Acetic acid/tacrolimus

Abstract

Severe otitis externa bilaterally with resultant scarring and lack of efficacy: case report A 73-year-old woman developed severe otitis externa bilaterally with resultant scarring during treatment with tacrolimus for otic lichen planus. Additionally, she experienced lack of efficacy while being treated with acetic acid for otic lichen planus [dosages not stated; not all routes stated]. The woman with a 20-year history of biopsy-proven lichen planus involving the scalp, body, mouth and genitals, presented for management of lichen planus. The mucocutaneous and genital symptoms were generally well controlled with hydroxychloroquine, doxycycline, fluocinolone-acetonide [fluocinolone] gel to the gingiva and clobetasol ointment to the body. Patch testing was negative for contact dermatitis as a contributor to her symptoms persistence. Dermatologic examination revealed focal areas of scarring alopecia without active inflammation and white reticulations on the bilateral buccal mucosa consistent with Wickham striae. Prior genital examinations were notable for a decrease in the labia minor with ulceration suggestive of lichen sclerosus and lichen planus. She had been also diagnosed with granular myringitis and stenosing external otitis that was followed closely by otolaryngology. Granular myringitis and stenosing external otitis had developed many years prior with left-sided external auditory canal impaction and hearing symptoms and subsequently progressed to bilateral otorrhea and worsening hearing loss. She also had multiple episodes of acute myringitis, otitis media and otitis externa. The symptoms were refractory and recurrent despite treatment with the range of pre-existing steroid and antibiotic otic drops [specific drug not stated], as well as dilute acetic acid solution. An audiogram demonstrated mixed hearing loss; more specifically, she had down-sloping bilateral high-frequency sensorineural hearing loss and superimposed conductive loss. It was postulated that she had otic lichen planus. However, there was reluctance to initiate additional systemic treatment without a definitive diagnosis, and biopsy was initially deferred due to concern for further scarring. Because of progressive left external auditory canal stenosis and hearing loss, she underwent canaloplasty and tympanoplasty of the left ear. Pathology of the ear canal contents were nonspecific. Surgery was uncomplicated, with initial improvement of hearing and otorrhea on the operated side. However, signs of inflammation redeveloped on the left, and symptoms continued to worsen on the right, nonoperated side. Otoscopic examinations were notable for ongoing inflammation and moistness of the auditory canals bilaterally and stenosis of the right external auditory canal. She had limited improvement with topical clobetasol, applied at intervals via binocular microscopy. Topical tacrolimus 0.03% ointment was also trialed with some improvement but she subsequently developed severe otitis externa bilaterally with resultant scarring requiring lysis [duration of treatment to reaction onset not stated]. Considering improvement after surgery on the left, the woman elected to undergo a similar procedure on the right 2 years after her first procedure. Biopsy performed at the time of surgery revealed lichenoid interface dermatitis, consistent with lichen planus. After an initial period of improvement, inflammatory findings again recurred bilaterally. Given her recurrent, refractory symptoms and now biopsy-proven otic lichen planus, she received off-label therapy with mycophenolate mofetil 1000mg twice daily. Additionally, she was continued on stable doses of hydroxychloroquine and doxycycline. After 6 months of treatment with mycophenolate mofetil, she had substantial decreases in bilateral ear inflammation and otorrhea. Occasional applications of clobetasol and intralesional injections of triamcinolone [Kenalog] were performed, but overall she had a marked improvement.