Syphilis

Stages and symptoms

Primary stage:

• A usually painless, round sore with firm edges (chancre) at the site of contact (genitals, anus, mouth)
• There may be one or more
• Heals on its own within 3–6 weeks; healing does not mean it has been treated

Secondary stage:

• A rash that can involve the palms and soles
• Patches on the mucous membranes
• Fever, fatigue, swollen lymph nodes, hair loss, headache
• Appears 1–6 months after the chancre
• Symptoms may fade on their own

Latent (hidden) stage:

• No symptoms
• Serological tests are positive
• Divided into early latent (first 1 year) and late latent (after 1 year or duration unknown)

Tertiary stage (years later):

• Gumma (soft tissue lesion)
• Cardiovascular involvement (aortic aneurysm)
• Neurosyphilis (meningitis, paralysis, dementia, tabes dorsalis)
• Ocular and otic involvement

Having no symptoms in the early stage, or symptoms going away on their own, does not mean the infection is over.

Diagnosis

The diagnosis is made with serological tests. Non-treponemal tests (RPR, VDRL) are used for screening and for monitoring treatment. A positive result is confirmed with a treponemal test (TPHA, TPPA, FTA-ABS or EIA). A non-treponemal test alone does not establish the diagnosis; false positives can occur.

If there is an active chancre, dark-field microscopy or NAAT may help. If neurosyphilis is suspected, cerebrospinal fluid testing is needed. An HIV test is recommended; syphilis and HIV often occur together. In pregnancy, screening is done at the first prenatal visit and, if there is risk, in the third trimester and at delivery.

Treatment

The first choice of treatment is benzathine penicillin G. According to CDC 2021:

• Primary, secondary and early latent: 2.4 million units intramuscularly as a single dose
• Late latent or unknown duration: 2.4 million units weekly, 3 doses in total (7.2 million units)
• Neurosyphilis, ocular or otic: aqueous crystalline penicillin G intravenously for 10–14 days

In pregnancy, penicillin is the only effective option. If there is an allergy, penicillin is given after desensitisation; alternative antibiotics are inadequate for preventing congenital syphilis in pregnancy. Outside pregnancy, doxycycline may be discussed for penicillin allergy; close follow-up is needed.

After treatment, RPR/VDRL titres are monitored. In early syphilis, at least a 4-fold decrease is expected within 6–12 months. A rising titre suggests reinfection or treatment failure. Treatment does not reverse damage; early diagnosis is important.

Partners and follow-up

Partners from the last 90 days (primary), 6 months (secondary) or 1 year (early latent) should be assessed and treated if needed. Avoid sex during treatment and until the lesions have healed. Serological checks at 3, 6 and 12 months are recommended. In late latent syphilis, follow-up may take longer.

Pregnancy and congenital syphilis

Untreated syphilis in pregnancy can lead to miscarriage, stillbirth, preterm birth and congenital syphilis. In congenital syphilis, the newborn may have an enlarged liver and spleen, rash, bone lesions and neurological involvement. It can be prevented with early treatment. If the test is positive in pregnancy, treatment is started immediately and the partner is assessed.

Prevention

• Using a condom every time you have sex
• Regular screening (if there is risk or during pregnancy)
• Partner treatment
• Serological follow-up after treatment
• Assessment before planning a pregnancy

Having had syphilis once does not give immunity. Reinfection is possible.

Our approach at SoftCare

At SoftCare Clinic, syphilis assessment begins with a gynaecological history and examination. If there is a chancre or rash, a sample may be taken; serological screening (RPR or VDRL) and, if needed, treponemal confirmation are done at a partner laboratory. Tests for HIV and other STIs can be planned at the same time.

If the result is positive, benzathine penicillin treatment is started according to the stage. If there is a pregnancy, management is adjusted accordingly. If neurosyphilis, ocular involvement or a severe course in pregnancy is suspected, an urgent referral is made. Informing the partner is discussed. Serological follow-up is planned. Notification obligations are fulfilled. HIV treatment is not provided at the clinic; a referral is arranged if needed.

Appointments: +90 212 241 30 10 · softcareclinic.com

References

• 1. Centers for Disease Control and Prevention (CDC). Syphilis. STI Treatment Guidelines, 2021.
• 2. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1–187.
• 3. Centers for Disease Control and Prevention (CDC). About Congenital Syphilis. https://www.cdc.gov/syphilis/about/about-congenital-syphilis.html
• 4. T.C. Sağlık Bakanlığı, Halk Sağlığı Genel Müdürlüğü (Ministry of Health of Türkiye, General Directorate of Public Health). Sifiliz. https://hsgm.saglik.gov.tr/tr/hastaliklar/sifiliz.html
• 5. World Health Organization (WHO). Syphilis. Fact sheet.
• 6. Stafford IA, Workowski KA, Bachmann LH. Syphilis Complicating Pregnancy and Congenital Syphilis. N Engl J Med. 2024;390:242–253.
• 7. Hamill MM, Ghanem KG, Tuddenham S. State-of-the-Art Review: Neurosyphilis. Clin Infect Dis. 2024;78(5):e57–e68.
• 8. Merck Manual Professional Edition. Syphilis.
• Note: Treatment doses, management in pregnancy and follow-up intervals are updated by the physician according to current national and international guidelines. This reference list is for information only.

Listing a source does not mean SoftCare wrote that text.

Medically reviewed by Op. Dr. Şükrü Sanus, Obstetrician & Gynecologist · Last medical review: 2 October 2026