Syphilis

Topic Overview

What is syphilis?

Syphilis is a sexually transmitted disease (STD). If it's not treated by a doctor, it can get worse over time and cause serious health problems.

The infection can be active at times and not active at other times. When the infection is active, you have symptoms. When it's not active, you don't have symptoms, even though you still have syphilis. But even when you don't have symptoms, you can pass it to others.

You don't have to have sexual intercourse to get syphilis. Just being in close contact with an infected person's genitals, mouth, or rectum is enough to expose you to the disease.

What causes syphilis?

Bacteria cause syphilis. They usually enter the body through the tissues that line the throat, nose, rectum, and vagina. A person with syphilis who has a sore or a rash can pass the disease to others. An infected pregnant woman can also pass syphilis to her baby.

Some things increase your chance of getting syphilis. They include:

• Having unprotected sex (such as not using condoms or not using them correctly). This risk is high among men who have unsafe sex with other men.
• Having more than one sex partner and living in an area where syphilis is common.
• Having a sex partner who has syphilis.
• Having sex with a partner who has many sex partners.
• Trading sex for drugs or money.
• Having HIV.

What are the symptoms?

You may not notice symptoms of syphilis. Sometimes they are the same as symptoms for other diseases. This can cause someone with the disease to put off seeing a doctor. And it can make it harder for a doctor to tell if you have syphilis.

The four stages of syphilis have different symptoms.

• Primary stage: One of the first signs is a painless open sore called a chancre (say "SHANK-er"). Because syphilis is usually spread when people have sexual contact, chancres are often found in the mouth, the anus, or the genital area. They may also be found wherever the bacteria entered the body.
• Secondary stage: A skin rash and other symptoms may show up 4 to 10 weeks after a person is infected. At this stage, it is very easy to spread the disease through contact with the mouth, the anus, the genitals, or any area where there is a skin rash.
• Latent stage: After the rash clears, a person may have a period with no symptoms. This is often called the 'hidden stage.' Even though symptoms go away, the bacteria that cause syphilis are still in the body and begin to damage the internal organs. This stage may be as short as 1 year or last from 5 to 20 years. Often, a woman with latent-stage syphilis doesn't find out that she has the disease until she gives birth to a child with syphilis.
• Late (tertiary) stage: If syphilis is not found and treated in the early stages, it can cause other serious health problems. These can include blindness, problems with the nervous system and the heart, and mental disorders. It can also cause death.

How is syphilis diagnosed?

If you have sores, bumps, a rash, blisters, or warts on or around your genital or anal area, or if you think you were exposed to an STD, see your doctor.

He or she will do a physical exam and will ask you about your symptoms and your sexual history. You will probably have one or more blood tests to check for the disease. Because the open sores from syphilis make HIV infection more likely, you may also be tested for HIV.

To prevent babies from getting syphilis, experts recommend that all pregnant women have a syphilis blood test.

How is it treated?

Syphilis can be cured with antibiotics. Both you and any sex partners that you may have exposed to the disease will need to be treated.

It is important to know that syphilis is not a disease that you can treat on your own. It must be treated with medicine that only your doctor can give you. With treatment, you avoid other serious health problems, and you keep from spreading syphilis to others.

If a woman is pregnant and has untreated syphilis, it can cause miscarriage or stillbirth. It can also cause the baby to be born with the disease. This is called congenital syphilis.

At any stage of the disease, antibiotics work well to cure syphilis. They can't undo the damage already caused by late-stage syphilis. But they can help you avoid further problems from the disease.

How can you prevent syphilis?

There are some things you can do to prevent syphilis. Whether you have never had the disease or you have had it before and are trying to keep from getting it again, you can use these tips:

• Limit how many sex partners you have, and be aware of any risky behaviors.
• Always use condoms, and use them correctly. Be aware of the condom's expiration date.
• Buy condoms made in the United States, where strict safety standards are met.
• Keep the condom in the wrapper until you are ready to use it.
• Women can use a female condom.

Frequently Asked Questions

Cause

Syphilis is caused by the bacterium Treponema pallidum.

Transmission

Transmission of the bacteria usually occurs during vaginal, anal, or oral sex. The syphilis bacteria are passed from person to person through direct contact with:

• The open sore (chancre) that appears during the primary stage.
• Mucous membrane or other sores during the secondary stage and sometimes during the latent stage.

Sores mainly occur on the external genitals, vagina, anus, or rectum. Sores can also occur on the lips and in or around the mouth. The bacteria most commonly enter the body through mucous membranes, usually in the area around the genitals and urinary system.

In rare cases, syphilis enters the body through openings in the skin, such as cuts and scrapes, or even through wet kisses, if the infected person has a sore on the mouth or lips. Syphilis may also be transmitted by using a needle previously used by an infected person. Syphilis can be transmitted through a blood transfusion. But this is very rare because all donated blood in the United States and Canada is screened for some sexually transmitted diseases (STDs), and syphilis bacteria cannot survive more than 24 to 48 hours in blood stored using modern blood-banking methods.

A pregnant woman with syphilis can pass the disease through the placenta and infect her baby any time during pregnancy or delivery (congenital syphilis).

Syphilis cannot be spread through casual contact with toilet seats, door knobs, swimming pools, hot tubs, bathtubs, shared clothing, or eating utensils.

Having been infected with syphilis in the past does not usually protect a person from becoming infected again.

Incubation period

An incubation period is the time between exposure to a disease and the development of the first symptom. A skin sore called a chancre is the first symptom of sexually transmitted syphilis. A chancre usually appears between 3 weeks and 3 months after a person has been infected with syphilis.¹

Contagious period

A person with syphilis can easily pass the disease (is contagious) to physically intimate partners when primary- or secondary-stage sores are present. However, the person may continue to be contagious for years, off and on, and is always contagious whenever an open sore or skin rash from syphilis is present.

Symptoms

Syphilis develops in four stages, each with a different set of symptoms.

Primary stage

During the primary stage of syphilis, a sore (chancre) that is usually painless develops at the site where the bacteria entered the body. This commonly occurs within 3 weeks of exposure but can range from 10 to 90 days. A person is highly contagious during the primary stage.

• In men, a chancre often appears in the genital area, usually (but not always) on the penis. These sores are often painless.
• In women, chancres can develop on the outer genitals or on the inner part of the vagina. A chancre may go unnoticed if it occurs inside the vagina or at the opening to the uterus (cervix), because the sores are usually painless and are not easily visible.
• Swelling of the lymph nodes may occur near the area of the chancre.
• A chancre may also occur in an area of the body other than the genitals.
• The chancre lasts for 28 to 42 days, heals without treatment, and may leave a thin scar. But just because the chancre has healed does not mean the syphilis is cured or that a person cannot pass the infection to others.

Secondary stage

Secondary syphilis is characterized by a rash that appears from 4 to 10 weeks after the chancre develops and sometimes before it heals. Other symptoms may also occur, indicating that the infection has spread throughout the body. A person is highly contagious during the secondary stage.

A rash often develops over the body and commonly includes the palms of the hands and the soles of the feet.

• The rash usually consists of reddish brown, small, solid, flat or raised skin sores that are less than 2 cm (0.8 in.) across. But the rash may look like other more common skin problems.
• Small, open sores may be present on mucous membranes. The sores may contain pus, or moist sores that look like warts (called condyloma lata) may be present.
• In dark-skinned people the sores may be a lighter color than the surrounding skin.

The skin rash usually heals in 2 to 12 weeks on its own, without scarring. After healing, skin discoloration may develop. But just because the skin rash has healed does not mean the syphilis is cured or that a person cannot pass the infection to others.

When syphilis has spread throughout the body, the person may have:

• A fever of usually less than 101 °F (38.3 °C).
• A sore throat.
• A vague feeling of weakness or discomfort throughout the body.
• Weight loss.
• Patchy hair loss, especially in the eyebrows, eyelashes, and scalp hair.
• Swelling of the lymph nodes.
• Nervous system symptoms of secondary syphilis, which can cause headaches, stiff neck, vision or hearing problems, irritability, paralysis, unequal reflexes, and irregular (different-sized) pupils.

Latent (hidden) stage

If untreated, an infected person will progress to the latent (hidden) stage of syphilis. The latent stage is defined as the year after a person becomes infected. After the secondary-stage rash goes away, the person will not have any symptoms for a time (latent period). The latent period may be as brief as 1 year or range from 5 to 20 years.

Often during this stage, an accurate diagnosis can only be made through blood testing, the person's history, or the birth of a child with congenital syphilis.

A person is contagious during the early part of the latent stage and may be contagious during the latent period when no symptoms are present.

Relapses

About 20% to 30% of people with syphilis have a relapse of the disease during its latent stage.² A relapse means the person was symptom-free, but then started having symptoms again. Relapses can occur several times.

When relapses no longer occur, a person is not contagious through contact. But a woman in the latent stage of syphilis may still pass the disease to her unborn baby and may have a miscarriage or a stillbirth or give birth to a baby infected with congenital syphilis.

Tertiary (late) stage

This is the most destructive stage of syphilis. If untreated, the tertiary stage may begin as early as 1 year after infection or at any time during a person's lifetime. A person with syphilis may never experience this stage of the illness.

During this stage, syphilis may cause serious blood vessel and heart problems, mental disorders, blindness, nerve system problems, and even death. The symptoms of tertiary (late) syphilis depend on the complications that develop. Complications of this stage include:

• Gummata, which are large sores inside the body or on the skin.
• Cardiovascular syphilis, which affects the heart and blood vessels.
• Neurosyphilis, which affects the brain or the lining that covers the brain.

Congenital syphilis

Congenital syphilis refers to syphilis passed from a mother to her baby during pregnancy or during labor and delivery. The U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Preventive Services Task Force strongly recommend that all pregnant women be screened for syphilis because of the severe consequences of being pregnant while infected or having a child born with congenital syphilis. Screening should be done:³

• At the first prenatal visit for all pregnant women.
• At the beginning of the third trimester of pregnancy and again at delivery for women who are at high risk of acquiring syphilis.

Congenital syphilis increases the risk of fetal death and medical complications in newborns. Syphilis enters the fetal blood system through the placenta, causing infection of the newborn or death of the fetus. Symptoms of congenital syphilis include:

• A highly contagious watery discharge from the nose ("snuffles").
• Painful inflammation of the bone coverings.
• Contagious rash-frequently appearing over the palms of the hands and soles of the feet.
• Reduced red blood cells in the blood (anemia).
• Enlarged liver and spleen.
• Swelling of the lymph nodes.
• Failure to grow and develop normally (failure to thrive).

Because there are other conditions with similar symptoms, an accurate diagnosis is important for treatment.

What Happens

About 3 weeks-although the range is from 10 to 90 days-after being infected with syphilis, a sore (chancre) that is usually painless often appears on the genitals. This first stage in the course of syphilis is referred to as the primary stage. The chancre usually heals without treatment in 28 to 42 days.

If syphilis is not treated during the primary stage, it often progresses to later stages.

In the secondary stage of syphilis, a skin rash will usually develop about 2 months after the chancre appears. The symptoms usually disappear without treatment in 1 to 12 weeks.

After the rash clears, a person may have a period with no symptoms. This symptom-free period is called the latent (hidden) stage. Even though symptoms disappear, the bacteria that cause syphilis remain in the body and begin to damage the internal organs. The latent period may be as brief as 1 year or range from 5 to 20 years.

A person is contagious during the primary and secondary stages and may still be contagious during the early part of the latent stage. During this time, symptoms characteristic of the second stage of syphilis may reappear-this is called a relapse and can occur several times.

If not detected and treated, syphilis may then progress to the tertiary (late) stage, the most destructive stage of syphilis. During this stage, syphilis may cause serious blood vessel and heart problems, mental disorders, blindness, nerve system problems, and even death. It may begin as early as 1 year after infection or at any time during the infected person's life. Approximately one-third of untreated people who are infected with syphilis will develop the complications of tertiary (late) syphilis. Any organ system (such as the central nervous system) may become involved.

Complications of tertiary (late) syphilis include:

• Gummata, which are large sores inside the body or on the skin.
• Cardiovascular syphilis, which affects the heart and blood vessels.
• Neurosyphilis, which affects the brain or the lining that covers the brain.

Congenital syphilis refers to syphilis passed from the mother to the baby during pregnancy or during labor and delivery.⁴ Congenital syphilis can cause complications in newborns and children.

What Increases Your Risk

Your risk of syphilis increases if you:³

• Have unprotected sex (do not use condoms or do not use them correctly). This risk is especially high among men who have unprotected sex with other men.⁵
• Have multiple sex partners, particularly if you live in an area of the country where syphilis is more common.
• Have a sex partner who has syphilis.
• Have sex with a partner who has multiple sex partners.
• Exchange sex for drugs or money.
• Have human immunodeficiency virus (HIV) infection and engage in any of the behaviors above.

Syphilis is contagious whenever an open sore or skin rash is present. The risk of being infected with syphilis from a single sexual encounter with an infected partner is approximately 3% to 10%.⁶

Infection with syphilis also increases a person's risk of being infected with HIV. Syphilis causes open sores on the genitals that allow the HIV infection to enter the body easily. Syphilis is generally more common in people who are also infected with HIV.

When To Call a Doctor

Call to make an appointment if you:

• Have sores, bumps, rashes, blisters, or warts on or around the genital or anal area or on any area of the body where you think they could be caused by a sexually transmitted disease (STD).
• Think you have been exposed to a sexually transmitted disease.

For more information about symptoms of other sexually transmitted diseases, see the topic Exposure to Sexually Transmitted Diseases.

Watchful Waiting

Watchful waiting, which means taking a wait-and-see approach, is not appropriate if you think you were exposed to or have syphilis or another sexually transmitted disease (STD). Any symptoms or other changes that suggest syphilis or another sexually transmitted disease should be evaluated by a health professional. If you suspect a syphilis infection:

• Make an appointment with your health professional. Early treatment can reduce the complications of syphilis and prevent the spread of the infection to others.
• Do not have sexual intercourse or other sexual contact until you have been treated by a health professional.

If you are diagnosed with syphilis, your sex partner(s) will need to be treated as well.

All states require health professionals to report newly diagnosed cases of syphilis (all stages) to health authorities.

Who To See

Generally, your primary health professional can diagnose and treat syphilis.

Health professionals who can diagnose and treat sexually transmitted diseases (STDs) include:

• Internists.
• Family medicine doctors.
• Gynecologists.
• Obstetricians.
• Dermatologists.
• Physician assistants.
• Nurse practitioners.

Complications of secondary or later stage syphilis may require treatment by an infectious disease specialist.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

The first steps in diagnosing syphilis are discussing the history of your symptoms and sexual activities with a health professional and having a physical exam.

The diagnosis of syphilis is usually confirmed with one of several blood tests. This is especially true if no sores are present. If sores are present, a health professional may examine the fluid from one of the sores with a microscope to see whether syphilis bacteria are present (dark-field examination).

• A careful examination of the skin and mouth is performed to look for any rash or other abnormalities.
• For women, a pelvic exam is done to look for signs of syphilis. During the pelvic exam, your health professional will look for abnormal sores in the vagina or on the vulva, labia, rectal area, and inner thighs; these sores occur during the primary stage of syphilis.
• For pregnant women, the U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Preventive Services Task Force strongly recommend screening for syphilis because of the severe consequences of being pregnant while infected or having a child born with the disease (congenital syphilis). Screening should be done:³
  • At the first prenatal visit for all pregnant women.
  • During the third trimester and again at delivery for pregnant women who have an increased risk of acquiring syphilis.
• For men, a genital exam is done to look for signs of syphilis.
• For newborns, the initial evaluation for congenital syphilis begins with a review of the mother's health and testing the mother for syphilis. The health professional will examine both mother and newborn for symptoms.

In the diagnosis of the primary and secondary stages of syphilis, lumbar puncture (spinal tap) is needed in rare cases. A lumbar puncture may be done in adults:

• If there is evidence of tertiary syphilis (such as aortic aneurysm, gumma, or iritis) or if neurosyphilis is suspected.
• If penicillin or another recommended antibiotic cannot be used for treatment in latent syphilis. If the appropriate antibiotic cannot be used, it is important to determine whether fluid from the spinal column and brain (cerebrospinal fluid) is infected because specific treatment methods are needed to effectively treat infected cerebrospinal fluid.
• Infected with HIV. Some experts recommend lumbar puncture in all HIV-infected people with syphilis.
• To check whether a person is cured of neurosyphilis.

In newborns and children, a lumbar puncture may be done if:

• There are signs of congenital syphilis.
• The child's mother had syphilis and she was not treated, was not treated adequately, or was treated after the 20th week of pregnancy.
• The child's mother was treated with an antibiotic other than penicillin.

Additional testing should be done to determine whether other sexually transmitted infections are present, especially:

• Chlamydia.
• Gonorrhea.
• Human immunodeficiency virus (HIV). People who have syphilis have a greater chance of being exposed to HIV.

The diagnosis of syphilis can be delayed or complicated because its symptoms are very similar to those of many other diseases and are sometimes not recognized. Syphilis has historically been referred to as "the great imitator."

Early Detection

Screening for syphilis is strongly recommended for pregnant women and for people who are at increased risk for the disease.

People at high risk of contracting syphilis include those who:⁵

• Have unprotected sex (do not use condoms or do not use them correctly). This risk is especially high among men who have sex with men.
• Have multiple sex partners, particularly if they live in an area of the country where syphilis is more common.
• Have a sex partner who has syphilis.
• Have sex with a partner who has multiple sex partners.
• Exchange money or drugs for sex (prostitution).
• Have human immunodeficiency virus (HIV) infection.

The CDC and the U.S. Preventive Services Task Force strongly recommend that pregnant women be screened for syphilis because of the severe consequences of being pregnant while infected or having a child born with congenital syphilis. Screening should be done:³

• At the first prenatal visit for all pregnant women.
• During the third trimester and again at delivery for pregnant women who have an increased risk of acquiring syphilis.

Treatment Overview

Prompt treatment of syphilis is needed to cure the infection, prevent complications, and prevent the spread of the infection to others.

• Antibiotics effectively treat syphilis during any stage.
• Antibiotic treatment cannot reverse the damage caused by complications of late-stage syphilis, but it can prevent further complications from developing.
• Follow-up blood tests are required to ensure that treatment has been effective.³
• Exposed sex partners need to be examined, tested, and treated for syphilis.

Penicillin is the preferred drug for treating syphilis.³ Although penicillin is the standard therapy for the treatment of neurosyphilis, congenital syphilis, or syphilis acquired or detected during pregnancy, other antibiotics (such as ceftriaxone) may also be considered. If you are allergic to penicillin, it is very important to tell your doctor. Your doctor will still be able to treat the syphilis but may consult with a specialist on the best antibiotic choice.

What To Think About

The treatment of syphilis can be delayed or complicated because its symptoms are very similar to those of many other diseases and are sometimes not recognized. Syphilis has historically been referred to as "the great imitator."

Prevention

Self-care can effectively prevent an initial infection of or reinfection with syphilis or other sexually transmitted diseases (STDs).

• Practicing safe sex to prevent STDs . Limit your sex partners, know whether your partner engages in risky sexual behaviors, and use a condom during sex. Using a condom is the best way to protect yourself from STDs.
• Buying and storing condoms . Buy condoms sold in the United States where strict safety standards must be met. Keep the condom in the wrapper until you are ready to use it, and be sure to check the expiration date before using it.
• How to use condoms . Put the condom on the erect penis before intercourse begins. At the end of intercourse, secure the condom by pressing on the bottom of the condom (by the hairline), and pull out while the penis is still hard to keep the semen inside the condom.
• Extra protection for women . The female condom is a tube of soft plastic with a closed end and can be inserted up to 8 hours before sexual intercourse. It cannot be used at the same time as a male condom.

Home Treatment

It is critical that you seek professional health care treatment of syphilis. It is not appropriate to try to treat syphilis on your own. Syphilis must be accurately diagnosed and treated with medicines, such as antibiotics, that can only be prescribed by a health professional.

After you are diagnosed and prescribed medicine to treat syphilis, self-care can help you manage symptoms and effectively prevent reinfection with syphilis or another sexually transmitted disease (STD).

• Practicing safe sex to prevent STDs . Limit your sex partners, know whether your partner engages in risky sexual behaviors, and use a condom during sex.
• How to use condoms . Check the expiration date of the condom before using it, put the condom on the erect penis before intercourse begins, and remove the condom by pressing on the bottom of the condom (by the hairline) and pulling out while the penis is still hard.
• Buying and storing condoms . Buy condoms made in the United States where strict safety standards must be met. Keep the condom in the wrapper until you are ready to use it, and be sure to check the expiration date before using it.
• Extra protection for women . The female condom is a tube of soft plastic with a closed end and can be inserted up to 8 hours before sexual intercourse. It cannot be used at the same time as a male condom.

Medications

The treatment of syphilis and other sexually transmitted diseases (STDs) is complex. If taken properly, antibiotic treatment with penicillin will usually cure a syphilis infection. If syphilis has progressed to the tertiary stage, antibiotics can prevent further complications, but they cannot reverse damage that has already occurred. Prompt antibiotic treatment will decrease complications and prevent the spread of the infection.

Exposed sex partners should be treated for syphilis. The chancres in syphilis can make transmission of HIV more likely, so testing for both syphilis and HIV should be done.

Medication Choices

Antibiotics are always used to treat syphilis.

What To Think About

In rare cases, the first attempt at treatment does not cure the syphilis infection. Follow-up blood tests are needed to be sure the infection is cured.

Guidelines for the treatment of syphilis and other sexually transmitted diseases are continually updated by the U.S. Centers for Disease Control and Prevention (CDC).

Surgery

There is no surgical treatment for syphilis.

Other Treatment

There is no other treatment for syphilis at this time.

Other Places To Get Help

Organizations

Related Information

• Chlamydia
• Early Disease Detection
• Exposure to Sexually Transmitted Diseases

References

Citations

1. Augenbraun M (2006). Syphilis and the nonvenereal treponematoses. In DC Dale, DD Federman, eds., ACP Medicine, section 7, chap. 6. New York: WebMD.

2. Hook EW (2004). Syphilis. In L Goldman, D Ausiello, eds., Cecil Textbook of Medicine, 22nd ed., vol. 2, pp. 1923-1932. Philadelphia: Saunders.

3. Centers for Disease Control and Prevention (2002). Syphilis: General principles. MMWR, 51(RR-6): 18-28.

4. Tramont EC (2005). Treponema pallidum (syphilis). In GL Mandell et al., eds., Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 6th ed., vol. 2, pp. 2768-2785. Philadelphia: Elsevier.

5. Centers for Disease Control and Prevention (2006). Sexually Transmitted Disease Surveillance 2005 Supplement: Syphilis Surveillance Report. Atlanta: Department of Health and Human Services. Available online: http://www.cdc.gov/std/Syphilis2005/default.htm.

6. Eckert LO, Lentz GM (2007). Infections of the lower genital tract. In VL Katz et al., eds., Comprehensive Gynecology, 5th ed., pp. 569-606. Philadelphia: Mosby Elsevier.

Other Works Consulted

• Centers for Disease Control and Prevention (2003). HIV/STD risks in young men who have sex with men who do not disclose their sexual orientation: Six U.S. cities, 1994-2000. MMWR, 52(05): 81-85.

• Centers for Disease Control and Prevention (2003). Incorporating HIV prevention into the medical care of persons living with HIV. MMWR: Recommendations and Reports, 52(RR-12): 1-24.

• Centers for Disease Control and Prevention (2006). Syphilis section of Sexually Transmitted Diseases Treatment Guidelines 2006. MMWR, 55(No. RR-11): 22-30. Available online: http://www.cdc.gov/std/treatment/default.htm.

• Golden MR, et al. (2003). Updates on syphilis. JAMA, 290(11): 1510-1514.

• Lukehart SA (2005). Syphilis. In DL Kasper et al., eds., Harrison's Principles of Internal Medicine, 16th ed., vol. 1, pp. 977-985. New York: McGraw-Hill.

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