"A syphilis sore on the nipple, a rare but potentially deceptive manifestation, underscores the importance of considering a broader range of diagnoses for persistent or unusual lesions, even when symptoms appear far from the typical genital presentation."
A recent medical image published in The New England Journal of Medicine showcases a highly unusual location for a primary syphilis lesion: the nipple. This case, titled "Syphilitic Chancre on the Nipple," by physicians Yangbin Wang and Chun-Fang Guo of Shenyang Seventh People’s Hospital in Liaoning province, China, draws attention to the diverse and sometimes unexpected ways syphilis can present. A chancre, the hallmark of primary syphilis, marks the initial site of infection by the bacterium Treponema pallidum. When it appears in non-genital areas, it can be easily misdiagnosed, leading to delayed treatment and potential progression of the disease. This rare presentation serves as a critical reminder for both healthcare professionals and the public to maintain a high index of suspicion for sexually transmitted infections, even when symptoms manifest in seemingly unrelated locations.
Extragenital chancres, those occurring outside the typical genital regions, are relatively uncommon, accounting for approximately 2% of primary syphilis cases, according to a 2018 report published in the dermatology journal Cutis. Among these extragenital sites, the lips and mouth are the most frequently observed, representing between 40% and 70% of such occurrences. The nipple, however, presents an even rarer locale for a syphilitic chancre. A comprehensive review of the medical literature conducted in 2018 by the authors of the Cutis report identified only nine English-language case reports detailing chancres on the nipple or areola. Intriguingly, in all but one of these documented instances, the affected individuals reported a history of oral contact with the nipple or physical trauma to the area sustained from a sexual partner. This suggests that such intimate contact or minor injury can create an entry point for the Treponema pallidum bacterium.
The transmission of syphilis, in general, occurs through direct contact with a syphilis sore, commonly referred to as a chancre. This transmission typically happens during vaginal, anal, or oral sexual intercourse, as outlined by the Centers for Disease Control and Prevention (CDC). The CDC also emphasizes that syphilis sores can develop in areas not covered by condoms, meaning that contact with these lesions can still lead to infection. This underscores the pervasive nature of the infection and the importance of recognizing that syphilis is not confined to conventional sexual acts or specific anatomical locations.
The diagnostic challenge posed by a nipple chancre is significant, as its appearance can mimic a range of more common or far more serious conditions. The Cutis report authors meticulously listed several differential diagnoses that physicians often consider when faced with a nipple lesion. These include nipple eczema, a benign inflammatory condition; erosive adenomatosis of the nipple, a non-cancerous proliferation of the milk ducts; ulcerated basal cell carcinoma, a form of skin cancer; and Paget disease of the breast, a rare but serious malignancy that often begins as a scaly or crusted patch on the nipple. The overlapping clinical presentations of these conditions can considerably delay an accurate diagnosis. Initially, a crusted sore might be mistakenly treated as a simple skin irritation or a routine bacterial infection. If the lesion fails to respond to conventional treatments, a physician may then escalate their concern towards the possibility of cancer.
Compounding the diagnostic difficulty is the often deceptive nature of chancres, which are typically painless. The CDC describes syphilis sores as usually, though not always, firm, round, and painless. These lesions characteristically persist for three to six weeks and have a tendency to heal spontaneously, regardless of whether treatment is administered. This spontaneous healing can be profoundly misleading, as it does not signify the eradication of the infection. The bacterium remains within the body, and the syphilis can progress to secondary and tertiary stages, potentially affecting the skin, nervous system, eyes, and vital organs. The variability in the appearance of nipple chancres is further illustrated by earlier documented cases. A 2020 report in Case Reports in Dermatological Medicine detailed a patient with secondary syphilis whose nipple chancre was subjected to a skin biopsy and immunohistochemistry, a sophisticated laboratory technique employing antibodies to detect the presence of bacteria within tissue samples. In a separate instance from 2014, published in Acta Dermato-Venereologica, primary syphilis manifested as eczema-like lesions affecting both the nipples and areolas of a patient.
Despite the geographical origin of this particular case from China, syphilis remains a significant public health concern in the United States. Provisional data from the CDC’s 2024 surveillance reports, which represent the most current national figures available, indicate a total of 190,242 reported syphilis cases, translating to a rate of 55.9 cases per 100,000 individuals. While there has been a notable decrease of 9.1% in overall syphilis cases compared to 2023, and a substantial drop of 21.7% in primary and secondary syphilis cases (the most infectious stages) to 41,496, congenital syphilis, transmitted from a pregnant individual to their infant, has seen an increase. Congenital syphilis cases rose by 1.6% to 3,941, and the CDC anticipates this number will likely see further upward revision once the final data are compiled.
The treatment for early-stage syphilis is straightforward and highly effective when the necessary medication is accessible. The CDC’s treatment guidelines recommend a single intramuscular injection of benzathine penicillin G for adults diagnosed with primary or secondary syphilis. This treatment is typically accompanied by HIV testing at the time of diagnosis and scheduled follow-up examinations at six and twelve months post-treatment. However, a persistent challenge in the United States has been the availability of this crucial medication. The CDC’s latest product update indicates that the primary U.S. manufacturer of Bicillin L-A, the key formulation for this treatment, anticipates a full recovery in its supply chain by the fourth quarter of 2027. In response to this shortage, the U.S. Food and Drug Administration (FDA) has authorized the temporary importation of alternative penicillin products. Furthermore, in a March 2026 communication to clinicians, the CDC issued guidance urging healthcare providers to prioritize the penicillin injection for pregnant patients. For men and non-pregnant women diagnosed with early syphilis, the CDC advises the use of doxycycline, an oral antibiotic regimen typically taken for 14 days, as an alternative treatment.
The publication of this NEJM image serves as a crucial reminder that syphilis does not always conform to conventional expectations of its presentation. When a sore appears on the nipple, lips, mouth, fingers, or any other part of the body and fails to heal within a reasonable timeframe, clinicians must broaden their diagnostic considerations. This may necessitate inquiring about recent sexual contact and ordering syphilis blood tests, which are generally inexpensive and widely accessible. For individuals, the takeaway message is one of proactive health management. Any sore on the body that does not resolve within a few weeks, particularly if it emerges following sexual contact, warrants prompt medical evaluation. Even if a sore appears to heal on its own, it is imperative to seek medical attention, as the underlying infection may persist and require treatment. Furthermore, sexual partners of an infected individual may also require testing and treatment to prevent further transmission and reinfection. Pregnant individuals or those planning a pregnancy are especially encouraged to adhere to current syphilis screening recommendations, as early diagnosis and treatment during pregnancy are critical for preventing congenital syphilis, a potentially devastating condition for newborns.
