Dr Keith Hopcroft continues our series of fascinating but often unrecognised conditions
The case
‘I can't sleep, doctor,' said the elderly man, settling into the consulting room chair.
As opening gambits go, this is a bit of a heartsink. I braced myself for a long consultation. What I hadn't expected was for him to point to his ear.
‘The problem's here,' he explained, showing me a crusty nodule on the upper part of his outer ear. ‘It hurts like hell when I lie on it.'
He explained that he'd had the problem for a few months. The discomfort had become so intense that it was disturbing his sleep.
I took a closer look. The nodule was about half a centimetre wide, with a small central ulceration. There were no lymph nodes palpable nearby.
The diagnosis
This man had chondrodermatitis nodularis. Or, to give the condition its full and somewhat preposterous name, chondrodermatitis nodularis chronicus helicis – which does have the merit of explaining exactly what it is (a long-term inflammatory nodule affecting the skin and cartilage of the ear).
Typical features
It presents as a tender nodule, usually on the ear's most prominent point – that's the helix in men and the antihelix in women. Prevalence figures are unknown, but it's more common in elderly men. The discomfort can be so severe as to disrupt sleep, as in this case.
The nodule may have some central crusting and ulceration, which leads to possible confusion with a basal cell carcinoma, though this is usually painless. The other differentials include actinic keratosis, keratoacanthoma and squamous cell carcinoma – so in cases of doubt, referral is required.
Treatment
It's thought that chondrodermatitis may be caused simply by pressure on the ear. So the situation can be resolved just by advising the patient to sleep on the opposite side. If that's not possible, simple pressure-relief with, for example, a corn-plaster may do the trick.
If active treatment is needed, options include steroids – topically or intralesionally – or lignocaine gel applied at bedtime.In refractory cases, cryotherapy or even excision may be required.
Issues for the GP
There's more to knowing this label than being able to impress the patient with your Latin – a precise diagnosis means appropriate treatment. Which, in turn, means a patient who can sleep again.
Take-home point
There aren't many chronic, discrete skin lesions that cause significant discomfort. The fact that this condition also affects a specific, consistent site means you can make the diagnosis even before you've taken a proper look.
Dr Keith Hopcroft is a GP in Laindon, Essex
Chondrodermatitis nodularis Chondrodermatitis nodularis
