Effective management of circinate balanitis in Reiter’s syndrome with the combination of dapsone and colchicine: A case report

Dear Editor, Circinate balanitis is among the most common dermatological manifestations of reactive arthritis (formerly known as Reiter’s syndrome). Although it often occurs alongside the classical triad of arthritis, conjunctivitis, and urethritis, it can also occur independently. Current treatment options are limited, including topical steroids and calcineurin inhibitors. We present a case of refractory circinate balanitis that was successfully treated with a novel combination of dapsone and colchicine. A 65-year-old married, uncircumcised male presented with progressive erythematous lesions on the glans penis for 4 months. Examination revealed multiple erythematous maculopapular erosive lesions (0.1–0.5 cm) in a characteristic circinate pattern, without pruritus or pain [Figure 1]. Despite 4 months of antibiotic treatment at the genitourinary department, the lesions progressively worsened with time. The patient also reported occasional bilateral knee pain but denied fever, oral lesions, ocular symptoms, or urinary complaints. He had no recent sexual exposure history.Figure 1: (a) Circinate lesions present on glans penis before treatment. (b) Circinate lesions present on corona of glans penis before treatment.Laboratory investigations revealed HLA-B27 positivity, with normal results for complete blood count (CBC), liver panel, renal function, and urinalysis. Serological testing was positive for Chlamydia trachomatis immunoglobulin (Ig) M but negative for human immunodeficiency virus, herpes simplex virus, and syphilis. Skin culture isolated Chryseobacteriumindologenes and C. trachomatis, while testing negative for Neisseriagonorrhoeae. Histopathological examination showed central epidermal erosion with adjacent lymphoplasmacytic infiltration in the perivascular area, along with neutrophilic infiltration and exocytosis in the epidermal and subcorneal layer. Epidermal atrophy with hydropic changes in the basal layer is also observed [Figure 2].Figure 2: Skin biopsy from the glans penis revealed erosion with dense lymphoplasmacytic cells infiltrating the perivascular area. Neutrophil infiltration is present in the perivascular area, as well as exocytosis in the epidermis and subcorneal area (H and E stain; ×200).Given the clinical and histopathological findings mentioned above, the patient was given a diagnosis of reactive arthritis. He was initially treated with oral sulfasalazine and prednisolone, with a combination of topical steroids and fusidic acid. However, limited response was observed, with new erosions still being developed. Therefore, we attempted a combination of dapsone and colchicine, which achieved significant improvement within 2 weeks and complete remission after 1 month, including the resolution of arthralgia. Circinate balanitis is one of the most common dermatologic manifestations of reactive arthritis.[1] It typically presents as erythematous, pustular, plaque-like, or erosive lesions primarily involving the glans penis. The typical histological findings of circinate balanitis include parakeratosis with occasional erosions or ulceration in the epidermis, along with neutrophil-predominant infiltrations in the dermis. This can be differentiated from plasma cell balanitis (also known as Zoon’s balanitis), which typically presents with hyperkeratosis, diamond- or rhomboid-shaped keratinocytes, and dense, band-like plasma cell infiltration in the upper dermis. For treatment, topical corticosteroid therapy is currently the first choice for circinate balanitis, while topical calcineurin inhibitors are considered second-line alternatives.[2] However, dapsone is rarely listed as an option for refractory patients. Dapsone inhibits neutrophil chemotaxis, neutrophil adherence to skin-localized IgA and the release of inflammatory mediators.[3] As for colchicine, it preferentially concentrates in neutrophils and inhibits their proliferation, chemotaxis, adhesion, and granule secretions.[4] Their complementary immunomodulatory and anti-inflammatory effects targeting neutrophils supported our rationale for their use in this case. Although dapsone and colchicine are generally considered safe, both medications are associated with hematological side effects, such as hemolysis, agranulocytosis, and methemoglobinemia. Therefore, several tests should be conducted to minimize the risk of adverse effects. Before treatment, patients should be screened for glucose-6-phosphate dehydrogenase (G6PD) deficiency, as G6PD-deficient individuals are at increased risk of hemolysis when given dapsone.[5] During treatment, regular monitoring of CBC, liver function, and renal function is crucial for detecting early signs of toxicity. In conclusion, this report highlights a refractory case of reactive arthritis that demonstrated an excellent response to a combination of dapsone and colchicine. Therefore, we propose the possibility of incorporating dapsone and colchicine into current treatment guidelines for refractory circinate balanitis who fail to respond to conventional treatment. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent form. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Data availability statement The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.