Syphilis: Transmission, Signs, Symptoms in Men and Women, Disease Stages, Diagnosis and Treatment, Antibiotics

Syphilis: Symptoms, Signs, Diagnosis & Treatment, Disease Stages

What is Syphilis?

Syphilis is a chronic systemic venereal infectious disease, which leads to severe damage to the skin, mucous membranes, internal organs, bones, nervous system caused by a bacteria Treponema pallidum (pale treponema), subspecies pallidum – a spirochetal organism belonging to the genus Treponema.

Modern medicine is able to cope easily with this type of STD disease, but if patients are not treated, then they are fated to die a slow and painful death with a wide range of symptoms.

Transmission Routes

Features of the syphilis transmission can be explained by some biological characteristics of the pathogen, in particular, the demand for moisture and temperature of the environment.

In most cases, syphilis is a sexually transmitted disease and therefore refers to the group of STDs such as gonorrhea, chancroid, and fourth venereal disease (Lymphogranulomatosis inguinalis). However, it can potentially be transmitted through blood, e.g., in result of blood transfusion from an infected donor, or in drug users through common syringes and / or shared reservoirs for the drugs solutions, or through contaminated hands or objects such as toothbrushes or razors.

Domestic “bloodless” route of transmission of syphilis is not excluded, but it is extremely rare and requires close contact with patients infected with tertiary syphilis, who have open syphilitic sores or syphiloma from which the pathogen can get the dishes, towels, spoons, toothbrushes, linens, etc. contacting with mucous membranes. The ability of the patient’s urine and perspiration to pass the infection has not been proved. Pale treponema is detected in saliva only in the presence of lesions in the oral cavity. A newly-born baby can be infected by mother’s milk even without any visible changes in the mammary gland. The sperm can be also contagious even without visible lesions on the penis of a patient. Medical personnel can become infected with the disease during medical and diagnostic measures, as well as during the postmortem dissection of patients infected with syphilis.

Signs of Syphilis

Getting into the human body, a pale treponema, the causative agent of syphilis, passes the incubation period, which lasts from 1 to 6 weeks. At the time people don’t even realize they have syphilis, since they don’t have any symptoms. At this stage even tests can not detect the disease. There is a high probability that a patient will infect several sexual partners with syphilis, not suspecting the consequences.

The first signs of the disease appear at the end of the incubation period – it is the primary syphilis stage. A syphilis sore (called a chancre) pops up — that sore is where the syphilis infection entered your body. They can be on the skin in the form of a solid chancre, multiple chancre, syphilitic rash, baldness (skin syphilis) and on the mucous membranes – chancro in the mouth, on the genitals (syphilis mucous membranes).

Signs of Syphilis in Women

The end of the asymptomatic period is marked by the formation of the first sign of infection (3-4 weeks after infection). The first signs of syphilis in women in the form of a hard chancre become visible. Its formation is a sign of the primary stage of syphilis. A hard chancre is formed as an immune response to the pale treponema bacterium. It is localized in the mouth, on the external and internal genital organs, anus.

Hard chancre is an inflammatory outgrowth of a rounded shape. It does not hurt at the primary stage of its formation. If you do not carry out the treatment, the chancre can be accompanied by a syphilitic rash in the visible places of the body and on the mucous membranes.

Signs of Syphilis in Men

In men, as in women, the first noticeable sign of infection appears in the form of a hard chancre. The ulcer is formed on the penis, at its base and on its head. However, it can also appear in the mouth, on the scrotum and on the opening of the anus. Symptoms and course of the disease are practically the same for male and female.

Symptoms of Syphilis

Symptoms of Primary Syphilis

  • The primary stage of syphilis begins with the formation of a hard chancre on the skin or mucous membranes of a patient. At the initial stage, this does not cause any serious discomfort. Then the gradual inflammation of the chancre occurs, it becomes red- or blue colored – a sign of a strong inflammatory process.
  • Within the first week after formation of the first symptoms, inflammation of the lymph nodes and vessels around the chancre begins (regional scleradenitis). Lymphonoduses inflame in the form of tangles. If the sore is localized in the mouth, it can cause the inflammation of a tonsil and swelling of the throat, making it difficult to swallow and breath. These symptoms can cause a considerable suffering during verbal communication and food intake. Scleradenitis in the genital area complicates the walking process and the act of defecation.

The end of the primary and the beginning of the secondary syphilis is considered to be the occurrence of a specific rash on the patient’s body. Modern diagnostic methods can detect syphilis immediately after the appearance of the first symptoms. Most often, enzyme immunoassay (ELISA) and polymerase chain reaction (PCR) are used. These tests are prescribed by the therapist or venereologist in a skin-venereal dispensary. But these types of analyzes may be done only at the stage of primary syphilis. Earlier analyzes will show only a seronegative reaction, indicating the absence of pale treponema in the body.

Symptoms of Secondary Syphilis

  • The skin around the chancre is covered with spots and ulcers, which diameter ranges from 10 to 15 mm. The rash can grow and unite in vast areas on the skin and mucous membranes, causing severe discomfort to a patient. There are three types of syphilitic rash.
    Roseolous rash – pink or red spots with clear or blurred edges 5-50 mm in diameter. There are no cavities.
    Papular rash – small conical outgrowths of pink color, peel off on top. It looks extremely unpleasant.
    Pustular rash – outgrowths with purulent cavities.Syphilis rash on hands

    Syphilis rash

    Skin rash caused by syphilis

  • Along with the formation of the rash, the nervous system may be affected. Degradation of the nervous tissue adversely affects the eyesight, memory, attention, coordination of movements. Unfortunately, there is no treatment that is able to restore the lost functions of the central nervous system. It only stops the process of further damage to the nervous tissue.
  • There are signs of partial or complete baldness. At first, the quality of the hair cover deteriorates: the hair is thinning and coming out. When the process of hair thinning increases, there are extensive bald areas of the skin. After the treatment of syphilis, the hair does not resume.

Syphilis Video

In this video: syphilis causes, symptoms, diagnosis, treatment and pathology.

Syphilis Pictuses

Images of patients with syphilis

A medical illustration from ‘Bilze De Nieuwe Natuurgeneeswijze’ (by F.E. Bilz) depicts six different cases of syphilis, 1923.

Syphilis vintage imageSyphilis Picture

Stages of Syphilis

Nowadays each person infected with pale treponema can be treated very quickly and effectively. Very few people pass through all stages of syphilis. Without an adequate treatment, patients usually live 10-20 years in terrible agony, and then they die.

Below is a brief description of the stages of syphilis.

The Incubation Period

StageTime boundariesDescription of symptoms
Incubation period189 days since the moment of bacterial penetration into human organism.During this period, there are no visible manifestations in the patient’s body.
If the infection gets to several parts of the body at the same time, then the incubation period is about 1-2 weeks. If an infected person takes antibiotics, for example, from influenza or from angina, then the incubation period can last for more than six months. The end of this period coincides with the appearance of the first symptom – a hard chancre and inflammation of the lymph nodes. If the pathogen has got directly into the blood, then the stage of primary syphilis is not manifested and the disease immediately develops into the secondary stage.

The Primary Syphilis Stage

StageTime boundariesDescription of symptoms
The primary syphilis stageSince the formation
of a hard chancre
before the
appearance of a rash and inflammation
of the lymph nodes around the chancre
Hard chancre is a small, painless sore that appears on a person’s body, caused by an immune reaction to pale treponema. It has a rounded shape and undermined edges. Localized in the area of ​​infection (genitalia, mouth, anus, fingers).
It does not cause any pain, but its formation should motivate a patient to refrain from sexual contacts and immediately consult a doctor to begin a treatment before the appearance of syphilitic rash.At the end of the primary stage, a multiple chancre can appear.
The second symptom is the formation of inflamed lymph nodes next to the hard chancre.
At the end of the primary syphilis stage, patients can suffer from a slight indisposition, dizziness, and body temperature increase.
At this stage, some atypical symptoms may appear. Read more about them further in the article.
Syphilis without chancresHardly determinableObserved when the infection penetrates through the blood. No symptoms, the disease immediately goes to the secondary or latent stage, bypassing the primary one.

The Secondary Syphilis Stage

It is divided into four stages. Without an adequate treatment, the course of the disease may be the following:

The course of secondary stageTime boundariesSymptoms
Early (Lues secundaria recens)From 60 to 70 days after infection.
From 40 to 50 days after the formation of chancres. It lasts from a few days to 1-2 weeks.
Three types of eruptions, caused by an active response of the immune system and the production of endotoxins fighting the infection.
The nervous system, internal organs, bones suffer.
The temperature rises to 37-37.5 ° C, accompanied by lack of energy, coughing, runny nose, conjunctivitis.
Extensive inflammation of the lymph nodes, which are firm to the touch occurs without any pain and discomfort.
All the symptoms can be accompanied with half or complete baldness.
LatentSince the 60th day after the chancre formation or laterIn a certain period the immune system blocks the infection that destroys the body. The rash does not appear. The infection does not go away from the organs and tissues; a patient lives in anxious expectation of a relapse.
RecurrentAfter a latent phaseA relapse may occur because of immunity weakening (stress, cold, skipping meals, trauma). It manifests itself in a more extensive rash with cutaneous hemorrhages. All the symptoms that are characteristic of early syphilis are repeated. A multiple chancre of genital organs is formed.
Early neurosyphilis2 years after
the disease
Caused by inflammation and damage to blood vessels and neurons of the brain, internal organs (almost always the heart and liver), as well as bones and joints. It manifests itself in the form of chronic meningitis. The disease impairs an ability of pupils to narrow when exposed to light. Inside the brain vessels miliary gumma is formed, which increase intracranial pressure, worsening health and causing headaches. Many symptoms disrupt the higher mental functions, such as attention, memory, coordination of movements. The changes are irreversible.

The Tertiary Syphilis Stage.

It is divided into three stages. Without an adequate treatment, the consequences will be as follows:

Description of symptoms
The latent chronic stageLasts
from 1 year
to 20 years
About 70% of patients live as carriers of infection, moving from the latent phase of tertiary syphilis to the recurrence phase. However, the immunity system eventually fails. A person goes to the next stage with a high probability of becoming disabled or with a fatal outcome.
The tertiary syphilisWith the corresponding symptomsAn extensive damage to all organs and tissues, bones and the nervous system occurs. Gummas are formed in several parts of the body. These are purulent tumors, often bleeding and wet from the lymph. Often appear on the face, forming scars on the skin. Often, gummas can be infected with other bacteria, leading to serious complications: abscess and gangrene.
Late stage of neurosyphilisThe final stage leading to disability and imminent
10-15 years since the appearance
of the first symptoms.
Extensive damage to the central nervous system, leading to loss of vision, paralysis, cognitive dysfunctions.
Infectious diseases of the brain may also develop – meningitis, brain gummas and gummas of bones.

Neurosyphilis begins at the end of the secondary syphilis stage. Usually manifested in the form of the following diagnoses:

  • Asymptomatic neurosyphilis: no painful manifestations, but tests show inflammation and infection of the CSF. This stage of neurosyphilis usually begins in 1,5 years after infection.
  • Gummous neurosyphilis – accompanied by the formation of gummas inside the brain and spinal cord. This is a painful symptom – a large tumor, causes permanent pain, an increase in pressure inside the patient’s skull.
  • Syphilitic meningitis is a lesion of the brain lining at the base of the skull and in the cranial vault. It is accompanied by severe symptoms, including alteration of attention, memory problems, emotional state.
  • Meningovascular form of neurosyphilis – destroys the vessels of the brain, accompanied by chronic meningitis. Without an adequate treatment leads to headaches, change of behavior, sleep disorders, convulsions and strokes as a result.
  • Spinal amyelotrophy – lesions of the nerve fibers of the spinal cord, their dysfunction. This leads to an irreversible disorientation: gait disorder, a patient may fall, feeling as if the ground slipping from under his feet.
  • Progressive paralysis – causes dysfunctions of the central nervous system, accompanied by a violent behavior. Patients lose control of themselves and can easily get into a psychiatric clinic if they are not diagnosed with syphilis in time. Ultimately, the progressive paralysis leads to complete paralysis of the body.
  • Atrophy of the optic nerve – degradation of the visual function. At first, only one eye is damaged, but the infection gradually approaches the second optic nerve. Without treatment it leads to complete blindness. Changes in the visual apparatus are irreversible.
  • Late visceral syphilis – degradation of internal tissues. In most cases the cardiovascular system and the liver suffer. Other organs are rarely affected. Patients complain of health worsening, they have systolic heart murmurs due to the aorta expansion. If the late visceral syphilis localizes in the heart then a heart attack may occur.
  • Late syphilis of bones and joints – causes local enlargement of bones and joints. It is accompanied by the formation of gummas on bones.

Atypical Syphilis

In addition to hard chancres, other so-called “atypical chancres” may appear at the stage of primary syphilis. That is why such course of the disease is called atypical syphilis. Atypical chancres may be in the following forms:

  • Indurative edema.

It looks like a change in the color of the scrotum in men, the clitoris and the labia in women. Color varies from scarlet to cyanotic in the center, but pale along the edges. Women are susceptible to this symptom more often than men. Usually, the patient perceives the inductive syphilitic edema as an infectious-inflammatory disease of a different kind, since the blood test at this stage of syphilis does not provide any information about the cause of edema. It is possible to distinguish it from another infection by the absence of an inflammatory process in the blood and the presence of inflammation of the lymph nodes.

  • Chancre of the Panaritium.

It may appear in people caring for patients infected with syphilis: medical staff, relatives. Thumb, index and middle fingers of a hand are affected. This is a very painful signs. The skin peeling on the fingers, forming extensive bleeding sites, as with second-degree burns. Panaritium is accompanied by a swelling and inflammation of the fingers. Often a hard chancre of the genitals appears.

  • Chancre amygdalite

It manifests itself in the form of inflammation of one amygdala, its surface is not damaged and it remains smooth. The oral cavity is exposed to severe pain, swallowing is difficult; a patient experiences a fever. The difference from angina is that in case of amygdalitis only one tonsil inflames.

Congenital Syphilis

The transmission of the disease during pregnancy is highly undesirable. The fetus is exposed to pale treponema, which leads to irreversible consequences, a violation of intrauterine development.

There are three main symptoms:

  1. Parenchymal keratitis is a pathology of the external epithelium of internal organs and the eyeball. It is characterized by a strong reddening and inflammation of the organ from the outside. Sometimes the inflammation penetrates a little deeper. After treatment scars and opacity remain. The most common consequence is a decrease in visual acuity. Keratitis is accompanied by a clouding of visual perception, acute pain and lacrimation.
  2. Deafness from birth. The causative agent of syphilis actively destroys the neural tissues of the fetus during pregnancy. One of the options may be the pathology of the auditory nerve, which leads to irreversible deafness.
  3. Congenital malformations of the teeth, which occur due to tooth tissue hypoplasia. This pathology is called the Getschinson’s teeth. Teeth grow in the form of a screwdriver, there is a lot of distance between them. Sometimes teeth are not completely enameled what leads to their early destruction.

A child who has undergone intrauterine syphilis has weakened health even if a mother has successfully completed the course of treatment. Without an adequate treatment the child will have severe malformations and remain disabled. If a woman is still infected the breastfeeding should be stopped immediately, as syphilis is transmitted through the woman’s milk.

If a woman who previously had had syphilis wants to become pregnant, she should be tested for pale treponemia (ELISA or PCR). After receiving the results, women can safely decide on pregnancy.

The Causative Agent of Syphilis

Pale treponema (Treponema pallidum) is a bacterium – the causative agent of syphilis.

German scientists in 1905 discovered the cause of one of the most common venereal disease. After discovering the bacterial nature of the disease, microbiologists and pharmacists found the key to a quick syphilis treatment, and they opened the way to the invention of methods for early diagnosis.

Properties of the Pathogen

The bacteria treponema was called pale because scientists could not put it under a microscope. The transparent treponema is difficult to be colored into other colors. For staining, the methods of Romanovsky-Gizma and silver impregnation are used, which make it possible to detect a bacterium under a darkfield microscope for further studies.

It was found that under favorable conditions (it should only be the human or animal body) pale treponema cell is divided every 30-32 hours. Treponema lives and multiplies only at a temperature of 37 ° C. This explains the effectiveness of archaic methods of treating syphilis by artificially raising the patient’s body temperature to 41 ° C and infecting the syphilis patient with malaria; – there was some relief of symptoms.

The length of the bacterium is 8-20 μm, a thickness is about 0.25-0.35 μm. Its body is relatively long with curls in the form of a tangle. At the same time, it constantly changes the shape and quantity of curls because of the ability of cells to contract.

(photo of Treponema pallidum)

The Incubation Period

The incubation period is a period, which lasts from the moment of penetration of pale treponema into the body till the onset of primary affect, including a hard chancre in combination with lymphadenitis. During this period there is a gradual increase in the number of cells of the pathogen in the place of their penetration into the patient’s body. Treponema multiplies by dividing once every 30-32 hours. This period of the disease is characterized by the absence of clinical and serological changes in the patient’s body (no visible symptoms are observed), it lasts 3-4 weeks, it may shorten to 8-15 days or lengthen up to 108-190 days. The shortening of the incubation period occurs, as a rule, with simultaneous infection of the organism from 2 different places of the body, lengthening with the intake of antibiotics after the moment of infection. Although it should be noted that the increase in the incubation period is not always due to the intake of antibiotics.

When the formation of a hard chancre on the body in combination with inflammation of the lymph nodes occurs – this means a transition from the incubation period to the stage of primary syphilis.

How Is Syphilis Transmitted? Ways of Transmission. How Do You Get Syphilis?

In most cases the process of transmission occurs through sexual contact. People can become infected through traditional, anal and oral sex, even if their partner is in the incubation period of disease. Hard chancre is formed in the places of bacteria penetration.

When nursing patients, healthcare staff may become infected through contact with the patient’s clothing, personal items, body. In this case, chancre-panaritium appears, affecting the fingers and toes. This is one of the most painful symptoms at the stage of primary syphilis. Then a hard chancre of the genitals may form.

Syphilis can be transmitted through the blood: when transfusing contaminated blood, with used syringes, razors, scissors, utensils.

Diagnosis of Syphilis

Serological Blood Test

This test is based on the search for antibodies, which are produced by the body to fight pale treponema. For the analysis the patient’s blood, freed from blood balls – serum (serum) is used. This is the reason why the test is called serological. It is performed at mass prophylactic examinations of the population, several times during pregnancy and in some other cases.

Wasserman’s Reaction

A sample of blood from the ulnar vein is taken and introduced to the antigen. When a person is infected with syphilis, the Wasserman reaction test gives a positive result not immediately, but only after 6-7 weeks.

Proceeding from this, primary syphilis is divided into seronegative and seropositive stages.

At the seronegative stage of primary syphilis, Wasserman’s negative reaction can not serve as an indicator of the absence of the disease and more accurate diagnostic methods are used to confirm or disprove the diagnosis.

The positive Wasserman reaction can be of different extent of intensity. The intensity of the reaction (classed 1, 2, 3, or 4) indicates the severity of the condition, is denoted by the sign “+” with a certain index:

  • 1 + 2+ – result is weakly positive
  • 3+ – positive
  • 4+ – strongly positive

The Wassermann’s Reaction test may also give FALSE positive results during pregnancy, after current or completely cured syphilis, under some other circumstances.

The Reaction of Immunofluorescence (RIF)

At RIF pale treponema, which is taken from a rabbit infected with syphilis, when interacting with the immune serum of a patient with syphilis gives a yellowish-greenish glow in a luminescent microscope. If a person is not infected with syphilis, then no glowing is observed. If the luminescence is detected, then its intensity is estimated in the same way as in the case of the Wasserman reaction test:

  • 1+ or no glowing – negative
  • 2+, 3+, 4+ – positive

The RIF gives a positive result in earlier stages of syphilis, because of its greater sensitivity.

The Reaction of Immobilization of Pale Treponeme (RIBT)

This test allows to detect false-positive results during the standard serological tests and to differentiate a healthy person from a patient. Patients with a positive result of Wasserman’s reaction are subject to RIBT to confirm or disprove diagnosis.

Treatment of Syphilis

Treatment should be started with the appearance of the first signs of syphilis. It will make the process of recovery as fast as possible.

Since the 1950s, antibiotics have been used to treat syphilis. Penicillin is the antibiotic most commonly used to treat syphilis, because pale treponema has not lost its sensitivity to this group of antibacterial drugs. For the treatment of syphilis in patients with allergic reactions to penicillin erythromycin or tetracycline are used.

Sex partners of a person diagnosed with primary syphilis should be treated presumptively if their exposure was within 90 days prior to the onset of the primary syphilis symptoms.

If secondary syphilis is diagnosed, it is necessary to treat all sexual partners that have been in contact with a patient during the past year.

In tertiary stage of syphilis along with antibiotics, highly toxic drugs based on bismuth are used. Treatment should be accompanied by multilevel maintenance therapy.

If the course of the disease has reached neurosyphilis, then the treatment becomes more complicated. Pyrotherapy (artificial increase in body temperature) and intramuscular injection of antibacterial drugs are added.

It is necessary to disinfect all personal items of the patient in the house: dishes, linen, underwear, clothing, etc.

Hospitalization in the initial stages of syphilis is not required; outpatient treatment is enough. Only at the secondary stage of syphilis and in its severe forms, the patient must be put in hospital. Usually, the treatment of syphilis for insurance is free and anonymous.

Coping with the disease using folk remedies is not recommended. Only a well-designed treatment can defeat a pale treponema. Otherwise, there is a high probability of transition to more severe stages.

Antibiotics for the Treatment of Syphilis

For the treatment of syphilis, the following drugs are used:

  1. Penicillin G (Bicillin LA).
    The first-line agent for primary and secondary syphilis infection. It acts by interfering with the cell wall synthesis of microorganisms during replication.
  1. Penicillin G procaine.
    The first-line agent for the treatment of late latent syphilis.
  1. Doxycycline (group of tetracyclines).
    Used as an alternative therapy for syphilitic infection. Tetracyclines inhibit protein synthesis through reversible binding to bacterial 30 S ribosomal subunits.
  1. Erythromycin (group macrolides and azolides).
    It blocks the synthesis of proteins of sensitive microbial cells.
  1. Azithromycin (group macrolides and azolides).
    Azithromycin acts by binding reversibly to the 30S ribosomal subunits of sensitive microorganisms and thereby inhibiting protein synthesis, making the growth and multiplication of bacteria slower.
    Azithromycin concentrates in phagocytes and fibroblasts, as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues. Azithromycin is used for the treatment of microbial infections of mild or moderate severity.
  1. Ceftriaxone (Cephalosporin group).
    It is an alternative in patients with penicillin allergy. This is the third generation of cephalosporin. It suppresses the growth of bacteria by binding to one or more penicillin-binding proteins.

Side effects of antibiotics for syphilis include the Jarisch-Herxheimer reaction. This acute febrile reaction is often accompanied by headache, muscle pain, and other symptoms that may occur within the first 24 hours after the onset of any therapy for syphilis. The most common among people suffering from the primary stage of syphilis. Antipyretic drugs can be used to relieve pain.

Most Common Drugs and Medications to Treat Syphilis

List of Congenital Syphilis Medications:

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Drugs Used to Treat Congenital Syphilis (Only Generics)
penicillin g benzathine
procaine penicillin
penicillin g potassium
penicillin g sodium
Medications for Congenital Syphilis (Brand Names)
Bicillin L-A
Penicillin G Procaine

List of Syphilis, Early Medications:

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Drugs Used to Treat Syphilis, Early (Only Generics)
penicillin g benzathine
procaine penicillin
Medications for Syphilis, Early (Brand Names)
Doxy 100
Achromycin V
Bicillin L-A
Doryx MPC
E.E.S.-400 Filmtab
E.E.S. Granules
Erythrocin Lactobionate
Erythrocin Stearate Filmtab
PCE Dispertab
Penicillin G Procaine

List of Syphilis, Latent Medications:

Click to open!


Drugs Used to Treat Syphilis, Latent (Only Generics)
penicillin g benzathine
procaine penicillin
Medications for Syphilis, Latent (Brand Names)
Doxy 100
Bicillin L-A
Doryx MPC
Achromycin V
Penicillin G Procaine

List of Tertiary Syphilis Medications:

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Drugs Used to Treat Tertiary Syphilis (Only Generics)
penicillin g benzathine
procaine penicillin
Medications for Tertiary Syphilis (Brand Names)
Doxy 100
Achromycin V
Doryx MPC
Bicillin L-A
Penicillin G Procaine

How Long Can Syphilis Be Treated?

The duration of syphilis treatment is determined only by the doctor. Depending on the stage of the disease, complications and general condition of the body, it may take from two weeks to six months.

It is very important to know that patients must not interrupt the course of treatment. If the treatment is not completed, the patient will soon relapse. Treatment of syphilis should always be taken very seriously.

Dr. Jack Johnson, MD