10.5826/dpc.1201a22
text/xml
2160-9381
1725
en
Claudio Conforti
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
sexually transmitted diseases
Syphilitic Balanitis of Follmann: Can Dermoscopy Be a Useful Tool in the Diagnosis?
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2022-02-02
2021-03-15
2022-02-02
2022-02-09
e2022022
Dermatol Pract Concept
Claudio Conforti
2022/02/02
10.5826/dpc.1201a22
e2022022
Dermatology Clinic, University of Trieste, Ospedale Maggiore di Trieste, Italy
2160-9381
sexually transmitted diseases
en
e2022022
Conforti C, Giuffrida R, Di Meo N, et al. Benign dermatoses of the male genital areas: A review of the literature. Dermatol Ther. 2020;33(3):e13355. DOI: 10.1111/dth.13355. PMID: 32239734.
Syphilitic Balanitis of Follmann: Can Dermoscopy Be a Useful Tool in the Diagnosis?
https://dpcj.org/index.php/dpc/article/download/1725/1498
    Syphilitic Balanitis of Follmann: Can Dermoscopy
      Be Useful Tool in the Differential Diagnosis?
     Roberta Vezzoni1, Claudia Colli2, Giacomo Rebez3, Carlo Trombetta3, Andrea Boltar3,
                              Iris Zalaudek1, Claudio Conforti1


1 Dermatology Clinic, University of Trieste, Ospedale Maggiore di Trieste, Italy
2 MST Centre, ASUGI, Trieste, Italy
3 Department of Urology, University of Trieste, ASUGI, Trieste, Italy



Key words: syphilitic balanitis of Follmann, dermoscopy, dermatology, urology, sexually transmitted diseases
Citation: Vezzoni R, Colli C, Conforti C, et al. Syphilitic balanitis of Follmann: can dermoscopy be useful tool in the differential diagnosis?
Dermatol Pract Concept. 2022;12(1):e2022022. DOI: https://doi.org/10.5826/dpc.1201a22
Accepted: June 2, 2021; Published: January 2022
Copyright: ©2022 Vezzoni et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License
BY-NC-4.0, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors
and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Claudio Conforti, MD, Dermatology Clinic, Maggiore Hospital of Trieste, Trieste, Italy.
E-mail: Claudioconforti@yahoo.com




Introduction                                                              and foreskin associated with edema and ulceration of the
                                                                          coronal sulcus (Figure 1A). Dermoscopy revealed the pres-
Syphilis is a sexually transmitted infection caused by the                ence of homogeneously distributed glomerular v­ essels and
spirochete Treponema pallidum that has different clinical                 focused linear curved vessels on an e­rythematous back-
presentations. Among them, there is Follmann balanitis, that              ground with hyperpigmented post-­
                                                                                                          inflammatory areas
was first described by Eugene Follmann in 1948. It is a rare              (Figure 1B). ­Bi­lateral inguinal lymphadenopathy was also
manifestation of primary syphilis that presents as erosive                observed. The patient reported a high-risk sexual contact
balanitis [1]. Herein we report the dermoscopic description               2 months earlier. A polymerase chain reaction test per-
of a Follmann balanitis and discuss how to differentiate it               formed for common sexually transmitted diseases was
from other sexually transmitted or genital diseases.                      negative. Serological tests for syphilis were positive: VDRL
                                                                          1:32 and TPHA 1:1280. Based on these results, a diagnosis

Case Presentation                                                         of Follmann syphilitic balanitis was made. The first choice
                                                                          of treatment for primary syphilis is a single i­ntramuscular
A previously healthy 28-year-old man was admitted to the                  injection of 2.4 million units of benzathine-penicillin, but
Urology Department for the presence of painless erosions                  due to allergy reported by the patient, treatment with
on the glans and erythema. He was initially treated with                  ­doxycycline 100 mg twice daily for 14 days was started.
topic antibiotics and steroids but without benefit. ­Physical             At the one-month follow-up visit, complete healing of the
examination revealed painless crusted erosions of the glans               glans was observed.




Research Letter | Dermatol Pract Concept. 2022;12(1):e2022022                                                                                1
Figure 1. (A) Detail of the penis, glans, and foreskin. Importantly, note the erosive erythema with adherent crusts and the presence of a
hardened ulceration compatible with a chancre in the coronal sulcus. (B) Dermoscopic evaluation of the coronal sulcus showing the presence
of homogeneously distributed glomerular vessels and focused linear curved vessels on an erythematous background with hyperpigmented
post-inflammatory areas.



Conclusions                                                            Zoon balanitis [2]. In our case, the presence of glomerular
                                                                       and hairpin vessels on an erythematous background without
The clinical features of syphilitic balanitis or balanoposthitis       other typical signs of other pathologies helped us to exclude
are variable, as they can manifest as an edematous balanitis           the differential hypotheses reported above.
with erosions and crusted lesions or as a papular form with                Follmann erosive balanitis may be the only clinical
smooth white/pink coalescent papules and plaques on the                ­expression of primary syphilis, so it is essential to include
surface of the glans. Common clinical manifestations are the           this rare clinical manifestation in the differential diagnosis of
hardening of the glans penis and bilateral inguinal lymph-             balanitis and balanoposthitis [1]. Dermoscopy could be an
adenopathy [1].                                                        extremely useful tool that can direct the experienced clinician
    The differential diagnosis requires the exclusion of in-           towards the correct diagnosis and allow proper treatment.
fectious such as Candida albicans, groups B and D Strepto-
cocci and herpes simplex virus, and noninfectious diseases                 Informed consent: Written informed consent for publica-
such as lichen sclerosus et atrophicus, Zoon balanitis, pso-           tion of clinical details and clinical images was obtained from
riasis, eczema, fixed drug rash and erythroplasia of Queyrat           the patient.
(EQ). Even if dermoscopy is not the gold standard test for
the diagnosis, it is a useful tool in the differential diagno-         References
sis. Candidal balanitis is characterized by cottage cheese-
like structures and blurry linear vessels, psoriasis is defined         1. Follmann E. Le problème de la balanite syphilitique. Ann ­Dermatol
                                                                           Syph. 1948;8:470–483.
by a quite monomorphic pattern with diffusely distributed
                                                                        2. Conforti C, Giuffrida R, Di Meo N, et al. Benign dermatoses
dotted vessels. On the other hand, glomerular vessels are a                of the male genital areas: A review of the literature. Dermatol
constant finding in EQ while focused linear curved vessels                 Ther. 2020;33(3):e13355. DOI: 10.1111/dth.13355. PMID:
and orange structureless areas are dermoscopic findings of                 32239734.




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