheers

Delia

RE: Malassezia otitis externa.

Stephen Courtney — Tue, 29 Jun 2021 18:45:20 GMT

I regularly use human itraconazole for these - dose in BSAVA formulary. The licensed ketoconazole has the potential to cause severe liver damage and most dermatologists I know won't use it because of that

the vet itrafungol is designed for cats - so anything larger than a cat requires unfeasible large volumes, even when ridiculous costs are not taken into account, so I feel quite happy prescribing the human 100mg itraconazole capsules

And it works brilliantly for these cases

RE: Malassezia otitis externa.

Julian Earl — Sat, 26 Jun 2021 12:00:08 GMT

[quote userid="5904" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29901/malassezia-otitis-externa/230973#230973"]Has anyone found a permanent solution? [Apart from surgery][/quote]

I think the benefit of surgery is that this facilitates constant drying of the canal and as I said earlier, being a yeast it does not survive well in dry conditions. The only downside that I can see, apart from the cost, pain, etc., is that if the infection is secondary to contact allergy or atopy eg to pollen, a lateral wall resection exposes the skin more directly to contact with the allergens! /but on t'other hand it does also allow physical cleaning of the skin there after being outside exercising through grassy fields or whatever. I know from my own hay fever that physically rinsing my eyes reduces the degree of allergic inflammation dramatically, resulting from the exposure to pollens!

So the answer to your initial question..., Sorry, No! But I do not think that surgery should be dismissed at all! The drying is crucial to success against Malassezia!

RE: Malassezia otitis externa.

Anthony Todd — Sat, 26 Jun 2021 11:30:38 GMT

[quote userid="5012" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29901/malassezia-otitis-externa/230970#230970"]So far, the treatments seem to work but the condition flares up again/recurs once it stops.[/quote]

Has anyone found a permanent solution? [Apart from surgery]

Does anyone disagree with the notion [or suggestion] that Mal. is not the cause, nor an "infection" but just a biological response of Mal population related directly to "food" supply, ie sebum?

My experience, from memory, was that recurrence was intermittent and "cure" was total even on each recurrence.

PS is it seasonal??

RE: Malassezia otitis externa.

Clive Ansell — Sat, 26 Jun 2021 09:57:21 GMT

Thanks once again for the ideas.

So far, the treatments seem to work but the condition flares up again/recurs once it stops.

It seems we are the fourth vets within 12 months; so there is an issue with compliance on the owners part, and a lack of follow up checks being advised from the numerous different vets in the different practices. The owners had the impression that a bottle of ears drops would be job done, they seemed to have no idea that it is likely to be long term ongoing and will likely become chronic.

First thing I will have a conversation with the owners, and trial longer term treatment with regular follow checks, and try and manage their expectations.

I know it may become a surgical case, but the owners and I are keen to avoid that.

RE: Malassezia otitis externa.

Anthony Todd — Fri, 25 Jun 2021 17:30:57 GMT

How do they go without the dex??

How do they go just with the dex and without the ear cleaner?

just as well I wager, or may be even better as the cleaner may also cause some irritation and/or reaction?

Mind you if was still in practice i'd smuggle Panalog in instead of more sensitive imports.....

RE: Malassezia otitis externa.

Thomas Johnson — Fri, 25 Jun 2021 16:45:54 GMT

[quote userid="5012" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29901/malassezia-otitis-externa/230926#230926"]Recicort has been used, it helps, but as soon as it is discontinues the condition flares up again.[/quote]

I've got a couple of dogs with chronic ear disease that are very well managed on ear cleaner with dexamethasone added, 5ml Colvasone in 100ml ear cleaner. Twice a week seems to work well, though I usually start with daily and gradually reduce the frequency.

RE: Malassezia otitis externa.

Judith Joyce — Fri, 25 Jun 2021 09:07:50 GMT

Agree, adequate dose and length of steroids essential and sometimes more action required when either persistence of initiating cause and prolonged use of polypharmacy has resulted in chronic ? irreversible secondary change to the ear canal

RE: Malassezia otitis externa.

Anthony Todd — Fri, 25 Jun 2021 08:53:24 GMT

I always understood that Malassexia was a normal coloniser of canine ears living happily on the small amounts of sebum, normal in all ears.

When ears are inflamed,usually by an allergic reaction, numbers rise in parallel which is why Csteroids alone always worked for me if there was no secondary bacterial infection.

I just treated the cause, not the obvious effect. [i think someone else said this last time it was raised]

PS this can happen on the body when there is a severe allergic reaction

RE: Malassezia otitis externa.

Julian Earl — Fri, 25 Jun 2021 08:20:29 GMT

[quote userid="12930" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29901/malassezia-otitis-externa/230955#230955"]otodine (chlorhexidine) or similar proprietary produc[/quote]

I seem to recall that chlorhexidine is contra-indicated for Malassezia? Something about it even encouraging growth of said entity! Iodine-based antiseptics are better for fungal-type pathogens. I'm now going to see what Entrez Pub-Med has to say on this...

HTH...?

Edit Not much in fact:( But treatment with an azole is mentioned a lot when searching for this. Also , often secondary o allergic dermatitis and reatment of the underlying pathlology is crucial, hence why steroids help s well!

Avoid antibiotics?

RE: Malassezia otitis externa.

Beats — Fri, 25 Jun 2021 06:59:04 GMT

If true, then continuing it indefinitely may be an option?

Unlikely from description, but otitis media could be a perpetuating factor. (systemic treatment or myringotomy and clear out if is) more likely that chronic changes in external ear are problem.

I would use topical steroids and cleaning as required.

Failing that I'd consider surgery (I think vertical ear canal resection has merits), but only if I failed to maintain with regular steroids in ear as required and cleaning.

Topical steroid choices: might be worth considering an alternative to recicort, I have certainly found it quite irritating in some cases (is it acidic perhaps?). Mometasone 0.1% (Elocon Scalp lotion 0.1%) seems milder in some cases; cortavance is alternative. If get controlled, then I'd wean very gradually and see if can get down to twice weekly, or 3 days a week without re-flaring.

Cleaner: I like Epi-Otic (Virbac) and a training session showing owner how.

Anti-yeast: Topical clotrimazole works well, but so do lots of things. I often start with otodine (chlorhexidine) or similar proprietary product. Acetic acid fine, but is bit irritating perhaps.

Can mix the steroid and cleaner/anti-yeast (eg 5ml colvasone in bottle of otodine), but I prefer to keep the 2 bits separate (clean then put in medicated steroid drops).

RE: Malassezia otitis externa.

Julian Earl — Thu, 24 Jun 2021 22:14:11 GMT

Iused to use Dermisol as a General skin cleanser, slightly acidic. Also bear in mind that being a yeast, Malassezia enjoys = thrives in, damp conditions so the other strategy is to keep the ear canal dry if possible. HTH?

RE: Malassezia otitis externa.

Judith Joyce — Thu, 24 Jun 2021 19:43:52 GMT

This sounds like it's heading towards surgery if its not already there. The environment for Malassezia overgrowth needs to be addressed and it sounds like that might not be possible without. The chronic changes (e.g. epidermal hyperplasia and ceruminal gland hyperplasia, producing the 'wrong sort of cerumen' ) may be reversible but may take weeks to months of consistent (other than courses) anti-inflammatory (glucocorticoid) treatment, combined with something like Malacetic if tolerated. It's worth withdrawing all topicals in case there is sensitisation and replacing oral prednisolone. There may be a persisting initiating cause of the Malassezia problem to be addressed. Anyone using ear wicks?

RE: Malassezia otitis externa.

Chris Barker — Thu, 24 Jun 2021 12:10:56 GMT

?surgery I am no longer a fan of the old fashioned Lateral Wall Resection - too many cases of continued disease of the remaining medial wall... So Vertical Canal pull throughs are my usual recommended surgery for the majority of troublesome ears

Except...

This year an owner begged me to do a second LWR on his dog - the first ear had been done by me many moons ago to open a sweaty ear where recurrent Malassezia was the problem. Such a success that he now wants the second ear done... n=1

RE: Malassezia otitis externa.

Sue white — Thu, 24 Jun 2021 10:15:51 GMT

Ideas - Clip out ears if not already. Dexamethasone added to malacetic can help as longer term use. I find posatex very good for flare ups malessezia. Have used oral itraconazole off licence on 2days week in past for malessezia as safer and cheaper than ketoconazole - however not as good for ears cf skin. Also tried canesten hc cream with varying success. Trial hypoallergenic food just in case!

RE: Malassezia otitis externa.

Clive Ansell — Thu, 24 Jun 2021 09:03:05 GMT

Thanks for all the input so far.

Recicort has been used, it helps, but as soon as it is discontinues the condition flares up again.

Malacetic has already/is being used.

Next step I think is trial specific antifungals. Unsure about oral Ketoconazole, can be toxic and not specifically licenced for Malassezia, and is expensive.

RE: Malassezia otitis externa.

janine redman — Wed, 23 Jun 2021 23:00:02 GMT

I have to say I have found recicort very useful with similar cases . Seems to be good at drying the ear , reducing inflammation and wax and making the environment more hostile for malassezia

RE: Malassezia otitis externa.

Anthony Dennison — Wed, 23 Jun 2021 22:21:52 GMT

[quote userid="3169" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29901/malassezia-otitis-externa/230921#230921"]oral Ketoconazole (fungiconazol)?[/quote]

I've used this in problem cases before. Works well.