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Acute Thrombosed External Hemorrhoid. Young male suffered sudden onset of rectal pain and bleeding after a bowel movement. (Photo contributor: Lawrence B. Stack, MD.)


The authors wish to thank Diane M. Birnbaumer, Lynn K. Flowers, and Brian R. Sharp for their contributions to prior editions.

Clinical Summary

Syphilis is caused by the spirochete Treponema pallidum and occurs in three distinct stages. Primary syphilis usually presents within 2 to 6 weeks of exposure as a single papule that develops at the site of inoculation. This papule turns into a painless ulcer with indurated margins and a nonexudative base known as a chancre. Longer incubation periods and multiple primary ulcers are seen less commonly. Regional bilateral lymphadenopathy is common. Ulcers resolve spontaneously within several weeks, but without treatment, the infection progresses to the secondary stage. Treatment will prevent progression of disease.

Secondary syphilis involves systemic dissemination of T pallidum and manifests several weeks to months after the primary chancre as a diffuse nonpruritic eruption consisting of pink, violaceous, or copper-colored macule and papules primarily on the trunk, palms, and soles. Mucous patches, condyloma lata, and patchy alopecia may also be present. Diffuse painless lymphadenopathy is common. These symptoms resolve within months, but if untreated, syphilis will persist as latent disease and/or tertiary syphilis may develop. Tertiary syphilis has serious cardiac and neurologic sequelae, a discussion of which is beyond the scope of this text.


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 Wisdom A. A Colour Atlas of Sexually Transmitted Diseases. London, United Kingdom: Mosby-Wolfe Ltd; 1992. Copyright © Elsevier.)


Primary Chancre—Male. Painless, solitary penile ulcer in a sexually active male with multiple partners. (Photo contributor: Larry B. Mellick, MD.)


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.)


Secondary Syphilis—Trunk. Rash on trunk due to secondary syphilis. (Photo contributor: Andrew Wong, MD.)


Secondary Syphilis—Palms. Papulosquamous eruption of secondary syphilis. Note the annular appearance of the palmar scales. (Photo contributor: H. Hunter Handsfield, MD. From Handsfield HH, ed. Atlas of Sexually Transmitted Diseases, 3rd ed. New York, NY: McGraw Hill; 2011.)


Secondary Syphilis—Palms. Resolving palmar eruption of secondary syphilis. (Photo contributor: Andrew Wong, MD.)

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