Case and research letter
Chondrodermatitis Nodularis Helicis: Successful Treatment with 2% Nitroglycerin Gel
Condrodermatitis nodularis helicis tratada con éxito con nitroglicerina al 2% en gel
Servicio de Dermatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Yélamos, J. Dalmau, Ll. Puig" "autores" => array:3 [ 0 => array:4 [ "nombre" => "O." "apellidos" => "Yélamos" "email" => array:1 [ 0 => "oyelamos@santpau.cat" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Dalmau" ] 2 => array:2 [ "nombre" => "Ll." "apellidos" => "Puig" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding Author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Condrodermatitis <span class="elsevierStyleItalic">nodularis helicis</span> tratada con éxito con nitroglicerina al 2% en gel" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2008 "Ancho" => 1500 "Tamanyo" => 718762 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythematous ulcer on the helix of the left ear consistent with chondrodermatitis nodularis helicis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Chondrodermatitis nodularis helicis (CNH) is a condition that affects the skin and cartilage of the pinna, manifesting as a single painful nodule on the helix, and less commonly the antihelix. The pathogenesis of CNH is unknown, but has been associated with decreased blood flow caused by prolonged pressure upon the auricular cartilage. Treatment is challenging, with recurrence being common following both conservative treatment and surgery.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of an 83-year-old woman who presented an erythematous nodule with central ulceration on the helix of the left ear; the nodule had appeared 2 years earlier, was extremely painful to touch, and had not responded to treatment with several courses of topical corticosteroids (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) The results of a skin biopsy revealed hyperkeratosis, an acanthotic epidermis with signs of dysplasia, and numerous ectatic capillaries in the upper dermis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In view of these findings, and after malignancy had been ruled out, the patient was diagnosed with CNH and the lesion was treated topically with a 2% nitroglycerin gel once every 12<span class="elsevierStyleHsp" style=""></span>hours for 3 months. An improvement was observed in the appearance of the lesion (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) and the pain almost completely disappeared. Pain was assessed using a visual analog scale, with 10 corresponding to the worst pain imaginable and 0 to no pain; the patient's score decreased from 8 on the first visit to 1 following 3 months of treatment with nitroglycerin gel. Thus, 4 months after starting treatment (3 months of treatment and 1 of control), a significant improvement in the patient's condition was observed, with no adverse effects.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">CNH is an inflammatory condition characterized by a solitary, firm, well-defined, pink or reddish nodule several millimeters in diameter on the helix or, less commonly, the antihelix, sometimes with central ulceration and crusting. Typically, the lesion is extremely painful to touch, a feature that can facilitate differential diagnosis with other entities, such as actinic keratosis, squamous cell carcinoma, and basal cellular carcinoma.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Histologically, CNH is characterized by a hyperkeratotic stratum corneum with areas of parakeratosis, acanthosis, and in some cases the presence of an ulcer covered by a crust. In more advanced stages, degeneration of the dermis is accompanied by an increase in the number of blood vessels and the presence of perivascular inflammatory infiltrate.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Cartilage degeneration is also observed in biopsies that include cartilage (approximately 70% of all biopsies).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The pathogenesis of the condition is unknown. It is thought that repeated trauma or prolonged pressure, such as that which occurs during sleep at night, may lead to ischemia of the cartilage and the auricular perichondrium, structures that lack the protection of a thick layer of subcutaneous tissue.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Once initiated, ischemia causes necrosis of the cartilage and consequent transepithelial elimination of the degenerated material.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Accordingly, CNH is currently considered a perforating dermatosis.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">For this reason several recent reports have described the treatment of CNH treatment with topical nitroglycerin, which has known vasodilatory effects. Flynn et al. described a series of 12 CNH patients who were treated with 2% nitroglycerine gel once every 12<span class="elsevierStyleHsp" style=""></span>hours for 3 months, resulting in cure rates of up to 92%. Complete disappearance of the visible lesion and resolution of pain was observed in 61.5% of patients, while in 30.8% the pain was resolved but some degree of visible lesion persisted.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Topical nitroglycerine acts to relax the arteriolar smooth muscle, reestablishing blood flow and reversing necrosis of the cartilage. The most common adverse effect of topical nitroglycerin for other indications is transient headache, which can affect up to 72% of patients, although in patients with CNH this adverse effect has only been observed in 17% of patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Other conservative treatments for CNH include the administration of topical or intralesional corticosteroids,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> photodynamic therapy,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and the use of pressure-relieving prostheses,<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,8</span></a> with cure rates of 61% to 87%. Surgical techniques, such as cartilage resection with<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> or without<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> conservation of the skin, result in cure rates of up to 83%. However, in the majority of studies it is not specified whether successful treatment involves disappearance of the visible lesion or merely resolution of the pain, and follow-up periods vary greatly, complicating any comparison between different treatments.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In summary, we have presented a new case of CNH that was successfully treated with 2% nitroglycerin gel, a therapy that substantially improved the patient's pain. We consider this treatment to be a useful alternative to currently available therapies, with good tolerance and clinical results and no adverse effects.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Yélamos O, et al. Condrodermatitis <span class="elsevierStyleItalic">nodularis helicis</span> tratada con éxito con nitroglicerina al 2% en gel. Actas Dermosifiliogr. 2013;104:531-2.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2008 "Ancho" => 1500 "Tamanyo" => 718762 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythematous ulcer on the helix of the left ear consistent with chondrodermatitis nodularis helicis.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2008 "Ancho" => 1500 "Tamanyo" => 548667 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Improvement in the clinical appearance of the lesion after 3 months of treatment with 2% nitroglycerin gel.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical appearance, differential diagnoses and therapeutical options of chondrodermatitis nodularis chronica helicis Winkler" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 22 | 12 | 34 |
| 2024 October | 3497 | 59 | 3556 |
| 2024 September | 233 | 67 | 300 |
| 2024 August | 250 | 60 | 310 |
| 2024 July | 276 | 51 | 327 |
| 2024 June | 246 | 43 | 289 |
| 2024 May | 212 | 51 | 263 |
| 2024 April | 166 | 26 | 192 |
| 2024 March | 186 | 37 | 223 |
| 2024 February | 190 | 49 | 239 |
| 2024 January | 148 | 40 | 188 |
| 2023 December | 151 | 20 | 171 |
| 2023 November | 240 | 45 | 285 |
| 2023 October | 207 | 38 | 245 |
| 2023 September | 197 | 51 | 248 |
| 2023 August | 182 | 36 | 218 |
| 2023 July | 183 | 90 | 273 |
| 2023 June | 184 | 47 | 231 |
| 2023 May | 194 | 64 | 258 |
| 2023 April | 180 | 32 | 212 |
| 2023 March | 266 | 37 | 303 |
| 2023 February | 173 | 33 | 206 |
| 2023 January | 174 | 60 | 234 |
| 2022 December | 157 | 53 | 210 |
| 2022 November | 58 | 40 | 98 |
| 2022 October | 56 | 23 | 79 |
| 2022 September | 52 | 60 | 112 |
| 2022 August | 35 | 35 | 70 |
| 2022 July | 49 | 43 | 92 |
| 2022 June | 40 | 38 | 78 |
| 2022 May | 261 | 49 | 310 |
| 2022 April | 250 | 50 | 300 |
| 2022 March | 254 | 67 | 321 |
| 2022 February | 250 | 32 | 282 |
| 2022 January | 234 | 38 | 272 |
| 2021 December | 213 | 43 | 256 |
| 2021 November | 197 | 47 | 244 |
| 2021 October | 204 | 66 | 270 |
| 2021 September | 210 | 44 | 254 |
| 2021 August | 231 | 27 | 258 |
| 2021 July | 211 | 31 | 242 |
| 2021 June | 210 | 34 | 244 |
| 2021 May | 247 | 43 | 290 |
| 2021 April | 623 | 89 | 712 |
| 2021 March | 376 | 58 | 434 |
| 2021 February | 338 | 45 | 383 |
| 2021 January | 229 | 40 | 269 |
| 2020 December | 165 | 30 | 195 |
| 2020 November | 165 | 18 | 183 |
| 2020 October | 129 | 18 | 147 |
| 2020 September | 135 | 15 | 150 |
| 2020 August | 143 | 31 | 174 |
| 2020 July | 141 | 29 | 170 |
| 2020 June | 101 | 26 | 127 |
| 2020 May | 72 | 20 | 92 |
| 2020 April | 75 | 25 | 100 |
| 2020 March | 59 | 22 | 81 |
| 2020 February | 3 | 8 | 11 |
| 2020 January | 0 | 9 | 9 |
| 2019 December | 4 | 12 | 16 |
| 2019 November | 0 | 2 | 2 |
| 2019 September | 6 | 1 | 7 |
| 2019 August | 0 | 1 | 1 |
| 2019 July | 0 | 7 | 7 |
| 2019 June | 0 | 11 | 11 |
| 2019 May | 3 | 9 | 12 |
| 2019 April | 2 | 7 | 9 |
| 2019 March | 0 | 27 | 27 |
| 2019 February | 4 | 0 | 4 |
| 2019 January | 1 | 1 | 2 |
| 2018 December | 0 | 1 | 1 |
| 2018 November | 2 | 0 | 2 |
| 2018 October | 1 | 0 | 1 |
| 2018 September | 5 | 9 | 14 |
| 2018 August | 0 | 12 | 12 |
| 2018 July | 0 | 12 | 12 |
| 2018 June | 0 | 18 | 18 |
| 2018 May | 0 | 22 | 22 |
| 2018 April | 0 | 17 | 17 |
| 2018 March | 15 | 17 | 32 |
| 2018 February | 297 | 33 | 330 |
| 2018 January | 350 | 43 | 393 |
| 2017 December | 222 | 15 | 237 |
| 2017 November | 175 | 30 | 205 |
| 2017 October | 159 | 27 | 186 |
| 2017 September | 111 | 26 | 137 |
| 2017 August | 120 | 27 | 147 |
| 2017 July | 183 | 37 | 220 |
| 2017 June | 267 | 41 | 308 |
| 2017 May | 244 | 21 | 265 |
| 2017 April | 128 | 27 | 155 |
| 2017 March | 157 | 26 | 183 |
| 2017 February | 379 | 24 | 403 |
| 2017 January | 178 | 26 | 204 |
| 2016 December | 208 | 27 | 235 |
| 2016 November | 343 | 36 | 379 |
| 2016 October | 300 | 39 | 339 |
| 2016 September | 328 | 28 | 356 |
| 2016 August | 316 | 41 | 357 |
| 2016 July | 185 | 15 | 200 |
| 2016 June | 8 | 8 | 16 |
| 2016 May | 6 | 19 | 25 |
| 2016 April | 4 | 31 | 35 |
| 2016 March | 2 | 31 | 33 |
| 2016 February | 6 | 20 | 26 |
| 2016 January | 10 | 1 | 11 |
| 2015 December | 7 | 11 | 18 |
| 2015 November | 7 | 4 | 11 |
| 2015 October | 24 | 1 | 25 |
| 2015 September | 10 | 1 | 11 |
| 2015 August | 12 | 3 | 15 |
| 2015 July | 130 | 21 | 151 |
| 2015 June | 107 | 24 | 131 |
| 2015 May | 119 | 14 | 133 |
| 2015 April | 126 | 23 | 149 |
| 2015 March | 132 | 19 | 151 |
| 2015 February | 97 | 18 | 115 |
| 2015 January | 82 | 19 | 101 |
| 2014 December | 83 | 19 | 102 |
| 2014 November | 67 | 20 | 87 |
| 2014 October | 80 | 27 | 107 |
| 2014 September | 71 | 15 | 86 |
| 2014 August | 74 | 15 | 89 |
| 2014 July | 66 | 16 | 82 |
| 2014 June | 84 | 17 | 101 |
| 2014 May | 58 | 27 | 85 |
| 2014 April | 58 | 10 | 68 |
| 2014 March | 56 | 18 | 74 |
| 2014 February | 56 | 21 | 77 |
| 2014 January | 45 | 28 | 73 |
| 2013 December | 30 | 5 | 35 |
| 2013 November | 18 | 10 | 28 |
| 2013 October | 20 | 4 | 24 |
| 2013 September | 3 | 5 | 8 |
| 2013 August | 5 | 8 | 13 |
| 2013 July | 5 | 2 | 7 |
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