Painful, nonbleeding 
lesion on the ear - Clinical Advisor

Painful, nonbleeding 
lesion on the ear

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  • Chondrodermatitis nodularis helicis_1013 Derm Clin

A woman, aged 72 years, presented to the dermatology clinic with complaints of a persistent lesion located on the helix of her right ear. The lesion, which had been present for seven months, was extremely tender but had not bled or changed in size since its initial appearance.

The woman reported that the pain was most severe when she slept on her right side and occasionally woke her up at night. Unfortunately, the patient was unable to sleep in a different position due to a previous spinal surgery. Pertinent dermatologic history included a squamous cell carcinoma on her left cheek and multiple actinic keratoses. 



TAKE THE POST-TEST: This Clinical Advisor CME activity consists of 3 articles. To obtain credit, you must also read Enlarging white patches and White facial papules and sparse, brittle hair.

The patient was diagnosed clinically with chondrodermatitis nodularis helicis (CNH). This condition presents as one or more inflamed nodules on the helix or antihelix of the ear and is most commonly seen in middle-aged or elderly populations. Men are more...

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The patient was diagnosed clinically with chondrodermatitis nodularis helicis (CNH). This condition presents as one or more inflamed nodules on the helix or antihelix of the ear and is most commonly seen in middle-aged or elderly populations. Men are more frequently affected than women.

The nodules will spontaneously appear as flesh-colored or pink lesions measuring 3 mm to 20 mm and can have a central crust. Once they appear, the lesions will typically remain stable in size and are usually quite tender. One or both ears can be affected at the same time. The lesions will occur on the part of the ear with the most outward projection. Men are more at risk on the helix, whereas women are more affected on the antihelix. In general, the apex of the helix is the most common site.1

The exact cause of CNH is unknown, but lesions are thought to occur due to ischemia of the dermis. The ear has relatively little subcutaneous tissue for insulation and padding, and only small dermal blood vessels supply the epidermis, dermis, perichondrium, and cartilage. These anatomic features of the ear prevent adequate healing and lead to perichondritis. Ischemia can be increased due to favoring one side during sleep, as the ear is crushed into the pillow.

Other causes may include pressure from piercings and use of earphones, cell phones, and hands-free phone devices with ear attachments. Actinic damage, repetitive trauma, or previous frostbite may predispose patients to easier breakdown of dermal tissue.2 CNH may occasionally be associated with autoimmune or connective-tissue disorders, including autoimmune thyroiditis, lupus erythematosus, dermatomyositis, and scleroderma. Such cases may be more common in pediatric or young-adult female patients.3

Diagnosis of CNH can be made clinically based on patient history and symptoms. A shave biopsy can be performed to rule out such similarly appearing conditions as basal cell carcinoma, squamous cell carcinoma, actinic keratoses, atypical fibroxanthomas, and pseudocysts.3 Basal cell and squamous cell carcinomas are caused by chronic sun damage or radiation, will typically continue to enlarge, and can bleed easily if traumatized.

Actinic keratoses are premalignant scaly or crusted papules or plaques with scale that will often appear on sun-exposed skin and can be tender or bleed. Atypical fibroxanthomas are rapidly growing pink or red nodules on sun-exposed skin that are frequently mistaken for malignancies.4 Pseudocysts present as a noninflamed and painless swelling of the pinna and typically occur in men in the third or fourth decade of life. Pseudocysts also may occur from repeated minor trauma or pressure.5

Because of the similar presentations of these conditions, a biopsy is often needed to secure the correct diagnosis. Histologic changes include those similarly seen in a decub­itus ulcer but on a smaller scale. These changes include epidermal ulceration and dermal homogeneous acellular collagen degeneration with fibrin deposition. Granulation tissue flanks the zone of necrosis on both sides.6 A workup for autoimmune conditions should be performed if the patient presents with lesions at a younger age or if otherwise suspected from the patient’s history.

Treatments for CNH are varied and can be challenging. The main objective of therapy is to relieve pressure being exerted on the ear and may include removing piercings or discontinuing use of electronic devices that pinch the ear. Sleeping on the opposite side of the head can be helpful but is not always possible, and there is a risk that the patient will develop a CNH nodule on the other ear. Special pillows have been designed to alleviate pressure on the ear during sleep. These pillows work by creating an air space in which the ear can rest while the other parts of the head are supported.

Intralesional injections of triamcinolone acetonide and twice-daily topical betamethasone valerate cream 0.025% for six weeks have been shown to be effective in approximately 25% of patients studied.7 Antibiotics can be used if infection is suspected. Cryotherapy and CO2 laser ablation are third-line options.7

When CNH lesions are recalcitrant and the patient is willing to undergo a more invasive approach, excision of the nodule and surrounding cartilage can be performed by a surgeon. The most common method is to perform a wedge excision of the nodule with reconstruction of the skin and cartilage margins. It is important that the cartilage edges are smooth so as not to create any additional pressure points on the ear.

While a punch excision can also be performed to encompass the entire nodule,8 this approach is less favored because it will likely require a skin graft. The prognosis after excision is generally good, but lesions may recur in the same or different areas unless chronic pressure is relieved. Reassurance that the lesion is not a tumor may put the patient’s mind at ease and no treatment may be desired.9

The woman in this case was initially treated with an intralesional injection of triamcinolone acetonide, which decreased the size of the lesion by approximately half. After reporting moderate pain at her follow-up appointment, the patient opted to use a pillow designed to alleviate pressure on the ear during sleep. She will be reevaluated in six months.

Kristen Grippe is a physician assistant at Dermatology Associates of Erie in Erie, Pa.


TAKE THE POST-TEST: This Clinical Advisor CME activity consists of 3 articles. To obtain credit you must also read Enlarging white patches and White facial papules and sparse, brittle hair.


References

  1. Yaneza MM, Sheikh S. Chondrodermatitis nodularis chronica helicis excision and reconstruction. J Laryngol Otol. 2013;127:63-64.
  2. Chrondrodermatitis nodularis chronica helicis. In: James W, Berger T, Elston D, eds. Andrew’s Diseases of the Skin, 10th Ed. Philadelphia, Pa.: Saunders; 2006:610.
  3. Medscape. Chondrodermatitis nodularis helicis. Available at emedicine.medscape.com/article/1119141.
  4. Medscape. Atypical fibroxanthoma. Available at emedicine.medscape.com/article/1056204.
  5. Vano-Galvan S. Dermacase. Auricular pseudocyst. Can Fam Physician. 2009;55:271-272. Available at www.cfp.ca/content/55/3/271.long.
  6. Chung HJ, Cam K, Schwartz L. Firm papules on the auricular helix. Weathering nodules (WNs) of the ear. JAMA Dermatol. 2013;149:475-480.
  7. Beck MH. Treatment of chondrodermatitis nodularis helicis and conventional wisdom? Br J Dermatol. 1985;113:504-505.
  8. Rajan N, Langtry JA. The punch and graft technique: a novel method of surgical treatment for chondrodermatitis nodularis helicis. Br J Dermatol. 2007;157:744-747.
  9. Lawrence, C. Chondrodermatitis nodularis helicis chronica. In: Lebwohl M, Heymann W, eds. Treatment of Skin Diseases, 3rd ed. Philadelphia, Pa.: Saunders; 2010:139-141.

All electronic documents accessed October 7, 2013.

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