Ear Skin Cancer: A Comprehensive Guide

Your outer ear is one of your face’s most prominent features. But besides its impact on your appearance, your outer ear is also critical to your daily activities. Those curves leading to the ear canal optimize sound transmission, allowing you to converse smoothly, appreciate music, and protect yourself from potential dangers like oncoming street vehicles.

That is why skin cancer on ear parts like the top rim or the ear canal’s entrance—the most commonly affected sites—can easily take these gifts away from you. But there’s hope if you or a loved one has this condition. Learn from this article how ear skin cancer arises and what you can do to prevent and treat it.

What Tissues Comprise the Ear?

It’s easy to pull up a labeled ear picture to name its parts. However, the aspects that matter more in the battle against ear skin cancer are the lesion’s location and the tissue types present in that area. The outer ear is covered with skin. The superficial epidermis and deep dermis comprise the thin ear skin, which has little subcutaneous fat except in the cartilage-lacking earlobe.

Beneath the ear skin lies the perichondrium, a layer of tough connective tissue covering the even tougher outer ear cartilage. Blood vessels, nerves, muscles, and more connective tissue lie within and between the dermis and perichondrium, maintaining the outer ear’s vital functions.

Any of these tissues can be involved in ear cancer development. However, studies show that most outer ear cancers arise from the skin. If caught early, ear cancer may only affect the skin, sparing the underlying cartilage.

Ear skin’s uniqueness presents surgical challenges. Subcutaneous fat is scantier on the outer ear’s concave (inner) than convex (outer) surface. Tumors on both sites lie close to the perichondrium and underlying cartilage but even more so on the concave segment near the ear canal. The outer ear’s curvy contour, especially on the concave portions, can make tumor removal difficult. Incomplete excisions are likely in inexperienced hands.

Neglected lesions can invade the perichondrium and cartilage, increasing the risk of distant spread. Surgical removal of deep ear cancer risks distorting your outer ear’s appearance, impairing ear function, and causing problems in the organs where they spread.

Why Is the Outer Ear Vulnerable to Skin Cancer?

The most significant skin cancer risk factor is UV exposure. Besides the midface, facial skin cancer commonly involves the ear canal entrance (concha) and the ear’s upper outer edge (helix), which are often sun-exposed. Cancer of the lower ear parts, including the earlobe, is relatively rare as these areas are less exposed to UV rays.

Men are generally more susceptible to ear skin cancer than women due to greater ear exposure from their shorter haircuts. Older individuals are likelier to develop the condition, reflecting years of skin photodamage.

What Skin Cancer Types Develop in the Outer Ear?

Although basal cell carcinoma is generally the most frequent skin cancer type, studies report that squamous cell carcinoma is the most common ear skin cancer. A cancer center study reported that squamous cell cancer, including early-stage ones, comprised 72% of the ear cancer cases treated at the facility from 2009 to 2014. Patients with basal cell cancer made up 23%. Rare tumor types included melanoma (4.04%) and atypical fibroxanthoma (0.1%).

Squamous cell carcinoma involves nonpigmented epidermal skin cells that can aggressively invade the dermis. Most tumors of this type grow slowly and rarely metastasize, except in patients with health risks like familial skin cancer history and immunodeficiency. Squamous cell skin cancer lesions often occur on sun-exposed areas like the ear, appearing as firm, skin-tone to reddish lumps. The tumors may also develop thick, scaly skin and ulcerate.

Basal cell carcinoma also involves nonpigmented epidermal skin cells that behave less aggressively. The tumors are locally destructive but metastasize rarely. The condition often presents with nonhealing, ulcerating lesions surrounded by broken capillaries (telangiectasia) and a rolled border.

Most basal cell carcinoma tumors are reddish, scarlike, and translucent. However, some lesions appear dark due to a high density of pigmented cells, called “melanocytes,” and increased melanin content.

Melanoma is, essentially, melanocyte cancer. The tumors are irregularly shaped, large, rapidly evolving, and nonuniformly colored. The lesions may have varying brown, black, blue-gray, red, and gray-white hues. Melanoma skin cancer is rare, though it is the most significant cause of skin cancer deaths in the US. Growth and color changes may be observed within months. Relapses may occur even decades after initial clearance and can affect internal organs.

Atypical fibroxanthoma is a low-grade dermal tumor involving connective tissue. The lesions are often slow-growing, non-itchy, painless, and firm, with distinct borders. Some tumors of this kind may ulcerate, but they rarely metastasize unless the patient has risk factors.

What Are the Biggest Risk Factors for Ear Skin Cancer Development?

Knowing the most significant skin cancer risk factors can help you minimize your odds of developing the condition. They include the following:

UV Radiation

Chronically heavy exposure to UV rays is the most important skin cancer risk factor. UV-induced skin cell mutation initiates tumor formation. Skin cancer incidence is greater in locations near the equator and at high altitudes. UV tanning and phototherapy can increase a person’s risk of developing skin cancer.

Genetic Predisposition

Individuals with familial cancer syndromes or family members with a history of any skin cancer type have an increased skin cancer risk. People born with fair skin, red hair, and blue eyes are also vulnerable to skin cancer development. These individuals have little skin melanin, which protects against the condition.

Carcinogens

Exposure to cancer-causing chemicals can increase one’s skin cancer risk. People may encounter these substances at work or in polluted environments. Common carcinogens include heavy metals, coal tar, ash, and polycyclic hydrocarbons. Ionizing radiation, such as x-rays, may also cause tumor formation if exposure is heavy and prolonged.

Excessive alcohol consumption increases the likelihood of melanoma and nonmelanoma skin cancers. Cigarette smoking reduces melanoma risk, but melanoma-associated death is higher among chronic smokers than never-smokers.

Immunosuppression

A robust immunity protects against all cancer types. Conversely, immunosuppression makes people vulnerable to malignancies, including skin tumors. Thus, immunosuppression after solid organ transplantation and conditions like HIV infection and leukemia increase skin cancer risk.

Drugs

Medications that can elevate your skin cancer risk include agents with photosensitization as a side effect like the rosacea drug doxycycline. Immunosuppressants like steroids and cancer drugs may also cause skin cancer.

Viral Infection

Many viruses can cause cancer. However, the most notorious for producing skin cancer is human papillomavirus, the wart virus. You may read my previous blog, “Are Warts Contagious? Here’s What You Should Know Before Attempting Any Treatment,” to learn about high-risk human papillomavirus strains and their relationship to skin cancer.

Chronic Skin Inflammation

Chronic skin inflammation can lead to abnormal skin cell growth and, consequently, malignancies. Thus, individuals with chronic immune-driven skin disorders like psoriasis are skin cancer-prone. People with nonhealing lesions and burns are also susceptible to skin cancer.

Most skin cancer risk factors are avoidable or modifiable. Genetic factors, while unmodifiable, may be addressed by constant surveillance. Identifying your risks and making lifestyle adjustments can reduce your susceptibility to skin cancer.

How Do You Detect Ear Skin Cancer Early?

Vigilance allows you and your healthcare provider to treat skin cancer at its early stages. A regular skin self-exam effectively detects skin tumors, which is vital to people vulnerable to skin cancer development. My article, “Mole vs. Melanoma: Knowing the Difference Could Save Lives,” discusses the features that can distinguish melanoma lesions from a benign mole. The article also has pictures to help you identify these skin tumors easily.

The ABCDE melanoma recognition guide can help you spot a potentially cancerous skin lesion easily. Briefly, it describes a melanoma tumor as having the following characteristics:

• Asymmetry
• Borders that are irregular
• Color that’s not uniform throughout the lesion
• Diameter greater than 6 millimeters/li>
• Evolution or enlargement that is fast, i.e., within weeks to months

You can use this guide during your self-skin exam to identify melanoma. You can also modify it to detect nonmelanoma skin cancers by including my above descriptions of these lesions.

Generally, you should consult a healthcare specialist if you find a suspicious, nonhealing lesion that bleeds with minimal trauma, has an unusual color, or grows or multiplies rapidly. Other telltale malignancy symptoms include on-and-off fever, weakness,  loss of appetite, lymph node enlargement, and unintentional weight loss. The sooner you treat a suspicious lesion, the better for you, as it helps you get the best treatment results and avoid complications.

How Do You Perform a Self-Examination for Ear Skin Cancer?

You can conduct a skin self-examination in various ways, even using mobile apps. The American Cancer Society proposes a simple method for inspecting all skin surfaces with the following steps:

• Stand before a large mirror, examining your face, ears, neck, chest, and belly. Women should lift their breasts to check underneath.

• Examine your underarms, both sides of your arms, the tops and palms of your hands, the spaces between your fingers, and the area under your fingernails.
• While seated, inspect the front of your thighs, shins, tops of your feet, spaces between your toes, and beneath your toenails.
• Use a hand mirror to examine the soles of your feet, calves, and backs of your thighs.
• Use the hand mirror to inspect your genital area, buttocks, lower and upper back, and the back of your neck and ears. Alternatively, it may be easier to look at your back in the wall mirror using a hand mirror.
• You may use a comb or hair dryer to part your hair to check your scalp.

A yearly skin exam may suffice for most individuals. However, people vulnerable to skin cancer, such as those with prior melanoma history, must check more frequently as advised by their providers.

How Is Ear Skin Cancer Diagnosed?

Ear skin cancer evaluation starts with your dermatologist’s clinical examination. Skin specialists usually ask for details about the lesion’s evolution and if it causes other symptoms like hearing loss, dizziness, or loss of balance. They may inquire about activities that increase your skin cancer risk, such as frequent daytime outdoor recreation and alcohol consumption. They may also ask if you or a family member has a prior cancer history.

After noting your medical history, your dermatologist will examine the lesion. Patients with suspected skin cancer usually receive a full-body skin examination, with the doctor checking for distant spread. Don’t worry—they will conduct the exam with utmost respect for your privacy.

Suspected skin cancer lesions require a biopsy. This diagnostic procedure entails taking a small tissue sample from the lesion and examining the specimen microscopically. Local anesthesia is injected to make it painless.

Your dermatologist may order imaging tests, such as CT or MRI, after identifying the lesion as cancer. Imaging tests help rule out possible spread within the skull, neck lymph nodes, and other distant sites in people with large tumors, aggressive cancer types on biopsy, or lymph node swelling.

Blood tests may be ordered If you have a medical condition and are considering surgical tumor removal as a treatment option. These tests can help your dermatologist determine if you are suitable for surgery.

What Are the Treatment Options for Ear Skin Cancer?

Ear skin cancer treatments may be surgical or nonsurgical. Surgical removal generally yields better cosmetic, functional, and clinical outcomes than nonsurgical therapy and is thus recommended universally. Additionally, techniques that ensure “margin clearance”— or when the excised lesion’s edges are microscopically confirmed to be free of cancer cells—have the best cure rates. That means the chance of recurrence after the treatment is low.

However, not all patients are good surgical candidates. For these individuals, the doctor may recommend less invasive therapies.

The different ear skin cancer options are explained below.

Ear Skin Cancer Surgery

Mohs micrographic surgery (or simply Mohs surgery) and wide local excision are the two most commonly performed procedures for ear skin cancer. Mohs surgery is suitable for lesions confined to the skin. Wide local excision is usually recommended when the tumor invades deeper tissues, such as the ear cartilage or temporal bone (the bone behind the ears).

Mohs surgery involves cutting the tumor in stages. The lesion is excised little by little until a thin strip of healthy tissue is obtained, ensuring margin clearance at the last stage. The technique removes the entire tumor while minimizing damage to the treatment area. A Mohs surgeon is a specially trained board-certified dermatologist who is also certified by the American Board of Dermatology to perform the procedure.

Wide local excision removes the entire tumor along with a large piece of the normal-looking tissue surrounding it. Margin clearance is usually confirmed only after the procedure, which can take days. Lymph node or temporal bone involvement often requires expanding the surgical target area and possible reconstructive surgery.

A board-certified dermatologist may perform wide local excision on skin-confined tumors. An otorhinolaryngologist or plastic surgeon may be consulted for deeply invading lesions.

Outer ear skin cancers have a high recurrence risk if caught in the late stages. Incomplete excision is likely due to the outer ear’s contour. Thus, ensuring margin clearance after surgery is vital. Radiotherapy may be recommended to kill off invisible cancer cells if the excised lesion’s margins have residual tumor tissue on microscopy.

Other surgical techniques for ear skin cancer treatment include curettage and electrodesiccation and cryosurgery. Curettage and electrodesiccation involves scooping out the tumor with a surgical scalpel followed by cauterizing the blood vessels. Cryosurgery destroys skin cancer tissue using liquid nitrogen.

Neither of these procedures ensures margin clearance, so posttreatment recurrence is likely. Additionally, the cosmetic and clinical outcomes after curettage and electrodessication and cryotherapy are often unsatisfactory. However, these modalities may be offered to patients with contraindications to Mohs surgery and wide local excision or if specialists in the latter two are unavailable.

Nonsurgical Ear Skin Cancer Treatment

Nonsurgical treatment options for this condition include radiotherapy, chemotherapy, topical medications, and photodynamic therapy. None of these modalities ensure margin clearance, but your healthcare provider may recommend them if you have contraindications to any form of surgery.

Radiotherapy uses ionizing radiation to destroy the tumor. This treatment is a viable surgical alternative for large, inoperable lesions. However, radiation therapy’s cosmetic outcomes are less satisfactory than surgery because the treated skin deteriorates with time. Thus, this modality is better suited for older than younger patients

Chemotherapy is not the standard of care for skin tumors. However, it may be attempted for inoperable lesions or those with distant spread, such as ear melanoma metastasizing to the heart. It is an alternative “cleanup treatment” to radiotherapy in cases of incomplete tumor excision. Immune checkpoint inhibitors like cemiplimab improve quality of life for patients with advanced skin cancer.

Topical medications include 5-fluorouracil and imiquimod. The agent 5-fluorouracil disrupts cancer cell growth. Imiquimod enhances the skin’s immune response to the tumor cells. These medications may be used on small, low-grade tumors if surgery cannot be performed.

Photodynamic therapy involves applying a photosensitizing substance to the treatment area before exposing it to powerful blue or red light. This procedure may be attempted on superficial basal cell carcinoma. Response rates reach 93%, but the chance of recurrence is up to 31%.

Is Mohs Surgery Effective for Ear Skin Cancer?

The Mohs procedure is considered the gold standard for nonmelanoma skin cancer treatment, offering excellent cosmetic outcomes and cure rates approaching 99-100%. Its early-stage melanoma cure rate is as high as 98%, though tumor pigmentation can make the procedure challenging for inexperienced surgeons. By comparison, wide local excision’s cure rates are only as high as 96% for nonmelanoma skin cancers and 85% for early-stage melanoma.

The Mohs technique spares as much normal tissue as possible, maintaining the treated area’s appearance and function. Recurrence is low after the procedure, so you may consider it highly cost-effective. However, its main limitation is that it is unavailable in many locations. Not all dermatology clinics have a board-certified Mohs surgeon.

The Mohs specialist ensures complete margin clearance before closing up the surgical area, unlike in a wide local excision where lab analysis of the excised tissue is performed after the session. Mohs surgery is best for ear cancers confined to the skin as it significantly reduces incomplete excisions.

You may read my article, “Mohs Surgery vs. Excision: Comparing the Uses, Benefits, and Risks of Commonly Performed Skin Cancer Treatments,” to learn more about how Mohs treatment compares with wide local excision.

What Is Your Dermatologist’s Role in Managing Ear Skin Cancer?

Many ear skin cancer cases are managed by multidisciplinary healthcare teams coordinated by the primary care provider. Your dermatologist’s roles in this team include the following:

• Ensuring that the diagnosis of skin cancer is accurate
• Performing surgical procedures, especially Mohs treatment, when appropriate
• Guiding you on preventing recurrence
• Prescribing the proper skincare routine

In complex cases, such as when temporal bone cancer has developed from skin tumor invasion, the care team may also include specialists in head and neck cancer and plastic surgery. The dermatologist’s diagnostic and recurrence-preventive recommendations remain highly valuable in such a team, as dermatologists are the skin cancer experts.

How Do You Take Care of Your Skin After Ear Skin Cancer Treatment?

The aftercare regimen depends on the kind of therapy you receive. Most patients who undergo surgery are given instructions for proper wound care after the session. They will also be advised about pain relief methods, activity restriction, follow-up, and the expected recovery time.

However, the most important aspect of skin cancer posttreatment care is recurrence surveillance. Most squamous and basal cell carcinoma relapses occur within the first 5 years. The likelihood of recurrence significantly declines afterward.

Most melanoma relapses also occur in the first 5 years after treatment. However, regrowth of this aggressive tumor is still possible even decades later. Continuous posttreatment monitoring is vital because recurrent tumors, whether melanomatous or not, are usually more aggressive than the first.

How Do You Prevent Ear Skin Cancer?

Preventive measures for skin cancer, in general, include the following:

• Regular and adequate sun protection, seeking shade and using wide-brimmed hats, clothes, and sunscreen when outdoors
• Periodic skin self-examinations
• Treating precursor lesions like actinic keratosis
• Maintaining a healthy diet, ensuring balanced levels of skin cancer-protective niacinamide and vitamin A

Additionally, patients on immunosuppressants may talk to their healthcare providers about modifying their immunosuppressive regimen. People who receive skin cancer treatment should schedule regular follow-ups with their healthcare providers for recurrence monitoring. Skin cancer prevention is always much better than cure, as prevention helps you avoid complications from the condition or its treatment.

Your Best Hope After an Ear Skin Cancer Diagnosis

Outer ear cancers often involve the skin, with slow-growing squamous cell carcinoma being the most common. Of the currently available treatment options, Mohs surgery offers the best outcomes for skin-confined tumors, whereas wide excision serves as an alternative for deeper but still operable lesions. Still, vigilance is key to dealing with this condition, as prevention and early treatment are the best strategies that can help vulnerable people avoid complications.

Ear skin cancer requires a specialized team of doctors for proper management. Among these professionals, the dermatologist is pivotal. With their skin health expertise, they ensure accurate diagnosis, provide the necessary treatment, and educate patients on prevention and skincare practices to avoid recurrence.

Finding a qualified and reputable dermatologist to fulfill all these roles is vital in battling this serious illness. Your best move is to trust a board-certified dermatologist with a solid track record to guide you through this journey.

Bothered by a Suspicious Ear Lesion? LA’s Award-Winning Skin Cancer Doctors Can Help

Your ears contribute to your physical appeal. More importantly, they are crucial to daily functions like social interaction, responding to environmental cues, and protection from hazards. Needless to say, a serious condition like skin cancer can impact your health and quality of life.

If you or a loved one has ear skin cancer, worry not. BHSkin Dermatology’s skin cancer specialists are some of the best in California. For years, they have helped many patients get rid of this condition. Visit us at our Glendale or Encino office or use our telederm portal for your initial consultation.

Book your appointment today!

References:

1. Alam, M., et al. (2018. January 10). Guide of care for the management of cutaneous squamous cell carcinoma. Journal of the American Academy of Dermatology. 78(3). 560-578. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6652228/
2. American Cancer Society. (2019, July 2023). How to Do a Skin Self-Exam. Retrieved April 19, 2024, from https://www.cancer.org/cancer/risk-prevention/sun-and-uv/skin-exams.html
3. Beecher, S. M., et al. (2016). Skin Malignancies of the Ear. PRS Global Open. 4(1). https://doi.org/10.1097%2FGOX.0000000000000585
4. Bhurosy, T., et al. (October 2020). Prevalence and correlates of skin self-examination behaviors among melanoma survivors: a systematic review. Translational Behavioral Medicine. 10(5). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7549412/
5. Ciazynska, M., et al. (2021). The incidence and clinical analysis of non-melanoma skin cancer. Scientific Reports. 11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8319379/
6. Garbe, C., et al. (2020, August 24). The evolving field of Dermato-oncology and the role of dermatologists: Position Paper of the EADO, EADV, and Task Forced, EDF, IDS, EBDV-UEMS and EORTC Cutaneous Lymphoma Task Force. Journal of the European Academy of Dermatology and Venereology. 34(10). 2183-2197. https://pubmed.ncbi.nlm.nih.gov/32840022/
7. Garcia-Foncillas, J., et al. (February 2022). Update on Management Recommendations for Advanced Cutaneous Squamous Cell Carcinoma. Cancers. 14(3). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8833756/
8. Halily, S., et al. (August 2022). An extensive squamous cell carcinoma of the auricle: From curative to reconstructive treatment. A case report. International Journal of Surgery Case Reports. 97. https://pubmed.ncbi.nlm.nih.gov/35933948/
9. Hassel, J. C. and Enk, A. H. (2019). Chapter 116: Melanoma. Fitzpatrick’s Dermatology. 9th ed. https://accessmedicine.mhmedical.com/content.aspx?bookid=2570&sectionid=210435350
10. Jackson, K. M., et al. (2024, February 6). Smoking Status and Survival in Patients With Early-Stage Primary Cutaneous Melanoma. Journal of the American Medical Association. 7(2). https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2814571
11. Liu, L. and Chen, J. (2023, December 29). Advances in Relationship Between Alcohol Consumption and Skin Diseases. Clinical, Cosmetic and Investigational Dermatology. 16. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10759914/
12. Lonsdorf, A. S. and Hadaschik, E. N. (2019). Chapter 112: Squamous Cell Carcinoma and Keratoacanthoma. Fitzpatrick’s Dermatology. 9th ed. https://accessmedicine.mhmedical.com/content.aspx?bookid=2570&sectionid=210434544
13. Peters, M., et al. (October-December 2020). Treatment and Outcomes for Cutaneous Periauricular Basal Cell Carcinoma: A 16-Year Institutional Experience. OTO Open. 4(4). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7580161/
14. Sand, M., et al. (2008). Cutaneous Lesions of the External Ear. Head and Face Medicine. 4(2). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2267455/#:~:text=The%20lesions%20are%20erythematous%2C%20scaly,external%20side%20of%20the%20auricle.
15. Sangers, T., et al. (2022). Validation of a Market-Approved Artificial Intelligence Mobile Health App for Skin Cancer Screening: A Prospective Multicenter Diagnostic Accuracy Study. Dermatology. 238(4). 649-656. https://karger.com/drm/article/238/4/649/828305/
16. Sim, J., et al. (2022, April 7). Atypical Fibroxanthoma Resected without Auricular Deformity in an Elderly Patient: A Case Study. Ear, Nose, and Throat Journal. https://pubmed.ncbi.nlm.nih.gov/35387526/
17. Tang, J. Y., et al. (2019). Chapter 111: Basal Cell Carcinoma and Basal Cell Nevus Syndrome. Fitzpatrick’s Dermatology. 9th ed. https://accessmedicine.mhmedical.com/content.aspx?bookid=2570&sectionid=210434418
18. Tolkachjov, S. N. (August 2017). Understanding Mohs Micrographic Surgery: A Review and Practical Guide for the Nondermatologist. Mayo Clinic Proceedings. 92(8). https://pubmed.ncbi.nlm.nih.gov/28778259/
19. Walocko, F., et al. (March 2022). Micrographic dermatologic surgery (MDS) diplomates: a demographic evaluation and comparison of Medicare case volume. Archives of Dermatological Research. 314(2). https://pubmed.ncbi.nlm.nih.gov/35133478/

Author: Don Mehrabi

Don Mehrabi, MD, FAAD, is LA’s leading board-certified dermatologist who treats patients, builds the BHSkin clinics, and raises three kids. This blog builds on medical studies combined with Dr. Mehrabi's first-hand experiences from practicing in Encino-Tarzana, Glendale, and online