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Case Report
Follmann balanitis as an atypical form of primary cutaneous syphilis
1 Al Wattan Medical Group, Riyadh 11461, Saudi Arabia
2 Dermatology and Andrology Department, Suez Faculty of Medicine, Suez University, Suez 41552, Egypt
3 Dermatology Department at Sheikh Jaber Al-Ahmad Al-Sabah Hospital, Kuwait
Address correspondence to:
Ahmed Bakr Elazab
Suez Faculty of Medicine, El-zahra district, Suez 41552,
Egypt
Message to Corresponding Author
Article ID: 100020Z16AE2026
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Bakr Elazab A, Ibrahim Ali A, Mohamed Eldisoky I. Follmann balanitis as an atypical form of primary cutaneous syphilis. J Case Rep Images Infect Dis 2026;9(1):9–12.ABSTRACT
Introduction: Follmann balanitis is a rare and atypical manifestation of primary syphilis, characterized by erosive, inflammatory lesions of the glans penis that can mimic other infectious or inflammatory causes of balanitis. Due to its unusual clinical appearance, misdiagnosis or delayed diagnosis is common, emphasizing the importance of maintaining a high index of suspicion in sexually active individuals.
Case Report: A 33-year-old male presented with a painful erythematous plaque with erosions over the glans penis, persisting for 20 days. The lesion appeared eight days following unprotected oral and vaginal heterosexual intercourse. There was no history of new medication use, drug intake, systemic symptoms, or previous similar episodes. Physical examination revealed a large, well-demarcated erosive erythematous plaque involving the glans and extending to the foreskin, with no associated regional lymphadenopathy or other cutaneous lesions. Based on the sexual history, a comprehensive screening for sexually transmitted infections was performed. Swabs from the erosive lesions were negative for bacterial and fungal cultures, and herpes simplex virus polymerase chain reaction (HSV PCR) results were also negative. Serological testing demonstrated a positive Treponema pallidum hemagglutination assay (TPHA 1/320) and a positive rapid plasma reagin (RPR 1/32), confirming the diagnosis of primary syphilis presenting as Follmann balanitis. The patient was treated with a single intramuscular dose of 2.4 million international units of benzathine penicillin G, resulting in significant clinical improvement within two weeks. Rapid plasma reagin (RPR) titer dropped to fourfolds within three months.
Conclusion: This case underscores the importance of considering syphilis in the differential diagnosis of atypical erosive balanitis. Prompt serological testing and appropriate antibiotic therapy are essential for achieving rapid resolution and preventing disease progression or transmission.
Keywords: Erosive balanitis, Follmann balanitis, Primary syphilis, Sexually transmitted infections, Treponema pallidum
SUPPORTING INFORMATION
Author Contributions
Ahmed Bakr Elazab - Substantial contributions to conception and design, Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Ahmed Ibrahim - Acquisition of data, Analysis of data, Interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Islam Mohamed Eldisoky - Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Final approval of the version to be published
Guaranter of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone
Consent StatementWritten informed consent was obtained from the patient for publication of this article.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
Conflict of InterestAuthors declare no conflict of interest.
Copyright© 2026 Ahmed Bakr Elazab et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.
