Syphilis staging and treatment

Syphilis Staging and Treatment (2025 Update)

Staging of Syphilis: Syphilis is typically divided into several stages, each with distinct clinical features and treatment approaches. The CDC's 2021 guidelines remain relevant, with some updates based on recent data.

1. Primary Syphilis:
2. Duration: 10-90 days after exposure.
3. Presentation: A single, painless chancre (ulcer) at the infection site, often accompanied by swollen lymph nodes.
4. Diagnosis: Darkfield microscopy, serologic tests (RPR, VDRL, FTA-ABS).
5. Treatment: Benzathine penicillin G 2.4 million units IM x 1 dose (CDC, 2021).

1. Secondary Syphilis:
2. Duration: Weeks to months after primary infection.
3. Presentation: Skin rashes (palms/soles), mucocutaneous lesions, fever, lymphadenopathy, and possible systemic symptoms (e.g., hepatitis, nephritis). CNS involvement may occur in 10% of cases (Mayer et al., 2024).
4. Diagnosis: Clinical evaluation + serologic tests.
5. Treatment: Benzathine penicillin G 2.4 million units IM x 1 dose (CDC, 2021). Note: Erythema/edema of skin lesions may transiently worsen post-treatment; reassure patients that this is normal and does not require steroids.

1. Latent Syphilis:
2. Early latent: Infection <1 year (no physical signs).
3. Late latent: Infection >1 year (no physical signs).
4. Diagnosis: Serologic tests (positive nontreponemal + treponemal tests).
5. Treatment:
   • Early latent: Benzathine penicillin G 2.4 million units IM x 1 dose.
   • Late latent: Benzathine penicillin G 2.4 million units IM per week x 3 weeks.

1. Tertiary Syphilis:
2. Duration: Years after infection.
3. Presentation: Gummas (destructive skin lesions), neurosyphilis, cardiovascular syphilis.
4. Diagnosis: Clinical evaluation + serologic tests + specialized tests (e.g., CSF analysis for neurosyphilis).
5. Treatment: Benzathine penicillin G 2.4 million units IM daily x 10–14 days (for neurosyphilis) or 3 doses at weekly intervals (for other manifestations).

Key Considerations:

• Neurosyphilis: If suspected, treat with 10–14 days of IV penicillin G. Serologic testing post-treatment is critical for all syphilis cases, especially in HIV-coinfected patients (CDC, 2021).

• HIV Coinfection: More frequent follow-up (3, 6, 9, 12, 24 months) is recommended, as syphilis progression and serologic responses may differ (CDC, 2021).

• Follow-Up: Reassess at 6, 12, and 24 months (or more frequently for HIV+ patients) to confirm resolution (4-fold decline in RPR/VDRL titers for early syphilis; seroreversion for latent syphilis).

Recent Updates (2024–2025):

• Emerging antibiotic resistance in some regions may necessitate alternative treatments (e.g., ceftriaxone) in specific cases (Mayer et al., 2024).

• Enhanced emphasis on rapid diagnostic tests for field use (WHO, 2025).

Resources:

• CDC 2021 Syphilis Guidelines (for detailed protocols): CDC Syphilis Guidelines

• Interactive training on staging and treatment: CTC Syphilis E-Learning

Always consider patient-specific factors, such as allergies or comorbidities, when prescribing treatment. If penicillin allergy is confirmed, desensitization is preferred over alternative regimens due to higher efficacy and lower relapse rates.

Source Citations:

• CDC (2021). Sexually Transmitted Infections Treatment Guidelines.

• Mayer et al. (2024). Emerging Challenges in Syphilis Management. Journal of Infectious Diseases.

• WHO (2025). Rapid Diagnostic Tests for Syphilis: Field Application.