Nicorandil ulcer: moves beyond the mucosa

Abstract

The management of wounds is a specialty in its infancy. Success requires more than the use of dressings. All wounds require a diagnosis, a point well illustrated by the management of these cases which depended solely on stopping nicorandil.

Nicorandil and prepuce ulcers

“…Nicorandil has been known as a causative factor of many apthous ulcers [3][4][5][6] and painful perianal, 7 vulval 8 and peristomal 9 ulceration. The exact mechanism for ulcer development remains unclear.…”

“…Putative causative factors include toxic metabolites of nicorandil and the vascular steal phenomenon. 3 Patel and Harding 3 argued against the toxic metabolite hypothesis to substantiate ulcer occurrence in gastrointestinal and mucocutaneous areas, as nicorandil metabolites are excreted through the kidneys. The vascular steal phenomenon was also thought unlikely, as the ulcer sites are well vascularised, the surrounding skin appearing healthy with no histological evidence of ischaemia.…”

“…3 The association of mucosal ulcers has been observed to be more common among patients who are on higher doses at or above 20mg twice daily. In some cases the ulceration develops after a dosage increase.…”

“…3 Once the medication is discontinued, the associated pain usually disappears within weeks and complete healing occurs thereafter. If the size of the prepuce defect is large, complete healing may take 2-6 months.…”

“…Nicorandil-mediated mitochondrial potassium-channel opening also appears to provide cardioprotection against ischaemia. 3 Even though the association of chronic mucosal ulceration and prolonged usage of nicorandil has been known for some time, 1,[3][4][5] foreskin ulceration associated with use of nicorandil has been identified only relatively recently, with few reports in the literature so far. 1,2…”