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Chancroid
AUTHOR: Charles B Hicks, MD
SECTION EDITOR: Jeanne Marrazzo, MD, MPH, FACP, FIDSA
DEPUTY EDITOR: Jennifer Mitty, MD, MPH

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Dec 2023.

This topic last updated: Jul 25, 2023.

INTRODUCTION

Chancroid is a rare infection in the United States and most other developed countries.
However, the true incidence of chancroid remains uncertain because a definitive diagnosis
requires detection of the causative organism, Haemophilus ducreyi, and few laboratories have
the capability of proper microbiologic diagnosis (eg, culture or nucleic acid amplification
testing [NAAT]) [1,2]. In addition, many clinicians do not attempt to diagnose genital ulcer
disease caused by pathogens other than Treponema pallidum or herpes simplex virus (HSV).

This topic will review the clinical manifestations, diagnosis, and treatment of chancroid. Topic
reviews that discuss the approach to patients with genital ulcer disease, syphilis, and genital
herpes are found elsewhere. (See "Approach to the patient with genital ulcers" and "Syphilis:
Epidemiology, pathophysiology, and clinical manifestations in patients without HIV" and
"Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus
infection".)

MICROBIOLOGY

H. ducreyi is a small, fastidious, gram-negative rod that requires an enriched growth medium
containing hemin and usually serum for successful cultivation [3]. Cultures must be delivered
expeditiously to the laboratory and incubated at 33° to 35°C in high humidity with CO2
enrichment. Small, heterogeneous colonies appear on culture medium after 48 to 72 hours.
The gray to tan translucent colonies slide intact across the agar plate when pushed.

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When examined by Gram stain, organisms from culture often clump in long parallel strands,
producing a so-called "school of fish" or "railroad track" appearance. This morphology can
occasionally be seen in gram-stained smears from clinical specimens, but it is not a
consistent or reliable clinical finding.

PATHOGENESIS

The pathogenesis of chancroid is incompletely understood. In the vast majority of cases,

organisms are thought to gain access to tissues via microabrasions in the skin that occur
during sexual intercourse since H. ducreyi does not typically infect intact skin. However, the
organism has also been identified as a cause of cutaneous ulcers in children and young
adults on islands in the South Pacific Islands and in parts of equatorial Africa [4-7].

H. ducreyi is a highly infectious bacterium. The likelihood that inoculation will lead to papule
formation appears to be mainly influenced by inoculum dose and host factors [8]. Data from
a human model of experimental infection demonstrates that inoculation of a single colony
forming unit (cfu) results in papule formation in 50 percent of cases; inoculation of 100 cfu
leads to papule formation in 90 percent of cases [9].

The initiation of infection requires attachment of bacteria to susceptible cells, a process that
appears to involve the interaction of a protein mediator (probably pili) and
lipooligosaccharide with fibronectin contained in the extracellular matrix [10]. Bacterial
adherence to cells then occurs via the elaboration of a heat shock protein (GroEL), which may
also contribute to the bacterial chaining described above [11]. (See 'Microbiology' above.)

A cytotoxin secreted by H. ducreyi may then play an important role in epithelial cell injury and
subsequent development of an ulcer [12,13]. This cytotoxin, present in the majority of
strains, has been found to be similar to cytolethal distending toxins (CDTs) from other
bacterial species, including Escherichia coli, Shigella, Campylobacter, and Aggregatibacter
actinomycetemcomitans [14]. Similar to other CDTs, this toxin causes distension of cultured
epithelial cells and fibroblasts, leading to irreversible cell-cycle arrest in the G2 phase of cell
growth.

The histologic and immunophenotypic characteristics of chancroid lesions were described in

a 1996 report of 11 men, 5 of whom were coinfected with HIV [15]. A superficial purulent
exudate was typically present in the epidermis, and a perivascular and interstitial
mononuclear cell infiltrate was seen in the dermis. Neutrophils were prominent in most
patients without HIV but were less common in those with HIV. The mononuclear cell infiltrate
contains many CD4+ lymphocytes, which may explain the increased risk of HIV transmission
among persons with chancroid [16-18].

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EPIDEMIOLOGY

Chancroid is a rare infection in the United States and most other developed countries,
although it can occur in localized outbreaks while remaining endemically absent in most
areas. In such settings, there can also be occasional imported cases, which were acquired in
endemic areas. However, the true incidence of chancroid remains unclear because of the
difficulty isolating H. ducreyi in the laboratory. In addition, most facilities do not test for this
organism.

United States and other resource-rich settings — As noted, chancroid is infrequently

identified as a cause of genital ulcer disease in developed countries, and, when it has
appeared in recent decades, it has generally been in the setting of a localized epidemic, with
modest to large numbers of cases. Thus, clinicians and public health agencies must still
remain on alert for its reintroduction.

In the United States, chancroid has been diagnosed primarily in certain racial and ethnic
groups (African Americans and Hispanic individuals), in heterosexuals, and among female
sex workers and their clients [1,3,19]. Cases are more commonly reported in men, at least in
part because chancroid is more easily diagnosed in males [20], and uncircumcised men have
the highest incidence of infection. Crack cocaine and the exchange of sex for drugs have
been implicated in several outbreaks.

Fewer than 20 cases of chancroid per year have been reported in the United States since
2011. A total of 36 cases were reported from 2015 to 2019 [21]; in 2021, only three cases
were reported, but the CDC qualified this data by noting that chancroid is not a reportable
condition in all jurisdictions. In a report from a sexually transmitted disease (STD) clinic in
Paris, France, only 8 of 278 cases of genital ulcer disease evaluated between 1995 and 2005
were diagnosed as being caused by H. ducreyi, and no cases of chancroid were diagnosed
after 2002 [22]. However, during recognized outbreaks, chancroid has accounted for up to 20
percent of patients presenting to public STD clinics with genital ulcer disease [19,20,23,24].

While the absence of reported cases of chancroid most likely represents the rarity of this
infection, it is important to note that lack of testing may contribute to the apparent
disappearance of chancroid [20,23-27]. Limited data suggest that very few patients evaluated
in STD facilities are tested for chancroid. As an example, in 1996, a survey of 405 STD
treatment facilities in the United States found that only 32 (8 percent) tested patients for
chancroid [25]. It is unlikely that this proportion has increased in recent years.

The potential significance of this lack of testing was demonstrated in a study conducted from
1988 to 1990 in New York, where H. ducreyi caused 27 of 65 cases (42 percent) of genital ulcer
disease when a microbiologic diagnosis was established [26]. Similar findings were noted in

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a report of 299 men with nonsyphilitic genital ulcer disease from New Orleans [19]; cultures
revealed H. ducreyi in 39 percent and herpes simplex virus (HSV) in 19 percent; culture were
negative in 41 percent. These data exemplify the episodic nature of chancroid outbreaks.

Use of nucleic acid amplification testing (NAAT) also suggests that chancroid may be more
common than previously believed [20,23,24]. In 1996, data obtained using a multiplex
polymerase chain reaction (PCR) test demonstrated that H. ducreyi tended to occur in
epidemiologic clusters and accounted for a substantial proportion of genital ulcer cases
when present [20]. As an example, cases of chancroid were identified in Memphis and
Chicago and accounted for 20 and 12 percent of all cases of genital ulcers in these cities,
respectively. In Memphis, the diagnosis of chancroid was not made in any of the patients
when clinical criteria were used, and only two of these patients were prescribed an antibiotic
regimen that would treat chancroid. However, there are no molecular diagnostic assays for
chancroid approved for use by the United States Food and Drug Administration [21]. (See
'Nucleic acid amplification tests' below.)

Resource-limited settings — Although definitive epidemiologic data are not generally

available, chancroid has been considered a major cause of genital ulcer disease in sub-
Saharan Africa and in many parts of Southeast Asia and Latin America [1,28-30]. However,
the prevalence of chancroid has dramatically declined in some countries [31-38], including
Thailand, Kenya, Uganda, Namibia, Botswana, and Tanzania. One potential explanation for
this observation is the widespread use of the World Health Organization's guidelines for the
treatment of sexually transmitted infections, where treatment algorithms are based upon
the identification of consistent groups of symptoms and easily recognized signs [39,40].

Nonsexually transmitted cutaneous ulcer disease caused by H. ducreyi has been identified in
children and young adults (and in some visitors) from islands in the South Pacific, including
Papua New Guinea, Samoa, and Vanuatu, where the cutaneous ulcer disease yaws is
endemic [6,40-42]. Identification of the pathogen occurred as part of mass drug
administration programs for yaws and trachoma, where azithromycin was given and nucleic
acid amplification diagnostic tools were used to assess the etiology of cutaneous ulcers in
the treated population [4].

CLINICAL MANIFESTATIONS

Genital ulcers — The incubation period of chancroid is typically 4 to 10 days (range 1 to 35

days). Infection with H. ducreyi leads to an erythematous papule that rapidly evolves into a
pustule, which erodes into an ulcer [1,43]. Infected persons commonly have more than one
ulcer, and the lesions are almost always confined to the genital area and its draining lymph
nodes.

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At presentation, a typical chancroid ulcer is about 1 to 2 cm in diameter ( picture 1), but the
size is variable and there may be more than one ulcer present, especially in patients with HIV.
The ulcer is painful and has an erythematous base; the borders are clearly demarcated and
sometimes undermined. The base of the ulcer is usually covered with a gray or yellow
purulent exudate and bleeds when scraped.

As predicted by the pathogenesis of H. ducreyi infections, the most common sites for
chancroid are those that are typically subject to friction during sex. In men, most lesions
involve the prepuce, corona, or glans penis. In women, the labia, vaginal introitus, and
perianal areas are most commonly affected. Some cases of chancroid may go undiagnosed,
especially in asymptomatic women with vaginal or cervical lesions.

Lymphadenopathy — Inguinal lymphadenitis is present in about one-half of infected men

( picture 1), but is somewhat less common in women. The involved nodes may undergo
liquefaction and present as fluctuant buboes. Most buboes arise one to two weeks after the
appearance of the primary ulcer and are often quite painful. Untreated buboes may
spontaneously rupture and discharge frank pus.

Nonsexually transmitted cutaneous ulcers — Nonsexually transmitted cutaneous ulcer

disease caused by H. ducreyi has been identified in yaws-endemic areas [41], although there
is no apparent pathogenetic connection to yaws. (See 'Resource-limited settings' above.)

Compared with the lesions of yaws, cutaneous ulcers caused by H. ducreyi are less circular in
shape and are less likely to have central granulating tissue indurated edges. In addition,
most lesions are on the limbs rather than the torso. The cutaneous manifestations of yaws
are described elsewhere.

DIAGNOSIS

Approach to diagnosis — Most providers rely on clinical criteria to make a diagnosis of

chancroid in patients with clinical manifestations consistent with infection [25]. The diagnosis
of chancroid is challenging since most sexually transmitted disease (STD) treatment centers
do not have the capability of testing for H. ducreyi. (See 'Tests to identify the organism'
below.)

However, the sensitivity and specificity of using clinical criteria to make a probable diagnosis
of chancroid is variable, and the accuracy of a clinical diagnosis ranges from 33 to 80 percent
[19,28,29,44]. Thus, if a diagnosis of chancroid is being considered, patients should also be
evaluated for other causes of genital ulcer disease, such as T. pallidum and herpes simplex
virus (HSV), which are more likely to occur. In addition, coinfection with H. ducreyi and other

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sexually transmitted infections have been reported [15,26]. (See "Approach to the patient
with genital ulcers".)

Diagnostic criteria — The United States Centers for Disease Control and Prevention (CDC)
has developed a case definition for definite and probable chancroid to be used for reporting
purposes, and often as a guide for initiation of therapy [45,46]:

● Confirmed – A clinically compatible case that is laboratory confirmed. However, the

special culture media required for isolation is not widely available. (See 'Culture' below.)

● Probable – A "probable" diagnosis is made if all four of the following criteria are met:

• The patient has one or more painful genital ulcers

• The patient has no evidence of T. pallidum infection by direct detection (darkfield

examination or nucleic acid amplification test [NAAT] of the ulcer exudate or serous
fluid) or by serologic testing performed at least 7 to 14 days after the onset of ulcers

• The clinical presentation, appearance of genital ulcers, and if present, regional

lymphadenopathy are typical for chancroid (see 'Genital ulcers' above)

• HSV-1 or HSV-2 NAAT or HSV culture performed on the ulcer exudate or fluid is
negative

The CDC surveillance case definition does not include NAAT testing for H. ducreyi, even if
using a Clinical Laboratory Improvement Amendments (CLIA)-verified test. However, if such a
test is clinically available, we would report cases diagnosed in this way as confirmed. (See
'Nucleic acid amplification tests' below.)

Tests to identify the organism — Both culture and NAAT testing are available to identify H.
ducreyi. However, these tests are not able to provide rapid results and are not always
available. Thus, in most instances, clinicians are unable to base treatment decisions on the
results of microbiologic testing and empiric therapy is administered. (See 'Approach to
diagnosis' above and 'Antimicrobial therapy' below.)

Gram stain — Gram stain of the exudate from an ulcer can show typical small gram-
negative rods in a chain, the so-called "school of fish." However, the sensitivity of the Gram
stain is poor [47,48]. (See 'Microbiology' above.)

Culture — A definitive diagnosis of chancroid has traditionally required identification of H.

ducreyi on special culture media that is not widely available from commercial sources. The
sensitivity of culture for isolating H. ducreyi has been reported to be 60 to 80 percent in
patients with clinical symptoms when compared with polymerase chain reaction (PCR)
[29,35,49]. Despite modifications in culture media that have improved the yield [1,48], the

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availability of NAAT testing for many pathogens, including H. ducreyi, has further diminished
the value of culture for the diagnosis of chancroid.

Nucleic acid amplification tests — Nonculture methods for the diagnosis of H. ducreyi (eg,
PCR) may lead to improvements in the diagnosis of chancroid and H. ducreyi-associated
cutaneous ulcer disease [29,49]. Although no United States Food and Drug Administration-
cleared nucleic acid amplification tests (NAATs) for H. ducreyi are available in the United
States, testing can be performed by commercial laboratories that have developed their own
PCR or other NAAT, if the performance of the test has been verified with a CLIA validation
study [46]. However, NAAT testing outside of clinical research settings is generally not
available in many areas of the world where H. ducreyi cutaneous ulcer disease is found. (See
'Resource-limited settings' above.)

An investigational multiplex PCR assay, which tests for H. ducreyi, T. pallidum, and HSV, was
evaluated in 105 patients attending a genitourinary medicine clinic in Lesotho, and was
determined to have a sensitivity for H. ducreyi of 95 percent [29]. A similar study, which
evaluated 298 genital ulcer swab specimens collected in New Orleans, reported a sensitivity
of PCR for H. ducreyi of 98.4 percent and a specificity of 99.6 percent [49].

Despite the potential benefits, PCR or other NAATs may not be a practical diagnostic tool for
most publically-funded STD clinics because of the cost and complexity of the test. In addition,
NAAT technology for H. ducreyi has not to date been adapted to provide rapid results.

DIFFERENTIAL DIAGNOSIS

The differential diagnosis of genital ulcer disease in sexually active persons is broad and is
influenced by the geographic location where the infection was acquired ( table 1). In the
United States (and increasingly worldwide), most cases are due to herpes simplex virus (HSV)
or syphilis. Chancroid remains exceedingly rare, particularly in developed countries.
Noninfectious causes include drug eruptions and Behçet syndrome. (See "Approach to the
patient with genital ulcers", section on 'Etiologies'.)

A diagnosis based on history and physical examination alone is often inaccurate since
findings such as pain, inguinal lymphadenitis, and multiple ulcers are not specific for any one
diagnosis. Nonetheless, some findings are more common in certain infections [43]. A
detailed discussion of how to evaluate patients with genital ulcers is found elsewhere and
summarized below (see "Approach to the patient with genital ulcers"):

● The classic genital presentation of chancroid is with a deep, undermined, purulent ulcer
that may be associated with painful inguinal lymphadenitis.

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● The classic presentation of genital herpes is with multiple, shallow, tender ulcers that
may be vesicular. In addition, only HSV is associated with recurrent disease. (See
"Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus
infection".)

● The classic genital presentation of primary syphilis is with a painless, indurated, clean-
based ulcer called a chancre. (See "Syphilis: Epidemiology, pathophysiology, and clinical
manifestations in patients without HIV", section on 'Clinical manifestations'.)

● Granuloma inguinale (donovanosis) usually presents as a painless, progressive

ulcerative lesion without regional lymphadenopathy [46]. The lesions are highly
vascular and beefy red in appearance. As with chancroid, granuloma inguinale is
exceedingly rare in the United States but endemic in other areas, such as India, Papua,
New Guinea, and southern Africa.

More than one pathogen may be present, further complicating the diagnosis. Nucleic acid
amplification testing (NAAT) has shown that this phenomenon may be more common than is
evident with culture-based methods used in the past (17 versus 4 percent with culture in one
series) [29].

TREATMENT

Antimicrobial therapy — Antimicrobial therapy should be administered to patients with

either confirmed or probable chancroid. (See 'Diagnosis' above.)

Several treatment options exist, including azithromycin, ceftriaxone, ciprofloxacin, or

erythromycin ( table 2) [35,46]. H. ducreyi has developed increasing resistance to some of
the antimicrobials that were previously effective, such as trimethoprim-sulfamethoxazole
and tetracycline [50-53].

Empiric treatment is reasonable if the clinical manifestations and epidemiology are strongly
suggestive of the diagnosis, especially for patients who are unlikely to follow up after their
initial evaluation. A detailed discussion of the epidemiology and clinical manifestations of
chancroid are found above. (See 'Epidemiology' above and 'Clinical manifestations' above.)

If empiric therapy for chancroid is administered, we typically administer empiric treatment

for herpes simplex virus (HSV) and syphilis as well. For most patients, HSV and syphilis are
more likely causes of genital ulcer disease. In addition, there are data that describe
coinfection with H. ducreyi and T. pallidum [26]. The treatment for syphilis is discussed
elsewhere. (See "Syphilis: Treatment and monitoring", section on 'Treatment of early
syphilis'.)

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The duration of infectivity after initiation of treatment is uncertain. Thus, patients with
chancroid should abstain from sex until the ulcer has healed, and condom use should be
stressed. (See 'Sex partners' below.)

Preferred regimens — We suggest that patients with proven or suspected chancroid be

treated with directly observed single-dose therapy with either azithromycin (1 gram orally) or
ceftriaxone (250 mg intramuscularly) ( table 2).

Most of the evidence for the efficacy of these regimens comes from uncontrolled
observational studies that have shown high cure rates. As examples:

● Azithromycin given as a single 1 gram dose was evaluated as treatment for chancroid in
two study sites in Africa. At the first site in Kenya, 127 culture-positive patients were
treated with either azithromycin or erythromycin. Cure rates were approximately 90
percent with both drugs. Treatment failure in both groups was significantly associated
with HIV infection or being uncircumcised [54]. At the second study site in South Africa,
patients were treated in a noncomparative trial [55]. Azithromycin cured 89 percent of
patients with culture-positive H. ducreyi infection.

● Ceftriaxone given as a single 250 mg intramuscular injection has been associated with
cure rates as high as 98 percent [56]. However, limited data suggest that this regimen
may not be as effective in Kenya where failure rates as high as 35 percent have been
described [57]. Failure was more common among persons coinfected with HIV. (See
'Patients with HIV' below.)

● Single-dose azithromycin was compared to treatment with single-dose ceftriaxone in a

randomized, prospective, unblinded trial of 65 culture-positive patients in New Orleans
[58]. Clinical cure or improvement was seen in all patients.

Alternative regimens — A multiple dose regimen of ciprofloxacin (500 mg orally twice daily
for three days) is an alternative for patients who cannot take azithromycin or ceftriaxone
[46]. Erythromycin base 500 mg orally three times daily for seven days is also effective, but
patient adherence to the regimen may be challenging. Both ciprofloxacin and erythromycin
have been associated with cure rates above 90 percent [50,59].

As noted, the requirement for multiple doses makes these alternative regimens less
desirable. In addition, with erythromycin, there is an appreciable incidence of
gastrointestinal side effects, as well as a risk of sudden cardiac death due to QT interval
prolongation (especially when other drugs metabolized by CYP3A4 are taken concurrently).
(See "Acquired long QT syndrome: Definitions, pathophysiology, and causes".)

Special populations

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Patients with HIV — As with other sexually transmitted diseases (STDs), the presence
of HIV infection may result in atypical manifestations of chancroid. Such patients may
present with numerous lesions, extragenital involvement, and delayed resolution after
treatment [47,60]. However, there are no large case series of chancroid in persons with HIV
to determine the true incidence or predominant clinical features.

We administer the same antimicrobial regimens to patients with HIV as those described
above ( table 2). Some experts recommend multiple dose regimens with ciprofloxacin or
erythromycin for initial treatment of patients with HIV, based upon a small number of
reported treatment failures with single-dose regimens [35]. However, this approach has not
been studied prospectively, and we prefer single-dose regimens for patients with HIV,
especially those with well-controlled HIV and reasonable immune function [1]. In either case,
close follow-up is essential.

Pregnant women — Both azithromycin and ceftriaxone can be used for the treatment
of pregnant women with chancroid. The safety of these drugs has been well established
based upon studies and clinical experience with the use of azithromycin to treat C.
trachomatis and ceftriaxone to treat Neisseria gonorrhoeae in pregnant women [46]. (See
"Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and
adolescents", section on 'Pregnant women' and "Treatment of Chlamydia trachomatis
infection", section on 'Pregnant individuals'.)

If neither ceftriaxone nor azithromycin can be used, erythromycin is an alternative, but is

poorly tolerated. Ciprofloxacin is generally avoided during pregnancy and lactation due to
the small risk of toxicity to the fetus. (See "Fluoroquinolones", section on 'Pregnancy and
breastfeeding'.)

Management of buboes — Fluctuant lymphadenitis should be drained, usually by needle

aspiration. Data from the era before effective antimicrobial therapy was available suggest
that failure to aspirate fluctuant buboes may lead to the development of draining fistulas or
secondary ulcers at the site of spontaneous rupture [61]. If the area is not clearly fluctuant, it
is reasonable to initiate medical therapy, follow closely, and drain the node if fluctuance
develops.

Drainage can be performed by needle aspiration through normal skin ( picture 2), or
through incision and drainage [35,46]. In a small study performed during a chancroid
epidemic in New Orleans, 27 patients with inguinal buboes were randomly assigned to either
needle aspiration or incision and drainage [62]. Both groups ultimately did well without any
adverse events during the period of follow-up. The patients managed with needle aspiration
often required repeated aspirations, but these were well tolerated.

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Patient monitoring — Clinical improvement usually occurs promptly after treatment is

initiated. Relief of pain is noted by most patients within two to three days, and objective
improvement in the ulcers is usually apparent within a week [63]. If no clinical improvement
is evident after seven days, then the clinician should consider the following [46]:

● The diagnosis may be incorrect

● The patient is coinfected with another STD (especially syphilis)

● The patient is coinfected with HIV

● The patient was not adherent with medications (if a multiple-dose regimen was
prescribed)

● The H. ducreyi strain is drug resistant

For patients who are considered treatment failures, more prolonged treatment with
ceftriaxone or a fluoroquinolone may be effective, but there are no definitive data to support
this strategy.

The response of chancroid-associated lymphadenitis may occur more slowly. In one study,
for example, 8 of 35 patients with inguinal lymphadenitis developed fluctuance that required
needle aspiration despite successful treatment of the genital ulcer with erythromycin [64]. In
advanced cases, scarring may result despite eradication of infection [46].

SEX PARTNERS

The duration of infectivity after initiation of treatment is uncertain. Thus, patients with
chancroid should abstain from sex until the ulcer has dried/resolved, and condom use
should be stressed.

Sex partners of patients with chancroid should be treated if they have had sexual contact
with the patient within 10 days of symptom presentation [46]. Treatment does not depend
upon the presence of symptoms or signs of the disease in the exposed partner. The
treatment for exposed partners is the same as for persons with diagnosed infections
( table 2), and a single-dose regimen should be administered whenever possible. (See
'Antimicrobial therapy' above.)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Sexually transmitted

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infections".)

SUMMARY AND RECOMMENDATIONS

● The causative agent of chancroid is Haemophilus ducreyi, a small, fastidious, gram-

negative rod that requires an enriched growth medium for successful culture. (See
'Microbiology' above.)

● Chancroid is very rare in the United States and most other developed countries.
However, the true incidence of chancroid in most areas remains unclear because of the
difficulty identifying H. ducreyi in the laboratory. (See 'Epidemiology' above.)

● The incubation period of chancroid is typically 4 to 10 days. Patients typically present

with a painful genital ulcer, and multiple ulcers can be present. These ulcers may be
associated with regional lymphadenopathy. (See 'Clinical manifestations' above.)

● The diagnosis of chancroid is challenging because testing for H. ducreyi is not routinely
available. As such, most providers rely on clinical criteria to make a diagnosis of
chancroid in patients with signs and symptoms consistent with infection. In addition,
testing for herpes simplex virus (HSV) and syphilis should also be performed. (See
'Diagnosis' above.)

● Empiric treatment is reasonable if the clinical manifestations and epidemiology are

strongly suggestive of the diagnosis, especially for patients who are unlikely to follow
up after their initial evaluation. If empiric therapy for chancroid is administered, we
typically administer empiric treatment for syphilis and HSV as well. (See 'Antimicrobial
therapy' above.)

● For patients with confirmed or probable chancroid, we suggest a single-dose regimen

using azithromycin (1 gram orally) or ceftriaxone (250 mg intramuscularly) rather than a
regimen that requires multiple doses (Grade 2C). Alternative regimens include
ciprofloxacin (500 mg orally twice daily for three days) or erythromycin base (500 mg
orally three times daily for seven days). (See 'Preferred regimens' above and 'Alternative
regimens' above.)

● Fluctuant inguinal lymph nodes should be drained, usually by needle aspiration. (See
'Management of buboes' above.)

● Clinical improvement usually occurs promptly after treatment is initiated. Relief of pain
is noted by most patients within two to three days, and objective improvement in the
ulcers is usually apparent within a week. (See 'Patient monitoring' above.)

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● The presence of HIV infection may result in atypical manifestations of chancroid. In

addition, such patients may be at higher risk for treatment failure, and must be
followed carefully after the initiation of therapy. (See 'Patients with HIV' above.)

● The duration of infectivity after initiation of treatment is uncertain. Thus, patients with
chancroid should abstain from sex until the ulcer has dried/resolved, and condom use
should be stressed. In addition, sex partners of patients with chancroid should be
treated if they have had sexual contact with the patient within 10 days of symptom
presentation. (See 'Sex partners' above.)

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REFERENCES

1. Lewis DA. Epidemiology, clinical features, diagnosis and treatment of Haemophilus

ducreyi - a disappearing pathogen? Expert Rev Anti Infect Ther 2014; 12:687.
2. Lewis DA, Müller E, Steele L, et al. Prevalence and associations of genital ulcer and
urethral pathogens in men presenting with genital ulcer syndrome to primary health
care clinics in South Africa. Sex Transm Dis 2012; 39:880.
3. Trees DL, Morse SA. Chancroid and Haemophilus ducreyi: an update. Clin Microbiol Rev
1995; 8:357.

4. Gangaiah D, Webb KM, Humphreys TL, et al. Haemophilus ducreyi Cutaneous Ulcer
Strains Are Nearly Identical to Class I Genital Ulcer Strains. PLoS Negl Trop Dis 2015;
9:e0003918.

5. Ghinai R, El-Duah P, Chi KH, et al. A cross-sectional study of 'yaws' in districts of Ghana
which have previously undertaken azithromycin mass drug administration for trachoma
control. PLoS Negl Trop Dis 2015; 9:e0003496.

6. Ussher JE, Wilson E, Campanella S, et al. Haemophilus ducreyi causing chronic skin
ulceration in children visiting Samoa. Clin Infect Dis 2007; 44:e85.
7. González-Beiras C, Marks M, Chen CY, et al. Epidemiology of Haemophilus ducreyi
Infections. Emerg Infect Dis 2016; 22:1.
8. Janowicz DM, Ofner S, Katz BP, Spinola SM. Experimental infection of human volunteers
with Haemophilus ducreyi: fifteen years of clinical data and experience. J Infect Dis 2009;
199:1671.
9. Al-Tawfiq JA, Harezlak J, Katz BP, Spinola SM. Cumulative experience with Haemophilus
ducreyi 35000 in the human model of experimental infection. Sex Transm Dis 2000;
27:111.

https://www.uptodate.com/contents/chancroid/print?source=mostViewed_widget 13/23
21/1/24, 2:36 Chancroid - UpToDate

10. Alfa MJ, DeGagne P. Attachment of Haemophilus ducreyi to human foreskin fibroblasts
involves LOS and fibronectin. Microb Pathog 1997; 22:39.
11. Parsons LM, Limberger RJ, Shayegani M. Alterations in levels of DnaK and GroEL result in
diminished survival and adherence of stressed Haemophilus ducreyi. Infect Immun
1997; 65:2413.
12. Cope LD, Lumbley S, Latimer JL, et al. A diffusible cytotoxin of Haemophilus ducreyi. Proc
Natl Acad Sci U S A 1997; 94:4056.

13. Purvén M, Frisk A, Lönnroth I, Lagergard T. Purification and identification of

Haemophilus ducreyi cytotoxin by use of a neutralizing monoclonal antibody. Infect
Immun 1997; 65:3496.
14. Cortes-Bratti X, Chaves-Olarte E, Lagergård T, Thelestam M. The cytolethal distending
toxin from the chancroid bacterium Haemophilus ducreyi induces cell-cycle arrest in the
G2 phase. J Clin Invest 1999; 103:107.
15. Magro CM, Crowson AN, Alfa M, et al. A morphological study of penile chancroid lesions
in human immunodeficiency virus (HIV)-positive and -negative African men with a
hypothesis concerning the role of chancroid in HIV transmission. Hum Pathol 1996;
27:1066.
16. Spinola SM, Orazi A, Arno JN, et al. Haemophilus ducreyi elicits a cutaneous infiltrate of
CD4 cells during experimental human infection. J Infect Dis 1996; 173:394.
17. King R, Gough J, Ronald A, et al. An immunohistochemical analysis of naturally occurring
chancroid. J Infect Dis 1996; 174:427.

18. Gelfanova V, Humphreys TL, Spinola SM. Characterization of Haemophilus ducreyi-

specific T-cell lines from lesions of experimentally infected human subjects. Infect
Immun 2001; 69:4224.

19. DiCarlo RP, Armentor BS, Martin DH. Chancroid epidemiology in New Orleans men. J
Infect Dis 1995; 172:446.
20. Mertz KJ, Trees D, Levine WC, et al. Etiology of genital ulcers and prevalence of human
immunodeficiency virus coinfection in 10 US cities. The Genital Ulcer Disease
Surveillance Group. J Infect Dis 1998; 178:1795.
21. Sexually Transmitted Disease Surveillance 2021. United States Centers for Disease Contr
ol and Prevention. Available at: https://www.cdc.gov/std/statistics/2021/default.htm (Acc
essed on July 23, 2023).

22. Hope-Rapp E, Anyfantakis V, Fouéré S, et al. Etiology of genital ulcer disease. A

prospective study of 278 cases seen in an STD clinic in Paris. Sex Transm Dis 2010;
37:153.
23. Centers for Disease Control and Prevention (CDC). Chancroid detected by polymerase
chain reaction--Jackson, Mississippi, 1994-1995. MMWR Morb Mortal Wkly Rep 1995;
https://www.uptodate.com/contents/chancroid/print?source=mostViewed_widget 14/23
21/1/24, 2:36 Chancroid - UpToDate

44:567, 573.

24. Mertz KJ, Weiss JB, Webb RM, et al. An investigation of genital ulcers in Jackson,
Mississippi, with use of a multiplex polymerase chain reaction assay: high prevalence of
chancroid and human immunodeficiency virus infection. J Infect Dis 1998; 178:1060.

25. Beck-Sague CM, Cordts JR, Brown K, et al. Laboratory diagnosis of sexually transmitted
diseases in facilities within the United States. Results of a national survey. Sex Transm
Dis 1996; 23:342.

26. Dillon SM, Cummings M, Rajagopalan S, McCormack WC. Prospective analysis of genital
ulcer disease in Brooklyn, New York. Clin Infect Dis 1997; 24:945.
27. Risi JB Jr, Centers for Disease Control (CDC). Using surveillance data for decision making
in public health. MMWR Morb Mortal Wkly Rep 1992; 41 Suppl:57.
28. O'Farrell N, Hoosen AA, Coetzee KD, van den Ende J. Genital ulcer disease: accuracy of
clinical diagnosis and strategies to improve control in Durban, South Africa. Genitourin
Med 1994; 70:7.
29. Morse SA, Trees DL, Htun Y, et al. Comparison of clinical diagnosis and standard
laboratory and molecular methods for the diagnosis of genital ulcer disease in Lesotho:
association with human immunodeficiency virus infection. J Infect Dis 1997; 175:583.
30. Totten PA, Kuypers JM, Chen CY, et al. Etiology of genital ulcer disease in Dakar, Senegal,
and comparison of PCR and serologic assays for detection of Haemophilus ducreyi. J Clin
Microbiol 2000; 38:268.

31. Department of Communicable Disease Control MoPH, Thailand. Reported incidence of p

rimary syphilis, chancroid and genital herpes from Bangkok and 12 regional CDC centre
s, 1982-1997. Bangkok; 1998
32. Kaul R, Kimani J, Nagelkerke NJ, et al. Monthly antibiotic chemoprophylaxis and
incidence of sexually transmitted infections and HIV-1 infection in Kenyan sex workers: a
randomized controlled trial. JAMA 2004; 291:2555.
33. Suntoke TR, Hardick A, Tobian AA, et al. Evaluation of multiplex real-time PCR for
detection of Haemophilus ducreyi, Treponema pallidum, herpes simplex virus type 1 and
2 in the diagnosis of genital ulcer disease in the Rakai District, Uganda. Sex Transm
Infect 2009; 85:97.
34. Ministry of Health and Social Services. Microbiological surveillance for sexually transmitt
ed infections: Namibia 2007 survey. Ministry of Health and Social Service; Windhoek, Na
mibia: 2007

35. O'Farrell N, Lazaro N. UK National Guideline for the management of Chancroid 2014. Int
J STD AIDS 2014; 25:975.
36. Riedner G, Todd J, Rusizoka M, et al. Possible reasons for an increase in the proportion of
genital ulcers due to herpes simplex virus from a cohort of female bar workers in
https://www.uptodate.com/contents/chancroid/print?source=mostViewed_widget 15/23
21/1/24, 2:36 Chancroid - UpToDate

Tanzania. Sex Transm Infect 2007; 83:91.

37. Gomes Naveca F, Sabidó M, Amaral Pires de Almeida T, et al. Etiology of genital ulcer
disease in a sexually transmitted infection reference center in Manaus, Brazilian
Amazon. PLoS One 2013; 8:e63953.
38. Makasa M, Buve A, Sandøy IF. Etiologic pattern of genital ulcers in Lusaka, Zambia: has
chancroid been eliminated? Sex Transm Dis 2012; 39:787.
39. The World Heatlh Organization. Guidelines for the management of sexually transmitted
infections. 2004. http://apps.who.int/iris/bitstream/10665/42782/1/9241546263_eng.pd
f?ua=1 (Accessed on June 08, 2016).
40. Lewis DA, Mitjà O. Haemophilus ducreyi: from sexually transmitted infection to skin ulcer
pathogen. Curr Opin Infect Dis 2016; 29:52.
41. Mitjà O, Lukehart SA, Pokowas G, et al. Haemophilus ducreyi as a cause of skin ulcers in
children from a yaws-endemic area of Papua New Guinea: a prospective cohort study.
Lancet Glob Health 2014; 2:e235.
42. McBride WJ, Hannah RC, Le Cornec GM, Bletchly C. Cutaneous chancroid in a visitor from
Vanuatu. Australas J Dermatol 2008; 49:98.

43. DiCarlo RP, Martin DH. The clinical diagnosis of genital ulcer disease in men. Clin Infect
Dis 1997; 25:292.
44. Lewis DA. Diagnostic tests for chancroid. Sex Transm Infect 2000; 76:137.
45. Centers for Disease Control and Prevention. Chancroid (Haemophilus ducreyi) 1996 case
definition. https://wwwn.cdc.gov/nndss/conditions/chancroid/case-definition/1996/ (Acc
essed on April 04, 2016).

46. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment
Guidelines, 2021. MMWR Recomm Rep 2021; 70:1.
47. Morse SA. Chancroid and Haemophilus ducreyi. Clin Microbiol Rev 1989; 2:137.
48. Joseph AK, Rosen T. Laboratory techniques used in the diagnosis of chancroid,
granuloma inguinale, and lymphogranuloma venereum. Dermatol Clin 1994; 12:1.
49. Orle KA, Gates CA, Martin DH, et al. Simultaneous PCR detection of Haemophilus
ducreyi, Treponema pallidum, and herpes simplex virus types 1 and 2 from genital
ulcers. J Clin Microbiol 1996; 34:49.
50. Naamara W, Plummer FA, Greenblatt RM, et al. Treatment of chancroid with
ciprofloxacin. A prospective, randomized clinical trial. Am J Med 1987; 82:317.

51. Plourde PJ, D'Costa LJ, Agoki E, et al. A randomized, double-blind study of the efficacy of
fleroxacin versus trimethoprim-sulfamethoxazole in men with culture-proven chancroid.
J Infect Dis 1992; 165:949.

https://www.uptodate.com/contents/chancroid/print?source=mostViewed_widget 16/23
21/1/24, 2:36 Chancroid - UpToDate

52. Abeck D, Johnson AP, Dangor Y, Ballard RC. Antibiotic susceptibilities and plasmid
profiles of Haemophilus ducreyi isolates from southern Africa. J Antimicrob Chemother
1988; 22:437.
53. Knapp JS, Back AF, Babst AF, et al. In vitro susceptibilities of isolates of Haemophilus
ducreyi from Thailand and the United States to currently recommended and newer
agents for treatment of chancroid. Antimicrob Agents Chemother 1993; 37:1552.
54. Tyndall MW, Agoki E, Plummer FA, et al. Single dose azithromycin for the treatment of
chancroid: a randomized comparison with erythromycin. Sex Transm Dis 1994; 21:231.
55. Ballard RC, Ye H, Matta A, et al. Treatment of chancroid with azithromycin. Int J STD AIDS
1996; 7 Suppl 1:9.
56. Bowmer MI, Nsanze H, D'Costa LJ, et al. Single-dose ceftriaxone for chancroid.
Antimicrob Agents Chemother 1987; 31:67.
57. Tyndall M, Malisa M, Plummer FA, et al. Ceftriaxone no longer predictably cures
chancroid in Kenya. J Infect Dis 1993; 167:469.

58. Martin DH, Sargent SJ, Wendel GD Jr, et al. Comparison of azithromycin and ceftriaxone
for the treatment of chancroid. Clin Infect Dis 1995; 21:409.
59. Malonza IM, Tyndall MW, Ndinya-Achola JO, et al. A randomized, double-blind, placebo-
controlled trial of single-dose ciprofloxacin versus erythromycin for the treatment of
chancroid in Nairobi, Kenya. J Infect Dis 1999; 180:1886.
60. Quale J, Teplitz E, Augenbraun M. Atypical presentation of chancroid in a patient infected
with the human immunodeficiency virus. Am J Med 1990; 88:43N.
61. Sullivan, M. Chancroid. Am J Syphilis Gonorrhea Venereal Dis 1940; 24:480.
62. Ernst AA, Marvez-Valls E, Martin DH. Incision and drainage versus aspiration of fluctuant
buboes in the emergency department during an epidemic of chancroid. Sex Transm Dis
1995; 22:217.
63. Schmid GP. The treatment of chancroid. JAMA 1986; 255:1757.
64. Plummer FA, D'Costa LJ, Nsanze H, et al. Antimicrobial therapy of chancroid:
effectiveness of erythromycin. J Infect Dis 1983; 148:726.
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GRAPHICS

Chancroid ulcer on penis

Penile ulcer due to chancroid which is accompanied by marked inguinal lymphadenitis

Graphic 76843 Version 1.0

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Clinical characteristics of infectious causes of genital ulcer disease

GUD Classic ulcer

Etiologic agent Incubation Pain Adenopat
syndrome characteristics

HSV HSV-1 and HSV-2 Multiple small 2 to 7 days Usually Reactive painf
grouped ulcers; painful; nodes commo
erythematous can be
base. painless
Occasionally, or
single pruritic
lesions/fissures
can be seen

Vesicles can open,

forming shallow
ulcers/erosions
that may coalesce

Syphilis Treponema pallidum Indurated, 7 to 90 days Usually Firm, rubbery

smooth firm painless; nodes
borders rarely
can be
painful

Clean base Not tender

Heals Regional
spontaneously

Usually singular, Discrete

although multiple
chancres can
occur

Chancroid Haemophilus ducreyi Sharply 3 to 10 days Marked 50 percent wit

circumscribed or inguinal
irregular, ragged adenopathy
undermined
edges

Not indurated Usually unilat

Base may have Often painful

gray or yellow
exudate

Multiple ulcers May

suppurate/rup

LGV Chlamydia trachomatis Usually not 5 to 21 days Usually More common

L1-L3 observed painless males

Small and shallow Matted cluste

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Rapid Unilateral or o
spontaneous bilateral
healing

Large painful
fluctuant "bub

Painful groove
sign

Sinus tracts
common

Granuloma Klebsiella granulomatis Extensive, 7 to 90 days Usually Pseudobuboe

inguinale progressive painless

Granulation-like
tissue

Rolled edges

GUD: genital ulcer disease; HSV: herpes simplex virus; LGV: lymphogranuloma venereum.

Graphic 81735 Version 3.0

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Treatment options for chancroid

Drugs of choice

Azithromycin 1 g orally in a single dose OR

Ceftriaxone 250 mg IM in a single dose

Alternatives
Ciprofloxacin* 500 mg orally twice daily for three days OR

Erythromycin ¶ base 500 mg orally three times daily for seven days

IM: intramuscular.

* Not recommended in pregnancy or breastfeeding.

¶ Erythromycin is rarely used given gastrointestinal toxicity. Erythromycin ethylsuccinate 800 mg may
be substituted for erythromycin base 500 mg.

Adapted from: Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment
guidelines, 2015. MMWR Recomm Rep 2015; 64:1.

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Aspiration of a chancroid bubo

Aspiration of purulent fluid (seen in the syringe) from a fluctuant bubo in a patient with chancroid.
Repeated needle aspirations may be necessary, even after effective antimicrobial therapy.

Graphic 59577 Version 1.0

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Contributor Disclosures
Charles B Hicks, MD No relevant financial relationship(s) with ineligible companies to
disclose. Jeanne Marrazzo, MD, MPH, FACP, FIDSA Grant/Research/Clinical Trial Support: BD
Diagnostics [Vaginal infections, STI]; GSK [Vaccines]. Consultant/Advisory Boards: Merck [HIV]. All of the
relevant financial relationships listed have been mitigated. Jennifer Mitty, MD, MPH No relevant
financial relationship(s) with ineligible companies to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.

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