Common Dermatologic Disorders of

the External Ear

• Skin disorders of the external ear are common
• The cutaneous disorders of the external ear are
divided into benign, premalignant, and malignant
groups
 BENIGN CONDITIONS

Seborrheic Keratosis
• Seborrheic keratoses (SKs) are common,benign
epithelial growths.
• They initially present in middle age and often
increase in number with time.
• SKs can vary in appearance but typically are
superficial, well-demarcated, warty or greasy
papules or plaques that have a “pasted on”
appearance.
• Color can range from flesh colored to very darkly
pigmented
 Diagnosis and treatment
• Can be confused with
melanomas
• Clinically diagnosed
• Skin biopsy to rule out
melanomas
• treatment options
include cryotherapy
with liquid nitrogen or
curettage.
 Seborrheic Dermatitis
• chronic inflammatory condition that primarily
affects regions of the body where sebaceous glands
are numerous, such as the periauricular area,
nasolabial folds, chest, and scalp.
• Cause unknown but the yeast Pityrosporum ovale
plays a key role.
• Affects 3–5 percent of the general population.
• Difficult to distinguish from psoriasis.
• SD manifests as bilateral, symmetric patches with
indistinct margins, mild to moderate erythema, and
a yellowish, greasy scale.
• majority of patients, the
external ears are involved.
• Classically, the skin of the
postauricular region and
conchal bowls show signs
of the disease.
• Other areas of
involvement are the scalp,
eyebrows, eyelids,
nasolabial creases, and
chest.
• Mild to moderate pruritus
and almost uniformly will
note persistent scaling.
 TREATMENT
• Therapy is primarily targeted at eliminating the yeast
Pityrosporum ovale.
• Shampoos containing pyrithione zinc (Head &
Shoulders)
• selenium sulfide
• ketoconazole
• If symptoms persist, topical 2% ketoconazole cream
to be applied to the ears daily
• Topical steroid creams, ointments, or solutions can
be used in and around the ears,
 Chondrodermatitis Nodularis Helicus
Chronicus(CNHC)
• CNHC is an inflammatory lesion found primarily on the free
edge of the helical rim.
• It is typically a single, tender, firm, red, 3–10 mm eroded
nodule covered with an adherent scale
• cause is unknown
• Risk factors are chronic sun, wind, and extreme temperature
exposure in addition to external pressure ( sleeping on that
ear).
• Other contributing factors are anatomical and include thin skin
overlying the helix, absence of subcutaneous tissue, and a poor
local blood supply.
• The majority of patients are men over the age of 50
MANAGEMENT
• Nonsurgical
• serial intralesional steroid
injections with use of a
special pillow (CNH
pillow) to prevent contact
or pressure to the lesion
• Cryo- and carbon dioxide
laser ablation-less efficay
• Complete surgical excision
is the definitive treatment
of choice.
 Psoriasis
• common papulosquamous pruritic skin condition
affecting approx.2% of the pop.
• Has genetic predisposition with increased
incidence in family members of affected
individuals.
• can be widespread or localized.
• Triggers are: trauma, infection, stress, and drugs
e.g beta blockers, lithium, ACEIs
• better in the summer when the skin is exposed to
more sunlight.
• In the external ear, conchal bowl
involvement is commonly seen
• described as well-demarcated,
erythematous plaques with a
“silvery scale.”
• If the superficial scale is
removed, pinpoint hemorrhage
can be seen (Auspitz sign).
• Ear psoriasis may not
demonstrate all of the classical
findings and instead may show
nonspecific red, dry, and scaly
skin.
• Patients will complain primarily
of itching.
 management
• topical steroid solutions
• Bland emollients (petroleum jelly or Aquafor)
• moisturizers with up to 10% urea to improve
hydration and remove scaling
• topical vitamin D3 derivatives (calcipotriene
ointment)
 PREMALIGNANT LESIONS
Actinic Keratosis
• AKA solar or senile keratoses, are very common precancerous
cutaneous lesions arising from keratinocytes.
• AKs develop from prolonged ultraviolet (UV) radiation
exposure and over time may transform into squamous cell
carcinomas.
• AKs increase in prevalence with age.
• 10% are seen in white adults aged 20–29 years, while 80% are
seen in white adults aged 60–69 years .
• occur on sun-exposed skin.
• Risk factors includes: age, UV radiation exposure, fair skin
pigmentation and immunosuppression.
• The typical AK lesion presents as a 2–8 mm flat,
erythematous, rough, scaly, ill-margined papule.
• Diagnosis: clinical
• Treatment:cryotherapy with liquid nitrogen,
topical tretinoin (e.g.Retin-A), or topical
chemotherapeutic agents eg 5-Fluorouracil.
• Less common treatments include curettage,
medium-depth chemical peels, dermabrasion,
laser resurfacing, and photodynamic therapy
 MALIGANANT LESIONS
Basal Cell Carcinoma
• most common of all skin malignancies
• It arises from malignant transformation of basal
keratinocytes in epidermis and from adnexal structures.
• BCCs can occur at any age, risk increases after 40
• found anywhere on the body, 85% are found on the head
and neck.
• can be found in non-sun-exposed skin such as behind or
inside the ears.
• Several subtypes of BCCs exist, including superficial,
nodular, sclerosing, and pigmented varieties.
• the most common appearance of a
classic BCC is that of a slightly
translucent or pearly plaque with
rolled borders and scattered
telangiectasias.
• There may be superficial crusting or
erosion.
• Pigmented BCCs can mimic other
dark-colored lesions such as
malignant melanoma or seborrheic
keratoses.
• The sclerosing variant of BCC can look
like a waxy, firm, pale plaque with ill-
defined borders and thus has an
appearance much different from the
• more common, classic BCCs.
• more aggressive with potential for
wide extension.
 Treatment
• depends on its subtype and location.
• The area around the ear is important for 2 reasons:
1. Because of the location on the face, good cosmetic
outcomes are essential.
2. BCCs around the nose, eyes, and ears can extend
deeper and behave more aggressively than BCCs
elsewhere.
• Mohs micrographic surgery
• superficial BCC, electrodesiccation and curettage,
cryosurgery, or topical imiquimod (Aldara) are
sometimes employed.
 Squamous Cell Carcinoma
• second most common type of • SCC has metastatic potential and must
skin cancer. be identified early and treated.
• • The site with the highest rate of
majority arise on sun-exposed
recurrence is the ear.
surfaces.
• Nonsurgical treatments are useful in
• Risk factors include precursor only a select group of patients
lesions (eg actinic keratoses), UV • include electrodessication and
radiation exposure, prev. radiation curettage, CO2 laser ablation, liquid
therapy, immunosuppression, nitrogen cryoablation, photodynamic
scars, burns, and fair skin. therapy, and topical or injectable
• The typical presentation is a firm, antineoplastic agents.
flesh-colored or erythematous, • The mainstay of treatment is surgical
keratotic papule or plaque with excision (either traditional or Mohs
micrographic surgery)
indiscreet margins and occasional
• External beam radiation can be used
tenderness.
as a primary treatment modality
 Melanoma
• malignant skin cancer that arises from • RISK FACTORS:Sun exposure, family
preexisting nevi or moles and history of melanoma, and having
melanocytes. many cutaneous nevi
• 4 different types of • clinical characteristics of a classic
• melanoma: superficial spreading, melanoma lesion follow the ABCDE
nodular, lentigo maligna, and acral
• acronym: Asymmetry, irregular
lentiginous.
Border, Color (known as the
• Highly metastasize.
“patriotic lesion”—red, white, and
• occur in the15-50year blue), Diameter > mm, and Evolution
• Primary melanoma of the head and (change).
neck accounts for 25–30 %of all
• Prognosis and treatment are based
melanomas.
on tumor thickness or depth of
• external ear accounts for approx.10%of
invasion.
all melanomas in the head and neck
region. • surgical excision with wide margins
• the helical rim is the most common site • chemotherapy, radiation, and
of involvement. interferon