Fiddler's neck

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Fiddler's neck
Classification and external resources
Specialty Occupational health

Fiddler's neck, sometimes referred to as a "violin hickey," or a "viola love bite" is an occupational disease that affects violin and viola players. [1]

An occupational disease is any chronic ailment that occurs as a result of work or occupational activity. It is an aspect of occupational safety and health. An occupational disease is typically identified when it is shown that it is more prevalent in a given body of workers than in the general population, or in other worker populations. The first such disease to be recognised, squamous-cell carcinoma of the scrotum, was identified in chimney sweep boys by Sir Percival Pott in 1775. Occupational hazards that are of a traumatic nature are not considered to be occupational diseases.

Violin bowed string instrument, usually with four strings tuned in perfect fifths

The violin, sometimes known as a fiddle, is a wooden string instrument in the violin family. Most violins have a hollow wooden body. It is the smallest and highest-pitched instrument in the family in regular use. Smaller violin-type instruments exist, including the violino piccolo and the kit violin, but these are virtually unused. The violin typically has four strings tuned in perfect fifths, and is most commonly played by drawing a bow across its strings, though it can also be played by plucking the strings with the fingers (pizzicato) and by striking the strings with the wooden side of the bow.

Viola bowed string instrument

The viola (; Italian pronunciation: [ˈvjɔːla]) is a string instrument that is bowed or played with varying techniques. It is slightly larger than a violin and has a lower and deeper sound. Since the 18th century, it has been the middle or alto voice of the violin family, between the violin (which is tuned a perfect fifth above) and the cello (which is tuned an octave below). The strings from low to high are typically tuned to C3, G3, D4, and A4.


It is a cutaneous condition usually characterized by redness, thickening, and inflammation on the left side of the neck below the angle of the jaw where the instrument is held. [1] Acne-like lesions and cysts may form at the site due to foreign body reactions, and infections may also occur due to poor hygiene. [1] The primary causes of fiddler's neck are constant friction and local pressure. [2] It is well known among professional orchestra musicians but is "not well recognized by dermatologists", [2] and a red mark on the left side of the neck under the jaw "functions as an identifying sign" of a violinist or violist "in public without seeing the instrument". [3]

Acne sebaceous glands disease characterized by areas of blackheads, whiteheads, pimples, greasy skin, and possibly scarring.

Acne, also known as acne vulgaris, is a long-term skin disease that occurs when hair follicles are clogged with dead skin cells and oil from the skin. It is characterized by blackheads or whiteheads, pimples, oily skin, and possible scarring. It primarily affects areas of the skin with a relatively high number of oil glands, including the face, upper part of the chest, and back. The resulting appearance can lead to anxiety, reduced self-esteem and, in extreme cases, depression or thoughts of suicide.

Orchestra large instrumental ensemble

An orchestra is a large instrumental ensemble typical of classical music, which combines instruments from different families, including bowed string instruments such as the violin, viola, cello, and double bass, brass instruments such as the horn, trumpet, trombone and tuba, woodwinds such as the flute, oboe, clarinet and bassoon, and percussion instruments such as the timpani, bass drum, triangle, snare drum and cymbals, each grouped in sections. Other instruments such as the piano and celesta may sometimes appear in a fifth keyboard section or may stand alone, as may the concert harp and, for performances of some modern compositions, electronic instruments.

Although the presence of fiddler's neck is sometimes used as an indicator of a violinist's skill, or 'battle scars' from constant practice, many violinists never develop fiddler's neck, due to differences in skin sensitivity, playing habits, and the materials used in the construction of the instrument. An accomplished professional player could practice hard their whole life and never develop fiddler's neck.

Signs and symptoms

Fiddler's neck usually involves highly localized lichenification, mild hyperpigmentation, and erythema where the chin rest or instrument body presses against the skin of the neck. [2] Other signs and symptoms include scale buildup, cyst and scar formation, papules and pustules related to local infection, and focal edema. [1] In Blum & Ritter's study in West Germany (1990), they found that 27% of their population had only minor issues, 72% had a palpable mass at the site, and 23% reported pain and other signs of inflammation such as hyperthermia, pulsation, and cystic, pustular, or papular lesions. [3] Size of masses were an average of 2 cm in diameter ranging up to 4 cm, some being associated with purulent drainage, continuous discharge, and crusting. Dystrophic calcinosis cutis has also been reported. [4] Other serious sequelae include sialolithiasis of the submandibular gland and adenolymphoma of the parotid gland. [3]

Hyperpigmentation darkening of an area of skin or nails caused by increased melanin

Hyperpigmentation is the darkening of an area of skin or nails caused by increased melanin.

Erythema symptom

Erythema is redness of the skin or mucous membranes, caused by hyperemia in superficial capillaries. It occurs with any skin injury, infection, or inflammation. Examples of erythema not associated with pathology include nervous blushes.

Cyst closed sac growth on the body

A cyst is a closed sac, having a distinct membrane and division compared with the nearby tissue. Hence, it is a cluster of cells that has grouped together to form a sac ; however, the distinguishing aspect of a cyst is that the cells forming the "shell" of such a sac are distinctly abnormal when compared with all surrounding cells for that given location. It may contain air, fluids, or semi-solid material. A collection of pus is called an abscess, not a cyst. Once formed, sometimes a cyst may resolve on its own. When a cyst fails to resolve, it may need to be removed surgically, but that would depend upon its type and location.

The histopathology of fiddler's neck frequently shows hyperkeratosis and acanthosis, along with plugging of follicles. [2] Histiocytic infiltration with granulomas to foreign body and follicular cysts are also common. [3] Foreign body granulomas are thought to derive from abrasion of the wooden surface of the chin rest and its absorption into the superficial dermis. [3] The location and complex mechanism of causation for fiddler's neck give rise to a wider spectrum of skin changes when compared to contact dermatitis from more common irritants. [1] Fiddler's neck can be differentiated from rosacea and sarcoid reaction with granulomas. [1]


Histopathology refers to the microscopic examination of tissue in order to study the manifestations of disease. Specifically, in clinical medicine, histopathology refers to the examination of a biopsy or surgical specimen by a pathologist, after the specimen has been processed and histological sections have been placed onto glass slides. In contrast, cytopathology examines (1) free cells or (2) tissue micro-fragments.

Hyperkeratosis thickening of the stratum corneum (the outermost layer of the epidermis), often associated with the presence of an abnormal quantity of keratin

Hyperkeratosis is thickening of the stratum corneum, often associated with the presence of an abnormal quantity of keratin, and also usually accompanied by an increase in the granular layer. As the corneum layer normally varies greatly in thickness in different sites, some experience is needed to assess minor degrees of hyperkeratosis.


Acanthosis is diffuse epidermal hyperplasia. It implies increased thickness of the Malpighian layer.


The proximal causes of fiddler's neck are friction and pressure, but both repetitive shearing stress and occlusion with consequent trapping of sweat give rise to progressive damage. [1] This damage along with poor hygiene predisposes the area to local infection, and such infection can progress to scarring and other long-term effects. [1] Hot weather is reported to exacerbate fiddler's neck, as are tiredness, playing emotional music, and playing in smaller groups where individual stress is higher. [2] Type I hypersensitivity reactions may also be involved, particularly to rosewood and ebony in the chinrest and tailpiece, as well as to varnish of the instrument body when chinrests are not used and to rosin deposits on the instrument and on chin cloths. [3] Nickel or other metal allergies are common causes if the chin rest has a metal clip that comes into constant contact with the skin. Rosin exposure in particular may lead to abietic acid dermatitis. [3]

Type I hypersensitivity

Type I hypersensitivity is an allergic reaction provoked by reexposure to a specific type of antigen referred to as an allergen. Type I is not to be confused with type II, type III, or type IV hypersensitivities, nor is it to be confused with Type I Diabetes or Type I of any other disease or reaction.

Rosewood wood

Rosewood refers to any of a number of richly hued timbers, often brownish with darker veining, but found in many different hues.

Ebony wood

Ebony is a dense black hardwood, most commonly yielded by several different species in the genus Diospyros, which also contains the persimmons. Ebony is dense enough to sink in water. It is finely-textured and has a very smooth finish when polished, making it valuable as an ornamental wood. The word ebony comes from the Ancient Egyptian hbny, through the Ancient Greek ἔβενος (ébenos), into Latin and Middle English.


Differential diagnoses

The differential diagnoses of fiddler's neck include branchial cleft cyst, disease of the salivary glands, tumors of the parotid gland, psoriasis, lichen planus, contact dermatitis, herpes simplex and similar infections, and insect bites and stings especially from fleas. [1] [3]

In medicine, a differential diagnosis is the distinguishing of a particular disease or condition from others that present similar clinical features. Differential diagnostic procedures are used by physicians to diagnose the specific disease in a patient, or, at least, to eliminate any imminently life-threatening conditions. Often, each individual option of a possible disease is called a differential diagnosis.

Branchial cleft cyst

A branchial cleft cyst is a cyst as a swelling in the upper part of neck anterior to sternocleidomastoid. It can, but does not necessarily, have an opening to the skin surface, called a fistula. The cause is usually a developmental abnormality arising in the early prenatal period, typically failure of obliteration of the second branchial cleft, i.e. failure of fusion of the second and third branchial arches. Branchial cleft cysts account for almost 20% of neck masses in children. Less commonly, the cysts can develop from the first, third, or fourth clefts, and their location and the location of associated fistulas differs accordingly.

Parotid gland

The parotid gland is a major salivary gland in many animals. In humans, the two parotid glands are present on either side of the mouth and in front of both ears. They are the largest of the salivary glands. Each parotid is wrapped around the mandibular ramus, and secretes serous saliva through the parotid duct into the mouth, to facilitate mastication and swallowing and to begin the digestion of starches. There are also two other types of salivary glands; they are submandibular and sublingual glands. Sometimes accessory parotid glands are found close to the main parotid glands.


Treatment for fiddler's neck is unnecessary if it is painless and shows minimal swelling, [3] particularly since minor cases are taken as a mark of pride. But fiddler's neck may lead to worse disorders. The primary methods of treatment involve adjustments to playing of the instrument: [3]

Surgery is necessary for sialolithiasis, parotid tumors, and cysts. [3] Cervical lymph nodes that are larger than 1 cm must be biopsied. [3] Connective tissue can be removed by excision when a non-inflamed mass is large, and there is generally little recurrence. [3] Infections should be treated conservatively, and causative species should be identified through smear and culture for appropriate antibiotic selection. [3] Reduction of playing time may be helpful for cases without inflammation, but in 30% of cases this did not improve the symptoms. [3]


Fiddler's neck does not usually form unless the musician is practicing or playing for more than a few hours each day, and only seems to develop after a few years of serious playing. [2] Thus, when not infected or otherwise problematic, fiddler's neck may be known as a benign practice mark and may be worn proudly as an indication of long hours of practice. [3] Blum & Ritter (1990) found that 62% of 523 professional violinists and violists in West Germany experienced fiddler's neck, with the percentage among violists being higher (67%) than among violinists (59%). [3] Viola players are believed to be more predisposed to developing fiddler's neck than violinists because the viola is larger and heavier, but this has not been empirically confirmed. [2]

The development of fiddler's neck does not depend on preexisting skin problems, and Blum & Ritter find that only 23% of men and 14% of women in their study reported cutaneous disorders in other parts of the face (mainly acne and eczema) that were independent of playing the violin or viola. [3] Fiddler's neck may exacerbate existing acne, but acne may also be limited solely to the lesion and not appear elsewhere. [2] Nonetheless, musicians with underlying dermatologic diseases like acne and eczema are more endangered by fiddler's neck than others. [3] Males may develop folliculitis or boils due to involvement of beard hair. [3]

Related Research Articles

Folliculitis Human disease

Folliculitis is the infection and inflammation of one or more hair follicles. The condition may occur anywhere on the skin except the palms of the hands and soles of the feet. The rash may appear as pimples that come to white tips on the face, chest, back, arms, legs, buttocks, or head.

Sebaceous gland microscopic exocrine glands in the skin that secrete an oily or waxy matter, called sebum, to lubricate and waterproof the skin and hair of mammals

Sebaceous glands are microscopic exocrine glands in the skin that secrete an oily or waxy matter, called sebum, to lubricate and waterproof the skin and hair of mammals. In humans, they occur in the greatest number on the face and scalp, but also on all parts of the skin except the palms of the hands and soles of the feet. The type of secretion of the sebaceous glands is referred to as holocrine. In the eyelids, meibomian glands, also called tarsal glands, are a type of sebaceous gland that secrete a special type of sebum into tears. Fordyce spots are ectopic (misplaced) sebaceous glands found usually on the lips, gums and inner cheeks, and genitals. Areolar glands surround the female nipples.

Calcinosis cutis

Calcinosis cutis is a type of calcinosis wherein calcium deposits form in the skin. A variety of factors can result in this condition. The most common source is dystrophic calcification, which occurs in soft tissue as a response to injury. In addition, calcinosis is seen in Limited Cutaneous Systemic Sclerosis, also known as CREST syndrome. In dogs, calcinosis cutis is found in young, large breed dogs and is thought to occur after a traumatic injury.

Acne keloidalis nuchae (AKN) is a destructive scarring folliculitis that occurs almost exclusively on the occipital scalp of people of African descent, primarily men.

Comedo clogged hair follicle in the skin

A comedo is a clogged hair follicle (pore) in the skin. Keratin combines with oil to block the follicle. A comedo can be open (blackhead) or closed by skin (whitehead) and occur with or without acne. The word comedo comes from the Latin comedere, meaning 'to eat up', and was historically used to describe parasitic worms; in modern medical terminology, it is used to suggest the worm-like appearance of the expressed material.

Alclometasone chemical compound

Alclometasone is a synthetic corticosteroid for topical dermatologic use, possessing anti-inflammatory, antipruritic, and vasoconstrictive properties.

ICD-10 is an international statistical classification used in health care and related industries.


A chinrest is a shaped piece of wood attached to the body of a violin or a viola to aid in the positioning of the player's jaw or chin on the instrument. The chinrest may be made of ebony, rosewood, boxwood, or plastic. It was invented by Louis Spohr in the early 19th century; historically, this has been explained as a response to increasingly difficult repertoire which demanded freer left hand techniques than had previously been used; however, Spohr intended his small block attached to the bout to protect the tailpiece, which he reportedly broke with his vigorous playing. However, after being promoted by prominent violinists of the day, such as Pierre Baillot and Giovanni Battista Viotti, it gained quick acceptance among most violists & violinists and is today considered a standard part of the viola and violin.

Shoulder rest

The shoulder rest is an accessory that can be found on violins and violas. It may be made of wood, aluminium, carbon fiber or plastic. Usually, the shoulder rest attaches to the edge of the back of the violin with "feet" padded with rubber tubing or made of soft plastic. The goal of a shoulder rest is to allow a more comfortable attitude while playing by adding height to the shoulder and preventing the instrument from slipping. A shoulder rest generally follows the curve of the shoulder; some shoulder rests are bendable, others are made of sponge-like material, and a few have an extension that hooks further over the shoulder for stability. It is a relatively recent invention, and though it is quite commonly used among modern violinists and violists, it is not universally used. Depending on body type and style of clothes, some musicians need no more than a thin sponge, a cloth or sometimes nothing at all under the instrument.

Sialadenitis inflammation of a salivary gland

Sialadenitis (sialoadenitis) is inflammation of salivary glands, usually the major ones, the most common being the parotid gland, followed by submandibular and sublingual glands. It should not be confused with sialadenosis (sialosis) which is a non-inflammatory enlargement of the major salivary glands.

Hidradenitis is any disease in which the histologic abnormality is primarily an inflammatory infiltrate around the eccrine glands. This group includes neutrophilic eccrine hidradenitis and recurrent palmoplantar hidradenitis.

Feline acne

Feline acne is a problem seen in cats primarily involving the formation of blackheads accompanied by inflammation on the cat's chin and surrounding areas that can cause lesions, alopecia, and crusty sores. In many cases symptoms are mild and the disease does not require treatment. Mild cases will look like the cat has dirt on its chin, but the dirt will not brush off. More severe cases, however, may respond slowly to treatment and seriously detract from the health and appearance of the cat. Feline acne can affect cats of any age, sex or breed, although Persian cats are also likely to develop acne on the face and in the skin folds. This problem can happen once, be reoccurring, or even persistent throughout the cat's life.

Pityrosporum folliculitis

Pityrosporum folliculitis or Malassezia folliculitis is a skin condition caused by infection by pityrosporum yeast.

Abietic acid dermatitis

Abietic acid dermatitis is a contact dermatitis often seen in association with musical instruments.

Garrod's pads are a cutaneous condition characterized by calluses on the dorsal aspect of the interphalangeal joints, i.e. the back side of the finger joints. They are often seen in violin, viola, and cello players, along with fiddler's neck and other dermatologic conditions peculiar to string musicians. Although Garrod’s pads are conventionally described as appearing on the proximal interphalangeal joint, Rimmer & Spielvogel document an instance on the distal interphalangeal joint of a cellist.

Sodium hypochlorite washes are skin cleansers formulated with sodium hypochlorite (NaOCl) and surfactants. These cleansing liquids or gels are lathered onto wet skin and rinsed off. They are recommended for inflammatory skin conditions, microbial driven skin disorders and body odor.

The intense contact between a musical instrument and skin may exaggerate existing skin conditions or cause new skin conditions. Skin conditions like hyperhidrosis, lichen planus, psoriasis, eczema, and urticaria may be caused in instrumental musicians due to occupational exposure and stress. Allergic contact dermatitis and irritant contact dermatitis are the most common skin conditions seen in string musicians.


  1. 1 2 3 4 5 6 7 8 9 Gambichler, T.; Boms, S.; Freitag, M. (2004). "Contact dermatitis and other skin conditions in instrumental musicians". BMC Dermatology. 4: 3. doi:10.1186/1471-5945-4-3. PMC   416484 . PMID   15090069.
  2. 1 2 3 4 5 6 7 8 Peachey, R. D.; Matthews, C. N. (1978). "'Fiddler's neck'". The British Journal of Dermatology. 98 (6): 669–674. doi:10.1111/j.1365-2133.1978.tb03586.x. PMID   150281.
  3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Blum, Jochen; Ritter, G. (December 1990). "Violinists and violists with masses under the left side angle of the jaw known as "fiddler's neck"". Medical Problems of Performing Artists. 5 (4): 155–160. ISSN   0885-1158.
  4. Oga, A.; Kadowaki, T.; Hamanaka, S.; Sasaki, K. (1998). "Dystrophic calcinosis cutis in the skin below the mandible of a violinist". The British Journal of Dermatology. 139 (5): 940–941. doi:10.1046/j.1365-2133.1998.02544.x. PMID   9892983.