A solid chancre

Object of primary syphiloma, dense ulcer: all these names describe the hard chancre that forms on the skin and mucous membranes as a sign of primary syphilis. This is a chronic infectious disease, which is infected mainly by sexual transmission of the causative agent - pale treponema. Solid chancre develops directly in the zone of its entry into the body. The painful element is both single and multiple. Treatment of pathology is based on the use of antibiotic therapy.

Epidemiology

The incidence of syphilis and, in particular, of solid chancres, remains relatively high in all parts of the world. According to statistics, in 2000, approximately 250 million people on the planet were affected by sexually transmitted diseases. Of these, 2 million patients had syphilis. Over the past two decades, the incidence of the disease has decreased somewhat, but it continues to be quite high.

In post-Soviet countries, the incidence of the disease fluctuates between 30-300 per 100,000 population.

Solid chancre is more commonly diagnosed in patients 20-29 years of age. Men are more than twice as likely to get the disease as women.

According to experts, a major role in the rapid spread of syphilis is played by a low level of education and insufficient knowledge about infectious pathologies that are sexually transmitted.

Causes of the hard chancre

The "culprit" of the appearance of hard chancre is a gram-negative spirochete - pale treponema. After its penetration into the skin or mucous membrane after a certain period of time, a dense element is formed, which is a hard chancre - the primary sign of syphilitic lesions.

Pale Treponema is quite persistent and is able to live in the environment for about three years. In boiling water, the bacterium dies after fifteen minutes, but the spirochete is extremely resistant to cold influences.

Solid chancre infection occurs through sexual intercourse with a person with syphilis or by direct contact, for example, by treating the wound of a syphilitic patient without using protective equipment. Rarely, but sometimes, infections occur through the use of clothing and household items belonging to a syphilis patient: intimate items, bed linens, linens and utensils can be dangerous.

Transmission from the expectant mother to the fetus through placental protection, to the child during labor or lactation is also not excluded. [1]

Risk factors

Groups of people with an increased risk of syphilis infection and risk of developing a hard chancre have been identified:

• people who are promiscuous and do not have a regular sexual partner;
• Persons with alcohol or drug dependence;
• people of no fixed abode;
• homosexuals;
• people with immunodeficiency, HIV infection.

Pathogenesis

Pale Treponema, a facultative anaerobe, enters the tissues, lymphatic fluid or bloodstream of the partner within a fairly short time (half an hour to a couple of hours) after sexual intercourse (or other contact) with an infected person. Chemotactic factors point neutrophils to the zone of penetration, which is the trigger mechanism for the formation of a solid chancre. Next, neutrophils are replaced by lymphocytes that produce lymphokines. The latter, in turn, attract macrophages, phagocytizing and causing the death of treponemes. The leading role in the local reaction of cells is played by T-helpers, an excessive amount of cytokines and plasma cells is formed. This is how the immune response becomes established.

The detection of antibodies becomes possible from the moment of formation of the hard chancre. IgM, IgA and then IgG are the first to be detected. The immune response leads to the death of the spirochete in the area of the hard chancre, as well as to the subsequent scarring of the ulcer. Circulation of the pathogen in the bloodstream is detected already during the primary stage, with a sharp "jump" in the secondary and relapse stage. This stimulates active production of antibodies, suppressing local immune defense, which inhibits the reproduction of spirochete and leads to the reverse development of secondary syphilides. [2]

Symptoms of the hard chancre

The duration of the incubation period - from the moment of infection to the formation of a solid chancre - is defined as 3-4 weeks. Sometimes this period is shorter or longer - from 1-2 to 8 weeks.

The hard chancre in syphilis may be localized:

• on the genitals;
• in the anus area;
• in other atypical locations (depending on where the pathogen is introduced).

The first signs of pathology consist in the formation of the primary element - erosion or ulcer, the development of regional lymphadenitis and lymphangitis.

It is imperative to imagine what a hard chancre looks like. At first, it is a nodule, transforming into an erosive ulcerative defect. The ulcer has slightly raised borders, insignificant serous discharge. It does not hurt, is characterized by a rounded configuration and a fleshy reddish color. The size varies from a couple of millimeters to 1.5-2 centimeters. The surface may be covered with a crust. A characteristic distinguishing feature: a hard chancre has a dense elastic (cartilage-like) consistency when the base is palpated.

Regional lymph node enlargement can be single or multiple. A single element is defined as a hard ball under the skin, which appears approximately 1 week after the formation of a solid chancre. The skin over the "ball" has no signs of inflammation and there is no pain.

Solid chancres in women can be found on the cervix, in the vaginal cavity, on the clitoris or vulva. In some patients, there are also extragenital locations of the lesions - for example, the anal area, oral cavity, lips or gums, tongue, tonsils, mammary glands, arms or neck, etc. May be affected.

Solid chancre on the labia may quickly become complicated by vulvitis, vulvovaginitis. The development of gangrenization, phagedenization (tissue destruction) processes is possible.

The primary period may end with general symptomatology: fever, chills, headache.

Hard chancre in men usually affects the inner foreskin, the cervix, the glans and the glans itself, and the base of the penis. Non-standard localizations are also possible on almost any part of the body. [3]

A hard chancre on the penis, foreskin, or elsewhere rarely has atypical features and appears as follows:

• by the type of indurative edema - has the appearance of dense lymphoedema of the external genitalia, does not leave an indentation after finger pressure;
• chancre-amygdalitis - looks like a painful erosive or ulcerative defect on the enlarged tonsils;
• by the type of chancre-panaricia - formed as a painful ulcer on the carpal finger phalanx.

Stages

The classical course of syphilitic infection is subdivided into four stages:

• incubation stage;
• Primary stage (hard chancre stage);
• secondary stage;
• tertiary stage.

The initial stage of hard chancre in women or men predetermines the primary stage of syphilis development, which lasts until the appearance of characteristic rashes on the surface of the skin and mucous membranes. This stage lasts about 1.5-2 months.

The initial stage of solid chancre in men is practically no different from that in the weaker sex and is conditionally divided into two parts: we are talking about seronegative and seropositive period. In the first case, standard serologic reactions are negative. In the second case, the reactions become positive, which allows the diagnosis of "primary seropositive syphilis". By the way, the above classification of periodicity is not currently used by all specialists, since there are already more advanced ways of detecting infection in patients (ELISA, PCR, RIF, etc.).

Forms

The primary syphilitic stage is accompanied by the formation of a hard chancre and regional involvement of the lymphatic system. In the first half of this period, serologic reactions may be negative, and only after a couple of weeks the diagnosis gives positive results. At the same time, lymphadenitis is detected, which has a different intensity of manifestation. In general, the primary syphilitic period is talked about from the moment of formation of a hard chancre. Localization corresponds to the place of introduction of pale treponemes into the tissues of the body.

In more than 90% of cases, localization is determined in the genital area, but during diagnosis, one should not forget about the possible extragenital location.

One of the founders of venereology, dermatologist Jean Fournier, identified the main signs of a hard chancre:

• painless hard chancre (erosion);
• smooth flat bottom;
• the typical color of "raw meat"-"spoiled lard", with a dirty, bloody tint;
• absence of inflammatory symptoms;
• the presence of a thickening, noticeable when palpating the painful element.

Why is a hard chancre painless? Some experts believe that the painlessness is due to the fact that the pale treponema during its development produces anesthetic substances that block the painful syndrome.

Venereologists distinguish a number of varieties and forms of hard chancre:

• by localization - genital, extragenital, bipolar hard chancre;
• erosive or ulcerative;
• in terms of numbers - single or multiple;
• by form - cocardial, cortical, diphtheritic, combustiform, petechial;
• by configuration - rounded, oblong, semi-lunar, horseshoe-shaped.

In diagnostic terms, the most difficult is considered atypical hard chancre, which exists in the form of amygdalitis, panaritia, and indurative edema.

Indurative edema is formed in areas saturated with lymphatic vessels. Most often such a hard chancre is found in the vagina and in the area of the labia majora. In male patients, it can be found in the area of the scrotum and prepunctal sac. Damaged tissues are severely swollen, thickened. The color may not change.

Amygdalitis is an atypical hard chancre on the tonsil. The fact is that most often a hard chancre in the throat has the appearance of an erosion or ulcer with a clinic characteristic of syphilis. Amygdalitis is a unilateral growth of the tonsil, its thickening, without accompanying redness. At the same time, there is an increase in submandibular, cervical and parotid lymph nodes.

Syphilitic panaricosis is an atypical hard chancre on the hand that has an obvious resemblance to a banal panaricosis. This disease is more often occupational, since it is found mainly in surgical and gynecological specialists, pathologists, etc. Infection occurs with a cut or other damage to the fingers during surgical intervention, medical examination, etc. Solid chancre on the finger develops mainly in the area of the terminal phalanx. The finger becomes club-shaped, with a purplish-red tint. The formed ulcer is characterized by uneven, hanging (as if bitten) edges. The bottom can be as deep as possible (up to the bone tissue), draws attention to the sharp odor. A person complains of sharp shooting soreness. Pain is also present in enlarged lymph nodes.

It is necessary to pay attention to the fact that a hard chancre on the lip, mouth, tongue is often mistaken for ordinary inflammatory and infectious processes such as stomatitis or even herpes. The fact is that with such pathologies, patients usually go not to a dermatologist or venereologist, but to a dentist or therapist. Solid chancre on the gum begin to treat incorrectly, which contributes to the delay of the disease process, which further creates certain difficulties, both in diagnosis and treatment. Specialists warn: a hard chancre on the hard palate or in any other area of the oral cavity should always be subjected to careful differential diagnosis.

Unfortunately, the oral cavity is not the only place with which some diagnostic problems can occur. Even a hard chancre on the pubic area can transform and take the form of other diseases when self-treated. Therefore, it is necessary to be vigilant, be responsible for your health and not try to cure a serious disease on your own.

When identifying the disease, some features of the current clinical picture of the primary syphilitic stage must also be taken into account:

• A few decades ago, hard skin chancres were predominantly isolated. Today, every second patient has multiple foci of syphilomas. On average, they can be counted from two to six units. There are descriptions of patients with several dozens of syphilomas.
• Solid leg chancre is detected extremely rarely, but it can reach quite large sizes (primarily due to late diagnosis of pathology).
• Extragenital cases of syphilomas are becoming more common - for example, in the past, hard chancres on the neck, thighs, and abdomen were rarely found. Now this localization is no longer rare.
• Hard chancre in the anus also became more common, with women three times more common than men (even when homosexuality was concordant).
• Solid chancre on the face is often complicated by secondary infection and sometimes (in 5-10% of cases) is not accompanied by regional lymphadenitis, which again can complicate diagnosis.
• The seronegative period is somewhat shorter (up to 2-3 weeks).

Complications and consequences

In the absence of treatment and further development of the disease, hard chancre acquires a complicated course, and the infection spreads to other organs and tissues in the body.

If a secondary infection occurs, male patients will develop inflammation of the glans (balanitis) and the inner foreskin (postitis). These complications, in turn, can cause more serious conditions such as phimosis (narrowing of the foreskin). Phimosis can also be complicated by impingement of the head of the penis - paraphimosis.

In addition, weak immune defense and bad habits can lead to other unpleasant consequences of a hard chancre - for example, tissue necrosis and phagedenism (ulcerative-necrotic lesions).

Solid chancre, existing in a woman during pregnancy, can provoke transplacental infection of the fetus with further fetal death at the prenatal stage. A baby with congenital syphilitic pathology dies some time after birth, or it shows severe pathological changes in internal organs.

Diagnostics of the hard chancre

The basic diagnostic methods for suspected solid chancres are syphilis tests, external examination of the patient's body and laboratory tests. [4] A wide range of different tests are available, but the main ones are blood tests, in particular:

• Serologic analysis - based on the detection of immunoglobulins that begin to be produced in persons who have syphilis. The specific assay is called complement binding reaction, or Wasserman reaction: this test is based on the property of complement adsorption by the antigenic complex.
• MF (microprecipitation) reaction is a reaction of antibodies with antigen. The test is simple and quick, and is one of the screening methods for syphilitic diagnosis.
• Immunofluorescence reaction (RIF) is a technique for detecting syphilis with a latent course. It is a difficult but accurate way to confirm the presence of the disease.
• Bacterioscopy - involves examination of the print of the hard chancre. The procedure is quite effective if used within the first month after infection.

Instrumental diagnostics is connected in the presence of other symptoms from the cardiovascular, nervous system. May be indicated:

• consultation with an angiosurgeon, neurologist, psychiatrist;
• electrocardiography, echocardiography;
• CT of the aorta, angiography;
• CT or MRI scan of the brain (spinal cord);
• liquor studies;
• Ultrasound of internal organs, fibrogastroduodenoscopy;
• histologic studies.

Differential diagnosis

Differential diagnosis of hard chancre is carried out with such diseases as traumatic erosion, soft chancre, banal balanitis (balanoposthitis), fissures of the anus, gonorrhea, herpes, tonsillitis, stomatitis and so on.

Soft and hard chancres are two different diseases with completely different etiologies. Soft chancre is also caused by infection and refers to sexually transmitted pathologies. But such an element is loose, soft, painful when palpated, can release particles of pus. Otherwise, soft chancre is called chancroid.

It is important to have an idea of how to distinguish a hard chancre from a pimple, from a boil. To do this, you should pay attention to these points:

• acne and furuncles are more often formed on the face, neck, back, chest;
• Solid chancre occurs in the area on which the pathogen (abnormal discharge, semen, vaginal secretion, etc.);
• acne is formed due to hormonal changes, and a hard chancre is formed as a result of sexual or other contact with a diseased person;
• pimple or furuncle heals after the breakthrough of purulent secretions, and the hard chancre is transformed into an ulcerative and erosive defect prone to enlargement;
• The furuncle is accompanied by painful sensations, while the nodule that precedes the solid chancre is usually painless.
• Gonorrhea is caused by gonococcus, manifested by primary signs such as swelling of the labia or head of the penis, itching and burning during urination, massive mucous discharge accompanied by an unpleasant odor. It may be difficult to outflow urinary fluid, body temperature rises. The formation of nodules, ulcers and erosions is not characteristic.
• Balanoposthitis - occurs as an acute inflammatory process, initially manifested by hyperemia, swelling of the head of the penis and the inner sheet of the foreskin. Subsequently, erosive defects of rounded, irregular configuration are formed. The bottom is soft, reddish, covered with easily removable dirty plaque. Dense areas are not detected. Patients indicate soreness, burning and a sensation of tense skin. The nearby lymph nodes are not fluctuant, they are painful and enlarged.
• Herpes is a viral pathology that is manifested by the appearance of painful blisters in the area of the lips, mouth, throat or nose. After a while, the bubble is covered with a crust. There are also general symptoms: fever, brokenness, a feeling of fatigue, apathy. It is especially difficult to differentiate genital herpes, which can be complemented by symptoms of mycoses, urethritis, etc. Therefore, to make the correct diagnosis requires laboratory tests - virological studies, RIF, PCR.

Treatment of the hard chancre

The therapeutic course for a hard chancre can last from a couple of weeks to 2 years: it all depends on the stage at which treatment was started. The course is regulated as follows:

• is prescribed in accordance with current revisions of the therapeutic regimen;
• is accompanied by the administration of drug doses sufficient for the required therapeutic effect;
• is supplemented with drugs that stimulate immune defense;
• requires mandatory compliance with the recommended therapeutic regimen.

The doctor selects antibiotics individually for each patient, which depends on what drugs the patient has taken before, to what stage a particular case of hard chancre belongs, whether there are contraindications and allergies to drugs. Penicillins, tetracyclines, Erythromycin, Sumamed, Ceftriaxone, etc. Are often the drugs of choice.

Throughout the therapy, biochemical indicators are necessarily monitored, general clinical laboratory tests are performed.

If concomitant venereal pathologies are detected, the patient may be prescribed an adjunctive course of antibiotics. The results of serologic control play a key role in changing and continuing treatment.

In parallel with antibiotic therapy of hard chancre, immunostimulating drugs, vitamins, UVA and other physical procedures are prescribed. Self-treatment should be completely excluded.

During the entire treatment period, the patient is forbidden to have any sexual intercourse. If there is a regular partner, preventive treatment is mandatory. [5]

Medications that are prescribed by a doctor

The basic etiotropic agent for the treatment of hard chancre is penicillin and antibiotics of this group.

For inpatient therapy, benzylpenicillin sodium salt is predominantly chosen, providing the necessary content of the antibiotic in the bloodstream and tissues of the body. At the same time, the drug has a fairly rapid excretion. Intramuscular injections of 500 thousand units are repeated every 4 hours (six times a day), or 1 million units - every 6 hours (four times a day).

Novocaine salt of penicillin and Procaine can be alternative preparations. These antibiotics are administered 1-2 times a day at 0.6-1.2 million units.

As preparations for outpatient therapy, such remedies are suitable:

• Extencillin, Bicillin-1, Retarpene are administered once every 5-7 days, in an amount of 2.4 million units;
• Bicillin-3 is administered intramuscularly in an amount of 2.4 million units twice a week;
• Bicillin-5 is administered intramuscularly in the amount of 1.5 million units twice a week.

Half an hour or an hour before the first antibiotic injection, the patient is given 10-15 mg of prednisolone or 0.1-0.15 betamethasone orally. Contraindications for penicillin-containing drugs for hard chancre are allergies and individual hypersensitivity. If there are such contraindications, the doctor prescribes alternative antibacterial drugs (Tetracycline, Oxacillin, Ceftriaxone, Erythromycin, Doxycycline). Possible side effects during treatment: vomiting, candidiasis of the external genitalia, vagina or oral cavity, hyperexcitability.

Vitamins

Decreased immune defense of the body aggravates the lack of B vitamins and ascorbic acid, the assimilation of which worsens sugar. Direct toxic effect on immunocytes has alcohol contained in any alcoholic beverages, and the formation of leukocytes is negatively affected by cholesterol.

Ascorbic acid and tocopherol are considered the most effective vitamins for syphilis and, in particular, for hard chancres. For some patients, doctors additionally recommend administering vitamins _B1 and _B6.

Tocopherol (vitamin E) is known for its strong anti-infective activity, it stabilizes the lipid layer of cell membranes due to its antioxidant properties. Regular intake of tocopherol helps to reduce pain syndrome, accelerates healing of hard chancres, strengthens immune defense. The drug is taken in the form of capsules. Sometimes doctors recommend applying an oil solution of the vitamin to the affected skin.

Ascorbic acid has all the properties of an antioxidant, and when taken regularly together with B-group vitamins, it accelerates the process of skin cleansing. It is recommended to take these vitamins in combination with zinc.

As a supportive immunotherapy, it is recommended to take one of the following herbal extracts along with vitamins:

• Pantocrine;
• Echinacea extract;
• Eleutherococcus or ginseng extract;
• golden root;
• thuja extract.

Such plant extracts increase the production of leukocytes, accelerate the repair of damaged cellular structures.

Physiotherapy treatment

Among the many physical procedures for hard chancre in the recovery stage can be used light therapy, UHF, darsonval, franklinization, etc.

The choice of physiotherapeutic technique depends mainly on the goal at the respective rehabilitation stage and the stage of wound healing. At the necrosis stage, the basic task is to fight infection and clear the ulcer of necrotic masses. The most recommended treatments at this stage are UHF, UVB, ultrasound, electrophoresis with enzymes and/or antibiotics.

Under the influence of physiotherapy is observed expansion of the smallest vessels, enhancement of local metabolism, increased phagocytic activity of connective tissue elements, accelerated resorption of toxic metabolic products and their removal from tissues, activation of recovery processes.

Folk treatment

Folk recipes for the treatment of hard chancres should be used only in consultation with a doctor, regardless of what components are included in the remedy. The use of only folk methods is inadmissible, as it will harm the patient's health, allow the disease to "lurk", which will subsequently significantly complicate treatment.

To get rid of hard chancres, folk healers use plant products that are characterized by strong wound-healing and anti-inflammatory abilities. For example, actively used such a remedy as raw grated potatoes: 1 tbsp. Of grated mass is applied to the affected area for 5-10 minutes in the morning and evening. Such procedures are repeated for 7-10 days.

Garlic is traditionally used to get rid of hard-to-heal ulcers. It is recommended to grind three garlic cloves, combine them with 1 tsp. Of fresh kefir and apply to the area of hard chancres.

It is considered useful to rinse the affected areas with a solution of baking soda. Dilute 1 tsp. Of baking soda in 200 ml of warm boiled water, use the resulting solution to rinse the lesions as often as possible (every hour).

Treatment with medicinal plants is no less actively used.

Herbal treatment

• Chamomile flowers are almost universal raw materials for the treatment of all kinds of inflammatory phenomena. According to folk healers, it will help with hard chancres. Take 1 tsp. Dried flower, brewed in 200 ml of boiling water, insist until cool, strain. Add 1 tbsp. Honey. Wash the area of hard chancre 4 times a day.
• Yarrow helps with inflammatory ulcer, accompanied by pain syndrome. One tablespoon of the plant is brewed with 200 ml of boiling water, insist for fifteen minutes. Used to rinse the affected area 4 times a day.
• Take oak bark (1 tbsp.), pour 200 ml of water, bring to a boil, kept on low heat, for 10 minutes. Then the decoction is cooled, filtered and used to rinse the affected skin 5 times a day.

In addition to the above plants, other remedies have a good healing effect:

• juice of fresh ergot (moisten a napkin and apply to the wound);
• Sea buckthorn oil (take orally 2 ml per day);
• St. John's wort oil (lubricate the affected skin);
• succession, strawberry rhizome and leaf, mint and linden leaves.

Homeopathy

Venereology specialists do not recommend using homeopathy and any other unconventional treatment to get rid of syphilis and hard chancres. But drugs of this type can be used to stabilize the immune response and rapid compensatory response of the body. The following homeopathic remedies are suitable for this purpose:

• Aconite - eliminates signs of general intoxication of the body.
• Apis - is indicated in acute inflammatory process, pronounced edema and profuse effusion.
• Arsenicum album - has an effect on the processes of cellular respiration.
• Belladonna - has a good effect in increasing all types of sensitivity, especially to light and pain.
• Eupatorium - relieves major painful symptoms, alleviates muscle and bone pain.
• Pulsatilla - affects venous circulation, has anti-inflammatory effects.
• Rus toxicodendron - is characterized by a pronounced anti-inflammatory effect, eliminates burning, stiffness sensation.
• Phosphorus - has immunostimulating effects, increases resistance to various kinds of infections.

Dosage and frequency of use is determined by a homeopathic specialist on an individual basis, which depends on the stage and severity of hard chancre, as well as on the constitutional and other characteristics of the patient.

Surgical treatment

The help of a surgeon is resorted to in the case of purulent lymphadenitis, the appearance of abscesses - these are serious indications for the opening of the focus, evacuation of purulent discharge, washing and drainage of the wound.

In the postoperative period, the patient is shown bed rest with restriction of motor activity. Conservative treatment is prescribed, including the administration of antibiotics, non-steroidal anti-inflammatory and desensitizing agents.

Prevention

General recommendations for the prevention of hard chancre are practically the same as for other venereal pathologies:

• follow-up of cured patients, placement on the dispensary register;
• sexual control;
• prohibition of donation in case of hard chancroid disease;
• mandatory treatment of sexual partners;
• use of condoms during sexual intercourse;
• timely seeking medical help (even at the slightest suspicion, it is better to take tests).

The earlier the doctor diagnoses the problem and prescribes treatment, the higher the chances of a quick cure without negative health consequences are estimated.

Forecast

The prognosis of treatment of hard chancre directly depends on its timeliness. An important role is also played by the behavior of the patient, because he must comply with all recommendations and appointments of the doctor. In general, if the disease was detected in the early stages of development, when the causative agent has not yet had time to cause irreversible damage to tissues and internal organs, we can talk about a positive outcome of the pathology.

Timely therapy with the use of complex drugs and modern antibiotics in the vast majority of cases guarantees complete healing with the transition of serologic samples to "minus". In such a situation, even late relapses of the disease can be prevented.

If a pregnant woman has a hard chancre, the prognosis depends on the gestational age and the condition of the fetus. When treatment is started in the first half of pregnancy, there are all chances to give birth to a healthy baby. But the therapeutic manipulations in the third trimester can not be effective enough. High-quality therapy can slow down the development of hard chancre, but not in all cases it is possible to fully restore the damaged tissues and organs.

The prognosis of the disease strongly depends on the stage: the earlier diagnosed hard chancre and started therapy, the more favorable the outcome will be. Therefore, at the first suspicion of the disease should not hesitate and do not delay, visit the doctor.