Lesion Has Been Giving Him an Earful

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Lesion on ear

Over the years, the lesion on this 49-year-old man’s right ear has waxed and waned in prominence. Although it never causes pain, its unrelenting existence coupled with a history of basal cell carcinoma (BCC) on his face has caused him to worry. He has had no other lesions and is in otherwise good health, except for occasional bouts of arthritis, for which he takes ibuprofen, with good results.

While his family had suggested that the lesion could be a cyst, his primary care provider (PCP) disagreed and referred him to dermatology.

A 5-mm firm papule is located at the right helical crest. The lesion is skin-colored, with no redness, and nontender on palpation, although it is moderately firm and mobile. No punctum is noted.

The surrounding skin has no signs of sun damage, although the patient is quite fair. As a young man, he had far too much sun exposure, burning easily and tanning only with difficulty.

After consultation with the patient, the decision is made to incise the lesion using a #11 blade to examine its contents. The incision reveals a dry crystalline substance, which is easily cleared with brief curettage. This effectively leads to a flattening of the lesion.

The most likely diagnosis for this lesion is


Gouty tophus

Epidermal cyst

Dystrophic calcification


The correct answer is gouty tophus (choice “b”).


Gout is a defect of purine metabolism, usually caused by underexcretion of uric acid. Diet and heredity also play parts in gout’s development. Gouty tophi usually develop after years of hyperuricemia. As uric acid builds up in the bloodstream over time, it can then begin to be deposited into joints—most commonly the first metatarsal-phalangeal—as well as cartilage or even bones.

On further questioning, the patient recalled having been told on several occasions that his serum uric acid was elevated. In retrospect, his arthritis was most likely gouty in nature.

In terms of the differential, BCC (choice “a”) is common on helical rims, but it would not have contained the type of material found in this patient’s lesion. Also, it would not have waxed and waned as this lesion had done.

Epidermal cysts (choice “c”) can certainly come and go in prominence, but they are filled with a cheesy, pasty material—not the dry crystalline substance found in this lesion. Moreover, most epidermal cysts will have a small comedonal punctum over the center of the lesion. Dystrophic calcification (choice “d”) can mimic gouty tophi, but it is usually rough, firm, and fixed. It certainly would not be coming and going as it pleases.


Surgical excision of the tophus was offered, but the patient was content with knowing the correct diagnosis. His PCP had previously explained therapeutic options—such as medication and dietary changes—that could address the overall problem. The patient elected to pursue treatment with his PCP.

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