Chondrodermatitis Nodularis Helicis

Chondrodermatitis nodularis helicis is a painful inflammatory nodule on the helix or antihelix of the ear, formed over cartilage under pressure. It is benign, but must be distinguished from skin cancer.

It affects mostly men aged 50 to 70 years, and is more common in fair skinned people with sun damage and in those who sleep on one side. Women are affected more often on the antihelix. It is usually unilateral, and about 10% are bilateral.

Pathophysiology.

Pressure, cold, actinic damage and reduced blood supply over thin skin and cartilage cause ischaemia and degeneration of the cartilage with a surrounding inflammatory response. The nodule is painful because of nerve irritation, and the lesion can ulcerate.

A firm, tender, round nodule of 4 to 6 mm with a central crust or ulcer, on the upper helix or the antihelix. Pain is worse on lying on the ear and may wake the patient.

Red flags.

• Rapid growth, bleeding or non-healing ulcer (squamous cell carcinoma).
• Pearly or pigmented lesion.
• Immunosuppression or organ transplant.

Diagnosis is clinical. Biopsy any lesion with atypical features, bleeding, rapid growth or failure to respond to treatment, since squamous cell carcinoma, basal cell carcinoma, actinic keratosis and keratoacanthoma can look similar. Biopsy shows ulcer, acanthosis, degenerated collagen and chondritis.

Differential diagnosis.

• Squamous cell carcinoma.
• Basal cell carcinoma.
• Actinic keratosis.
• Gouty tophus.
• Rheumatoid nodule.
• Chondrodermatitis from relapsing polychondritis.

Relieve pressure first, with a pillow with a hole (donut pillow), sleeping on the other side, and a protective ear dressing. Topical treatment helps some patients; surgery gives the most reliable cure. Cryotherapy and laser are options, but recurrence is common (about 10% to 30%).

• Clobetasol propionate 0.05% ointment: applied thinly to the lesion once daily for 2 to 4 weeks, then stop; maximum 4 weeks of continuous use; monitor for skin atrophy; avoid on broken infected skin.
• Glyceryl trinitrate ointment 0.2% (limited evidence): applied to the lesion twice daily for up to 12 weeks; maximum 2 applications daily; monitor for headache, hypotension and dizziness; avoid with phosphodiesterase inhibitors.
• Triamcinolone acetonide (intralesional): 10 mg/mL, 0.1 to 0.2 mL injected into the edge of the lesion, repeated after 4 weeks if needed; maximum 5 mg at each session; monitor for skin atrophy and hypopigmentation; avoid in infected lesions.

Surgical options include excision of the lesion and the underlying cartilage ridge (wedge or curettage with cartilage removal), which relieves pressure.

Monitoring. Review at 4 to 6 weeks, and biopsy if there is no response to 3 months of treatment.

Referral and escalation. ENT, dermatology or plastic surgery for surgery or if cancer is suspected.