STDs and dermatological symptoms
Sexually transmitted diseases and infections (STDs/STIs) are common health problems in the United States, according to Kenneth J. Tomecki, MD, physician in the Department of Dermatology at the Cleveland Clinic and former president of the American Academy of Dermatology.1 He cited 2018 data from the Centers for Disease Control and Prevention (CDC) which found that one in five people in the United States had an STI. In this year alone, there were 26 million newly acquired STIs, nearly 50% of which were acquired by people aged 15 to 24. Nearly $16 billion was spent on direct medical costs.2
In light of these statistics, it’s important for doctors to expand their knowledge of different STDs and how to treat them, Tomecki said.
Gonorrhea is caused by Neisseria gonorrhoeae, which are intracellular Gram-negative diplococci bacteria that present differently in men, women, and children. Typically, symptoms in men include urethritis which can cause painful urination and discharge of pus. Tomecki pointed out that many women are asymptomatic, but symptoms can include urethritis, cervicitis, dyspareunia, bleeding and discharge from the genitals. In newborns, the most common symptom is bilateral conjunctivitis.
Other symptoms are:
- Fritz-Hugh-Curtis syndrome, which is inflammation of the liver capsule with formation of adhesions.
- Arthritis-dermatitis syndrome, a localized septic arthritis, causing pain in several joints.
- Bleeding blisters or pustules in the joints, which can vary, Tomecki said.
- Face, scalp and mouth spread in newborns.
This can be diagnosed with a Gram stain test, nucleic acid amplification test (NAAT), chocolate agar culture, enzyme immunoassay (ELISA), polymerase chain reaction test, and DNA test. direct fluorescent antibody (DFA).
To treat the disease, Tomecki recommended:
- Ceftriaxone 500 mg injected intramuscularly (IM) and azithromycin 1 g,
- Cefixime 800 mg, or
- Gentamicin 240 mg and azithromycin 2 g if the patient is allergic to penicillin.
For infected newborns, the patient often also has chlamydia, Tomecki explained, so he suggested prescribing doxycycline as well.
Inguinal Granuloma (Donovanosis)
Donovanosis is an STI caused by Klebsiella granulomatis, a gram-negative bacterium that causes many painful ulcers. It presents as soft, itchy red nodules that become ulcers that may look like lymph nodes. It can be scarred and, on rare occasions, verrucous.
This can be diagnosed with a smear test looking for oval rod-like organisms and an inclusion in histiocytes. Once diagnosed, Tomecki suggested the following treatments:
- Doxycycline 100 mg twice a day for 3 weeks
- Trimethoprim/sulfamethoxazole (TMP-SMZ DS) twice daily for 3 weeks
- Azithromycin 1 g per week for 3 weeks
- Ciprofloxacin 750 mg twice a day for 3 weeks
Lymphogranuloma venereum (LGV)
LGV is caused by 3 unique strains of Chlamydia trachomatis—L1, L2, or L3—and can take anywhere from 3 to 21 days to incubate in the patient’s body. It appears more often in male patients who have sex with other men, Tomecki explained.
This infection has stages. The first stage is where painless erosion of the papules usually occurs at week 1 according to Tomecki. In the second stage painful inflamed and swollen lymph nodes appear and this may occur between 2 and 6 weeks and a sign of a furrow here where Poupart’s ligament is located may also appear. In the third stage fistula, ulcerative colitis, lymphatic obstruction (acute rectal syndrome, all have a chance to occur.
It can be diagnosed with a complement fixation test with a 1:64 titer in the cervix, an IF test with monoclonal antibodies, and a giemsa stain for Gamma-Favre bodies. His recommended treatment is doxycycline 100 mg 2 daily for 3 weeks.
Chancroid is a bacterial infection caused by Haemophilus ducreyi, a gram-negative bacterium, which produces a distended cytolethal toxin (HdCDT) that can cause cell death. The patient may present with bumps which may be painful, torn, punctured or mined ulcers and unilateral inflamed and tender skin areas near the groin. It can be diagnosed using a giemsa stain looking, what Tomecki describes, as a “school of fish” pattern as well as an immunochromatography test that would check for monoclonal antibodies against the receptor. hemoglobin.
To treat the patient, Tomecki recommended:
- Azithromycin 1g
- Ceftriaxone 250 mg IM
- Cirpofloxacin 500 mg 2 daily for 3 days
These treatments should be combined with drainage of lymph nodes or buboes.
Syphillis is caused by Treponema pallidum, a form of spirochete bacteria, with an incubation time of 3 to 90 days, he explained. There are 3 degrees of disease, each with its own set of problems, he said. The first degree of the disease is a painless chancre that develops over 4 to 6 weeks with painless lymphadenopathy and is infectious. Tomecki stressed the importance of being aware of the absence of constitutional symptoms.
The second degree of the disease, which Tomecki says occurs about a month later, has symptoms such as patchy hair loss, condyloma lata, pharyngitis and anterior uveitis, as well as mucous patches with erosions silver gray on the body. Other problems that may occur include scaly or cleft papules on the trunk, extremities, palms, and soles of the feet.
Untreated third degree disease often occurs about a year after onset and may include gum disease, neurosyphilis, tabes dorsalis, Argyll-Robertson pupil, and cardiovascular disease. At birth, neonates born to patients with syphilis present with immediate symptoms including low birth weight, bone disease, rhinitis, rhagades, lymphadenopathy, and neurosyphilis. As the child grows, other symptoms include Hutchinson’s triad, mulberry molars, high arched palate, saddle nose, saber shins, retinitis, and dactylitis.
Syphilis can be diagnosed in several ways, including biopsy to look for psoriasiform changes, silver stain to identify spirochetes, dark field microscopy, DFA-TP, immunohistochemical stains, reaction test polymerase chain (PCR) test and a Venereal Disease Research Laboratory (VDRL) test. There are also treponemal tests, the key points of which are obtaining a rapid plasma reaction (RPR) at 3 months and 6 months with the search for other STIs/STDs, according to Tomecki.
The disease can be treated in the following way, said Tomecki:
- Benzathine penicillin G, 2.4 million units, IM, one dose
- If patient has pencil allergy, doxycycline 100 mg twice a day for 2 weeks
- If undetermined, benzathine penicillin G for 3 doses, 1 week apart
- Or doxycycline for 28 days
For neurosyphilis and ocular syphilis:
- Aqueous penicillin G, 3-4 million units, IV, Q 4 hours for 10-14 days
There is a risk of Jarisch-Herxheimer reaction, which can occur in patients infected with spirochetes who are undergoing antibiotic treatment. This can happen 1-2 hours after the treatment.
Herpes is caused by the human herpes virus (HHV), which is a double-stranded DNA virus. There are 8 main types of herpes, each with their own unique characteristics. HHV can be transmitted by direct contact, mucous membranes or broken skin and incubation can last from 1 to 26 days. Seventy percent of cases are caused by herpes simplex 2 (HSV-2) with a 95% recurrence rate, according to Tomecki. Many times this disease can be spread during asymptomatic shedding.
Patients are usually asymptomatic, Tomecki said, but patients may present with clustered papules, which can turn into vesicles, which can turn into ulcers. There may also be tender, firm lymph nodes. Tomecki warned that most cases go unrecognized because they don’t have these symptoms. This is a particular concern for pregnant patients, he added. If the patient is pregnant and delivers vaginally, the baby may be infected with herpes, Tomecki pointed out.
The diagnosis can be made with or without the appearance of symptoms. Tests include Tzanck smear and tissue culture, serology, DFA or PCR.
Treatment may include
- Famciclovir, or valycyclovir, or acyclovir for 7-10 days. If the infection is severe, an IV acyclovir can be used along with rest, compresses, and pain medication for the patient.
For recurrent genital HSV infections that occur 4-6 times a year.
- Episodic treatment (5 days) vs sustained treatment
- Aciclovir 400 mg 2 per day; famciclovir twice a day; valcyclovir daily
Tomecki ended his presentation with key facts about STDs/STIs in 2022:3
- There are 1 million STIs contracted every day worldwide, with most patients being asymptomatic,
- Each year, an estimated 374 million new infections occur, of which a quarter of STIs are chlamydia, gonorrhea, syphilis and trichomoniasis,
- It is estimated that more than 500 million people between the ages of 15 and 50 have genital HSV infection and up to 1 million pregnant women had syphilis in 2018,
- There are up to 350,000 side effects
- Drug resistance of these diseases is increasing, especially in gonorrhea
Tomecki reported no relevant disclosures.
- Tomecki, K.STDs: The Dirty Half Dozen. Presented at: 2022 Fall Clinical Dermatology Conference for PAs & NPs; June 3-5, 2022 Scottsdale, AZ and virtual.
- CDC Newsroom. CDC. Published January 25, 2021. Accessed June 3, 2022. https://www.cdc.gov/media/releases/2021/p0125-sexualy-transmitted-infection.html
- Sexually transmitted infections (STIs). Accessed June 3, 2022. https://www.who.int/news-room/fact-sheets/detail/sexually-transmitted-infections-(stis)