Dermatology

Module 4
Syphilis
It is caused by treponema pallidum, ,may has chronic course and recurrents,affects all organs and systems.
Ways of contamination: 1) sexual contact 2) close contact 3) transplacental 4) transfusional
Ways of spreading: 1) lymphogenic 2) haemotgenic
Conditions of contamination by syphilis:
1) Presence of contagious period of syphilis. (1,2)
2) Defect of skin (don’t’ spreading for mucous membranes,they may be normal)
3) Preservation of virulence treponema pallidum which exist in the external environment.
Periods of syphilis
1) Incubation period(3-4week)
2) 1st (6-8)
3) 2nd (some weeks—some years)
4) 3 Some years
Classification
- 1st S (seronegative, seropositive, latent)
- 2nd (fresh, recurrent, latent)
- 3rd (active, latent)
- Latent or occult S (early, late, incognita)
- Congenital S (early, late, latent)
- Neurosphilis (early, late)
- Vesicular S
The incubation period is the duration from intercourse to appear 1 st sing of syphilis—hard chancre average 3-4 weeks
May decreasing, often increasing due to using of antiB(1-1.5 month).
After incubation period starting of primary syphilis, which begin by hard chancre (1st syphiloma) then accompanied by lymphadenitis and lymphagitis .
Classification of hard chancre
1) Type—erosion or ulcer
2) Localization—genital, extragenital, bipolarical
3) Number—single or pleural
4) Size—carlic(<5mm), (5-10mm), large(>10mm)
5) Configuration—round , oval, fissure(in natural folds)
6) Complications—complicated or uncomplicated
The hard chancre has round form, well defined, shining fundus, clear configuration, hardness in base, painless without inflammatory signs.
The bipolaric chancre—localized on genitalia and extraginitacally.
After 7-10 days of hard chancre appear the lymphadenitis, painless, located near the localization of hard chancre have dense consistency and mobility.
Lymphagitis it is the inflammation of the lymphatic vessels from hard chancre to regional lymphadenitis as local swelling of skin.
Atypical types of hard chancre
1) Chancre—amigdalitis, the asymmetrical affection of tonsil, which characterized by edema and hyperemia.
2) Chancre—panarition, localize on any finger of hand, characterized by acute fulgurent pain, the lymphatic nodes are increasing and painful (axillar,
elbow).
3) Chancre—indurative edema, localize on major and minor labia of females, scrotum in males, due to affection of lympatic capillaries of skin. May be
swelling of effected areas , the skin is dense and not depressed.
Complications of hard chancre
1) balanitis-infllammation of glans penis.
2) balanopostitis-inflammation of glans penis and prepuce.
3) phymosis-edema and increasing in volume of prepuce-impeded the opening of glans penis.
4) paraphymosis-strangulation of glans penis by constricted prepuce,edema of prepuce →impeded the inverse taxis of glans penis → necessary the surgical
helping (due to disruption of lymph and blood circulation).
5) gangrenization—the ulcer necrotic process speed deep down→ ulcer with pus→ scar.
6) phagedenism—the hard form occur often in patient with cachexia, immunodeficiency caused by phusospirilous agents. The necrosis of tissue is swelling in
deep down and periphrecally→ injury of prepuce and glans penis.
The 1st S divided into sulfer-negative and sulfer-positive periods( it is besed on Wassermann reaction).
The secondary syphilis
Is straight after 1ST S, characterized by common signs of, fever, malaise, headache, and arthralgia. The 2 nd S is divided into, 2nd fresh, latent, recurrent periods.
The 2nd S is beginning with rash.
The 2nd fresh S may only be one time characterized by rosiols and papules, but the rosiols are dominated in this period (they are smaller but more in number).
The syphilitic rosiols are symmetrical, round form, rose spots, which do not scaling, do not grouped, localized on trunk( do not localize on face, ear, scalp, hand,
feet) prolonged about 1 month, then disappear trucelessly.
The 2nd recurrent S has lot of different signs may be popular pustular rash, changes of pigmentation, loss of --- and affection of mucous membrane.
The popular syphilides characterized by a rash of dense well defined clear pustules. They are symmetrically localized on the trunk, scalp, palms, soles, natural
folds, mucous membrane near the anus. May grouped and formed signs; different configurations; may scaling( from center to peripheral area named as Bielts
sign), have painful(on pressure on papules yaddasson sign); prolonged about 1.5 months→hyperpigmentation.
Classification of papules
1) Miliar(D 3-4mm)
2) Lenticular(D 5-8mm)
3) Nummular(D 9-25mm)
4) Hypertrophic(>25mm) or condiloma latum(near the anus).
5) Palms and soles
6) Erosive and weeping
The pustular syphilids are syphilitic impetigo, ectima, rupia, acne like syphilid occur rarely. Often occur syphilitic alopsia(local, diffuse , mixed) on scalp(appear
small lesions) eye brows (from lateral side as tram sign) lashes(step by step loss of hair pincus sign) .
The syphilitic leucoderma localized on neck and interscapular area, characterized by round form depigmentative spots(peripheraly has hyperpigmentative zone)D
1-3 cm which covered thin network( vanera necklace sign). Often effect the mucous membrane of mouth, vagina, urethra, caused the angina( affection of tonsils).
The affection of visceral organ occur in any patient.
WR is positive all the time (CSF may (+)too).
The papules may localized on forehead as seborrhic dermatitis “queen’s sign” at mouth especially on as “apal” papules.
Tertiary syphilis
It is last ,more hard ,but dispensable stage of syphilis infection,occur only in 50-75% of patients ,which don’t have treatment or have incompleted therapy.
Patients are not contagious,WR may be (-)in 40-50%.The pathmorphologic base of rash is it’s infectious granuloma appear after 5-10 years,characterized by
organic disorder of all organs and systems (neuro system,visceral system,bones ,joints,).
The tertiary syphilis are:
1)gummas(60%)
2)tubercles(40%)
3)furnye’s late roseola(1%)
The gummas and tubercles-result of tissue’s necrosis ,furney’s roseola-dilatation of vessels from from superfacial layers of skin.
Tubercles localized in dermis,elevated,red colour,irregular round or ovalform elements,D=3-10mm(5-8mm) have next types:
1) grouped
2) serpiginous
3) ground
4) carlic
The ways of clinical involution of tubercles: (during 1-1.5months)
1) through ulceration ,formation of scar(pathogenomically)
2) without ulceration”dry”(by resorption of necrosis ,but formation of scar atrophy).
After tubercles appear superfacial”mosaic”scars it is pathogenomical sign gor 3 syphilis.

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 Dermatology
Module 4
The gummas develop slowly,localizes in hypodermis, have D=1.5-4cm, dense nodes with central orifice-ulceration – (near the bones-periosthalitis)-deep starli
scars.
Latent syphilis Has only (+) reactions without clinical signs,may be
- early(duration less than 2 years)
- late (duration more than 2 years)
- Incognita(don’t separate early S from late)
For early diagnostic of latent S we have some examinations(medical,prophylaxic,serologic screening in stationars)
The lucashevich-hecsgimers’s reaction may (+) in 30% of patients (after first reaction of antiB, the treponema pallidum are died-cause syndrome of intoxication
–fever,malaise.
Congenital syphilis. May transmit from pregnant women to fetus in 4-5 months of pregnancy. The treponema pallidum pas into fetus body by these ways.
1) Through umbilical vein
2) Through the lymphatic fissure of umbilical vessels
3) Through the damaged placenta through blood flow of mother.
The pregnancy in females with S may finished by late miscarriage, premature delivery, delivery of fetus with early or late signs of S.
Classification (WHO 1980)
Early (duration 2 years) congenital S
Late congenital S (after 2 year)
Latent (absence of clinical but positive reaction)
The early congenital S Is diagnosed in child before 2 years—divided into S of placenta – the placenta is soft delicate mixed coloration , edematous and heavy,
treponema pallidum present in the umbilical and organ of fetus ; also presence of inflammatory infiltrative necrosis and abscess lesions.
2) S of fetus; often finished by death of fetus in 6-7 month of pregnancy. The death of fetus before 5 th month of pregnancy arise due to influence of syphilitic
toxins. The fetus is murated , has small size, cachexia, his skin is wrinkled, feacid dirty yellow color, the epidermis seprated as rays . the fetus has unusual senile
hair, liver pluns and other disease.
3) S of new born often occur 2-4 months, after delivery affected skin, mucous membrane ,visceral organ, CNS, bones, joints(duration from delivery to 1 year).
The clinical sign in this period very similar with 2 nd S in adults( acquiring); macular papules on extremities , buttocks, face, weeping papules near the mouth and
anus (nonspecific), but most often these signs occur for this period of time:
a) yochzingers , diffuse papular inflammation—diffuse infiltration near the mouth, on palms, soles, buttocks, near mouth formed the fissures→ robinson furnyes
radialical scars( diagnosed later, in late congenital S).
b) syphilitic pemphigus—blisters appear on palms and soles.
c) syphilitic rhinitis – has 3 stages—erythematous
-- secretoric , -- ulcer (defect of mucous)
Membrane of nose→disruption of nasal septum→formation of saddle nose, which diagnosed in late congenital S)
d) osteochondritis – diagnosed on X-ray localized on long bone of extremities→ caused the saber skin (diagnosed later).
e) osteoperiostatis – of frontal and parietal bones , local hydrocephaly are caused in late congenital period the buttock like cranium Olympic forehead.
f) choriorethinitis – affection of eyes , black point pigmentation appear on peripheral zones of eyes fundus—salts and pepper sign;
the children has polyscleradenitis, uncaused cry, trouble, vomiting , convulsions.
g) S of early child period—duration from 1-2 years has popular rash, condiloma latum, robinson furnyes scar, periorthitis, gummas, meningitis, epilepthiform
attacks, orchitis, affection of liver and lien.
The clinical signs very similar with clinics of 2nd and 3rd S in adults.
The late congenital S
Is diagnosed in child 2-17 year or more. The clinic is similar with 3 syphilids , gammas, tubercles affection of visceral organsbut during this period present these
signs more often;
1) Pathogenic( unconditional)
a) Parenchymatous keratitis – affection of eyes
b) Syphilitic lyberinthatis—affection of ears
c) Hethchinsons teeth—chised form
d) Saber shin—affection of legs due to osteochondritis .
2) Probable or possible
Tubercles, gammas, ulcers, radical scars of robinson—furnye near lips , chin, syphilitic choriorethinitis, buttock like skull, saddle nose, saber forearms.
3) Dystrophy or stigma (may occur in other disease)
-high hard palatinum(goticum)
- Dubua- Hissars sign—shortening of little finger, infantile.
- axyphoidism—absence of xephoied process of sternum
- Hoshes sign- large fissure between 2 upper incisors, Olympic forehead.
- Austidiskys sign—thickening of sternoclavicular part right hypertrichosis.
- Carabelly tuberculum—presence of additional tuberculum on chewing surface of 1 st molar of maxilla.
- increasing of frontal and parietal tubers of cranium
The prescence of some stigmas + pathogenic signs or some possible signs + positive serological reaction→ base for diagnostic of late congenital S.
The base of prophylaxy—timely exposing and treatment of full value in females. During the pregnancy females should be examined on WR(3 times) ;
1) Before 12 week( 1 visit of female to obestretics)
2) In 30 week (for taking maternity leave
3) Before delivery
Treatment of syphilis
Non specific;
-symptomatic
-vit
-immunotherapy
- physiotherapy
Specific treatment ( antiB)
Preventive (use by the persons who has sex or close cotact with the syphilitic patient , if the duration is less than 2 months after contamination).
Prophylactic (use by the pregnant women and child of this mother).
Sample or trial (clinical and lab signs are absent but the DOC is suspect of syphilitic infection in the body therefore they try to use antiB therapy for some
duration).
Immunity – on syphilis named as non-sterility or infectious.
Re-infection – repeated contamination of patient who was ill with syphilis but was cured.
The criteria
- trust of 1st contamination of syphilis
- full value treatment of contamination → negativation of serological reactions in blood and CSF
- classic course of S after sexual contact , may be after 1 year
- detection of treponema pallidun on the surface of chancre
- early periods of S ( incubation and 10-14 days )
3rd and congenital S

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