Speediatrics: Can you solve this case of itchy ear lesions?

Juvenile spring eruption (JSE) is a localised form of polymorphic light eruption (PLE) that predominantly affects children and young males. It is triggered by ultraviolet (UV) radiation exposure, typically appearing in early spring when sun exposure increases.

Clinical features

JSE primarily affects the ears, presenting as pruritic, erythematous papules and vesicles. The lesions typically develop 12–24 hours after sun exposure and progress to crusted or scaly plaques over several days. Unlike classic PLE, JSE is more localised and does not typically involve the face, neck, or dorsal hands.

Patients may report mild discomfort or itching, but systemic symptoms are absent. The eruption resolves spontaneously within 7–10 days without scarring, although post-inflammatory hyperpigmentation may persist. Recurrent episodes are common in the following springs or after intense sun exposure.

Epidemiology

JSE is most frequently observed in fair-skinned children and adolescents, particularly boys, aged 5–15 years. It occurs most commonly in early spring or during sudden increases in UV exposure, such as on ski trips or early summer holidays. The condition is more prevalent in northern European countries, including the UK, due to the seasonal variation in UV radiation.

Although the exact prevalence is unknown, JSE is considered an underdiagnosed condition, as mild cases may not be reported. A strong link with PLE suggests a genetic predisposition in some individuals.

Diagnosis

JSE is a clinical diagnosis based on the characteristic history of sun exposure and the appearance of lesions. Key diagnostic points include:

• Sudden onset of pruritic papules, vesicles, or crusted lesions on the helix of the ears
• Occurrence in early spring or after the first significant sun exposure of the year
• Absence of systemic symptoms
• Spontaneous resolution within a week

Dermoscopic examination may show non-specific erythematous and crusted features but is rarely necessary. Skin biopsy is usually not indicated unless there is diagnostic uncertainty.

Differential diagnosis

Several conditions can mimic JSE, and differentiation is essential for appropriate management. Key differentials include:

• Polymorphic Light Eruption (PLE): Unlike JSE, PLE affects broader sun-exposed areas such as the face, neck, and forearms. It presents with papules, plaques, or vesicles but is not localised to the ears.
• Herpes Simplex Virus (HSV) infection: HSV lesions are often painful, recurrent, unilateral and may be preceded by a prodrome
• Impetigo: Bacterial infection leads to honey-coloured crusting, which spreads and lacks a clear relationship to sun exposure.
• Contact dermatitis: Allergic or irritant reactions can mimic JSE but are usually linked to a specific trigger (eg, hair products, earrings) rather than UV exposure.
• Actinic prurigo: A chronic photodermatosis, often familial, with papules and excoriations affecting the face, hands, and other sun-exposed areas.

Management

JSE is self-limiting and does not require aggressive treatment. However, symptomatic relief and prevention of secondary infection are important considerations.

• Topical corticosteroids (eg, hydrocortisone 1% or clobetasone butyrate 0.05%) can reduce inflammation and itching.
• Emollients (eg, petroleum jelly or fragrance-free creams) help maintain skin barrier function and soothe irritation.
• Oral antihistamines may be considered if itching is significant, though they are usually unnecessary.
• Avoidance of further UV exposure during an active episode prevents exacerbation.
• Antibiotics are rarely needed but may be considered if secondary bacterial infection occurs.

Patient education

As JSE is recurrent in susceptible individuals, preventive education is key. GPs should provide the following advice:

• Sun protection: Encourage high-SPF (≥50) broad-spectrum sunscreen application to the ears, particularly in early spring.
• Physical barriers: Wearing wide-brimmed hats or caps with ear coverage can help prevent UV exposure.
• Gradual sun exposure: Allowing the skin to acclimatise to increasing sunlight over time may reduce recurrence.
• Recognition of early symptoms: Educating parents and children on early signs allows for prompt intervention and sun avoidance.

While JSE is a benign condition, reassurance is important, particularly for parents concerned about the appearance of lesions. GPs should emphasise the self-limiting nature of the eruption and provide strategies for reducing future episodes.