The Biett collarette: Secondary syphilis.

A 28 year old sexually promiscuous otherwise healthy male presented with diffuse symmetric hyperpigmented macules with marginal collarette of scales involving the palms for 20 days (Fig. 1). There were no other skin lesions noted. On examination the genitalia was normal. There was no generalized or inguinal lymphadenopathy. On interrogating, patient gave a history of noticing a tiny painless ulcer on the glans penis 2 months back that resolved on its own. Clinicial suspicion of syphilis was considered. Laboratory results showed a Venereal Disease Research Laboratory (VDRL) titer of 1:256 and a positive Treponema pallidum hemagglutination assay (TPHA). He was diagnosed to have secondary syphilis and was treated with single dose of benzathine penicillin 2.4 mega units administered intramuscularly. All partners were notified. On follow up after 6 months he had complete clinical resolution as well as fourfold decline in VDRL titer. Syphilis is popularly called as “great imitator” due to its polymorphic and atypical clinical features [1]. Secondary syphilis occurs 6–8 weeks after the onset of primary chancre [2]. It has varied spectrum of cutaneous features. Presence of hyperpigmented macules or papules with collarette of scales - Biett's sign on the palms and soles is considered to be a strong indicator of secondary syphilis and clinically distinguishes it from other papulosquamous conditions affecting the palms and soles. It resolves completely following effective treatment with pencillin [3].

Fig. 1

Multiple discrete symmetrical hyperpigmented macules with collarette of scales on both palms (Biett’s sign).