Clinical Stages of Syphilis

Note: the following signs and symptoms may or may not be present in all syphilis cases. Syphilis signs and symptoms vary from patient to patient, with some patients being asymptomatic at all stages.

A sore (or chancre) may occur at the site of infection, 9 to 90 days (average of 21 days) after transmission. Chancres are typically painless, 1–2 cm diameter, single or a few sores (sometimes on a part of the body that curves) with associated painless lymphadenopathy (swollen lymph nodes). Usually, chancres heal rapidly with treatment, and without treatment will heal spontaneously in 3 to 8 weeks and may still be present in up to a third of people at the onset of secondary syphilis symptoms.

A secondary infection, for example with a streptococcal or staphylococcal bacterial infection, can occur, where the chancre may be weeping and very tender with erythema (redness) and swelling around the ulcer, and tender localised lymphadenopathy (swollen lymph nodes). Secondary infections of chancres can be mistaken for genital herpes hence swabbing any genital lesion for genital herpes and syphilis is imperative. If secondary infection is present, it is best to treat the superficial bacterial infection as well as the syphilis infection.

Primary syphilis presentation summary:

• Chancre (sore): painless, 1-2 cm diameter, single or few sores
• Appears at site of infection 9-90 days afterwards
• Resolves spontaneously 3- 8 weeks post infection
• Can still be present in people presenting with secondary syphilis
• Swollen lymph nodes
• In conjunction with bacterial infection: chancre can be weeping and tender – treat bacterial infection as well

Stage of syphilis	Duration of infection from initial contact	Treatment	Infectious?
Primary syphilis	< 2 years	Benzathine benzylpenicillin injection 2.4 million units (1.8 gm) IM stat, given as two injections containing 1.2 MU (0.9g)*	Yes – Infectious

*Treatment note: If an alternative treatment needs to be considered due to an allergy or other reasons, discuss with a specialist.

⚠ View clinical images: this section contains images of genitalia and medical procedures

Image credit: Melbourne Sexual Health Centre STI Atlas