Palmoplantar syphilis misdiagnosed and treated as palmoplantar psoriasis for 2 years.

Dear Editor,

A 43-year-old woman presented with erythematous, hyperkeratotic papules, and plaques on her palms and soles for 2 years [Figure 1a and b]. She had used several topical steroid and moisturizing creams, without any benefit. She stated that punch biopsy had been taken from her palm in another medical center, which revealed psoriasis vulgaris 2 years ago. Basic laboratory tests were normal. She denied any systemic disease or drug use and abuse. There were no similar lesions in her family. Venereal disease research laboratory (VDRL) test and Treponema pallidum hemagglutination test were positive at titers of 1/256 and 1/320, respectively. Hepatitis B surface (HBs) antigen, anti-HBs, anti-hepatitis C virus, and anti-HIV antibodies were negative. There was no history of genital ulcer, surgery, or blood transfusion in recent years. With a diagnosis of palmoplantar syphilis, benzathine penicillin 2.4 MU intramuscular injection and topical urea lotion 10% were commenced. After 3 weeks, lesions almost completely disappeared [Figure 1c]. VDRL test titer reduced to 1/64 after 2 months of treatment. The UK British Association for Sexual Health and HIV guidelines recommend a single dose of benzathine penicillin 2.4 MU as intramuscular injection for uncomplicated syphilis.[1]

Figure 1

(a) Erythematous, hyperkeratotic papules, and plaques on her both palms. (b) Erythematous, hyperkeratotic papules, and plaques on her both palms and soles. (c) The appearance of the palms, 3 weeks after the treatment

Since syphilis chancre is not painful and may be localized in areas out of sights such as rectum and vagina, she might not have noticed the lesions. Histopathological findings of the secondary syphilis are diverse and psoriasiform and/or lichenoid patterns can be seen.[2] As a great imitator, clinicians should be familiar with all potential clinical forms of syphilis. Syphilis can be seen in the palmoplantar area mimicking psoriasis, lichen, etc.[3] When it is not recognized and treated properly, syphilis may progress into the devastating tertiary stage.[3] Early diagnosis of syphilis is important to avoid unnecessary invasive and costly procedures. Early diagnosis is also important from a public health perspective since the second stage of the disease is highly contagious. Thus, in suspected cases, simple screening and verification tests should be performed considering that the chancre does not always be recalled by the patient.

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