Painful Nodule of the Helix

Presented by: Charles LaGoy, MS IV
University of New England College of Osteopathic Medicine

Abstract: 57 yo man with one year history of a painful nodule on helix.
History: This retired jockey presented to the dermatologist for a general skin exam and incidental complaint of a painful nodule on the left ear helix which had interfered with his sleep. He had not sought treatment for this previously. Patient is recovering from a Whipple procedure performed after a pancreatic condition left him unable to eat without great pain and subsequent weight loss of 45 lbs from his normal weight of approximately 115 lbs.

O/E: Tender nodule approximately 4mm in diameter on superior aspect of left ear helix. Some erosion with scaling at site.

Clinical Photo(s): These are representative photos since we did not take pictures of this man.





Easily constructed foam ear guard.

Lab: n/a

Histopathology: n/a
Diagnosis or DDx: Chondrodermatitis nodularis chronica helicis - CNH (A.K.A. painful nodule of the ear)

Questions: n/a
Reason Presented: The primary care physician is likely to encounter (CNH), also known as painful nodule of the ear. The condition is most common in males over 50 years old (1), with a male to female ratio of 10:1(2) It is thought that minor trauma to the small blood vessels supplying the pinna (1), perhaps coupled with exposure to solar radiation (3), leads to tissue damage and that inadequate blood supply prevents healing (1).
While Fitzpatrick’s Dermatology text notes that surgical excision is the definitive treatment (1), a recent small study by Moncrieff and Sassoon suggests that mechanical protection of the site is an effective conservative treatment with a lower recurrence rate than surgery (4). Their described treatment gave the patients significant leeway in designing a method of protecting the pinna from pressure while sleeping (3rd photo). The results were good with only a 13% failure rate compared to a 34% recurrence rate within a mean of 13 weeks for the surgery group (4).
The establishment of the diagnosis of CNH was left to clinical judgment in this study, whereas other authors believe that a biopsy is always required to rule out a neoplastic process (2). It is likely that this belief would complicate a decision to treat conservatively, as it might be reasonable to excise the entire nodule during the biopsy. However, a clinician with confidence in the diagnosis would likely serve the patient well by presenting the conservative treatment of these lesions, holding biopsy and/or excision for those cases that fail to respond adequately.

References:

1) Freedberg I, et al. Eds, Fitzpatrick's Dermatology in General Medicine, 6th ed. New York, McGraw-Hill 2003

2) Avitia S, Hamilton J, Osborne R, Chondrodermatitis nodularis chronica helicis. Ear, Nose and Throat Journal 2005 Jul 84(7) P406-407

3) Goette D, Chondrodermatitis nodularis chronica helicis: a perforating necrobiotic granuloma. Journal of the American Academy of Dermatology, 1980 Feb; 2(2):148-54

4) Moncrieff M, Sassoon E, Effective treatment of chondrodermatitis nodularis chronic helicis using a conservative approach. British Journal of Dermatology, 2004; 150: 892-894

Tinea incognito

Abstract: 48 yo man with 8-10 month history of a hand dermatitis
History: This patient has had a dermatitis of the dorsum of his right hand for 8 - 10 months. He saw his PCP on a number of occasions and was treated with triamcinalone 0.1% cream and clobetasol 0.05% ointment (a super potent topical corticosteroid!). Some of the redness and scale improved, but process recurred when topicals were stopped. Good general health. Takes no meds by mouth.
O/E: Fairly well-demarcated dermatitis on dorsum of right hand. No scale. There are faint papules which may represent areas of increased fungal load.
Clinical Photo(s)




Lab: KOH pep loaded with septate hyaline hyphae.
Histopathology: N/A
Diagnosis or DDx: Tinea incognito
Questions: N/A
Reason(s) Presented: Topical steroids can change appearance of tinea. They suppress local inflammation and ablate the scaly surface. When they are stopped the process recurs. The corticosteroid facilitates fungal growth by suppressing local inhibitory factors. The tip off here was the localization on one hand and the relatively sharp border. There's a saying "Do a KOH prep when it is indicated and do one when it isn't indicated and you won't make many mistakes."
Reference:
Tinea incognito in Italy: a 15-year survey.
Mycoses. 2006 Sep;49(5):383-7.
Romano C, Maritati E, Gianni C
Institute of Dermatological Sciences, University of Siena, Via Monte Santo 3,

Tinea incognito or steroid modified tinea is a dermatophytic
infection in whichtopical or systemic steroids, administered
as a result of dermatological misdiagnosis or preexisting
pathologies, have modified the clinical appearance of the fungal
infection, transforming the typical ringworm and mimicking other
skin diseases. This is a retrospective study of the agents,
clinical aspects, sources of infection of 200 cases (98 males,
102 females, mean age 42 years) of tinea incognito, observed in
Siena and Milan, Italy, in the period 1987-2002. The clinical
appearance of the infection was lupus erythematosus discoid-like,
eczema-like, rosacea-like, especially on the face, impetigo-like
and eczema-like on trunk and limbs. Less often the dermatophytosis
resembled psoriasis, purpura, seborrhoic dermatitis and lichen
planus. There was folliculitis in 9% of cases and dermatophytid
in 3% of cases. Antimycotic therapy brought about clinical and
mycological recovery in allpatients except one, who had iatrogenic
immunodepression.

Hand rash and joint pain

Abstract: 15 y/o girl with rash and joint pain for 4 weeks

History: 15 y/o girl reported having a pruritic rash on the extensor surface of her hands and wrists that started 4 weeks ago and seemed to be getting worse. She also noticed morning stiffness that lasted 1 hour and joint pain in her wrists and hands. She was started on fluoxetine for depression almost 4 months prior and had a URI 2 months prior. She has been healthy since then.

On review of symptoms pt denied constitutional symptoms, rash/pain elsewhere or GI symptoms. She denied contact with new materials/chemicals.

Pt was given ibuprofen and then naproxen without improvement. She was then given a 10-day prednisone taper starting at 60 mg without any improvement.

PMH included allergic rhinitis, depression and hearing loss. Family history revealed maternal grandfather with psoriasis, no history of autoimmune or joint problems.

O/E: Afebrile. Examination of skin revealed abrasion-like plaques on the extensor surfaces of the wrists and MCP joints. These plaques initially had an erythematous base which later became hyperpigmented. There was crusting and dry skin but no exudate or ulcerations. No nail findings. There were no skin findings elsewhere. The hands were slightly edematous but no synovial thickening or effusions were detected. The wrist, MCP and some PIP joints were tender to palpation bilaterally. The remainder of the MSK exam was unremarkable.

Clinical Photo(s): Taken at pt's 3rd visit, 4 wks after her rash first appeared

Lab: CBC unremarkable except for Eos of 8%. ESR 22. CRP, RF, ANA were negative.
Histopathology: pending

Diagnosis or DDx: ? JRA, psoriatic arthritis, drug rxn, pseudo-PCT, post-viral exanthem...
Questions: Any more ideas? Does lack of response to prednisone change the DDx/plan? (Pt was referred to rheumatology) Thanks.
Reason(s) Presented: Interest
References:
Presented by: Stephanie Chu MS4