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  Table of Contents  
Year : 2014  |  Volume : 35  |  Issue : 2  |  Page : 146-148

Annular lichenoid syphilis: A rare entity

1 Department of Dermatology and STD, University College of Medical Sciences and GTB Hospital (University of Delhi), New Delhi, India
2 Department of Pathology, University College of Medical Sciences and GTB Hospital (University of Delhi), New Delhi, India

Date of Web Publication9-Oct-2014

Correspondence Address:
Ananta Khurana
86, Vikasheel Apartments, Sector 13, Rohini, New Delhi - 110 085
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0253-7184.142412

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Syphilis is a disease known for centuries, but still continues to be a diagnostic challenge as the myriad manifestations of secondary syphilis can mimic a lot many dermatological disorders. Lichenoid syphilis is an uncommon entity, reported only occasionally in the penicillin era. We present the case of a 32-year-old woman presenting with localized annular lichenoid lesions on the neck.

Keywords: Annular, lichenoid, syphilis

How to cite this article:
Khurana A, Singal A, Gupta S. Annular lichenoid syphilis: A rare entity. Indian J Sex Transm Dis 2014;35:146-8

How to cite this URL:
Khurana A, Singal A, Gupta S. Annular lichenoid syphilis: A rare entity. Indian J Sex Transm Dis [serial online] 2014 [cited 2020 Aug 11];35:146-8. Available from:

   Introduction Top

A 32-year-old married woman presented with complaints of itchy red rash on her forearms and nape of neck for 2 months. She was clinically diagnosed as polymorphic light eruption and started on mild potent topical corticosteroids and antihistaminics, along with instructions for strict photo protection and use of sunscreen. Her forearm lesions improved with this treatment, but lesions on the nape of neck had worsened with complaints of significant itching, when the patient came for follow-up 2 weeks later. Clinical examination at this point of time revealed presence of annular lichenoid plaques and few lichenoid papules [Figure 1]a. Mucosal examination revealed no abnormality. A skin biopsy was ordered from the lesion on the nape of neck, keeping differentials of annular lichen planus and sarcoidosis. The biopsy revealed acanthosis, and hyperkeratosis in the epidermis. A focal interface infiltrate composed of lymphocytes with a conspicuous presence of the plasma cells as well as eosinophils was seen within the dermis [Figure 2]a. There was also prominent endothelial inflammation with endothelial cell swelling and red blood cell extravasation [Figure 2]b. At places, complete obliteration of the vascular lumina (endarteritis obliterans) was seen, with presence of plasma cells in the vessel walls [Figure 2]b. Based on these findings, a possibility of syphilis was suggested by the pathologist. About a week later, patient reported to us with new lesions over her genitalia and groin. Examination revealed multiple skin coloured to pinkish, flat topped, moist appearing papules in the perianal region, labia majora, pubic region and groin folds, suggestive of condyloma lata [Figure 1]c. In addition, she had developed multiple hyperpigmented macules on both palms. Other mucosae were not involved. There was no evidence of generalized lymphadenopathy or hepatosplenomegaly. Husband was also examined but had no clinical evidence of syphilis. Dark ground illumination test performed from the wet lesions of condyloma lata revealed spiral spirochetes with characteristic motility. Venereal disease research laboratory assay came out to be positive in the titres of 1:256 for the patient and in 1:8 for her husband. Thus, a diagnosis of secondary syphilis (S2) was established. Both partners also had a positive  Treponema pallidum Scientific Name Search magglutination test. Serology for HIV and hepatitis B was negative in both. Repeated questioning about the possible source of infection was not rewarding. Both patient and her husband were treated with a single shot of 2.4 million units of benzathine penicillin after sensitivity testing. All lesions in patient resolved completely within a span of 2 weeks [Figure 1]b and d.
Figure 1: Annular lichenoid plaques on the nape of neck (a) subsiding completely 2 weeks posttreatment (b). Condyloma lata involving groins, labia majora and pubic region (c) with complete resolution post injection penicillin (d)

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Figure 2: Interface dermatitis with conspicuous presence of plasma cells and eosinophils (H and E, ×100) (a); prominent endarteritis obliterans with complete obliteration of the vascular lumina with plasma cell infiltrate (arrow) (H and E, ×400) (b)

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   Discussion Top

Syphilis continues to be a public health problem, with various studies showing a rise in its prevalence, in recent years, in India as well as in the west. [1],[2],[3]

Cutaneous signs are the commonest and most important manifestations of secondary syphilis, with up to 80% of patients developing lesions of the skin or mucous membranes. [4] A dermatologist needs to be aware of the protean mucocutaneous manifestations that secondary syphilis can present with, to avoid misdiagnosis of this infection.

Lichenoid eruptions in secondary syphilis have been reported since the prepenicillin era. However, they were believed to be caused by arsenicals, which formed the mainstay of treatment of syphilis in those days. [5] Jeerapaet and Ackerman were the first to report lichenoid histological changes in patients of S2. [6] In 1974, Lochner and Pomeranz established the clinical-histopathologic correlation for lichenoid lesions occurring in syphilis. [7]

In the penicillin era as well, lichenoid lesions have been reported, albeit occasionally. [8],[9],[10],[11] Most of these cases including the present case had associated pruritus, which is otherwise an unusual symptom in S2 per se.[7],[10],[11] Annular lichenoid lesions are even rare and have been reported previously on only two occasions. [10],[11] The localized annular lichenoid lesions may present as a diagnostic dilemma, more so when other features of secondary syphilis are absent, as seen on the first visit in the present case. In this situation, a clinician has to entertain other conventional differentials such as lichen planus, annular sarcoidosis and granuloma annulare. In addition, like secondary syphilis, all the aforesaid disorders may also show interface inflammatory infiltrate on histology. However, in the present case, the presence of profuse plasma cell infiltrate and prominent endarteritis strongly suggested a diagnosis of syphilis. Further, presence of eosinophils in the infiltrate as in the present case is of rare occurrence. Histology mimicking lichenoid drug eruption with the presence of eosinophils and high level civatte bodies has been described by Tang et al. [10]

   Conclusion Top

The presence of lichenoid lesions in a sexually active individual not responding to conventional therapy should arouse the suspicion of secondary syphilis. A thorough and serial clinical examination and careful histological evaluation is pertinent to reach at the definitive diagnosis.

   References Top

Ray K, Bala M, Gupta SM, Khunger N, Puri P, Muralidhar S, et al. Changing trends in sexually transmitted infections at a Regional STD Centre in north India. Indian J Med Res 2006;124:559-68.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
Jain A, Mendiratta V, Chander R. Current status of acquired syphilis: A hospital-based 5-year study. Indian J Sex Transm Dis 2012;33:32-4.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
Schumacher CM, Ellen J, Rompalo AM. Changes in demographics and risk behaviors of persons with early syphilis depending on epidemic phase. Sex Transm Dis 2008;35:190-6.  Back to cited text no. 3
Martin DH, Mroczkowski TF. Dermatologic manifestations of sexually transmitted diseases other than HIV. Infect Dis Clin North Am 1994;8:533-82.  Back to cited text no. 4
Ahlswede E. Arsphenamine eruptions resembling lichen planus. Arch Dermatol Syphilol 1924;9:479-81.  Back to cited text no. 5
Jeerapaet P, Ackerman AB. Histologic patterns of secondary syphilis. Arch Dermatol 1973;107:373-7.  Back to cited text no. 6
Lochner JC, Pomeranz JR. Lichenoid secondary syphilis. Arch Dermatol 1974;109:81-3.  Back to cited text no. 7
Carbia SG, Lagodín C, Abbruzzese M, Sevinsky L, Casco R, Casas J, et al. Lichenoid secondary syphilis. Int J Dermatol 1999;38:53-5.  Back to cited text no. 8
Monastirli A, Pasmatzi E, Georgiou S, Vryzaki E, Tsambaos D. Lichen planus-like secondary syphilis in an 83-year-old woman. Clin Exp Dermatol 2008;33:780-1.  Back to cited text no. 9
Tang MB, Yosipovitch G, Tan SH. Secondary syphilis presenting as a lichen planus-like rash. J Eur Acad Dermatol Venereol 2004;18:185-7.  Back to cited text no. 10
Narang T, De D, Dogra S, Kanwar AJ, Saikia UN. Secondary syphilis presenting as annular lichenoid plaques on the scrotum. J Cutan Med Surg 2008;12:114-6.  Back to cited text no. 11


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