First-line therapy: All patients should be counseled to protect the ear and avoid repeated external trauma. Initial therapy includes advising patients to avoid pressure to the area. Patients should use a soft pillow, including potentially a pillow with a gap for the ear or a pressure-offloading “doughnut.” Over-the-counter or custom-made protective ear prostheses exist. Patients may also attempt to use a sponge or foam padding, with a hole cut for the affected ear, which can be held in place by a headband or gentle wrap They should avoid using telephones on that side and avoid headphones. Conservative management alone with protective padding and trauma avoidance can lead to dramatic improvement, with some studies showing close to 90% of CNH lesions healing with this approach. Patients who fail to respond should be questioned about adherence, as noncompliance is a frequent cause of treatment failure with this approach.
There is limited data for a variety of local approaches, including light cryotherapy, topical corticosteroids, intralesional corticosteroids, or intralesional collagen/dermal fillers. Recently, topical nitroglycerin has been demonstrated to help some cases of CNH in a small study. Surgical options have long been the standard for recalcitrant cases. Certain lasers, typically ablative lasers, have been used. Curettage and electrodestruction has also been reported to help. In recurrent, refractory cases, surgical excision of the lesion and associated sub-ulcer cartilage is often very effective.
Chondrodermatitis nodularis helicis (failing conservative approach)
- Topical corticosteroids may help in some cases, with most data existing for mid-to high-potency topical steroids (betamethasone valerate 0.1%).
- Intralesional triamcinolone injections may be helpful; while a variety of concentrations have been reported (5 mg/cc to 40 mg/cc, 0.1 to 0.2 mL injected), given the thin skin of the area and frequent solar damage, we suggest starting with the lower concentrations (5 mg/cc, 0.1 mL).
- Topical nitroglycerine 2% has been shown to help moderate numbers of patients in a small case series, with patients experiencing improvement within weeks to months.
- Maintain pressure off-loading protective devices and trauma avoidance throughout therapeutic intervention.
- Surgical options include a number of variations of definitive lesion removal, ranging from simple excision to excision of the nodule and paring or excision of the altered sub-ulcer cartilage (wedge resection), which may require a flap or other tissue manipulation to cover the affected collagen; some surgeons utilize cartilage replacement or grafting as well.
- Lesions that fail to respond to therapy may represent alternative diagnoses, and physicians should consider biopsy and histologic evaluation to confirm the diagnosis in resistant cases.
- Recurrences are common; when they recur, physicians should revisit the counseling regarding protective measures and ensure patients are working to prevent repetitive trauma that can incite lesions of CNH.
- Conservative management and topical therapy is very effective, but traditionally the mainstay of therapy in recalcitrant cases remains surgical; it is important to treat the underlying cartilage as well as the ulcer in these cases.