Circinate Balanitis without Systemic Involvement: A Diagnostic Challenge

A 35-year-old male presented with multiple asymptomatic circinate annular lesions on the glans penis for 12 years.He had no history of joint pain, urethritis, conjunctivitis or gastrointestinal and genitourinary infections, and his sexual history was unremarkable.Clinical examination revealed well-defined erythematous annular plaques with a pseudopustular border over the glans penis [Figure 1a andb].Potassium hydroxide examination, Tzanck smear and Gram stain did not reveal any abnormality.However, with the clinical suspicion of candida balanoposthitis, the patient was treated with clotrimazole 1% cream for around 2 weeks.At follow-up visit, after 2 weeks, the patient did not notice any improvement, and the size of the erosions further increased [Figure 1c].Dermoscopic examination revealed areas of regular red dotted vessels over an erythematous background [Figure 1d].Further investigations showed human leucocyte antigen (HLA) B27 positivity, while serology for syphilis, human immunodeficiency virus, herpes simplex and hepatitis was negative.Potassium hydroxide examination, Tzanck smear, Gram stain, fungal culture, stool culture and X-ray of pelvis did not reveal any abnormality.e lesions responded well to topical corticosteroids and tacrolimus, with complete resolution within 3 weeks [Figure 2]; however, recurrence was noted on discontinuation of treatment.Given the chronicity, recurrence, HLA-B27 positivity and therapeutic response to topical steroids and topical immunomodulators, the possibility of circinate balanitis as an isolated manifestation of reactive arthritis (ReA) was considered.Circinate balanitis is a common mucocutaneous feature of ReA but rarely occurs without systemic involvement.Its chronic and recurrent nature can pose a diagnostic challenge.HLA-B27 positivity may indicate an early stage of ReA.Early recognition is crucial for timely management and preventing progression.Circinate balanitis presents as annular, erythematous erosive plaques with polycyclic borders affecting the glans penis and prepuce, commonly associated with ReA. [1]rcinate balanitis is seen in up to 40% of men with ReA. [2]Circinate balanitis can appear as an isolated finding or in conjunction with other mucocutaneous manifestations of ReA, such as keratoderma blenorrhagicum, ulcerative vulvitis, nail dystrophy, oral ulcers, geographic tongue and conjunctivitis.