The patient
This 68-year-old man asked for some cream to clear up an ear problem. He'd been aware of mild scaling on the helix of his left ear for a year or two, and until now had simply been using a moisturiser. But in the last few months he had noticed that the lesion bled and was regularly staining his pillow.
There was no associated pain and he was otherwise well, with no significant medical history – and, in particular, no previous skin disease.
First instinct
My reflex diagnosis was chondrodermatitis nodularis. This is commonly seen in primary care and the site was typical, even if the appearance was slightly less so – the lesion was quite large and ulcerated.
It was reassuring that there was no cervical lymphadenopathy palpable.
He insisted that there was no pain, even when lying on that side, which was unusual for chondrodermatitis. But I put this down to him being a stoical man and an infrequent attender.
Differential diagnosis
- Chondrodermatitis nodularis
- Actinic keratosis
- Basal cell carcinoma
- Squamous cell carcinoma
- Keratoacanthoma.
Actinic keratoses are very common and are typically found on sun-exposed areas, such as the ears.
But they are often more easily felt than seen – which was not the case with this patient.
Any persistent, ulcerating lesion in older patients should raise the possibility of carcinoma. The basal cell variety is more common than squamous cell carcinoma. Again, the location was characteristic, although the ulceration didn't have the rolled, pearly edge of a classical basal cell carcinoma.
Another possibility was a keratocanthoma – also linked to sun exposure – although these usually develop more rapidly, over a few weeks or months.
Keratoacanthoma is indistinguishable from more significant pathology, such as squamous cell carcinoma, and so requires referral for excision.
The hidden clue
Few benign lesions will ulcerate enough to cause bleeding or staining. And his history suggested pre-existing actinic keratosis which will occasionally transform into squamous cell carcinoma.
The patient needed urgent referral to the dermatologist to exclude malignancy.
Getting on the right track
I referred him under the two-week rule and he had a biopsy.
This confirmed my revised diagnosis – it was a squamous cell carcinoma rather than chondrodermatitis nodularis.
The lesion was completely excised and he remained well at follow-up.
Dr Keith Hopcroft is a GP in Laindon, Essex
