For suspected fungal otitis externa in a steroid-sensitive child, which topical antifungal would be most appropriate as first line?

• A. Hydrocortisone plus antifungal
• B. Miconazole spray
• C. Clotrimazole 1% solution
• D. Terbinafine cream

Answer: (C)

In suspected fungal otitis externa, especially in a child who is sensitive to steroids, the aim is to use a topical antifungal without a steroid as first line. Clotrimazole 1% solution fits this well because it has strong activity against the fungi that commonly cause ear infections (like Candida and Aspergillus) and is available as an ear-drop formulation, allowing direct, localized treatment of the canal.

Avoiding a steroid-containing preparation is important here because steroids can suppress local immune defenses and potentially worsen a fungal infection or delay healing in a steroid-sensitive patient.

Other options are less ideal for first-line use in this scenario: a combination product that includes hydrocortisone contains a steroid, which we’re trying to avoid; a miconazole spray could be less convenient or well-studied for the delicate ear canal in children; and terbinafine cream isn’t formulated for otic use and has less evidence for effectiveness in otitis externa.