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Primary Syphilis

Clinical Summary

Lesions of primary syphilis generally appear after an incubation period of 2 to 6 weeks, but they may appear up to 3 months after exposure. The patient usually presents with a solitary, round-to-oval, painless genital ulcer. However, the ulcer may be slightly painful, and several lesions are sometimes seen. The base of the genital ulcer is dry in males, moist in females; purulent fluid in the base is uncommon. The borders of the ulcer are often indurated. Patients may develop ulcers at any site of inoculation on the body. Bilateral, nontender, nonfluctuant adenopathy is common. Lesions resolve spontaneously in 3 to 12 weeks without treatment as the infection progresses to the secondary stage. Patients with primary syphilis are at risk for concurrent infection with other sexually transmitted diseases.

Emergency Department Treatment and Disposition

Treat with benzathine penicillin G, 2.4 million units intramuscularly once. Penicillin-allergic patients should be given doxycycline, 100 mg orally twice a day for 2 weeks or tetracycline, 500 mg orally four times a day for 2 weeks. An RPR or VDRL should be checked as well a test for HIV. Testing for other sexually transmitted infections such as gonorrhea and Chlamydia is recommended. Partners within the last 90 days should be treated presumptively; partners over the last 90 days should be treated on the basis of their serologic testing results. This is a reportable disease, and appropriate paperwork should be filed.

Figure 9.1.

Primary Chancre—Male. This dry-based, painless ulcer with indurated borders is typical for a primary chancre in a male patient. (Reproduced with permission from A. Wisdom. Sexually Transmitted Diseases. London: Mosby-Wolfe; 1992.)

Figure 9.2.

Primary Chancre—Female. A solitary, painless genital chancre with a clean base in a patient with primary syphilis. (Photo contributor: Department of Dermatology, Naval Medical Center, Portsmouth, VA.)


  1. Lesions are usually painless and solitary, but they may be slightly painful; two or three lesions may also be seen.

  2. Consider dark-field examination of the lesion to rapidly confirm the diagnosis.

  3. Chancres of primary syphilis can occur anywhere on the body at the site of inoculation.

  4. Evaluate patients with primary syphilis for concurrent sexually transmitted diseases and treat accordingly.

Secondary Syphilis

Clinical Summary

The rash of secondary syphilis occurs 2 to 10 weeks after resolution of the primary lesions. It begins as a nonpruritic macular rash that evolves into a papulosquamous rash involving primarily the trunk, palms, and soles. The rash is often annular in shape. Diffuse, painless lymphadenopathy is also seen at this stage. Mucous patches represent mucous membrane involvement of the tongue and buccal mucosa. Condyloma lata can be seen during ...

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