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Indurated plaques on the penis

A 56-year-old man presented with a 6-week history of itchy erythematous plaques on the glans penis and prepuce. He reported no dysuria or discharge. On physical examination, nontender infiltrative plaques on were seen both sides of the coronal sulcus (Fig. 1a). The rest of the patient’s skin was of normal appearance, and there was no inguinal lymphadenopathy. The clinical differential diagnosis included infection and malignancy. An adverse drug reaction was also suspected at the time as the patient was ‘buying medication over the internet’; however, on further questioning this was found to be paracetamol. Full screening for sexually transmitted diseases was negative. The patient was positive for antinuclear antibodies at a titre of > 1 : 100 and also had positive extractable nuclear antigen with positive Ro. There was a mild elevation of IgA but normal serum electrophoresis. The patient was treated empirically with metronidazole and doxycycline, and an incision biopsy was performed. Over a 3-month period, the lesions persisted and progressed to firm yellow nodules on the glans and foreskin (Fig. 1b). A xanthogranulomatous process was suspected clinically and a repeat biopsy was performed.