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A 77-year-old woman is referred for evaluation of a painful left ear. She states that the condition was first noticed several months ago and has increased in size and is accompanied by an increase in pain, especially severe at night when sleeping on her left side. She has a history of benign skin growths treated with cryosurgery and no prior skin cancers. Physical examination reveals an inflammatory response involving the mid-helix region of her left ear with central crusting. Palpation induces pain. Her right ear is uninvolved.
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Chodrodermatis nodularis helicis (CNH) is an inflammatory process that affects the skin and cartilage of the external ear, namely the helix or antihelix. The condition is also referred to as Winkler disease, named after the dermatologist who first described the disorder in 1915.1 The majority of patients with CNH are men with a median age of 65.2 Involvement of the antihelix is less common and occurs predominately in women. The disorder manifests as a tender papule or nodule that is often accompanied by a central crust and, less frequently, by ulceration. Discomfort is often severe and characteristically interferes with sleep. Mechanical pressure with resultant vascular compression plays a role in pathogenesis.3
Dermoscopy reveals a daisy pattern consisting of radially arranged white thick lines converging to a central rounded yellow-brown keratinaceous or serous crust.4 On histology, inflammation is noted with the underlying crater exhibiting vascular granulation tissue.1
Treatment is facilitated by alleviation of pressure and repetitive trauma to the affected area. This is best accomplished by sleeping on the opposite side or use of a protective covering such as a doughnut pillow or foam pad.5 Intralesional and topical steroids may hasten resolution of the nodule. Topical nitroglycerin ointment applied twice daily has also been demonstrated to decrease pain and enhance healing.6 Some clinicians consider surgical excision as first-line therapy.7
Stephen Schleicher, MD, is director of the DermDox Dermatology Centers, associate professor of medicine at Geisinger Commonwealth Medical College, and clinical instructor of dermatology at Arcadia University and Kings College.
References
1. Leung AKC, Barankin B. Can you identify this tender nodule on a women’s external ear. Consultant360. 2016;56(4). https://www.consultant360.com/articles/can-you-identify-tender-nodule-woman-s-external-ear
2. Wettlé C, Keller F, Will F, Lefebvre F, Cribier B. [Chondrodermatitis nodularis chronica helicis: a descriptive study of 99 patients]. Ann Dermatol Venereol. 2013;140(11):687-692. doi:10.1016/j.annder.2013.07.002
3. Upile T, Patel NN, Jerjes W, Singh NU, Sandison A, Michaels L. Advances in the understanding of chondrodermatitis nodularis chronica helices: the perichondrial vasculitis theory. Clin Otolaryngol. 2009;34(2):147-150. doi:10.1111/j.1749-4486.2008.01851.x
4. García-García B, Munguía-Calzada P, Aubán-Pariente J, Junceda-Antuña S, Zaballos P, Argenziano G, Vázquez-López F. Dermoscopy of chondrodermatitis nodularis helicis. Arch Dermatol Res. 2018;310(7):551-560. doi:10.1007/s00403-018-1844-6
5. Moncrieff M, Sassoon EM. Effective treatment of chondrodermatitis nodularis chronica helicis using a conservative approach. Br J Dermatol. 2004;150(5):892-894. doi:10.1111/j.1365-2133.2004.05961.x
6. Flynn V, Chisholm C, Grimwood R. Topical nitroglycerin: a promising treatment option for chondrodermatitis nodularis helicis. J Am Acad Dermatol. 2011;65(3):531-536. doi:10.1016/j.jaad.2010.06.012
7. Kechichian E, Jabbour S, Haber R, Abdelmassih Y, Tomb R. Management of chondrodermatitis nodularis helicis: a systematic review and treatment algorithm. Dermatol Surg. 2016;42(10):1125-1134. doi: 10.1097/DSS.0000000000000817
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