Ms Doong is a third-year medical student at Johns Hopkins University School of Medicine, Baltimore, Maryland.

Judy C Doong, MS3

	A healthy 14-year-old girl who is an avid violin player is brought to the office for evaluation of facial acne. The examination notes a rash on her left neck that has been present for a few years. The patch is mildly tender and itchy but otherwise asymptomatic.

	Instrument-associated skin conditions affect roughly 22% of musicians. Common conditions include calluses (58%), contact dermatitis (19%), fiddler’s neck (19%), and erosions (3%).

 Fiddler’s neck frequently affects violinists and viola players.

 Viola players are more likely to develop the condition because the instrument is larger.

 It is associated with high practice frequencies and professional status.

	Fiddler’s neck most often manifests as a localized area of lichenification (82%) and pigmentation (77%) on the left submandibular region of the neck, where the chin rest of the instrument touches the skin.

 Another common location is the left supraclavicular region, where the skin contacts the bracket that attaches the chin rest to the instrument.

Other clinical features include erythema, scaling, cyst formation, and focal neck edema. Within the area of fiddler’s neck, inflammatory papules and areas of induration also are often seen.

	The skin changes associated with fiddler’s neck on the submandibular region are likely an irritant contact dermatitis.

 This is attributed to a combination of factors, including friction that induces lichenification, in addition to local pressure, shearing stress, and occlusion causing cyst formation and acne-like changes.

 On the other hand, the supraclavicular lesions often are associated with an allergic contact dermatitis, most commonly to nickel, from the metal of the instrument’s brackets.

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	The differential diagnosis should include insect bites, herpes simplex, branchial cleft cyst, and nummular dermatitis. The diagnosis of fiddler’s neck is mainly based on clinical history and confirmed by the lesion locations coinciding with the sites where the instrument contacts the skin.

	Limited options are available for the treatment of these submandibular lesions. Cushions may be placed between the neck and chin rest to decrease the impact of the contact.

 Holding the instrument in a more horizontal position also can alleviate the focal neck edema.

 For the supraclavicular lesions caused by allergic contact dermatitis to metals, the best course of action would be to replace the metal-containing bracket with one made of hypoallergenic material.

	The girl is a member of a youth orchestra and she practices violin for at least 1 to 2 hours every day. The submandibular lesion will likely persist while she continues to play the violin for long periods at frequent intervals. The skin lesion is generally asymptomatic, and she was advised to moisturize frequently; apply triamcinolone acetonide 0.1% ointment sparingly up to twice daily for symptoms; and apply mupirocin 2% ointment if she develops signs of secondary infection.

	1. Gambichler T, Uzun A, Boms S, Altmeyer P, Altenmüller E. Skin conditions in instrumental musicians: a self-reported survey. 

	2. Gambichler T, Boms S, Freitag M. Contact dermatitis and other skin conditions in instrumental musicians. 

	3. Peachey RD, Matthews CN. Fiddler’s neck. 

	4. Caero JE, Cohen PR. Fiddler’s neck: chin rest-associated irritant contact dermatitis and allergic contact dermatitis in a violin player. 

	5. Stern JB. The edema of fiddler’s neck. 

	6. Moreno JC, Gata IM, Garcia-Bravo B, Camacho FM. Fiddler’s neck. 

	Ms Doong is a third-year medical student at Johns Hopkins University School of Medicine, Baltimore, Maryland. Dr Cohen, section editor for Dermcase, is professor of pediatrics and dermatology, Johns Hopkins University School of Medicine, Baltimore. The author and section editor have nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article. Vignettes are based on real cases that have been modified to focus on key teaching points. Images also may be edited or substituted for teaching purposes.

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A healthy 14-year-old girl who is an avid violin player is brought to the office for evaluation of facial acne. The examination notes a rash on her left neck that has been present for a few years. The patch is mildly tender and itchy but otherwise asymptomatic.

Judy C Doong, MS3

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