Can syphilis cause peeling of the skin on the fingertips?

Syphilis and Peeling Fingertips

Syphilis can cause peeling of the skin on fingertips during the secondary stage of infection, when widespread skin manifestations occur, particularly affecting the palms and soles. 1, 2

Clinical Manifestations of Syphilis Affecting the Skin

Secondary syphilis typically develops 2-8 weeks after the primary infection and involves multiple organ systems, with skin manifestations being among the most common presentations:

• Skin lesions in secondary syphilis:

  • Macular, maculopapular, papulosquamous, or pustular skin lesions
  • Typically begin on the trunk and spread peripherally
  • Distinctively involve palms and soles 1
  • Can include desquamation (peeling) of skin, particularly on palms and soles
  • May be accompanied by generalized lymphadenopathy, fever, malaise, anorexia, arthralgias, and headache 1, 2

• Other mucocutaneous manifestations:

  • Condyloma lata (moist, flat, papular lesions in warm intertrigenous regions)
  • Mucous patches in the oral cavity
  • Non-pruritic transient exanthems 3

Diagnostic Approach for Suspected Syphilis

When peeling fingertips are observed, especially with other suspicious symptoms:

1. Serologic testing:

   • Nontreponemal tests (VDRL, RPR) - should be reported quantitatively
   • Treponemal tests (FTA-ABS, TP-PA) for confirmation 2
   • Both tests are required as false-positive nontreponemal tests can occur 1

2. Direct detection methods (if active lesions are present):

   • Darkfield microscopy
   • Direct fluorescent antibody tests of lesion exudate or tissue 2

Treatment Recommendations

If syphilis is confirmed, treatment should be initiated promptly:

• Primary, secondary, or early latent syphilis:

  • Benzathine penicillin G 2.4 million units IM in a single dose 2

• For penicillin-allergic, non-pregnant patients:

  • Doxycycline 100 mg orally twice daily for 14 days, or
  • Tetracycline 500 mg orally four times daily for 14 days 2

• Late latent syphilis or latent syphilis of unknown duration:

  • Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM at 1-week intervals 2

Important Clinical Considerations

• HIV testing should be performed in all patients diagnosed with syphilis due to high co-infection rates 2

• Follow-up is essential:

  • Clinical and serologic evaluation at 3,6,9,12, and 24 months after treatment
  • Successful treatment is indicated by resolution of clinical symptoms and a fourfold decrease in nontreponemal test titers within 6 months for primary/secondary syphilis 2

• Partner notification and treatment is crucial:

  • Sexual partners exposed within 90 days of diagnosis should be treated presumptively
  • Partners exposed >90 days before diagnosis should be treated if serologic test results are not immediately available 2

Pitfalls and Caveats

• Peeling fingertips alone is not pathognomonic for syphilis and can occur in many other conditions including:

  • Contact dermatitis
  • Fungal infections
  • Psoriasis
  • Hand eczema
  • Vitamin deficiencies

• In HIV-infected individuals, syphilis may present with more severe or atypical manifestations 4

• Secondary syphilis can mimic many other dermatological conditions, leading to delayed diagnosis 5, 4

• Without treatment, skin manifestations of secondary syphilis typically resolve spontaneously within weeks to months, but the infection progresses to latent and potentially tertiary stages with more serious complications 3, 6