Syphilis Stages Explained: From Primary to Tertiary

Syphilis Stages Explained: From Primary to Tertiary

Key Takeaways

• Syphilis moves through four main stages, each with distinct signs and risks.
• Early detection relies on simple blood tests and careful symptom checks.
• Penicillin remains the gold‑standard treatment for all stages.
• Untreated infection can damage the heart, brain, and even unborn babies.
• Prevention and prompt medical care stop the disease before it spreads.

When you hear the word Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum, you might picture a single illness with one set of symptoms. In reality, the infection unfolds in a series of stages, each with its own timeline, clinical picture, and treatment nuances. Understanding the syphilis stages helps you recognize warning signs early, get the right tests, and start the effective therapy that prevents long‑term damage.

What Is Syphilis?

Syphilis is a bacterial infection transmitted primarily through sexual contact, but it can also pass from a pregnant person to their baby. The culprit, Treponema pallidum is a spiral‑shaped spirochete that can invade skin, mucous membranes, and internal organs.

Because the bacterium spreads silently for weeks or months, many people never realize they’re infected until later complications appear. That’s why a clear picture of each disease phase is critical for timely care.

How the Disease Progresses

Syphilis traditionally follows a predictable pattern, though the timing can vary. After exposure, the bacterium multiplies locally, then travels through the bloodstream, setting the stage for the next phase. Below is a quick timeline:

• 0-4 weeks: Primary stage (chancre appears)
• 4-12 weeks: Secondary stage (rash, systemic symptoms)
• 3 months to several years: Latent stage (no symptoms, but infection persists)
• 5-15 years (or later): Tertiary stage (organ damage, neurosyphilis, cardiovascular issues)

Not everyone reaches the tertiary stage-effective treatment at any earlier point halts progression.

Primary Stage

Primary syphilis is a stage marked by a painless ulcer called a chancre that appears at the site where the bacteria entered the body-usually the genitals, anus, or mouth. The sore is firm, round, and may go unnoticed because it hurts little and often heals on its own within 3-6 weeks.

Key symptoms include:

• Single or multiple chancres
• Swollen, non‑tender lymph nodes nearby

Because the chancre can disappear without treatment, a blood test is the only reliable way to confirm infection. The standard screening uses non‑treponemal tests like RPR (Rapid Plasma Reagin) or VDRL, followed by a treponemal confirmatory test such as FTA‑ABS.

Treatment for primary syphilis is a single intramuscular dose of Penicillin is the first‑line antibiotic that eradicates Treponema pallidum. Alternatives like doxycycline exist for penicillin‑allergic patients, but they require a longer course.

Secondary Stage

Secondary syphilis is a phase characterized by widespread skin rashes, mucous‑membrane lesions, and systemic symptoms. It typically emerges 4-10 weeks after the chancre and can last several weeks to months.

Common signs include:

• Reddish‑brown rash on palms, soles, trunk, or limbs (often described as “nickel‑coin” lesions)
• Moist, raised lesions called condylomata lata in the genital area
• Fever, sore throat, headache, muscle aches
• Patchy hair loss (especially on the scalp)

Because the rash can mimic other conditions, a doctor will order the same serologic panel used in the primary stage. Repeat testing may show higher antibody titers.

Penicillin therapy remains the same-usually one dose for early disease-but some clinicians add a second dose if symptoms linger.

Latent Stage

After the secondary rash fades, the infection enters the latent stage is a period without visible symptoms, but the bacteria stay alive in the body. This stage splits into two sub‑phases:

1. Early latent - within the first year after infection. Patients are still contagious, and regular blood tests will show active titers.
2. Late latent - beyond one year. Infectiousness drops, but the risk of progressing to tertiary disease rises.

Because you feel fine, many people skip follow‑up appointments. Health guidelines recommend at least three serologic tests over two years for anyone diagnosed with earlier stages.

Even in the latent stage, the recommended treatment is a full 2‑week course of Penicillin, administered as 2.4 million units intramuscularly each day for three consecutive days (the “Benzathine penicillin G” regimen).

Tertiary Stage

If infection remains untreated for years, it can advance to tertiary syphilis is a late stage that damages internal organs, especially the heart, blood vessels, and nervous system. Only about 15-30% of untreated cases reach this point, but the consequences are severe.

Major manifestations include:

• Gummatous lesions - soft, tumor‑like growths that can appear on skin, bone, or liver.
• Cardiovascular syphilis - aneurysms of the aorta, aortic valve insufficiency, and coronary artery disease.
• Neurosyphilis - infection of the central nervous system, causing headaches, personality changes, numbness, or even paralysis.

Neurosyphilis can emerge at any stage, but it’s most common in the tertiary phase. Diagnosis requires lumbar puncture and specific cerebrospinal fluid (CSF) tests (VDRL on CSF). If positive, the treatment escalates to intravenous penicillin for 10-14 days.

Standard benzathine penicillin may still be used for non‑neurologic tertiary disease, but many clinicians opt for the same intensive IV regimen to ensure CSF penetration.

Congenital Syphilis

When a pregnant person is infected, congenital syphilis is a serious condition passed to the baby during pregnancy or delivery. Babies can be born with rash, bone abnormalities, organ failure, or may die shortly after birth.

The CDC recommends universal screening at the first prenatal visit and again in the third trimester for high‑risk women. Early maternal treatment with penicillin prevents almost all cases.

Diagnosis Across All Stages

Because the symptoms shift, clinicians rely heavily on serologic testing:

• Non‑treponemal tests (RPR, VDRL) - detect antibodies produced in response to cellular damage; useful for monitoring treatment response.
• Treponemal tests (FTA‑ABS, TP‑PA) - detect antibodies specific to Treponema pallidum; remain positive for life.

For neurosyphilis, a spinal tap adds CSF VDRL and cell count. Dark‑field microscopy can directly visualize spirochetes from chancre fluid, but it’s rarely available outside specialist centers.

Treatment Overview

Penicillin remains the cornerstone of therapy because it reaches high concentrations in blood, CSF, and tissues. Regimens differ by stage:

For patients allergic to penicillin, desensitization is preferred over alternative antibiotics because cross‑reactivity with other classes is a concern.

Prevention & When to Seek Care

Safe sexual practices-condom use, limiting partners, and regular STI screening-stop syphilis before it starts. If you notice any of the hallmark signs (a chancre, unusual rash, swollen lymph nodes), schedule a doctor’s visit right away. Early treatment not only cures you but also protects anyone you may have exposed.

Pregnant individuals should get screened at the first prenatal appointment. If a test is positive, immediate penicillin therapy dramatically reduces the risk of congenital infection.

Patient Checklist

1. Know your risk factors: unprotected sex, multiple partners, previous STIs.
2. Watch for early signs: painless sore, rash on palms/soles, flu‑like symptoms.
3. Get tested: request RPR/VDRL and confirm with FTA‑ABS.
4. Follow treatment exactly: complete the full penicillin course.
5. Return for follow‑up serology at 3, 6, and 12months to ensure antibody titers drop.
6. Inform recent partners so they can be tested and treated.