Syphilis is a STI that can cause very serious health problems if left untreated. Syphilis is divided into stages: primary, secondary, latent, and tertiary. There are different signs and symptoms associated with each stage. Primary syphilis typically has one or more sores at the original site of infection that are usually firm, round, and painless. Secondary syphilis may include a skin rash, swollen lymph nodes, and fever. Primary and secondary syphilis symptoms can be mild and might go unnoticed. During the latent stage, there are no signs or symptoms. Tertiary syphilis is associated with severe health problems that can affect the heart, brain, and other organs of the body. Syphilis is curable with the right antibiotics. In 2018, Hawai‘i ranked 28th in the U.S. for rates of primary and secondary syphilis cases (6.4 per 100,000 population). 

WHY IS IT IMPORTANT TO TREAT SYPHILIS? 

Untreated syphilis can lead to severe health problems including permanent vision and hearing loss, stroke, organ damage, and in some cases, death. Having a syphilis infection also makes it more likely to get or spread HIV. 
If a pregnant woman has syphilis, she can pass it on to her baby. This is called congenital syphilis and it is very dangerous and can lead to congenital abnormalities or even death of the baby (see ‘Congenital Syphilis’ below).  

HOW IS IT SPREAD? 

Syphilis is spread from one person to another by direct contact with a syphilitic sore, called a chancre (pronounced shang-kr). Transmission of syphilis occurs during vaginal, anal, or oral sex. Pregnant mothers can transmit syphilis to their unborn baby during pregnancy (see ‘Congenital Syphilis’ below).  

WHAT ARE THE SYMPTOMS? 

Syphilis is referred to as “The Great Pretender” because its symptoms can look like many other diseases. The infection progresses in stages that can last for weeks, months, or even years:  

Primary Stage 
The first sign of primary syphilis often one or more chancres (usually firm, round, small, & painless). They appear at the location where syphilis entered the body (during sex), such as the external genitals, in the vagina, around the anus or in the rectum, or in or around the mouth. These painless chancres can occur in locations that make them difficult to notice, so you can have a chancre and not realize it. They go away after 3 to 6 weeks even without treatment, but you will still be infected. 

Secondary Stage 
The secondary stage of syphilis is marked by skin rashes and/or mucous membrane lesions (sores in the mouth, vagina, or anus) 1 to 6 months after becoming infected. The common symptoms of secondary syphilis are: 

• Rashes that are rough, red, or reddish-brown spots on the palms of the hands and the bottoms of the feet; usually not itchy 
• Rashes that are on the arms, legs, trunk or anywhere else on the body, rashes that are light/faint in color; usually not itchy 
• Large, raised, gray or white lesions (condyloma lata) that develop in warm, moist areas (mouth, underarm, or groin area) 
• Flu-like symptoms including fever, sore throat, headaches, fatigue 
• Patchy hair loss (alopecia) 
• Weight loss, muscle aches 

Symptoms usually last from one to three months and will go away even without treatment. However, without treatment, the infection will progress to the latent and possibly tertiary stage of disease.  

Latent Stage 
The latent (hidden) stage of syphilis is when a person is infected but shows no signs or symptoms. If you do not receive treatment, the infection can continue in your body for years without any signs or symptoms.  

Tertiary Stage 
Most people with untreated syphilis do not develop tertiary syphilis. However, when it does happen it can affect many different organ systems. These include the heart and blood vessels, and the brain and nervous system. Tertiary syphilis is very serious and would occur 10–30 years after your infection began.  In tertiary syphilis, the disease damages your internal organs and can result in death. 

Neurosyphilis and Ocular Syphilis 
Without treatment, syphilis can spread to the brain and nervous system (neurosyphilis) or to the eye (ocular syphilis). This can happen during any of the stages described above. 

Symptoms of neurosyphilis include 

• severe headache; 
• difficulty coordinating muscle movements; 
• paralysis (not able to move certain parts of your body); 
• numbness; and 
• dementia (mental disorder). 

• Symptoms of ocular syphilis include changes in your vision and even blindness. 

HOW DO I GET TESTED FOR SYPHILIS? 

In most cases, a blood test is used to test for syphilis. It is possible to diagnose syphilis by testing fluid from a syphilis chancre, but this method is less common. Your provider may also ask questions about your sexual history and examine parts of your body where you might have symptoms (chancres, rash, etc.) – these steps are important in helping your provider to stage the infection and decide on appropriate treatment. 

HOW IS SYPHILIS TREATED? 

Penicillin shots cure syphilis. Your provider can discuss options for you if you have a serious allergy to penicillin. The stage of syphilis that you are in will dictate the amount of penicillin you receive. Note that since March 2023, the manufacturer of the penicillin used for syphilis treatments in the U.S. has reported a manufacturing limitation that puts that medication in short supply. Your provider might discuss a treatment with you that is different from penicillin shots, such as pills known as doxycycline. Whatever your treatment, including penicillin, might not undo any damage that the infection has already done. 
It is very important to have repeat syphilis blood tests after you are treated to make sure the treatment worked, and the infection is completely gone. This is typically done 6, 12, and 18 months after treatment is completed. 
You should not have sex for one week after you’ve taken antibiotics. If your symptoms are still present after completing treatment, it is very important to tell your health care provider. 
Your sex partners will need to get treated as well. If your sex partners are not treated, you can get the infection again from them or they can infect others. 

CAN I GET SYPHILIS MORE THAN ONCE? 

Once you are adequately treated for syphilis, you will be cured. However, you are not immune to a second infection, meaning you can be re-infected if you’re exposed to the bacteria again. 

HOW CAN I AVOID GETTING SYPHILIS? 

If you are sexually active, using condoms consistently and correctly for vagina, oral, and anal sex will lower your chances of getting syphilis. 
You can also lower your risk by being in a long-term, mutually monogamous relationship with a partner who has been tested and is negative for syphilis. 
Have open and honest talks with your health care provider and establish a risk-reduction plan to protect your own health as well as the health of your sexual partners. 

CONGENITAL SYPHILIS 

Congenital syphilis (CS) is a disease that occurs when a mother with a syphilis infection passes it on to her baby during pregnancy. Cases of CS are increasing in Hawaii and across the nation – women and their families, providers, and the community should be aware in order to take appropriate action to protect the health of Hawaii’s mothers and babies. 

How can CS affect a baby? 
CS can have major impacts on a baby’s health. How much CS affects a baby depends on how long the mother had syphilis and if, or when, treatment was received for the infection. 

CS can cause: 

• Miscarriage (losing the baby during pregnancy), 
• Stillbirth (a baby born dead), 
• Prematurity (a baby born early), 
• Low birth weight, or 
• Death shortly after birth. 

Up to 40% of babies born to women with untreated syphilis may be stillborn, or die from the infection as a newborn. 
For babies born with CS, CS can cause: 

• Deformed bones, 
• Severe anemia (low blood count), 
• Enlarged liver and spleen, 
• Jaundice (yellowing of the skin or eyes), 
• Brain and nerve problems, like blindness or deafness, 
• Meningitis, and 
• Skin rashes. 

Babies with CS can be without any symptoms at birth, but without treatment the baby can develop serious health problems in the first few weeks or few years after birth. Babies who do not get treatment for CS and develop symptoms later can die from the infection. They may also be developmentally delayed or suffer from seizures. 

What should I do if I am pregnant? 
All pregnant women should tested for syphilis at the first prenatal visit (the first time you see your doctor for health care during pregnancy). A medical advisory from Hawaii Department of Health (08/2020) advises all pregnant women to be tested, in addition to the first prenatal visit, at 28-32 weeks gestation and then again at the time of delivery.  

Talk to your OB/GYN provider about testing for syphilis and keep in mind that you can have the infection and not know it. 

How do I know if my baby has CS? 
Your doctor should consider several factors to determine if your baby has CS. These factors include the results of your syphilis blood test and, if you were diagnosed with syphilis, whether you received treatment during your pregnancy. Your doctor may also want to assess your baby for CS by doing a blood test as well as a spinal tap, performing a physical exam of your baby, and other tests such as an x-ray. 

If my baby has CS, can they be treated for the infection? 
There is treatment for CS – babies with CS need to be treated right away or they can develop serious health problems. Depending on the results of your baby’s medical evaluation, they may need antibiotics in a hospital for 10 days.  
It is important that babies treated for CS get follow-up care to make sure that the treatment worked. 

HOW CAN I REDUCE THE RISK OF MY BABY GETTING CS? 

Your baby will not get CS if you do not have syphilis. There are two important things you can do to protect your baby from getting CS and the health problems associated with the infection: 

• Get a syphilis test at your first prenatal visit. 
• Reduce your risk of getting syphilis before and during your pregnancy. 

Talk with your doctor about your risk for syphilis. Have an open and honest conversation about your sexual history and STI testing. Your doctor can give you the best advice on any testing and treatment that you may need. 

Additional Resources

Hawaii STI Surveillance Summary 2009-2019
Syphilis Fact Sheet – CDC 
Congenital Syphilis Fact Sheet – CDC 
Recent Statistics (CDC)