Chondrodermatitis nodularis helicis chronicus

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Chondrodermatitis nodularis helicis chronicus

Clifford M. Lawrence

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Chondrodermatitis is a benign condition; the only indication for treatment is pain causing sleep disturbance. Painless areas of chondrodermatitis can be ignored or managed conservatively. Lesions on the helix are easier to treat surgically than antihelix lesions and give better cure results. A pressure relieving cushion is a good first choice alternative to surgery for antihelix lesions.

Management strategy

Chondrodermatitis usually occurs on the lateral portion of the ear on the preferred sleeping side. It is generally caused by the weight of the head crushing the ear against the pillow during sleep. Ear injury or surgery may leave an irregular ear margin that becomes a focus for sleep related pressure. The most protuberant part of the ear is affected; this is generally the helix in men and the antihelix in women. Patients who can only adopt one sleeping position due to arthritis, etc., are particularly vulnerable. The incidence increases with age because ear cartilage becomes less flexible with time. Patients should be reassured that it is not skin cancer, advised to use a soft pillow that is still compressible when the head is resting on it, and to change their sleeping position. Conservative or medical treatment, such as lidocaine (lignocaine) gel, a potent topical or intralesional corticosteroid or pressure-relieving cushion can be tried in all patients. If sleep is not disturbed there is really no need for any further intervention unless cosmesis is a problem.

Numerous surgical strategies have been described to treat chondrodermatitis and most work to some degree; it is tempting to suggest that some work by making the ear so painful that the subject is forced to adapt their sleeping position until the lesion resolves spontaneously. Most authors believe that the principle of surgical treatment is excision of the affected area of cartilage without the need for skin or ulcer excision. Other destructive therapies have been advocated but overall are less effective. Antihelix lesions respond so well to cartilage excision that many recommend surgery as a first line treatment.

First-line therapies

image Reassurance not cancer B
image Conservative management B
image Topical corticosteroids B
image Intralesional corticosteroids B
image 2% topical nitroglycerin C

Second-line therapies

image Helix lesions: excision of cartilage without skin excision B
image Antihelix lesions: pressure relieving cushion or device B

The treatment of chondrodermatitis nodularis with cartilage removal alone.

Lawrence CM. Arch Dermatol 1991; 127: 530–5.

Cartilage excision without skin removal resulted in cure rates of 84% for helix and 75% for antihelix lesions. Local anesthesia with lidocaine and epinephrine (adrenaline) reduced bleeding and improved the visibility without ear skin necrosis. On the helix the skin was reflected back from a helix rim incision to expose the cartilage. On the antihelix, a medially based skin flap was raised to expose cartilage. After exposed cartilage excision, all remaining cartilage edges were left smooth and gently shelving up to the uninvolved cartilage to prevent recurrences which may develop on rough or protuberant cartilage edges. Cartilage excision alone is not disfiguring and further cartilage edges can be removed if recurrences occur.

Modified surgical excision for the treatment of chondrodermatitis nodularis.

Ormond P, Collins P. Dermatol Surg 2004; 30: 208–10.

Excision of the cartilage alone is therapeutically and cosmetically effective. To simplify the surgical procedure, a narrow ellipse of skin over the nodule was excised and cold steel dissection of the adjacent skin replaced by hydrodissection to create a plane of cleavage between the skin and cartilage. These two refinements maintained the clinical and cosmetic efficacy but simplified the surgical technique.

All the above techniques are based around removal of damaged cartilage and avoidance of leaving irregular cartilage margins as these may act as a focus for recurrence. Skin excision can be included if this makes the procedure easier to perform but this is not required for surgical success.

Chondrodermatitis nodularis chronica helicis – a conservative therapeutic approach by decompression.

Kuen-Spiegl M, Ratzinger G, Sepp N, Fritsch P. J Dtsch Dermatol Ges 2011; 9: 292–6.

Using a self-made bandage of foam plastic applied during the night, 11 out of 12 patients reported substantial reduction of pain within the first month and were pain free after an average of 1.75 months.

Various types of ear cushion are described. They all share the same aim, i.e., to transfer the weight of the sleeping head from the ear to the surrounding scalp. Authors report a wide range of benefits, with between 15% and 80% of patients not requiring surgery. In the hands of this writer the results are generally disappointing. This technique can be helpful for patients in whom surgery has been unsuccessful and in frail patients with thin skin and antihelix lesions who are unable to adapt their sleeping position, because recurrences at this site are more common after surgery.

Third-line therapies

image Curettage B
image Incision and cartilage curettage E
image CO2 laser ablation C
image Punch and graft B

[/level-membership-for-dermatology-category][not-level-membership-for-dermatology-category]

Chondrodermatitis nodularis helicis chronicus

Clifford M. Lawrence

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Chondrodermatitis is a benign condition; the only indication for treatment is pain causing sleep disturbance. Painless areas of chondrodermatitis can be ignored or managed conservatively. Lesions on the helix are easier to treat surgically than antihelix lesions and give better cure results. A pressure relieving cushion is a good first choice alternative to surgery for antihelix lesions.

Management strategy

Chondrodermatitis usually occurs on the lateral portion of the ear on the preferred sleeping side. It is generally caused by the weight of the head crushing the ear against the pillow during sleep. Ear injury or surgery may leave an irregular ear margin that becomes a focus for sleep related pressure. The most protuberant part of the ear is affected; this is generally the helix in men and the antihelix in women. Patients who can only adopt one sleeping position due to arthritis, etc., are particularly vulnerable. The incidence increases with age because ear cartilage becomes less flexible with time. Patients should be reassured that it is not skin cancer, advised to use a soft pillow that is still compressible when the head is resting on it, and to change their sleeping position. Conservative or medical treatment, such as lidocaine (lignocaine) gel, a potent topical or intralesional corticosteroid or pressure-relieving cushion can be tried in all patients. If sleep is not disturbed there is really no need for any further intervention unless cosmesis is a problem.

Numerous surgical strategies have been described to treat chondrodermatitis and most work to some degree; it is tempting to suggest that some work by making the ear so painful that the subject is forced to adapt their sleeping position until the lesion resolves spontaneously. Most authors believe that the principle of surgical treatment is excision of the affected area of cartilage without the need for skin or ulcer excision. Other destructive therapies have been advocated but overall are less effective. Antihelix lesions respond so well to cartilage excision that many recommend surgery as a first line treatment.

First-line therapies

image Reassurance not cancer B
image Conservative management B
image Topical corticosteroids B
image Intralesional corticosteroids B
image 2% topical nitroglycerin C