palmar rashCase: A 41 year old male with one week of non-pruritic palmar rash that started on his trunk and spread to his hands. He has no history of travel, fever, joint pains, or medication use. What is your diagnosis for this palmar rash? Click on the image for a larger view.

Poll Results

[plot id=”1″] [su_spoiler title=”Diagnosis” style=”fancy” icon=”chevron-circle”]

Palmar rash from secondary syphilis


“The Great Imitator” is making a comeback. Between 2011 and 2012, the number of reported primary and secondary syphilis cases increased 12.1%. From 2005 to 2013 the number of cases nearly doubled.1 In 2012, 75% of the reported primary and secondary syphilis cases were among men who have sex with men.2

The rash of secondary syphilis is generally pink or dusky red and papular. The skin is indurated and there is often a superficial scale on the lesions. Though it typically involves the palms and soles, it can start on the trunk and spread to the entire body.3

A brief review of the stages of syphilis4:

StageTime CourseClinical Manifestations
Primary~21 days from innoculationPainless chancre
Secondary3-6 weeks after end of primary stageFever, headache, lymphadenopathy, malaise, rash, sore throat
Tertiary3-20 years after infectionDementia, granulomatous lesions (gummata), meningitis, neuropathy (tabes dorsalis), thoracic aneurysm

Master Clinician Bedside Pearls

Stuart Swadron, MD

Stuart Swadron, MD – Professor of Emergency Medicine, Keck School of Medicine of the University of Southern California (provided to ALiEM and recorded by Swadron, 2014)

Patton M E, Su J R, Nelson R, Weinstock H. Primary and Secondary Syphilis – United States, 2005-2013. Centers for Disease Control and Prevention. Published May 9, 2014.
STD Facts – Syphilis & MSM. Centers for Disease Control and Prevention.
Dylewski J, Duong M. The rash of secondary syphilis. CMAJ. 2007;176(1):33-35. [PubMed]
Nobay F, Promes SB. Chapter 144. Sexually Transmitted Diseases. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011.
Jeff Riddell, MD

Jeff Riddell, MD

Assistant Professor of Clinical Emergency Medicine
Co-Director, Medical Education Fellowship
LA County + USC Emergency Medicine Residency, Department of Emergency Medicine
Keck School of Medicine of the University of Southern California