Cutaneous manifestations of syphilis : recognition and management.
Am J Clin Dermatol. 2006;7(5):291-304.
Outpatient Clinic of Dermatology, Triemli Hospital, Zurich, Switzerland.
After a marked decline in the number of syphilis cases in the
context of AIDS prevention campaigns, a significant increase
has been observed in states of the former Soviet Union since
1994. In recent years, outbreaks have also been reported in
the US, Canada, and several European countries. The current
epidemic in the US and in different parts of Europe has largely
involved men who have sex with men, many of whom are infected
with HIV. Since a misdiagnosis of syphilis can have serious
consequences for the patient and also for pregnancies and newborns,
clinicians should be aware of the many manifestations of syphilis
and difficulties in the diagnosis and management of the disease.
Younger clinicians in particular are no longer familiar with
the diverse clinical symptoms and the complex diagnostics of
syphilis. Patients co-infected with HIV may present with atypical
clinical manifestations and laboratory test results. Furthermore,
through its association with an increased risk of HIV infection,
syphilis has acquired a new potential for morbidity and mortality,
and the diagnosis of syphilis should be routinely considered
in patients with uveitis, sudden deafness, aortic thoracic aneurysm,
or pregnancy. Only a minority of syphilis infections are detected
in the primary stage. This may be because of atypical locations
and, occasionally, atypical morphology of the lesions; however,
it may also be because of the difficulty of detecting the pathogen.
In the secondary stage, which is clinically extremely diverse,
the diagnosis is confirmed serologically. There is a need for
increased awareness of the symptoms and signs of acute infections,
together with a willingness to consider the diagnosis of syphilis
in patients with vague symptoms. An increasing number of diagnostic
tests (both specific and nonspecific) are now available. However,
in the absence of clinical symptoms or in cases with a low titer
or inconsistent test results, diagnosis of syphilis can be difficult
or even impossible. Treatment and follow-up should follow current
guidelines designed for the involved area. In this article,
the cutaneous manifestations of syphilis and their diagnostic
and therapeutic management are described in detail.
|Comments from Faculty and Members
Sunil Dogra MD, Assistant Professor, Dermatology,
PGIMER, Chandigarh, India on March 2, 2008
Thanks for sharing this case. It is lichenoid secondary syphilis.
Otherwise differential diagnosis may be considered - Penile
Tinea or Bowen's Disease if it was more psoriasiform, however,
unlikely in this case.
1. Lochner JC, Pomeranz JR. Lichenoid secondary syphilis. Arch
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2. Carbia SG, Lagodin C, Abbruzzese M et al. Lichenoid secondary
syphilis. Int J Dermatol 1999; 38: 53–55.
3. Kang SH, Lee D, Park JH, Kang MS, Cho SH, Park SW. Scrotal
lesion of secondary syphilis in an HIV-positive patient. Acta
Derm Venereol. 2005;85:536-7.
Ted Rosen MD, Professor, Department of Dermatology,
Baylor College of Medicine, Houston, Texas, USA on
March 2, 2008
Excellent case. My diagnosis based solely on morphology was
secondary syphilis. This exophytic, plaque presentation is common
with HIV co-infection. In the US, the yearly incidence of syphilis
is up dramatically since 2001, primarily amongst MSM. We should
also remember that there has been a worldwide resurgence of
LGV (L2 serovar) in MSM; in the present "epidemic"
(throughout Europe, in US and Australia), the patient presents
with symptoms of proctitis, not with inguinal adenopathy as
might be expected. Serovar specific PCR on rectal discharge
specimens is available through the CDC.
Julian Manzur MD, Dermatologist, Cuba on March
Despite it is important to keep in mind the possibility of
co-existence of two diseases, e.g.,syphilis and another disease,
my first diagnosis in this patient is secondary (annular) syphilis.
Bhushan Kumar MD, Former Head of Dermatology, Postgraduate
Institute of Medical Education & Research, Chandigarh, India
on March 3, 2008
Lichens of secondary syphilis in this region behave more like
moist lesions of condyloma lata. If left untreated for a while
they would have definitely become more succulent. Syphilis in
HIV patients does not behave differently in response to adequate
treatment. However, recurrences especially serological tests
are more frequent.
Thamir Alkubaisi MD, Dermatologist, College of Medicine,
Anbar, Iraq on Mar 6, 2008
Good pictures. Important to put in mind the great imitator
( secondary syphilis), and should remember that when there is
one sexual transmitted disease you should look for others. One
partner is preventive measure for all human beings.
Ashok Sharma MD, Consultant Dermatologist, Ministry
of Health, Kuwait on March 6, 2008
In a fully worked-up case like this the diagnosis of lichenoid
secondary syphillis is not in doubt. It reminds us constantly
that syphillis is a great imitator lest we forget! Purely from
clinical morphology of the lesions annular lichen planus and
annular sarcoidosis appear to be valid differential diagnoses.
Ibrahim Misk MD, Jordan on Apr 30, 2008
Nice case. With such clinical picture we should do serology
studies for syphilis to confirm clinical suspicion.