Chondrodermatitis nodularis chronica helicis H61.0

Winkler 1915

Chronic, benign nodule on the free edge of the auricle, which is very painful under pressure. The clinical picture usually persists for 10-15 months before the medical consultation.

Prevalence data are not available. Men are mainly affected (>60%).

Unknown. Probably pressure necrosis due to increasing hardening of the ear cartilage with advancing age and firm sleeping habits (e.g. sleeping only possible on one side) or due to permanent trauma caused by wearing a helmet or headphones etc. Furthermore, most patients report intensive UV exposure (in a larger study group of almost 100 patients, this figure was found in almost 60%).

Occurring in middle to older age (average age 58-72 years - average 65 years), only very isolated cases are described in children.

On the right side slightly more frequently than on the left side; very rarely bilateral (6-10%). Mostly upper external auricle margin above the Darwin hump; clearly more rarely anthelix, scapha and concha are involved.

On pressure or on firm palpation, moderate (about 20%), very severe (60%), to intolerable (20%) pain; spontaneously occurring, rapidly growing, skin-colored or whitish, often centrally ulcerated or encrusted dermal nodule (rarely nodulation), which is usually not displaceable on its base.

About 60% of patients report a very intense stabbing pain, sometimes shooting in spontaneously, which can last minutes but also up to several hours; characteristic is the statement of the patients that they could not sleep on this ear anymore.

The size is usually 0.4-0.7 cm in diameter; the maximum extension is about 2.0 cm in diameter.

CNCH localized atypically (not at the helix) may present as a flat painful ulcer or as a flat keratotic papule or plaque.

Basal cell carcinoma: Absence of pain; ulceration possible; in these cases smooth, "basalcell carcinoma-typical " border.

Gouty tophi: Rarely as a single finding; usually multiple; initially soft, yellowish, later increasingly coarse, usually painless nodules due to deposition of precipitated uric acid salts in the skin.

Keratosis actinica: Usually flat adherent scaling; mild pain may be present, but not intense pain.

Keratoacanthoma: Rapidly growing red nodule, no painfulness.

Squamous cell carcinoma: Important DD; clinically not always definite although the typical pain of CNCH is absent. Histology is conclusive.

Surgical procedures:

• The safest therapy is the complete surgical removal of the painful nodules by means of wedge excision, since recurrences can only be prevented if the removal is sufficiently extensive.
• A surgical therapy variant is the so-called "punch and graft procedure". In this technique, the lesional skin with the underlying cartilage is punched out and the defect is covered with full thickness skin.

Alternative: Intralesional glucocorticoid injections with triamcinolone (e.g. Volon A crystal suspension diluted 1:5 with LA such as lidocaine 1%). Initial success is good, with prompt diminishing pain. Long-term success is doubtful.

Alternative: therapeutic trial by electrocautery and curettage for superficial changes may be considered.

Alternative: Laser ablation by_CO2 or Erbium YAG laser.

Alternative: Topical glucocorticoids (Note: only moderate chance of success in chronic conditions).

Alternative: Pressure relief by individually adapted ear protection bandage. If necessary, pillow with auricular recess ("donut pillow").

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2. Hesse G et al (1994) Argon laser therapy of chondrodermatitis nodularis chronica helicis. dermatologist 45: 222-224
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8. Wagner G et al (2011) Clinical forms, differential diagnosis and therapeutic options of chondrodermatitis nodularis chronica helicis Winkler. JDDG 9: 287-291
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10. Winkler M (1915) Chondrodermatitis nodularis chronica helicis. Arch Dermatol Syphilol 121: 278