# Syphilis (Primary, Secondary & Early Latent) - Category: infectious - Review status: reviewed (every claim checked against a document named on this page) - Sources: CDC STI Treatment Guidelines 2021 · WHO Guidelines for the Treatment of Treponema pallidum 2016 · BASHH UK national guidelines for the management of syphilis 2024 · Syphilis - disease-level clinical article (syphilis-full.txt) - Verified date: 2026-08 ## Verified against - BASHH UK national guidelines for the management of syphilis 2024 - Syphilis - disease-level clinical article (syphilis-clinical.txt) - Syphilis - disease-level clinical article (syphilis-full.txt) ## Treatment metadata - Benzathine benzylpenicillin — injection - Referral & safety-netting (no drug therapy) - Doxycycline — 100 mg — oral.solid - Ceftriaxone — 1000 mg — injection ## Complete treatment card ```text SYPHILIS (PRIMARY, SECONDARY & EARLY LATENT) Sources: CDC STI Treatment Guidelines 2021 · WHO Guidelines for the Treatment of Treponema pallidum 2016 · BASHH UK national guidelines for the management of syphilis 2024 · Syphilis - disease-level clinical article (syphilis-full.txt) Review status: REVIEWED against BASHH UK national guidelines for the management of syphilis 2024, Syphilis - disease-level clinical article (syphilis-clinical.txt), Syphilis - disease-level clinical article (syphilis-full.txt) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (6) - Secondary-stage illness brings fever, muscle aches, headache, loss of appetite, sore throat, weight loss, and joint pain [fever · headache · joint pain · muscle pain · poor appetite · sore throat · weight loss] - Tabes dorsalis causes an unsteady walk, poor balance, stabbing leg pains, bladder problems, numbness, and vision changes [numbness · unsteadiness] - Early general paresis presents with mood swings, irritability, personality shift, sleep pattern changes, and forgetfulness [irritability · memory loss] - Advanced general paresis adds unstable mood, poor memory and judgment, confusion, depression, agitation, psychosis, delusions, and seizures [confusion · delusions · irritability · low mood · memory loss · seizures] - Meningeal neurosyphilis produces headache, nausea, vomiting, a stiff neck, light sensitivity, cranial nerve problems, and seizures [headache · nausea · neck stiffness · photophobia · seizures · vomiting] - Meningovascular neurosyphilis starts with vague headache, nausea, vomiting, and dizziness before focal deficits appear [dizziness · headache · nausea · vomiting] SIGNS - what you find (12) - Primary syphilis: a painless, firm ulcer with a raised, thickened rim, about 1 to 2 cm across, and a clean base - HIV-positive patients often develop more than one chancre at once - Painless, rubbery groin node swelling, sometimes on both sides, is found in up to 80% of primary-stage patients [lymphadenopathy] - Secondary syphilis produces a widespread blotchy rash that classically reaches the palms and soles, plus mouth lesions [rash] - Individual secondary lesions are usually under 6 mm across but can enlarge to 2 cm - Secondary-stage lesions are typically symmetric, scaly, and copper- or ham-colored, without itching [scaling] - Condyloma lata appear as raised wart-like plaques with a flat top, pink defined edges, and a reddened center [plaques · redness] - Malignant syphilis shows ulcerated, oval, dying skin lesions topped by a firmly stuck thick crust on the face, limbs, and trunk [skin lesions] - Cardiovascular syphilis most often causes an ascending aortic aneurysm, seen in nearly half of affected patients - Tabes dorsalis exam shows a positive Romberg sign along with Argyll Robertson pupils, eye muscle palsies, weak reflexes, and Charcot joints - Newborns with congenital syphilis most often show a widespread blistering rash, anemia, jaundice, and an enlarged liver and spleen [anaemia · hepatomegaly · jaundice · rash] - Classic late congenital stigmata include a saddle-shaped nose, a bulging forehead, bowed shins, and notched, peg-shaped upper incisors TESTS (12) - Darkfield microscopy gives an instant positive diagnosis but misses as many as 20% of true cases - Nontreponemal VDRL and RPR screening tests do not turn positive until after the primary chancre has formed - Nontreponemal tests false-positive in 1-2% of cases, so a confirmatory treponemal antibody test is required - FTA-ABS and TPPA are the preferred confirmatory treponemal tests across all disease stages - Treponemal antibody tests remain positive for life, so they cannot track disease activity over time - A cerebrospinal fluid work-up is warranted when the serum RPR titer reaches 1:32 or higher - CSF VDRL testing is specific for neurosyphilis but detects only 67% to 72% of actual cases - Neurosyphilis is very unlikely when both the CSF VDRL and CSF treponemal test come back negative - Rapid point-of-care testing needs only a finger-stick blood drop and gives a result in 15 to 30 minutes - Chest x-ray can first suggest an aortic aneurysm, a CT scan confirms it, and echocardiography checks for aortic regurgitation - Fetal ultrasound from 18 weeks gestation can show liver enlargement, an oversized placenta, and hydrops fetalis - Over three-quarters of infants with a placenta above the 90th percentile for their birth weight turn out to have congenital syphilis IF NOT THIS - what else fits (12) - Behcet syndrome - Chancroid - Contact or atopic dermatitis - Dementia - Erythema multiforme - Genital herpes - Granuloma inguinale - Lymphogranuloma venereum - Mononucleosis - Pityriasis rosea - Psychiatric illness - Viral exanthema Source StatPearls "Syphilis" - disease-level clinical article Status traced to the source above Rx: Main treatment | Penicillin allergy - parenteral alternative MAIN TREATMENT - choose one 1. BENZATHINE BENZYLPENICILLIN [1st line] Adult 2.4 million units IM as a single dose (administered as two 1.2 million unit injections in separate gluteal sites) - Single dose Peds Children with early acquired syphilis: 50,000 units/kg IM single dose (max 2.4 million units). Congenital syphilis requires IV aqueous crystalline penicillin G in a specialist pediatric unit. Source BASHH UK national guidelines for the management of syphilis 2024 Why Long-acting depot penicillin that maintains sustained treponemicidal blood levels after intramuscular injection, matching the slow replication cycle of Treponema pallidum; the standard treatment for early syphilis. Caution MUST be administered INTRAMUSCULARLY ONLY; accidental IV administration can cause cardiac arrest and death. Warn patient about Jarisch-Herxheimer reaction (fever, chills, headache, tachycardia) starting within 2-12 hours after injection. Perform baseline quantitative non-treponemal serology (VDRL/RPR) and repeat at 6 and 12 months to confirm cure. Egypt HAYA BENZ-R 1.2 M.I.U. VIAL FOR I.M INJ. SEDICO > HAYA PHARM-EGYPT 5.06 EGP PENICID LA 1 200 000 UNITS VIAL CID 6.50 EGP BENZACILLIN 1.2 M.I.U.FOR I.M.INJ VIAL. EL NASR 7.00 EGP RETARPEN 1.2 M.I.U. VIAL SANDOZ > OCTO... 10.50 EGP LASTIPEN 1 200 000 IU VIAL MISR 12.00 EGP BENZABIOTIC 1.2 M.I.U. I.M. VIAL. SEDICO 16.00 EGP DEPO-PEN 1.2 MIU VIAL. MUP 25.00 EGP PENCILONG (PENCITARD) 1200000 I.U./VIAL NCPC NORTH BEST CO > ACDIMA INTE... 25.00 EGP 2. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Syphilis - disease-level clinical article (syphilis-clinical.txt) Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - Doxycycline (and the tetracyclines) must not be used to treat syphilis in pregnancy. There is no proven penicillin alternative in pregnancy; penicillin-allergic pregnant patients need skin testing/desensitization instead. RED FLAG - The Jarisch-Herxheimer reaction (fever, headache, myalgia, rash within hours of the first antibiotic dose) can follow the first treatment dose; in pregnancy it carries a higher risk of obstetric complications. 3. DOXYCYCLINE [2nd line] Adult 100 mg twice daily x 14 days Peds Contraindicated in children under 8 years. A penicillin-allergic child with syphilis needs specialist desensitisation, or a specialist opinion on the alternatives. The Egyptian National Drug Formulary - Antimicrobial 2023, doxycycline monograph, gives the reason: used while the teeth are still forming - the second half of pregnancy, infancy, and childhood up to 8 years - it can stain the teeth permanently, leave the enamel underformed, or discolour tissue, and although long courses carry more of this risk, repeated short courses have done it too. Source BASHH UK national guidelines for the management of syphilis 2024 Why Doxycycline 100 mg BID for 14 days is the primary alternative for non-pregnant adults with penicillin allergy. Pregnant patients with penicillin allergy MUST undergo penicillin desensitization. Caution Pregnant women with syphilis who are allergic to penicillin MUST be desensitized and treated with benzathine penicillin G; doxycycline is contraindicated. Requires rigorous serological follow-up at 3, 6, 9, and 12 months. Egypt FARCODOXIN 100MG 10 CAPS. PHARCO 11.00 EGP (1.10/unit) DOXY M.R.100 MG 10 CAPS. ADWIA 12.00 EGP (1.20/unit) GRANUDOXY 100MG 10 F.C. TAB. GLOBAL NAPI P... 12.00 EGP (1.20/unit) DOXYDOX 100 MG 10 CAPS. EIPICO 23.00 EGP (2.30/unit) DOXYMYCIN 100 MG 10 CAPS. EL NILE. 30.00 EGP (3.00/unit) TABOCINE 100MG 10 CAPS. TABUK PHARMAC... 46.00 EGP (4.60/unit) VIBRAMYCIN 100MG 10 CAPS. PFIZER 65.00 EGP (6.50/unit) PENICILLIN ALLERGY - PARENTERAL ALTERNATIVE 4. CEFTRIAXONE [2nd line] Adult 1 to 2 g IM or IV once daily x 10 to 14 days Peds No paediatric syphilis regimen is stated in the documents held here. MSF gives ceftriaxone 50 to 100 mg/kg once daily for severe bacterial infection generally, which is not a syphilis regimen. AWaRe WATCH group - carries resistance cost. Egyptian EML 2025. Source Syphilis - disease-level clinical article (syphilis-full.txt) Why An earlier review refused this because MSF's ceftriaxone monograph names neurosyphilis and no course length. Re-opened under the two-claims rule: the condition's own article carries both claims. Indication - the article reports that the CDC, the European guidelines and the WHO all accept ceftriaxone as a reasonable alternative to penicillin in syphilis, where a shortage, a severe allergic reaction, a refusal or some comparable reason rules penicillin out. Dose - the alternatives it lists are doxycycline at 100 mg orally, twice a day for 14 days; ceftriaxone given intramuscularly or intravenously at 1 to 2 g daily, for 10 to 14 days; and tetracycline, 100 mg orally, 4 times a day across 14 days. Benzathine penicillin remains first line and doxycycline remains the oral penicillin-allergy option. Caution MSF's ceftriaxone monograph names only the late form of the disease in its indications - its list is of severe bacterial infection: septicaemia and meningitis, pneumonia, typhoid, shigellosis, leptospirosis, pyelonephritis, the tick-borne relapsing fevers and neurosyphilis among them. The early-syphilis indication and the 10-to-14-day course both come from the disease article. PREGNANCY - the article is explicit that this is not a substitute. Nothing else has been shown to be an acceptable alternative to penicillin for syphilis in pregnancy. The pregnant woman who reports penicillin allergy is therefore skin tested to establish what her real risk is, and desensitised so that penicillin can be given. The same article states both sides of the pregnancy question and both are printed here: doxycycline and the tetracyclines in particular are to be avoided in the later stages of pregnancy, and there is too little data on ceftriaxone and the cephalosporins for them to be used - yet where an alternative drug is genuinely unavoidable, ceftriaxone is the one it suggests (Syphilis - StatPearls - NCBI Bookshelf, NBK534780). Most reported penicillin allergy is not allergy. Confirm it before abandoning benzathine penicillin, which is the proven treatment. A Jarisch-Herxheimer reaction may follow the first dose of any effective treponemal treatment - warn the patient. Egypt ZOXIDEL 1 GM PD. FOR I.M. INJ. RAMEDA > DELT... 22.00 EGP CEFTRIAXONE SODIUM 1 GM I.M.VIAL (KAHIRA) KAHIRA 29.00 EGP ZOXIDEL 1 GM PD. FOR I.V. INJ. RAMEDA > DELT... 29.00 EGP WINTRIAXONE 1 GM PD. FOR I.V INJ. SANOFI 48.00 EGP VOTRIAXONE 1 GM I.M VIAL CHEMIPHARM 56.00 EGP OFRAMAX 1 GM I.M. VIAL RAMEDA > SUN ... 71.00 EGP TRIAXONE 1 GM I.M. VIAL TABUK PHARMAC... 106.00 EGP TRIAXONE 1 GM I.V VIAL TABUK PHARMAC... 106.00 EGP Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)