Otitis externa

Eye & Ear

Consultation guide for UK community pharmacy: clinical features, referral criteria, time frame to resolution and management strategy.

Clinical features

Acute diffuse otitis externa presents with ear pain and itch. Both the ear canal and external ear can be red and swollen and resemble eczema (with shedding of scaly skin and debris). A discharge may be present in the ear canal and tenderness may be evident when the ear or jaw moves

Localised otitis externa: small swelling in the ear canal. Later this develops to have a white/yellow centre in the spot (pus); the swelling may occludes the ear canal and cause a loss of hearing

Otitis externa

Moderate to severe symptoms (OTC acetic acid is really for mild symptoms, rather than infection/oedema). Moderate to severe symptoms include fever, cellulitis and symptoms spreading beyond the ear, lymphadenopathy, purulent discharge, a red and oedematous ear canal

Chronic skin condition (for example atopic dermatitis or psoriasis) should be well controlled first or referred back to the prescriber if not

Children with ventilation tubes (grommets) are best managed by the doctor/ear specialist

Suspected mastoiditis (unwell, fever, marked hearing loss, mastoid tenderness or swelling)

Suspected malignancy (painless lesion or ulcer, bleeds on contact) or 'malignant otitis' (severe pain, otorrhoea, fever, malaise, facial nerve paralysis) requires an urgent referral

Will depend on the cause. Note also product timeframe restrictions. For example, Earcalm^® SmPC states: Do not use for more than 7 days. If pain occurs during use, or if symptoms worsen or do not improve within 48 hours, or if your hearing becomes impaired, stop treatment and consult your doctor

Non-pharmacological advice

NHS states that cotton buds or other objects should not be used to clean the ear canal

Keep the ears clean and dry by: Using ear plugs when swimming (NHS recommends that those with acute otitis externa should abstain from water sports for at least 7-10 days) and keeping shampoo, soap, and water out of the ear when swimming/bathing/showering (and to use a hair dryer at a low heat setting to dry the ear canal afterwards)

Pharmacological advice

See BNF; the only OTC option mentioned is acetic acid. Suitable in 12 years+ and the patient should be counselled on the use of the product. The BNF states that "acetic acid 2% acts as an antifungal and antibacterial in the external ear canal. It may be used to treat mild otitis externa". There are other options available on prescription so patients should be made aware about this and that anything other than mild symptoms are probably outside the remit of the community pharmacist

Treat pain if present with an analgesic (paracetamol or ibuprofen are usually sufficient) and the application of local heat such as a warm flannel

Pregnancy: not typically managed OTC although Earcalm^® appears to be okay for use in pregnancy (as per most recent SmPC/PIL; double check this prior to recommendation/sales)

NB: Pharmacy First prescribing pathway (England). From 29 October 2026, approved NHS Prescribing Community Pharmacists at approved pharmacies can prescribe ear drops for acute otitis externa in adults aged 18 years and over. Only prescribers at approved sites provide this; many pharmacies will not yet offer it. It is separate from the seven existing patient group direction pathways, including the acute otitis media pathway (children aged 1–17 years). The pathway requires face-to-face examination with otoscopy, and applies where OTC acetic acid 2% ear spray has not worked despite correct use, or was not tolerated or is unsuitable. It excludes a known or suspected eardrum perforation and a current or possibly retained grommet. Otherwise manage within the OTC options above and refer where the referral criteria are met (NHS England, Pharmacy First acute otitis externa prescribing pathway, October 2026)