Macular Syphilid, or Syphilitic Roseola (Syphilis Maculosa, Roseola Syphilitica)

Macular syphilid is the most common morphological lesion of secondary syphilis, the early form in particular. It is a rosy-red vascular spot with a bluish hue, which disappears when pressed. It is round, not elevated above the skin surface as a rule, and reaches the size of the little-finger nail. No scaling occurs and no traces are left when these spots resolve. The roseola is usually found on the sides of the trunk, the chest, abdomen and the upper limbs (it never appears on the face, feet or hands). The spots develop gradually for one or two weeks, remain unchanged for one to three weeks, and then turn pale and disappear.

Deviations may sometimes be encountered from the common clinical picture of roseola described above. The spots, for instance, may be elevated above the skin surface permanently (elevated roseola) or temporary (urticarial roseola). In the latter case the patient may experience itching and a sensation of burning and scaling may be found when such spots resolve. In some cases the spots may coalesce (coalescent roseola), which is encountered mostly in children, or may form rings (late roseola developing in late recurrences or even in the tertiary period of syphilis). Granular roseola has been described in individuals suffering simultaneously from syphilis and tuberculosis, and hemorrhagic roseola in patients with increased permeability of the vascular walls.

Syphilitic roseola has to be differentiated at times from macular eruptions in certain infectious diseases and dermatoses. Roseola may develop after medication with various drugs or after eating spoiled food (toxicoderma). The spots of toxic roseola are brighter, tend to coalesce, follow a more acute course and are often attended with a sensation of burning and itching; scaling develops ultimately. Properly taken medical history and the results of serological examination of the blood for syphilis help in making the correct diagnosis.

The roseola in typhus and enteric fever is always attended with severe general symptoms. The eruption is not as abundant as in secondary early syphilis in which the general disorders if they had developed in the prodromal period disappear with the appearance of the rose-coloured spots.

Spots resulting from the bites of lice (maculae caeruleae) do not disappear on being pressed by the finger; they are attended with severe itching, have a bluish-red or brownish colour, and are localised in places inhabited by the parasites.

In pityriasis versicolor the colour of the spots may range from pink and light-brown to dark-brown, and scaling occurs (they are easily differentiated by the iodine test).

Papular Syphilid (Syphilis Papulosa)

Papular syphilid is a frequent manifestation of the secondary, especially the recurrent, period of syphilis. The papules are localized in the dermal papillary layer and may differ in size. Papules the size of a lentil (lenticular papules) are encountered more frequently, those the size of a pinhead (miliary papules, or lichenoid syphilids) are rarer. Lenticular papules are semispherical and have discrete boundaries and regular outlines; they are ham-coloured and do not coalesce. Scaling is often encountered and the scales are arranged on the periphery of the papule (Biett's collar). Miliary papules are arranged around the orifices of the hair follicles and are mostly found in weakened patients suffering, for instance, also from tuberculosis. Large papules with a diameter of about 10 to 20 millimeters are called nummular papules. Under the effect of rubbing and irritation with various secretions papules localized in the skin creases, around the anus and on the genitals may grow in size (hypertrophic papules). When they coalesce, plaque-like papules or condylomata lata form. These condylomata, hypertrophic papules and papules found in the skin creases often undergo erosion (erosive papules) as a result of rubbing, and oozing occurs (moist papules). The secretions of the erosive and moist papules and the condylomata lata contain treponemas in abundance. Such patients are therefore highly contagious and hazardous as a source of infection. Papular syphilid of the palms and soles (palmar-plantar syphilid) is very peculiar in appearance: the papules are not elevated above the skin surface but resemble congestive-red spots covered with clusters of hard horny scales. On palpation, however, the spots are found to be hard. The papules may coalesce sometimes and form patches of various size with discrete boundaries and hard horny masses on the surface.

In most cases the miliary and nummular papules are manifestations of the recurrent period of syphilis. The lenticular and erosive papules are encountered both in secondary early and in secondary recurrent syphilis. The lenticular papules may have an abundance of silver-white scales on their surface and thus resemble psoriatic papules (psoriasiform syphilid); when arranged on the face or scalp in patients with seborrhoea oleosa they are covered with oily yellowish scales (seborrhoeic syphilitic papules).

Syphilitic papules leave intensive pigmentation which disappears gradually.

Histological examination in cases with papules in the dermis reveals an inflammatory infiltrate composed mainly of plasma cells arranged like a muff around the vessels as well as diffusely (in the papillary layer). Marked hyperplasia of the vascular endothelium is seen.

Differential diagnosis. The absence of the terminal film, punctate hemorrhage and no tendency of the papules to coalesce and form patches distinguishes psoriasiform syphilitic papules from psoriatic papules. It is more difficult to differentiate seborrhoeic syphilitic papules and the common papules of seborrhoea. Other symptoms of syphilis must be taken into account in such cases (e.g. roseolar-papular syphilid of the trunk or limbs, the results of blood serological tests, the medical history and, finally, the results of specific treatment, particularly in different cases in which syphilitic and seborrhoeic papules are combined in patients suffering simultaneously from syphilis and seborrhoea oleosa).

The papules of lichen ruber planus differ from the syphilitic papules by their polygonal shape, characteristic lustre, a central umbilication, a tendency to form patches and by itching, which is very intense in some cases. Hypertrophic papules and condylomata lata have to be differentiated from (1) condylomata acuminatum (which have a thin pedicle and do not have a hard infiltrated base), (2) pemphigus vegetans (soft succulent vegetation covered with seropurulent and hemorrhagic crusts and surrounded by strands of epidermis or fresh bullae), and (3) hemorrhoids (tendency to bleed, smooth surface, pain). The patches of palmar-plantar syphilids have to be differentiated from palmar-plantar psoriasis, which proves to be extremely difficult at times. The papular syphilid on the palms and soles has on its periphery a narrow ring of violet infiltrate covered with horny masses. Besides, one should take into account the other symptoms of syphilis (e.g. the results of Wassermann's reaction) and psoriasis (e.g. the frequent involvement of the nail plates, psoriatic onychia).