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Secondary syphilis - Hair and Scalp
See also in: Overview,Anogenital,Oral Mucosal Lesion
Other Resources UpToDate PubMed

Secondary syphilis - Hair and Scalp

See also in: Overview,Anogenital,Oral Mucosal Lesion
Contributors: David O'Connell MD, Samantha R. Pop MD, Belinda Tan MD, PhD, Mary Gail Mercurio MD, Susan Burgin MD
Other Resources UpToDate PubMed


Secondary syphilis is the second stage of the infection caused by the spirochete Treponema pallidum, which has spread hematogenously throughout the entire body. It typically occurs 3-10 weeks after the appearance of the primary syphilitic chancre.

Secondary syphilis can present with varied manifestations. Patients generally develop constitutional symptoms including malaise, appetite loss, fever, headache, stiff neck, myalgias, pharyngitis, and flu-like symptoms. Generalized lymphadenopathy is typically present. Cutaneous manifestations of secondary syphilis may include a generalized rash that includes the palms and soles. Condyloma lata (gray, broad, papular lesions) may be seen in moist anogenital locations or in the mouth. They are teeming with spirochetes and are, therefore, extremely infectious. Ocular symptoms may include lacrimation, photophobia, and red, painful eyes.

The second stage of syphilis can have varied manifestations with respect to the hair and scalp. Patchy alopecia with a "moth-eaten" appearance can be observed on the scalp and facial hair. Telogen effluvium can be present. Syphilitic papules may line the scalp margin, known as corona veneris.

The lesions of secondary syphilis resolve in 3-12 weeks, with or without treatment. If left untreated, up to 25% of patients will relapse within the first 2 years.

Immunocompromised patient considerations: HIV infection can alter the clinical presentation of syphilis. Manifestations include multiple chancres, atypical cutaneous eruptions, increased severity of organ involvement (such as hepatitis and glomerulonephritis), and rapidly developing arteritis and neurosyphilis. Neurosyphilis can occur at any stage of syphilis.

Related topics: primary syphilis, tertiary syphilis, early congenital syphilis, late congenital syphilis, ocular syphilis


A51.39 – Other secondary syphilis of skin

240557004 – Secondary syphilis

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Differential Diagnosis & Pitfalls

The following differential will be focused on the cutaneous findings of secondary syphilis.

Patchy alopecia: Skin:
  • Pityriasis rosea – Look for herald patch, collarette of scale, and orientation of lesions (fir-tree pattern in skin tension lines).
  • Pityriasis rubra pilaris – Look for orange-red, waxy-like keratoderma of the palms and soles; consider tissue biopsy.
  • Guttate psoriasis – Systemic signs absent, palms and soles are spared; biopsy will aid in diagnosis.
  • Lichen planus – Very pruritic, violaceous, scaly papules, associated with hepatitis C; consider tissue biopsy.
  • Lichen amyloidosis – Monomorphous papules.
  • Drug eruption – Cutaneous lesions of drug eruption tend to be different than those seen in syphilis. Drug eruptions often present with urticarial, exanthematous, or vesicular / bullous lesions. Eosinophilia on CBC and histology are often seen (but eosinophilia is not an invariable finding). Look for NSAIDs, sulfonamides, and penicillin on medication history.
  • Erythema multiforme – Characteristic target lesions (3 concentric colors that are round and well demarcated) occur on the extremities more often than the trunk. Precipitating factors are infectious (eg, herpes simplex virus, mycoplasma) and usually not medication related.
  • Reactive arthritis (Reiter syndrome)
  • Tinea corporis – Check potassium hydroxide (KOH) test.
  • Scabies – Check for scabies mites in mineral oil.
  • Sarcoidosis
  • Mycosis fungoides
  • Granuloma annulare
  • Subacute cutaneous lupus erythematosus

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    Last Reviewed:09/02/2020
    Last Updated:08/18/2021
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    Patient Information for Secondary syphilis - Hair and Scalp
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    Secondary syphilis - Hair and Scalp
    See also in: Overview,Anogenital,Oral Mucosal Lesion
    A medical illustration showing key findings of Secondary syphilis : Fever, Headache, Lymphadenopathy, Malaise, Oral white plaque, Widespread distribution, Arthralgia, Multiple sexual partners, Myalgia, Pharyngitis, Stiff neck
    Clinical image of Secondary syphilis - imageId=2848052. Click to open in gallery.  caption: 'Multiple brown papules and small plaques, some with overlying thick scales and others with collarettes, on the palm.'
    Multiple brown papules and small plaques, some with overlying thick scales and others with collarettes, on the palm.
    Copyright © 2023 VisualDx®. All rights reserved.