Chondrodermatitis nodularis helicis
Chondrodermatitis nodularis chronica helicis (CNH) is a painful inflammatory condition affecting the ear. It is sometimes called Winkler disease.
CNH is most often seen in middle-aged or elderly men but may also affect women and younger adults. It results in a benign tender lump in the cartilaginous portion of the ear. The helix (thus
helicis) is the top of the ear. Strictly speaking the condition should be called
chondrodermatitis nodularis chronica antehelicis when it affects the inner rim of cartilage.
The affected area may only be a few millimetres wide, but to lie on it causes exquisite discomfort. There is often a tiny central core which may discharge a small amount of scaly material. It may persist for months or sometimes years, and may be confused with a skin cancer.
What is the cause of CNH?
The cause of CNH appears to be pressure between the head and the pillow at night. CNH occurs in people who sleep predominantly on one side. It can be precipitated by minor trauma, such as tight headgear or a telephone headset, or by exposure to cold. Reduction in the local blood supply of the ear by a chilblain or with aging prevents adequate healing.
Image provided by Dr Trevor Evans
How is CNH diagnosed?
In most cases, the diagnosis is made clinically because of typical history of a painful lesion on the ear, and the appearance of a small tender papule that may be ulcerated. Sometimes the diagnosis is made on skin biopsy, which shows typical pathology.
- It is important to avoid sleeping on the affected ear. Check your pillow is soft and consider fashioning a ‘hole’ in it so there is no pressure on the painful spot. Try to sleep evenly on both sides.
- Using foam rubber or a bath sponge, you can make a CNH ear protector that can be worn all night. Hold it in place with an elastic headband. Alternatively, you can purchase one from a dermatology supplies company.
- A made-to-measure silicone splint is a more expensive option to protect the affected site.
- Wear a warm hat over the ears when outside in the cold and wind.
- If the CNH is ulcerated, apply an antibiotic ointment under a light dressing; plain petroleum jelly may also be effective.
- Your doctor may treat the lesion with a cortisone injection or freeze it with liquid nitrogen to promote healing.
- Collagen may be injected under the skin above the cartilage to provide a protective layer.
- Topical 2% glyceryl trinitrate (nitroglycerin), normally used for angina, may be prescribed in severe cases to apply twice daily to the affected area. Side effects include headache, flushing and drop in blood pressure.
- Surgical treatment may be required (excision biopsy). Unfortunately CNH has a 10-30% recurrence rate after surgery.
- The affected area may be scraped out by curettage, and left to heal by secondary intention.
- The overlying skin is peeled back and the underlying abnormal cartilage excised, leaving a small scar.
- The ulcer may be excised by punch biopsy, with full thickness skin grafting.
- Flynn V, Chisholm C, Grimwood R. Topical nitroglycerin: a promising treatment option for chondrodermatitis nodularis helicis. J Am Acad Dermatol. 2011 Sep;65(3):531-6. Epub 2011 May 6.