Medical Care
Medical management of chondrodermatitis nodularis chronica helicis (CNH) is often unsatisfactory. The primary goal should be to relieve or eliminate pressure at the site of the lesion. [14] This is often difficult because of the patient's preference or necessity to sleep on the side with the lesion. A pressure-relieving prosthesis can be fashioned by cutting a hole from the center of a bath sponge. [15] This device can then be held in place with a headband. Additionally, a self-adhering foam sponge (Reston Foam, 3M, St. Paul, Minn) can be customized and shaped into either a rectangular or crescentic shape in order to maximize offloading. The foam is then applied to the non–hair-bearing postauricular scalp during sleep. This affordable technique helps to ensure that shifting of the pressure-relieving foam is minimal. [16]
A special prefabricated pillow is available that helps relieve pressure on the ear. For more information on this pillow, contact the following:
PO Box 1247
Abilene, TX 79604
Phone: (800) 255-7487 or (325) 672-2162
Fax: (325) 677-2410.
Topical antibiotics may relieve pain caused by secondary infections. Topical and intralesional steroids also may be effective in relieving discomfort. Collagen injections may bring relief by providing cushioning between the skin and cartilage. Cryotherapy also has been used as a treatment modality. Topical diltiazem and topical nitroglycerin 2% twice daily has been shown to relieve both symptoms and appearance. [17, 18]
Nitroglycerin patches have also been used. [19]
If specific efforts to relieve pressure are unsuccessful, surgical approaches almost always are needed. [20]
A series of photos demonstrating the self-adhering foam offloading technique is shown below.
Self-adhering foam in a curvilinear shape is placed on the non–hair-bearing postauricular scalp.
A rectangular piece of self-adhering foam is placed on the non–hair-bearing postauricular scalp.
Photodynamic therapy is promising, although multiple treatment sessions may be required. [20, 21]
Surgical Care
Various procedures have been used in the treatment of chondrodermatitis nodularis chronica helicis. These procedures include wedge excision, curettage, electrocauterization, photodynamic therapy, carbon dioxide laser ablation, and excision of the involved skin and cartilage. [22, 23, 24] In general, the recurrence rate is high unless the underlying focus of damaged cartilage is removed and the pressure relieved. Treatment with cartilage removal alone, as described by Lawrence, provides excellent curative, functional, and cosmetic results. [25]
Perform the procedure to remove cartilage with the patient under local anesthesia using 0.5-1% buffered lidocaine with epinephrine 1:200,000.
For lesions on the helix, make an incision on either side of the nodule running along the rim of the helix. Make the incision where the scar can be best hidden. Bluntly dissect and reflect the skin from the perichondrium to reveal the helix cartilage. Trim the cartilage immediately under the ulcer with a flat shaving technique using a scalpel to a depth of approximately 3 mm. The remaining cartilage must be smooth to touch because rough cartilage may produce pressure points. After hemostasis is achieved, reapproximate and suture the skin.
For lesions on the antihelix, raise a 3-sided flap that is approximately 25 mm wide and 15 mm long, with its attached margin directed toward the helix. Expose the perichondrium-covered cartilage, and excise cartilage with a scalpel until all edges are smooth to touch. Obtain hemostasis, and reapproximate and suture the flap. Conservation of the normal tissue is important for esthetic outcome. [26]
Another variation for treating lesions on the antihelix involves excising the affected cartilage and then closing the defect with bilateral advancement flaps that are based inferiorly and superiorly along the antihelix. [27]
Rajan et al reported a novel approach to the surgical treatment of chondrodermatitis for small, localized lesions. The area is anesthetized with 1% lidocaine with epinephrine. A punch biopsy instrument is used, the diameter of which is such that the lesion is encompassed by the punch. The punch is applied perpendicular to the skin surface and advanced until a deep punch of the underlying cartilage is cut. The specimen of skin is excised and sent for histopathological evaluation. The posterior auricular donor site is chosen for reasonable skin color match. The same size punch tool is used to harvest the full-thickness skin graft, and the donor site is closed with interrupted sutures. The graft is sutured with 6-0 suture after proper preparation of the graft. [28]
Cognetta et al described the "triangular window technique," which combines surgical treatment and biopsy in the same procedure. A triangular-shaped incision is made around the affected cartilage (the apex directed posteriorly with the wide base hinge located at the anterior helical rim). The affected cartilage is removed and the triangular-shaped skin is sutured to its original position. A 2-mm punch biopsy is then taken in the center of the cutaneous triangular window to be submitted to pathology and to serve as a "weep hole" for any drainage. [29]
In addition, Affleck, in an editorial comment, reiterates that full wedge excision of chondrodermatitis nodularis is often not necessary and can be avoided in favor of more conservative excision. [30] Conservative excision of the helical rim allows for repair with a chondrocutaneous helical rim advancement flap, as described by Ramsey et al, which leads to superior esthetic outcome and simpler reconstruction for helical rim defects. [31]
These simple surgical procedures provide excellent curative, functional, and cosmetic results with low morbidity and recurrence rates. If the disease recurs, the procedures may be repeated without causing deformity to the ear.
A series of surgical images from a single patient is below.
Taken during surgery, this photo demonstrates reflection of the skin, which reveals the underlying perichondrium and cartilage. After the cartilage is removed, the flap is reapproximated and sutured.
Consultations
Dermatologists, dermatologic surgeons, and Mohs micrographic surgeons are knowledgeable about this condition and the treatments described above.
Activity
If trauma, pressure necrosis, cold, or sun exposure is suspected as an exacerbating factor, then reduction of exposure is beneficial. If the patient sleeps on the affected side, then changing sides or using pressure-relieving pillows or pads may be helpful. Such measures often are difficult for the patient, and surgery may be the desired alternative.
Complications
While surgical intervention is a mainstay of therapy, multiple surgeries may be necessary. At times, removal of underlying protuberant cartilage results in adjacent protuberances that can be site(s) of recurrence of chondrodermatitis nodularis chronica helicis (CNH), owing to a change in pressure points.
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Classic chondrodermatitis nodularis chronica helicis on the superior helix.
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Close-up view of classic chondrodermatitis nodularis chronica helicis.
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Chondrodermatitis nodularis chronica helicis on the antihelix.
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Taken during surgery, this photo demonstrates reflection of the skin, which reveals the underlying perichondrium and cartilage. After the cartilage is removed, the flap is reapproximated and sutured.
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Taken 6 months after surgery.
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Self-adhering foam in a curvilinear shape is placed on the non–hair-bearing postauricular scalp.
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A rectangular piece of self-adhering foam is placed on the non–hair-bearing postauricular scalp.
