Cutaneous manifestations of syphilis are varied and may present with non-specific features. We describe a 45-year-old man who presented with erythematous scaly plaques and nodules on his scalp. In previously reported cases, there were only descriptions of nodules as well as tumors. However, in our case, the patient presented with plaques and nodules on his scalp that quickly resolved with treatment for syphilis. It is important to recognize and treat syphilis at an early stage

Gwee, Yee Yen

Ho, Peiying Audrey

Oh, Choon Chiat

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UC DavisDermatology Online JournalTitleErythematous scaly plaques and nodules on scalpPermalinkhttps://escholarship.org/uc/item/9r81m80nJournalDermatology Online Journal, 29(5)AuthorsHo, Peiying AudreyGwee, Yee YenOh, Choon ChiatPublication Date2023DOI10.5070/D329562412Copyright InformationCopyright 2023 by the author(s).This work is made available under the terms of a Creative Commons Attribution-NonCommercial-NoDerivatives License, available at https://creativecommons.org/licenses/by-nc-nd/4.0/ Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaVolume 29 Number 5|September/October 2023| 29(5):12   - 1 - Dermatology Online Journal  ||  Photo Vignette Erythematous scaly plaques and nodules on scalp Peiying Audrey Ho1 MB BCH BAO, Yee Yen Gwee2 MBBS, Choon Chiat Oh1 MBBS FRCP UK FAMS Affiliations: 1Department of Dermatology, Singapore General Hospital, Singapore, 2Department of Pathology, Singapore General Hospital, Singapore Corresponding Author: Choon Chiat Oh, Department of Dermatology, Singapore General Hospital, Outram Road, Singapore, 169608, Tel: 65-62223322, Fax: 65-62249221, Email: oh.choon.chiat@singhealth.com.sg     Keywords: infection, scalp, syphilis  Introduction Scalp manifestations of syphilis may be non-specific and confused with psoriasis, seborrheic dermatitis, tinea capitis, lichen planopilaris, or alopecia areata [1]. Often syphilis is not suspected when the clinical presentation is of erythematous, scaly plaques and nodules of the scalp.  Case Synopsis A 45-year-old man with a past medical history of hypertension and hyperlipidemia was referred to the dermatology clinic for sudden onset of rash over his scalp over the past two months. There was no cervical, axillary, or inguinal lymphadenopathy. There were no systemic symptoms of fever, malaise, or influenza. There were erythematous adherent thick scaly plaques and nodules on his scalp (Figure 1) and an erythematous maculopapular rash involving the trunk and back. The eruption had first started on the trunk before spreading to the rest of the body, involving the scalp. There were no new medications prior to the onset of the eruption. He had faint confluent erythematous macules on his trunk; his palms and soles were spared and the oral examination was unremarkable. A scalp biopsy was performed. Histopathology showed interface dermatitis and marked periadnexal as well as perivascular inflammation composed of plasma cells, lymphocytes, histiocytes, scattered neutrophils and eosinophils. Intraepithelial neutrophils are seen forming occasional microabscesses and were associated with inflammatory exudate within the surface parakeratin (Figure 2). Blood investigations Abstract Cutaneous manifestations of syphilis are varied and may present with non-specific features. We describe a 45-year-old man who presented with erythematous scaly plaques and nodules on his scalp. In previously reported cases, there were only descriptions of nodules as well as tumors. However, in our case, the patient presented with plaques and nodules on his scalp that quickly resolved with treatment for syphilis. It is important to recognize and treat syphilis at an early stage.  Figure 1. Erythematous plaques and nodules on scalp. Volume 29 Number 5|September/October 2023| 29(5):12   - 2 - Dermatology Online Journal  ||  Photo Vignette revealed that his Treponema pallidum particle agglutination assay (TPPA)was reactive and venereal disease research laboratory test (VDRL) was positive with a titer of 1:256. He was treated for secondary syphilis with one dose of intramuscular penicillin. Subsequently, the scalp nodules and plaques resolved with post-inflammatory hyperpigmentation (Figure 3). The differential diagnosis for erythematous plaques on the scalp is wide-ranging, with psoriasis possibly being amongst the more common. Histology is required to differentiate psoriasis from a plaque due to syphilis [1]. Other possible diagnoses include seborrheic dermatitis, tinea capitis, and lichen planopilaris. The recommended regimen for adults for the treatment of secondary syphilis is one dose of 2.4 million units of benzathine penicillin G given intramuscularly [2]. In our patient, the erythematous plaques on his scalp completely resolved with treatment of secondary syphilis.  Case Discussion Syphilis is a disease caused by Treponema pallidum and is known as “the great imitator” due to its multitude of cutaneous manifestations varying from a maculopapular rash that also affect the palmoplantar regions, to nodular, annular, pustular, and framboesiform lesions affecting various other sites on the body. With regard to duration, cutaneous secondary syphilis eruption usually presents 3- 10 weeks after the initial contact with the spirochete; the typical duration of cutaneous secondary syphilis eruption is that of weeks to months [3]. Scalp lesions are less commonly reported. In previously reported cases, there were descriptions of nodules, tumors, and alopecia over the scalp [4]. A summary of these case reports is presented in Table 1.  Conclusion It is important to recognize and treat syphilis at an early stage, to prevent the subsequent complications of tertiary syphilis. However, secondary syphilis can present atypically, which may lead to delayed diagnosis and treatment. Hence, it is important for clinicians to consider cutaneous secondary syphilis in patients with nodules or plaques on scalp.  Potential conflicts of interest The authors declare no conflicts of interest.    References 1. Gisondi P, Bellinato F, Girolomoni G. Topographic differential diagnosis of chronic plaque psoriasis: challenges and tricks. J Clin Figure 2. H&E histopathology shows perivascular lymphocytic infiltrate and plasma cells, 20×. Figure 3. Resolution of plaques with residual post-inflammatory hyperpigmentation. Volume 29 Number 5|September/October 2023| 29(5):12   - 3 - Dermatology Online Journal  ||  Photo Vignette Med. 2020;9:3594. [PMID: 33171581]. 2. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015 MMWR Recomm Rep. 2015;1-137. [PMID: 26042815]. 3. Stone CE, Onyekaba NA, Lucas M, Jukic D. Cutaneous secondary syphilis resembling non-melanoma skin cancer. Cureus. 2020;12:e10774. [PMID: 33033668]. 4. Al-Busani H, Namiki T, Miura K, Yokozeki H. Mixed-pattern syphilitic alopecia of the scalp associated with uveitis and asymptomatic neurosyphilis. J Dermatol. 2020;4:e311-e313. [PMID: 32441352]. 5. Park JH, Park YJ, Kim SK, et al. Histopathological differential   diagnosis of psoriasis and seborrheic dermatitis of the scalp. Ann Dermatol. 2016;28:427-432. [PMID: 27489423] 6. Li F, Wang T, Wang L. Secondary syphilis primarily presenting with multiple nodules on the scalp: Case report and published work review. J Dermatol. 2017;4:1401-1403. [PMID: 28714113]. 7. Wang X, Chen H, Sun J. Multiple nodules on the scalp as the only cutaneous symptom of secondary syphilis. Int J Dermatol. 2019;58:e203-e204. [PMID: 31236934]. 8. Tham SN, Ng SK. Secondary syphilis with framboesiform lesions. Genitourin Med. 1990;66:99-100. [PMID: 2341147]. 9. Lee ES, Lee MG, Lee JB. Tumorous syphilid. Genitourin Med. 1990;66:202-204. [PMID: 2370064]. Volume 29 Number 5|September/October 2023| 29(5):12   - 4 - Dermatology Online Journal  ||  Photo Vignette Table 1. Cases reported for syphilis presenting as nodules/plaques on scalp. Author Li F et al [6]  Wang X et al [7]  Tham SN et al [8]  Lee ES et al [9]  Number of Patients 1 1 1 1 Gender Male Male Male MaleAge 51 62 40 31 Length of Duration of Nodules 2 months 3 weeks 1 month 1 month Description of nodules Multiple rounded yellow to red to dull red, non tender nodules over scalp Multiple non tender firm red nodules over scalp Multiple crusted papules nodules on scalp Erythematous oozing tumors on scalp Other symptoms Nil  Nil Cervical, axillary and inguinal lymphadenopathy Nil Histopathological Findings Hyperplasia of epidermis, abundant perivascular infiltration in dermis mainly plasma cells. Epidermal hyperplasia, dense neutrophilic infiltrate in upper epidermis. Infiltration in dermis mainly plasma cells. Parakeratosis with scaly crusts, irregular epidermal hyperplasia with spongioform pustules and infiltration of neutrophils and lymphocytes in epidermis. Dermoepidermal junction- plasma cells, eosinophils, neutrophils, lymphocytes  Epidermis showed verrucous hyperplasia. Upper and mid dermis- heavy polymorphic infiltrate with perivascular and periappendegeal arrangement, mainly plasma cells and eosinophils. Serological Testing TPPA >1: 320 TRUST 1:8 RPR 1:64 TP-IgG and TPPA positive VDRL 1: 2048 VDRL 1:32, FTA-ABS reactive 4+, TPHA 1: 20480, 19s(IgM)-FTA 1:1280Immunohistochemistry  Warthin-Starry staining and immunohistochemical staining TP polyclonal antibody 1:100 Warthin-Starry silver staining and Periodic acid-Schiff negative TP polyclonal antibody 1:200 - Warthin-Starry stain negative, immunoperoxidase stain with avidin-biotin peroxidase complex demonstrated many T. pallida in epidermis and around dermal blood vessels.Secondary Infection Nil Nil Staphylococcus aureus Nil Treatment IM Benzathine penicillin G 2.4 MU once a week for 3 weeks IM Benzathine penicillin G 2.4 MU once a week for 3 weeksIM Benzathine Penicillin G 2.4 MU once a week for 2 weeksIM Benzathine Penicillin G 2.4 MU once a week for 3 weeksDuration to resolution/drop in titers 3 months to resolution of skin lesions TRUST titer still 1:8 3 months to resolution of lesions and 3 fold decrease in titers  2 months to resolution of lesions. 6 months for titers to drop to 1:32  1 month after initiation of therapy, skin lesions resolved.  6 months later, titers of serologic testing decreased: VDRL 1:4, FTA-ABS 4+, TPHA 1: 2560, 19s (IgM)-FTA 1:80Volume 29 Number 5|September/October 2023| 29(5):12   - 5 - Dermatology Online Journal  ||  Photo Vignette IM, intramuscular; TP, T. pallida; TPPA, Treponema pallidum particle agglutination assay; VDRL, venereal disease research laboratory test. 

Erythematous scaly plaques and nodules on scalp

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