Syphilis symptoms and signs

Primary syphilis, or chancre

Chancre is the localized skin symptoms of early syphilis. This stage lasts for one to two months. An initial local infection spreads quickly all over the body.

• 47 to 92 % of people who’ve contracted syphilis get a primary syphilis chancre, or sore
• 25% get multiple chancres
• Only 25% of chancres (mostly in the rectal area) become painful; it’s often misdiagnosed as a rectal fissure or fistula then

Incubation period

The incubation period for the chancre is 3 to 90 days (21 days on average).

From bump to ulcer to healing

• It starts as a single bump that eventually becomes an ulcer, which takes about 7 days.
• The sores are usually painless.
• The chancre ulcer is 1–2 cm in diameter, well defined, and firm with raised borders and a clean base (i.e., there’s no crusting at the base).
• It heals without treatment in 3 to 6 weeks. The mechanism of healing is not completely understood but it’s believed to be a local immune response.

Most common areas

• A chancre can develop anywhere on the skin, but it usually shows up in an area where the skin is thin and moist area and therefore can be easily damaged and penetrated by the syphilis spirochete.
• It is usually on the genitals, the most common site of contact.
  • Males: head and corona sulcus of the penis
  • Females (in descending order of frequency): labia majora, labia minora, fourchette (a thin fold of skin at the back of the vulva), perineum
• Because of oral to genital sex, 12 to 14% of primary syphilis sores affect the oral mucosa.

The following chart shows where a syphilis chancre most commonly appears in in homosexual males.

22% of homosexual males get chancres in their rectum.

Other associated symptoms

• Mild local bilateral inguinal lymphadenopathy (swollen lymph nodes in the groin area) is almost always present. It is usually (80% of the time) painless.

Chancre photos

Syphilis bump

This is a photo of a syphilis bump that will eventually (in seven days) ulcerate, forming the chancre (sore).

Image source: Ayurveda Treatment Venereal Diseases - KHOKAR. https://www.khokardispensary.com/ayurveda-treatment-venereal-diseases/. Accessed January 22, 2021.

Penile syphilis chancre

This photo is of a syphilis sore on the penile shaft. Note the raised, hard, well-defined borders and the clean base.

Image source: New York City Department of Health T, Hygiene Bureau of Sexually Transmitted Infections M. The Diagnosis, Management and Prevention of Syphilis An Update and Review STD HIV PREVENTION TRAINING CENTER.; 2019. https://www.cdc.gov/. Accessed January 22, 2021.

This image shows two syphilis sores with well-defined borders.

Image source: Vanessa Ngan, Staff Writer, 2003. Syphilis | DermNet NZ. Retrieved from https://dermnetnz.org/topics/syphilis/. Accessed January 22, 2021.

Vaginal chancre

Here is a photo of a syphilis sore on the vagina wall.

Image source: Ayurveda Treatment Venereal Diseases - KHOKAR. https://www.khokardispensary.com/ayurveda-treatment-venereal-diseases/. Accessed January 22, 2021.

Anal chancre

This image is of two syphilis sores near the anus. Note the hard, raised borders.

Syphilis sore on the lip

This photo shows a well-defined sore on the patient’s lip with raised, hard borders. “Well-defined” means there is a clear separation from the rest of the lip.

Image source: Qiao J, Fang H. Syphilitic chancre of the mouth. CMAJ. 2011;183(17):2015. doi:10.1503/cmaj.110664. Retrieved from https://www.cmaj.ca/content/183/17/2015.

Rectal syphilis sore

Here are rectal syphilis sores; 60% of people who contract syphilis don’t notice the primary syphilis lesion because of its location and the fact that it’s not painful.

Image source: Syphilis—Primary (Anal Chancre) - MSD Manual Professional Edition. https://www.msdmanuals.com/professional/multimedia/image/v1023437. Accessed January 22, 2021.

Image source: Chancre syphilitique= القرح الافرنجي الاولي. https://dermaamin.com/site/atlas-of-dermatology/3-c/248-chancre-syphilitique-.html. Accessed January 22, 2021.

Syphilis sore of the tongue

This image is of a syphilis sore on the tongue with well-defined borders and a clean base (there’s no pus).

Image source: Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention. www.cdc.gov/std/syphilis/images.htm

Syphilis sore of the tongue

Within a few weeks to a few months, 25% of people who contract syphilis will develop systemic symptoms that represent secondary syphilis. It is possible to have multiple episodes that resolve without treatment. Secondary syphilis can produce a wide variety of signs and symptoms:

Generalized symptoms

Patients with secondary syphilis can have systemic symptoms of fatigue, fever, body aches, and weight loss. These symptoms might be due to their body’s immune response to a widespread virus.

Lymph node enlargement

Half of people with secondary syphilis will have enlarged lymph nodes in the neck, armpits, or groin area that are usually not tender (or only very mildly tender).

Skin rash

Rash is the most common sign of secondary syphilis—75% to 90% of people who have syphilis get it.

Of those, 20% don’t notice the rash because it can be very subtle and get better on its own.

A syphilis rash can take any form or shape. Any rash can be a syphilis rash.

The classic presentation of the syphilis rash is a rash that affects the entire torso and extremities, including the palms of the hands and the soles of the feet. Rash on the palms and soles is a very important sign.

Usually, the rash is reddish-brown and 0.5 to 2 cm in diameter. Although it is usually scaly, it may be smooth.

Secondary syphilis rash

Widespread, brown reddish raised spots

Image source: Syphilis: Signs, Symptoms, How To Test, Stages, Picture, Treatment, Curable? https://www.gentside.co.uk/health/syphilis-definition-symptoms-treatment-what-is-it_art154.html. Accessed January 22, 2021.

Secondary syphilis rash affecting the palms and soles

Image source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides- Syphilis. https://www.cdc.gov/ std/training/clinicalslides/slides-dl.htm

Image source: Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention. www.cdc.gov/std/syphilis/images.htm

Hair loss

Secondary syphilis presents in 10%–15% of people with so called “moth eaten” alopecia (hair loss).

Image source: Qiao J, Fang H. Moth-eaten alopecia: A sign of secondary syphilis. CMAJ. 2013;185(1):61. doi:10.1503/cmaj.120229

Mucosal surfaces

Secondary syphilis can affect the oral mucosal surfaces—5% to 30% of patients may develop mucous patches, which are whitish erosions on the oral mucosa or tongue.

Photos of secondary syphilis white oral patches

They are very contagious.

Image source: Hertel et al. Oral Syphilis. J Oral Maxillofac Surg 2013.

Image source: Hertel et al. Oral Syphilis. J Oral Maxillofac Surg 2013.

Image source: Hertel et al. Oral Syphilis. J Oral Maxillofac Surg 2013.

Condylomata lata

Condylomata lata are large, raised, gray to white lesions that may develop in warm, moist areas such as the mouth and perineum. Five percent to 25% of patients with secondary syphilis get them.

They occur in areas containing a high concentration of syphilis infection and are highly contagious. Where they develop is believes to be close to the place where syphilis initially entered the patient’s body.

Photos of condylomata lata in the anal area

Image source: Bruins, F. G., Van Deudekom, F. J. A., & De Vries, H. J. C. (2015). Syphilitic condylomata lata mimicking anogenital warts. BMJ (Online), 350. https://www.bmj.com/lookup/doi/10.1136/bmj.h1259

Image source: Bruins, F. G., Van Deudekom, F. J. A., & De Vries, H. J. C. (2015). Syphilitic condylomata lata mimicking anogenital warts. BMJ (Online), 350. https://www.bmj.com/lookup/doi/10.1136/bmj.h1259

Latent (asymptomatic) syphilis

Latent syphilis occurs when the patient has syphilis but no sign or symptoms of the disease. Syphilis in the latent stage can be diagnosed only through a blood test.

Latent syphilis can be early-stage or late-stage. This division is, of course, based on how long the patient has had syphilis.

Doctors assume the duration of syphilis based on the last negative syphilis test.

• Early latent syphilis is assumed with a last negative syphilis test within the last 12 months.
• Late latent syphilis is assumed with a last negative syphilis test more than 12 month ago.

The division is important to the chance of syphilis transmission and the treatment.

• Syphilis is more likely to be transmitted to someone else when it is in its early latent phase because there’s a higher chance then of a skin lesion or rash that is very infectious.
• The treatment for early latent syphilis is one shot of penicillin, while the treatment for late latent syphilis is three shots (one per week for three weeks).

Tertiary (late) syphilis

Around 15% to 30 % of untreated syphilis patient will go into late-stage syphilis. In this stage, syphilis can damage the eyes, brain, nerve tissue, heart, blood vessels, bones, and joints.

Late-stage syphilis usually happens many years after the original untreated infection.

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