Secondary syphilis presenting as annular plaques on face and scalp

presented by

Henry Foong FRCP Edin

Ipoh, Malaysia

May 22, 2011

Consultant Dermatologist, Foong Skin Specialist Clinic, Ipoh, Malayisa


A 32-year-old man with secondary syphilis presented with annular plaques on the face and scalp.


32-year-old man

4 weeks
Scalp, face and perianal area

A 32 year old salesman presented with 2 week history of annular plaques on the face and scalp.  This was mildly pruritic and limited to the face and scalp.  He did not have any fever or polyarthralgia.  He had a recent history of dilated cardiomyopathy with reduced ejection fraction diagnosed 6 months ago and was followed up by a cardiologist.  A skin biopsy of the annular plaque was done. 2 weeks later, he returned to the clinic and he noticed multiple moist patches on the perianal areas. These lesions were not painful. He have had history of exposure several months ago but no preceding genital ulceration.

Physical Examination
Examination of the skin showed multiple annular erythematous plaques 1 – 1.5 cm diameter on the scalp and forehead, eyebrows, right cheek and chin.  They were not tender.   There were areas of localised non-scarring alopecia on the frontal scalp.  Large florid moist whitish plaques  2-3 cm diameter were noted on the perianal area.  The genitalia and oral cavity did not show any ulcers.  Regional nodes were not enlarged.

Laboratory Data

Blood counts and biochemistry normal
HIV negative
Hep BsAg negative

A Venereal Disease Research Laboratory test was positive at a titre of 1:256
Treponema pallidum haemagglutination test was reactive.

Skin biopsy of the facial annular plaques showed perivascular and perifollicular infiltrated of lymphocytes. No malignancy was seen.

Secondary syphilis

Reason for presentation

With the positive VDRL titre of 1:256 and reactive TPHA a diagnosis of secondary syphilis was made.  His wife was also screened for syphilis. He was treated with single dose of intramuscular Benzathine penicillin 2.4 mega units at the local hospital.

About 3 weeks later in the same clinic, a 34-year-old immigrant Bangladesh factory worker presented with 2-week history of multiple non pruritic well circumscribed scaly erythematous plaques on the palms and soles.  He thought it was skin allergy and bought some topical creams from the local pharmacy.  He admitted he had exposure to commercial sex worker recently about 2 months ago. 

Examination of the skin showed bilateral but asymmetrical well circumscribed scaly erythematous plaques on the instep of the feet and palms of the hands. There were no genital ulcerations.  His regional nodes were not enlarged. There were no psoriatic lesions on the scalp and trunk.

A Venereal Disease Research Laboratory test was positive at a titre of 1:32
Treponema pallidum haemagglutination test was reactive.

This findings confirmed secondary syphilis. He was treated with single dose of intramuscular Benzathine penicillin 2.4 mega units.


These two case presentations illustrate the many ways secondary syphilis can present to us. It has earned the name " The great imposter". A high index of suspicion is often invaluable to make a diagnosis.

  1. These condylomata lata are very large and atypical. Has anyone seen such florid ones?
  2. Contact tracing and disease notification is an important element of the management of syphilis. Should the wife of patient no. 1 be treated even if her VDRL is negative?
  3. Do your patients still undergo skin test for penicillin allergy? If a patient has a positive skin test to penicillin, should he be desensitised in the hospital? The efficacy of alternative oral antibiotics regime is often questionable and treatment failures had been reported.
  1. Narang T, De D, Dogra S, Kanwar AJ, Saikia UN.Secondary syphilis presenting as annular lichenoid plaques on the scrotum. J Cutan Med Surg. 2008 May-Jun;12(3):114-6.
    BACKGROUND: Secondary syphilis can have protean clinical manifestations and can present with unusual lesions, which may go unrecognized.
    METHODS: We report two cases of secondary syphilis with annular lichenoid plaques on the scrotum associated with generalized lymphadenopathy, fever, and malaise.
    RESULTS AND CONCLUSIONS: The serology revealed a reactive Venereal Disease Research Laboratory test and a positive Treponema pallidum hemagglutination assay. The human immunodeficiency virus (HIV) serology was nonreactive. The lesions cleared with a single dose of benzathine penicillin, 2.4 million units, given intramuscularly. The presentations of syphilis, often described as "the great imitator," can be varied and atypical. Increased clinical vigilance and awareness of the varied modes of presentation are needed to prevent missing this highly treatable, potentially serious condition
  2. Husein Husein-ElAhmed, Jose-Carlos Ruiz-Carrascosa Secondary syphilis presenting as rash and annular hyperkeratotic lesions. Int J Infect Dis. 2011 Mar;15(3):e220.

secondary syphilis, condylomata lata

Comments from Faculty and Members

Meenakshi Mohanram MD, Asst Prof, Dept of Dermatology, Chettinad Hospital & Research Institute, Chennai, India on May 22, 2011

This case is interesting because both patients had itching. Secondary syphilitic lesions are said to be non itchy.In tropics actinic lichen planus can present with similar itchy lesions on face.I agree that syphilis can present in many ways.

Alexander Wong, MD, FRCPC. Internal Medicine & Infectious Diseases, Schulich School of Medicine, University of Western Ontario, London, Ontario, Canada on May 22, 2011

The perineal lesions look pretty classic for condyloma lata although I will have to admit that I've not seen this personally as yet (we have some syphilis circulating up here but not much).

Secondary syphilis can cause a wide range of lesions and rash including nodular and annular type forms, and if they are co-infected with HIV they can present in weird and atypical sorts of ways as opposed to the usual maculopapular rash that everyone always thinks about and pictures in their mind.

I don't have much to add in terms of differential diagnosis from an infectious diseases perspective that would cause both lesions on the face and perineal lesions like this.

Would suggest that all of the usual STD testing be performed in addition to syphilis serology. So I would add HIV serology, HBV / HCV serology, and urine / genital samples for GC / chlamydia to the workup. Treatment would be with benzathine penicillin, one dose typically suffices for primary and secondary syphilis.

David Elpern MD, Dermatologist, The Skin Clinic, Williamstown, MA, USA on May 22, 2011

Lest we forget!  This is an extraordinarily important presentation.  Syphilis has been called the great imitator -- It was probably Osler who said something like "to know syphilis to know (all of) medicine.  The overuse of antibiotics in the West may partially treat this disease and push it further from our ken.  I haven't diagnosed a case of syphilis in 15 years and wonder how many I may have missed.  I think you should write this up for publication in a major journal somewhere -- perhaps in a Malaysian journal since it may well be that in your country the sex workers have a high incidence of syphilis (and possibly HIV as well).

Fadi Hajjaj MD, Dermatologist, Abu Dhabi, UAE on May 22, 2011

Thank you very much for presenting this interesting case. A message to take home is: take a detailed sexual history in any patient presenting with annular plaques around the mouth!!

The "great imitator" should always  be in the back of the physician's mind when encountering with an odd rash.

Julian Manzur MD, Professor, Department of Dermatology, Havana, Cuba on May 22, 2011

I enjoy your presentation very much. Answering the questions:

1) Yes, I have seen, but more then 30 years ago, two patients with large condylomata of the anogenital area. Very similar to your patient.

2) We treat all the sexual contacts with positive or negative serology with the same treatment of the patient. In patient like this (secondary syphilis) all the contacts since 6 months ago. Tracing is crucial

3) We treat primary, secondary and early latent syphilis in penicillin allergic patients with doxycycline 100 mg twice daily for 14 days, tetracycline or erythromyin 500mg four times a day for 14 days. We use Ceftriaxone (Rocephin) usually in pregnant women. Of course never tetracycline or doxycycline.

Anand Pemmulu MD Honorary Tutor, Cardiff University School of Medicine, Cardiff, Wales, UK on May 22, 2011

The first case is interesting for the fact that the condylomata lata are quite florid. I recently had written up another secondary syphilis case which had typical granuloma annulare type lesions on the penis with added 'clean cut ham' appearance on the palms and soles for added effect.

Ted Rosen MD Professor of Dermatology, Baylor College of Medicine, Houston, TX, USA on May 22, 2011

This is classic secondary syphilis.   The non specific biopsy is most consistent with this as well.   Sarcoid, GA, Wegener's granulomatosis or annular lichen planus could be in the differential. One of the lesions on face or scalp could even be epithelioid sarcoma or desmoplastic trichepithelioma, but not this many!  Syphilis is the only thing these presentations fit.

Carlos Garcia MD, Associate Professor, Department of Dermatology, Univeristy of Oklahoma, Oklahoma City, Oklahoma, USA on May 23, 2011

Thanks for sharing such great pictures! I rarely see syphilis any more, and most of my cases have presented with scaly papules on trunk, palms, and soles.
These condylomata lata are very large and atypical. Has anyone seen such florid ones? NO, I HAVE NOT
Should the wife of patient no.1 be treated even if her VDRL is negative? YES
Do your patients still undergo skin test for penicillin allergy? NO

Bhushan Kumar, MD, FRCP (Edin.), FRCP (London), Former Prof. & Head,
Department of Skin, STD & Leprosy, PGIMER, Chandigarh
on May 31, 2011

1. The condylomas can definitely be as big as shown - of course it does not happen often.
2. The wife can only be followed and VDRL repeated – if she becomes positive only then she is to be treated. This is the best medical practice/ethics. However, in practice for epidemiological purposes all contacts should be treated.
3. Testing for penicillin is strongly recommended. In sensitive individuals – other drugs can be given- but a more stringent follow up is essential. Desensitization procedure as recommended by CDC is hardly ever practiced- but one can try it if you have the patience and the time.

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