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- Presentation
Syphilis Epidemiology, Clinical Presentations, Testing, and Treatment Updates
Description
The talk reviews recent U.S. syphilis epidemiology, noting a long historical decline after penicillin, then a resurgence over the last decade with a sharp rise around 2020 and only a modest recent decline that may partly reflect incomplete CDC data, reduced public health capacity, and changes in testing. Rates appear to be falling more in men than women, likely influenced by MPOX-related risk reduction, doxycycline post-exposure prophylaxis, and HIV PrEP-related screening. The highest per-capita burden is highlighted in South Dakota, with important outbreaks in Native American communities and related congenital syphilis tragedy. The speaker emphasizes major social drivers such as housing instability, substance use, incarceration, poverty, limited healthcare access, and racial/ethnic and sexual/gender disparities. Clinically, syphilis is shown to have highly variable presentations across stages, from classic painless chancres and secondary palm/sole rashes to many atypical psoriasis-, eczema-, ecthyma-, targetoid-, mucosal-, and crusted forms, plus alopecia, gummas, and possible neurosyphilis at any stage. Diagnostic updates focus on reverse-sequence serology, the lifelong persistence of treponemal tests, the need to monitor RPR titers, and newer point-of-care and home tests, while treatment guidance stresses IV penicillin for neurosyphilis, penicillin for pregnancy, multiple doses for late disease, and doxycycline as an alternative amid recurrent long-acting penicillin shortages. The take-home message is to maintain a high index of suspicion, screen high-risk groups, assess for HIV and other STIs, and ask about vision and hearing symptoms.
View moreConclusions
- Syphilis cases have risen substantially in the U.S. over the past decade, with a recent slight decline that may be partly due to incomplete surveillance and reduced testing rather than a true reversal.
- The increase is uneven, with the largest recent decreases occurring among men while rates among women have stayed relatively flat, contributing to ongoing congenital syphilis.
- Marked racial, ethnic, and sexual/gender minority disparities persist, with especially severe outbreaks in Native American communities and in some geographically clustered regions.
- Social and structural factors such as homelessness, substance use, poverty, incarceration, and limited access to care appear to drive syphilis transmission as part of a broader syndemic.
- COVID-era public health resource shifts likely worsened syphilis control by reducing STI prevention, contact tracing, and local health department capacity.
- DoxyPEP and HIV PrEP-related screening may be helping detect or prevent some infections among high-risk men who have sex with men, but there is no comparable protective effect recommended for women.
- Ongoing long-acting penicillin shortages complicate treatment, especially for pregnant patients and neurosyphilis, increasing reliance on doxycycline for some nonpregnant patients.
- Syphilis often presents in atypical ways that mimic psoriasis, eczema, impetigo, varicella, or other dermatologic conditions, so clinicians must keep a high index of suspicion.
- Neurosyphilis and ocular or otic involvement can occur at any stage, so patients with syphilis should be asked about vision, hearing, and neurologic symptoms.
- Reverse-sequence serologic testing and point-of-care or home tests can improve diagnosis, but prior treated infection can leave treponemal tests positive for life and must be interpreted carefully.
- Anyone diagnosed with syphilis should also be evaluated for HIV and other STIs, counseled about prevention options, and screened for pregnancy when relevant.
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