Feedback AAD 2018


Infectious Diseases

Adventures in Syphilis

Presented by: Theodore Rosen, MD, FAAD
Professor of Dermatology, Baylor College of Medicine, Houston, TX, USA

The current trends of syphilis are startling with unprecedented highs since the early 1990s. Primary and secondary syphilis has increased a staggering 17.6% with more than 27,800 cases reported, a rate of 8.7 persons per 100,000.1 Regarding congenital syphilis, a 27.6% rate rise was observed since 2015 and an 82% increase in the United States, with the top 3 states being Louisiana, Nevada, and California. While Blacks have the highest rate of syphilis per 100,000, the rate of this disease is rising in all races and ethnicities.1

Bicillin is a proven and effective treatment for syphilis, however, there is currently an ongoing worldwide shortage of the drug.2 There are suitable treatments include:

  • Doxycycline 100 mg BID x14 days
  • Tetracycline 500 mg QID x14 days.

Use of ceftriaxone 1-2 mg IM x 10-14 days has shown uncertain efficacy results and azithromycin 2 g single dose has limitations for use in men who have sex with men (MSM), HIV positive patients, and pregnant women. A recent study demonstrated the effective use of minocycline 100 mg BID x 28 days in patients with primary and secondary syphilis with 87.3% of patients having no symptoms and a negative serology.3 Results were statistically significant over traditional bicillin treatment (77.5%).

Currently, syphilis is resurgent. Most chancres are on the genitals, but the lesions can also occur on other areas, such as the oral mucosa, so, it is important to check the entire body and mucous membranes. In fact, more than 5% of syphilis cases present with extragenital chancres (primarily lip and tongue, but may include mucous patches, tonsillar pillar, hard or soft palate).4-5 Annular syphilid may present in the peri-orofacial area of Blacks and Hispanics.

Traditional presentation includes solitary, indurated, and painless lesions in the groin. However, multiple atypical presentations may also surface. Abnormal presentations in the groin may include large ulcers with painful/nonpainful necrotic centers, glans and distal shaft involvement, large white nonviable looking ulcerations, and even large squamous cell carcinoma-like lesions. There is also the possibility for the concurrent presence of a primary chancre with secondary lesions emblematic of secondary syphilis. In these cases, there is a high probability of HIV co-infection.

Extreme facial eruptions should also be considered for syphilis as nodular and malignant syphilis (Lues maligna) may present as florid syphilis or as facial ulcerations with fever.6-8 Syphilis has also been presented as a patchy or moth-eaten alopecia and thus those abnormal presentations should also be worked up as a possible syphilis-related condition.9

Key messages

  • Syphilis is gaining increasing traction as a sexually transmitted disease.
  • Syphilis can present as traditional chancres or as atypical lesions both in the groin area and other parts of the body.
  • Consider syphilis as a possible diagnosis in high-risk patient population and when skin lesions do not represent classic skin diseases.


Present disclosure: The presenter has reported that no relationships exist relevant to the contents of this presentation.

Written by: Debbie Anderson, PhD

Reviewed by: Victor Desmond Mandel, MD



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