Clinical presentation
Easy. Common.
Antonio is 76 years old. He comes in because of a small bump that appeared on his left ear three months ago. He did not think much of it until something as ordinary as resting his ear on the pillow at night became painful.
The lesion also hurts when we examine and palpate it.
Antonio’s story, together with the appearance of this small fleshy bump with a keratotic area at its tip, is highly characteristic of a painful nodule of the helix, also known as chondrodermatitis nodularis helicis or Winkler’s nodule.
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| Painful nodule of the helix: a keratotic lesion on the rim of the ear. Photograph by the author. |
Why does it develop?
It is a benign inflammatory condition affecting the skin and tissues close to the ear cartilage. Its exact cause is not fully understood, but repeated pressure on a prominent part of the ear, particularly when sleeping on one side, is thought to play an important role.
There is very little soft tissue over the helix to cushion it. Sustained compression may therefore reduce local blood flow, leading to microischaemia and tissue damage. Other proposed contributing factors include repeated trauma, pressure from headphones or glasses, exposure to cold and sun damage. Not all of these mechanisms have been conclusively established.
The most useful clinical clue: a small, firm nodule that is very tender to pressure, located on the helix or antihelix, often with a central crust, erosion or keratotic plug. The pain can be considerable despite the lesion’s small size.
Can it be mistaken for skin cancer?
Yes. Even when the clinical picture is highly suggestive, actinic keratosis and non-melanoma skin cancer must always be considered, especially squamous cell carcinoma or basal cell carcinoma. These lesions can also occur on the ear and may have crusts or ulceration.
Features that should raise suspicion of another diagnosis
- Progressive or relatively rapid growth.
- Marked firmness, infiltration or atypical clinical features.
- Spontaneous bleeding or persistent ulceration.
- Recurrence, an unexpected course or failure to respond to adequate pressure relief.
A biopsy should be considered in these situations. A central crust does not, by itself, mean the lesion is malignant: this finding is also common in chondrodermatitis. However, if skin cancer is suspected, diagnostic assessment should not be delayed while trying conservative treatment.
How is it treated?
Several treatments are available. If the clinical diagnosis is convincing, there are no warning signs and the patient prefers this approach, it is reasonable to start with the least invasive measures. Treatment should be tailored to the individual and reassessed if there is no improvement.
1. First step: relieve the pressure (4–8 weeks)
The first step is to avoid mechanical irritation from earphones, headphones, telephones and glasses if they press directly on the nodule, and above all, pressure from the pillow at night.
This is where pillows with a central opening that leaves the ear free of pressure, or padded ear protectors that prevent direct pressure on the painful area, can be useful. They should be used consistently during sleep.
The response can be assessed after 4–8 weeks. This is a simple approach, although it requires consistent use and does not always achieve healing.
2. If the lesion persists: local medical treatment
If pain or the nodule persists despite pressure relief, it is important to reconsider the diagnosisbefore stepping up treatment. Options described in published studies include:
- Intralesional corticosteroid injection. One published regimen used triamcinolone 10 mg/mL, 0.2–0.5 mL per injection, combined in that study with topical betamethasone valerate 0.1% twice daily for eight weeks.
- Topical nitroglycerin. This aims to improve local blood flow through vasodilation. One published regimen used 0.2% nitroglycerin once daily for ten days, then every 12 hours until healing. Other reported regimens include 2% preparations applied twice daily and 5 mg patches used for 12 hours per day over two months in one study. This is an off-label treatment and may cause headache, dizziness and hypotension; it must not be combined with phosphodiesterase-5 inhibitors.
- Other procedures. Results have been reported with CO₂ laser, photodynamic therapy, platelet-rich plasma, collagen injections and other procedures. However, the evidence is limited, and these are not routine treatments.
3. Surgery: the highest published cure rates
When conservative measures fail, lesions recur or the diagnosis is uncertain, surgery often offers a more definitive solution.
It involves excising the nodule and/or removing or shaving down the underlying cartilage responsible for the pressure point, while preserving as much skin and the natural contour of the ear as possible. The excised tissue can also be examined histologically when indicated.
| Treatment | Published cure rate | Interpretation |
|---|---|---|
| Pressure relief alone | 37 % | Non-invasive; success depends greatly on consistent use. |
| Topical nitroglycerin | 51 % | Medical alternative with possible adverse effects. |
| Intralesional triamcinolone + topical betamethasone | 27 % | Result from a combined regimen; the rate cannot be attributed to the injection alone. |
| Surgery | 82 % | Highest cure rate in the 2016 review. |
Results reported in the systematic review by Kechichian and colleagues (2016). The 27% cure rate applies to intralesional triamcinolone combined with topical betamethasone, not to the injection alone. The figures do not come from randomized head-to-head comparisons. The review by Park and colleagues (2025) highlights the heterogeneity and limitations of the available evidence.
Painful nodule of the helix: diagnosis and treatment at a glance
| Key point | What to remember |
|---|---|
| Presentation | Small, firm, very tender nodule on the helix or antihelix, sometimes with a central crust or keratotic area. |
| Likely mechanism | Sustained pressure, particularly during sleep, with possible local impairment of blood flow. |
| Differential diagnosis | Rule out actinic keratosis, squamous cell carcinoma and basal cell carcinoma. Consider biopsy if the diagnosis is uncertain or warning signs are present. |
| Initial treatment | Pressure relief with a pillow with an opening or a padded ear protector for 4–8 weeks if the lesion is typical. |
| If there is no improvement | Reassess the diagnosis. Consider local treatments or surgery as appropriate. |
| Most definitive option | Excision of the lesion and/or reshaping of the underlying cartilage. |
Relieve pressure for 4–8 weeks
Reassess and treat
Consider surgery
Take-home message
A bump on the ear that hurts when the head rests on a pillow is highly suggestive of chondrodermatitis nodularis helicis. Relieving pressure is the simplest initial conservative measure, but any suspicious lesion must be evaluated to rule out actinic keratosis or non-melanoma skin cancer.
References
- Kechichian E, Jabbour S, Haber R, et al. Management of Chondrodermatitis Nodularis Helicis: A Systematic Review and Treatment Algorithm. Dermatol Surg. 2016;42:1125–1134. doi:10.1097/DSS.0000000000000817.
- Park M, Te B, Yilmaz O, et al. Clinical Manifestations and Therapeutic Management of Chondrodermatitis Nodularis Helicis: A Systematic Review. J Cutan Med Surg. 2025. doi:10.1177/12034754251336202.
Text based exclusively on the source materials provided. Treatment regimens are those reported in the literature and require assessment by a healthcare professional.
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