Varicella and NSAIDs – are you too chicken to prescribe?

Cite this article as:
Alasdair Munro. Varicella and NSAIDs – are you too chicken to prescribe?, Don't Forget the Bubbles, 2019. Available at:

Jaxon is a 3-year-old boy, brought to the ED by his mother with chickenpox because of decreased oral intake. On examination he has a rash consistent with chickenpox, but no red flags. He is febrile and looks uncomfortable, and you note his heart rate is high. You go to prescribe paracetamol, but his mum has given him four doses in the past 24 hours already. You wonder if you can prescribe ibuprofen instead, but your colleague warns against it.

Neonatal dermatology – the rashes you shouldn’t ignore

Cite this article as:
Trisha Parmar. Neonatal dermatology – the rashes you shouldn’t ignore, Don't Forget the Bubbles, 2016. Available at:

Neonates have rashes of all shapes and sizes. It’s important for us to be able to reassure parents where appropriate and act when we need to. This two part series deals with neonatal dermatology. In Part 1, we looked at the benign conditions, but in Part 2 we will look at the conditions that you shouldn’t ignore.

Otitis externa

Cite this article as:
Sinéad Davis. Otitis externa, Don't Forget the Bubbles, 2013. Available at:

A 7-year-old boy is brought to the ED by mum. He has ear pain (otalgia), reduction in his hearing and a little discharge from the ear. His symptoms have been getting worse over the last couple of days and now he is in a lot of pain despite analgesia, given by the parents. Mum thinks the infections might have started after he began his swimming lessons, 3 months ago.

 Is this history suggestive of otitis externa (OE) or acute otitis media (AOM)?

Bottom Line

  • Scanty white/yellowish discharge associated with an oedematous ear canal is otitis externa.
  • Pain often builds up over a couple of days and is increased on moving the pinna or pressing on the tragus.
  • Increased risk with exposure to water e.g. recent holidays, swimming lessons.
  • Treatment is with TOPICAL antibiotics (usually drops) and regular analgesia.

What is otitis externa?

It is acute inflammation and infection of the skin of the external auditory canal.

It might be localized, like a pimple, or more often is diffuse, involving all the skin of the ear canal. It might extend to involve the pinna, causing perichondritis, or infection of the side of the face, cellulitis or erysipelas.

from Hawke Library

Who gets it?

This condition is less common in children than acute otitis media, but certain conditions can predispose an individual to get this condition including:

  • Eczema, involving the skin of/near the ear
  • Psoriasis
  • Water exposure: recent holidays, regular swimming, frequent baths
  • Trauma, particularly from cleaning ears with cotton buds
  • Immunocompromised patients

What are the most common pathogens?

Otitis externa might be caused by bacterial, fungal, or viral infections.

Bacterial causes: Staphylococcus aureus, Pseudomonas aeruginosa
Fungal causes: Candida spp; Aspergillus niger
Viral causes: Varicella zoster; Herpes simplex

What are the clinical findings?

Patients will find it painful when you touch the pinna or if you push on the tragus. The ear canal is swollen and oedematous, to the point that it closes up in severe cases. White debris or yellowish discharge can be seen in the ear canal.

Signs of mucous, however, indicate a discharge from the mucosa in the middle ear, indicating a tympanic membrane perforation is present. In this case, the patient should be treated for AOM.

The patient will have reduced hearing. As the ear canal closes over from the swelling a conductive hearing loss develops.

from Hawke Library

How should I treat it?

If you can see into the ear canal, enough to see the discharge, then firstly treat with

TOPICAL antimicrobial agents: antiseptic  e.g acetic acid drops/spray, antibiotic e.g. aminoglycoside or fluoroquinolones (ciprofloxacin) drops

Steroids: topical – usually combined with the above drops.

Analgesia: this is a very painful condition – paracetamol/NSAIDS

If the canal is closed over, refer the patient to ENT for further management. This is likely to include micro-suction clearance of the ear canal debris and/or insertion of a dressing (wick) into the ear, onto which antimicrobial therapy can be instilled.

Side effects of the treatment

Aminoglycosides carry a risk of ototoxicity: the use of these agents is not advised if it is known that there is a tympanic membrane perforation.

Aminoglycosides, especially neomycin, can cause contact dermatitis in 15% of patients.

License for use of fluoroquinolone

Though the use of topical ciprofloxacin in the ear canal is licensed in the US and many countries worldwide, it is not licensed for this use in the UK. Despite this many clinicians, in the UK, will choose to prescribe this medication ‘off license‘; but in doing so should follow the published guidance of the General Medical Council, UK.

What are the other possible diagnoses?

In children, the most likely diagnosis is going to be AOM, with a TM perforation, so that the ear discharge has caused a secondary OE. In this case, the discharge will be mucoid (stringy) in consistency.

Selected references

Kaushik V, Malik T, Saeed S R. Interventions to treat acute otitis externa. Cochrane Database Syst Rev 2010;(1):CD004740

Marais J, Rutka J A. Ototoxicity and topical eardrops. Clin Otolaryngol Allied Sci 1998;23:360-367

GMC. Good practice in prescribing and managing medicines and devices.