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Chondrodermatitis Nodularis Auricularis: A New Name for an Old Disease

Feldman, Avital L.; Manstein, Carl H. M.D., M.B.A.; Manstein, Mark Eric M.D.; Czulewicz, Andrew M.D.

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Plastic and Reconstructive Surgery: January 2009 - Volume 123 - Issue 1 - p 25e-26e
doi: 10.1097/PRS.0b013e318194d1d4
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Sir:

Chondrodermatitis nodularis helicis is a degenerative noncystic inflammatory process limited to the ear skin and underlying cartilage. It commonly produces a painful papule or nodule on the helical rim or antihelix of the ear. Central ulceration also occurs and mimics either basal or squamous cell carcinoma. Chondrodermatitis appears to be an idiopathic degenerative process involving the upper dermis of the auricular rim, often with inflammatory nodules on the scaphoconchal portion of the external ear. With this variation in presentation, the alternative descriptive term of chondrodermatitis nodularis auricularis is suggested.

Chondrodermatitis nodularis chronica helicis was first described by Dr. Max Winkler of Luzerne, Switzerland (1875 to 1952).1 He described eight patients with the classic painful nodule and skin crusting. Winkler treated these patients with the surgical techniques of the early twentieth century. The eponym of Winkler's chondrodermatitis is still used.

We present a series of 55 Caucasian Fitzpatrick type I or II patients with 62 affected ears. There was an equal distribution of right to left ears, but a distinct right to left variation for men compared with women. This difference is fortuitous and cannot be explained by any obvious biologic or environmental factors. Unlike recent studies2,3 that claim a preponderance of male patients, our series found that 71 percent of our patients were female (Fig. 1). This is a disease of the older population, with men having a mean age of 58 years and median age of 63 years at the time of treatment. Women sought treatment much later, with a mean age of 72 years and median age of 74 years (Fig. 2). We conclude that environmental and societal factors play a role in the pathogenesis of this entity. The patients were initially referred to us because of failure of nonsurgical therapy, including topical and oral antibiotics and topical steroid creams.

Fig. 1.
Fig. 1.:
Ear distribution of chondrodermatitis by sex.
Fig. 2.
Fig. 2.:
Age distribution of chondrodermatitis.

Our overall “recurrence” rate was 11 percent, with recurrences equal in both sexes. We define recurrence as repeated inflammation or infection at the surgical site. Most recurrences resolved with warm compresses and oral antibiotics. Only 30 percent of these required re-excision and closure. Recurrences are due to a surgically induced acute inflammatory process of the resected cartilage.

Surgical treatment included wedge resection and primary closure or circumferential excision of skin and underlying cartilage and immediate reconstruction using a full-thickness skin graft harvested from the ipsilateral posterior auricular sulcus.4 Excisions included the inflamed skin and underlying infected cartilage. Patients returned for follow-up at 1 week and thereafter according to their individual needs. Patients who did not return or call with any problems or complaints were assumed to be satisfied with the results of their treatment.

Twenty-two of the affected ears had lesions on the antihelical fold (scaphoconchal angle) or the scapha itself. The presence of this disease in the concha and scapha indicates that other processes are in place beyond just pressure. Because of this variability in the location, we have begun describing this entity as chondrodermatitis nodularis auricularis.

DISCLOSURE

This study has received no funding or support of any kind.

Avital L. Feldman

Carl H. Manstein, M.D., M.B.A.

Mark Eric Manstein, M.D.

Division of Plastic and Reconstructive Surgery

Holy Redeemer Hospital and Medical Center

Meadowbrook, Pa.

Andrew Czulewicz, M.D.

Department of Pathology

Jeanes Hospital

Philadelphia, Pa.

REFERENCES

1. Winkler M. Knotchenfromige Erkrankung an Helix. Arch Derm Syph (Berlin). 1915;121:278–285.
2. Rex J, Ribera M, Bielsa I, Mangas C, Xifra A, Ferrándiz C. Narrow elliptical skin excision and cartilage shaving for treatment of chondrodermatitis nodularis. Dermatol Surg. 2006;32:400–404.
3. Magro CM, Frambach GE, Crowson AN. Chondrodermatitis nodularis helicis as a marker of internal disease [corrected] associated with microvascular injury. Cutan J Pathol. 2005;32:329–333.
4. Manstein CH, Manstein ME, Manstein G. Securing skin grafts of the ear by the double-bolster technique. Plast Reconstr Surg. 1996;98:903–905.

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