How to treat a chronic ulcer on the left earlobe in a patient with a history of ear piercing complication?

Treatment of Chronic Earlobe Ulcer Following Ear Piercing Complication

Remove any remaining jewelry immediately, assess for embedded foreign material or keloid formation, and initiate wound care with appropriate debridement and moisture-balanced dressings while addressing the underlying cause. 1

Initial Assessment and Diagnosis

The first critical step is determining the underlying etiology of the chronic ulcer, as this will guide treatment:

• Check for embedded jewelry or foreign material by gentle palpation; if not easily located, a small incision under local anesthesia may be necessary for removal 1, 2
• Evaluate for active infection by examining for warmth, erythema, tenderness, purulent drainage, or fluctuance suggesting abscess formation 1, 2
• Distinguish between keloid/hypertrophic scarring versus other pathology by examining whether the lesion extends beyond the original piercing site boundaries (true keloid) or remains confined to the site 3
• Assess for allergic contact dermatitis from nickel or other metals, which presents with inflammatory changes and responds to removal of offending jewelry 1, 3

Treatment Algorithm Based on Underlying Cause

If Infection is Present:

• Remove the earring immediately to prevent embedding and allow drainage 1
• Start fluoroquinolone antibiotics (ciprofloxacin or levofloxacin) if there is any cartilage involvement, as these cover Pseudomonas aeruginosa, the most common pathogen in auricular infections 1
• For earlobe-only infections with no cartilage involvement, topical antibiotics may suffice if very mild 1
• Perform incision and drainage if an abscess is present to prevent tissue necrosis 1

If Embedded Jewelry or Foreign Material:

• Do not attempt removal without proper technique, as this could damage tissue or cause tearing 1
• Surgical exploration under local anesthesia is necessary if gentle probing fails to locate embedded material 1, 2
• After removal, treat any secondary infection with appropriate antibiotics as outlined above 1

If Keloid Formation:

• Refer to a plastic surgeon for definitive management, as keloids require specialized surgical techniques combined with adjunctive therapies 3, 4
• Counsel the patient to avoid all future body modifications that puncture the skin, as keloid formation indicates high risk of recurrence with any skin trauma 3
• Do not attempt simple excision alone, as this has high recurrence rates without adjunctive measures such as steroid injection, pressure therapy, or radiation 4

If Allergic Contact Dermatitis:

• Remove the offending jewelry immediately and replace with hypoallergenic metals such as surgical steel, titanium, or high-karat gold 1
• Apply topical corticosteroids to reduce inflammation 1, 3

Wound Management for the Chronic Ulcer

Once the underlying cause is addressed:

• Debride nonviable tissue using autolytic, enzymatic, or mechanical methods to remove physical impediments to healing 5
• Apply moisture-balanced dressings that provide moisture to the wound bed while keeping the periwound area dry, with choice based on exudate management properties 5
• Ensure adequate nutrition, as malnutrition is a risk factor for impaired wound healing 5
• Monitor for healing over 48-72 hours; failure to improve requires reassessment for missed foreign material, inadequate antibiotic coverage, or need for surgical intervention 1

Critical Pitfalls to Avoid

• Never treat suspected cartilage infections without Pseudomonas coverage, as this leads to treatment failure and permanent cosmetic deformity 1
• Do not delay earring removal in the presence of infection or chronic ulceration, as this perpetuates the problem 1
• Avoid repiercing until at least 6-8 weeks after complete resolution of all swelling, tenderness, and ulceration 1
• Do not miss embedded jewelry, which requires surgical exploration if not palpable, as it will prevent healing 1, 2

When to Refer Urgently

• Spreading infection or systemic symptoms (fever, chills, malaise) require urgent evaluation 1
• Formation of an abscess necessitates surgical drainage 1
• Failure to improve after 48 hours of appropriate therapy indicates need for reassessment and possible subspecialty referral 1
• Confirmed keloid formation requires plastic surgery consultation for optimal management 3, 4