Primary syphilis is marked by a nonpainful ulceration that begins as a red papule and ulcerates over a period of a few days to weeks. The average time to onset of the ulcer is 3 to 4 weeks after exposure, but it can occur 3 to 4 months later. This primary ulcer, called a chancre, is firm to palpation. The ulcer can be found anywhere on the genitalia, including the labia, vaginal introitus, and mons in females and the glans, foreskin, and penile shaft in males. Lesions on the foreskin of males often show the Dory flop sign. This occurs when one grasps the area of the prepuce containing the ulcer and slowly retracts the proximal edge; after a critical angle has been achieved, the entire ulcer flops over. This occurs because the ulcer is firm and does not bow under pressure. If left untreated, these ulcers self-resolve within 1 to 3 weeks. After this occurs, the bacteria hematogenously disseminate to other organ systems.
The timing of secondary syphilis is variable: It can occur immediately after primary syphilis or up to 6 months after the chancre of primary syphilis has healed. The average time frame is approximately 6 weeks after healing of the primary ulcer. Without treatment, most if not all patients experience symptoms and skin lesions of secondary syphilis. Patients universally complain of constitutional symptoms such as malaise, fever, chills, fatigue, and weight loss. Cutaneous findings can be multifaceted. The most prevalent skin finding is that of skin-colored to red to slightly hyperpigmented papules and patches. The palms and soles are characteristically involved, and this is a clue that the diagnosis of syphilis should be entertained.
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