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Sexually Transmitted Infection: Cutaneous Manifestations

Sexually Transmitted Infection: Cutaneous Manifestations

We all exist because our parents had sex. Sex is simply not going away anytime soon. That is why sexually transmitted infections (STIs) will not go away, either, despite the diligent efforts of public health authorities and health care providers. Moreover, STIs are important. Left untreated, STIs can cause a myriad of ailments: infertility, ectopic pregnancy, stillbirth and spontaneous abortion, newborn birth defects, increased risk for HIV transmission or acquisition, cardiac and neurologic dysfunction, soft tissue destruction, internal organ damage, genital tract and oropharyngeal carcinoma, and even death. Because many STIs have cutaneous manifestations, it is imperative that dermatologists remain knowledgeable is this area.

Prevalence

Let’s first examine why STIs remain prevalent. First, sexual activity is encouraged by popular culture (in advertisements, television, and movies) without a simultaneous warning about the potential risks involved.1 The younger generation increasingly engages in various forms of sexual gratification in an uncommitted, casual manner, without the expectation of a traditional romantic relationship.2 The terms “friends with benefits,” “booty call buddies,” and “hooking up by sexting” say it all. While the internet revolution has brought many positives to modern life, it also has spawned innumerable websites and computer/mobile phone applications that facilitate finding anonymous sex partners. Older individuals who utilize erectile dysfunction (ED) drugs may also suddenly engage in risky sexual behaviors and are therefore more likely to acquire (and transmit) an STI to partners. It has been recommended that counseling about safe sex practices, as well as STI screening, should accompany every new prescription for ED medication.3 

Alcohol and psychotropic drug abuse, an epidemic in industrialized countries, clouds judgement and leads to risky behavior and subsequent STI.4-6 A recent representative nationwide survey suggests that, at an average of 7.2 unique lifetime sex partners, the United States actually fares badly in comparison to such countries as England (7.0 partners), Holland (6.9 partners), and Italy (5.4 partners).7 This is significant because as the number of different sex partners increases, the likelihood of acquiring an STI also increases. Aside from adverse societal factors, the very nature of STI promote their own perpetuation; diseases such as syphilis, herpes, and gonorrhea can all be transmitted during asymptomatic intervals, wherein the affected individual unwittingly passes on infection. Bottom line: the Centers for Disease Control recently proclaimed: “STDs [sexually transmitted diseases] are a persistent enemy, growing in number, and outpacing our ability to respond.”8 

STD figure 1

Figure 1. Atypical penile ulcer proved to be a chancre.

So where exactly do we stand? In the year 2016, the last year for which fully verified statistics exist, some 19 to 20 million cases of STI occurred in the United States, and it was projected that about 50% of all Americans will acquire at least 1 STI during their lifetime.9 Syphilis increased by more than 17% compared with the prior year; notably, increases were also documented for gonorrhea (18.5% increase) and chlamydia (4.7% increase).9 The highest syphilis rates (per 100,000 adult population) are currently in Louisiana, Nevada, California, Georgia, New York, and Florida. Cities with high syphilis rates include: Las Vegas, San Francisco, New Orleans, Atlanta, Orlando, and Los Angeles. Homosexual or bisexual men account for nearly 60% of all early syphilis cases,9 but clinicians should not discount the diagnosis in any individual regardless of age, gender, ethnicity, social status, or sexual preference.

figure 2

Figure 2. Periorificial plaques of annular syphilis.

Treating STIs in Dermatology

From a dermatologic perspective, clinical pearls related to syphilis include atypical genital ulcers (Figure 1); the chancre of primary syphilis may occur on the lip or tongue; condyloma lata may appear within the oral cavity; annular, periorificial plaques may indicate secondary syphilis in skin of color (Figure 2); the persistence of a chancre even as lesions of secondary syphilis appear, usually means concurrent HIV infection; and asymptomatic, patchy hair loss occurs in 3% to 7% of cases of secondary syphilis.10 Multiple facial nodules represents “florid” secondary syphilis (Figure 3). Lesions may ulcerate and the patient may become febrile (lues maligna). Long-acting benzathine penicillin (2.4 million units intramuscularly [IM], 1 dose) remains the treatment of choice for early infectious disease, although a relatively recent publication from China suggests that oral minocycline (100 mg twice daily for 28 days) performs as well or even better.11 

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Dermatologists are rarely called upon to treat acute, purulent gonococcal urethritis (“Clap”). However, early gonorrhea can present as a nonindurated swelling of the skin just behind the coronal sulcus, associated with minimal (if any) dysuria or discharge. This presentation is referred to as “Bull-headed clap” (Figure 4). Additional manifestations of gonorrhea, which might present to the dermatologist, include an intact or ruptured gonococcal abscess or gonococcal epididymitis (scrotal pain and swelling).12, 13 Gonorrhea is no longer universally sensitive to penicillin. Resistance to tetracycline and quinolone antibiotics is also common. Therefore, the recommended regimen for uncomplicated gonorrhea consists of ceftriaxone (250 mg IM, 1 dose) with concomitant azithromycin (1.0 g, by mouth, 1 dose). There is major concern that Neisseria gonorrhoeae resistance to ceftriaxone and azithromycin will become widespread.14

figure 3

Figure 3: Multiple facial nodules may be florid syphilis.

The most prevalent American STI is genital herpes, with 50 million people being infected, predominately with HSV-2. Most (70%-80%) genital herpes is transmitted during periods of asymptomatic viral shedding. Regardless the duration of infection, asymptomatic viral shedding decreases in frequency over time, but typically never ceases.15,16 Even a decade after acquisition, the virus may be shed 9% of days in the year.15 From a dermatologic perspective, it is important to remember that genital herpes among immunocompromised or immunuosuppressed individuals may present as persistent ulceration or as an exophytic vegetative mass. Recent case reports suggest that both atypical presentations may respond to off-label topical imiquimod 5%, applied 2 to 3 times a week (with or without concurrent antiviral therapy).17,18

Prospective studies done worldwide have conclusively demonstrated that all available human papillomavirus (HPV) vaccines are highly effective at preventing genital tract cancer; quadrivalent and nanovalent vaccines also prevent external genital warts.19,20 In the United States, the 9-valent vaccine has replaced the quadrivalent HPV vaccine, offering protection against additional oncogenic HPV types. However, nationally only about half of girls and a little over one-third of boys have completed the recommended vaccination regimen. Vaccine uptake may improve due to the current revised dosage schedule for those aged 9 to 14 years; only 2 (rather than 3) administrations are required.21 Potential genital wart treatments on the horizon include nitric oxide, concentrated hydrogen peroxide, ranprinase (RNA degrading enzyme) and AP611074 (inhibitor of HPV E1-E2 interaction).

figure 4

Figure 4. So-called “Bull-head clap.”

Lymphogranuloma venereum is rarely encountered. Over the last decade, however, this disease has drastically changed its morphology. Rather than presenting as a transient genital erosion followed by painful inguinal adenopathy, a new serovar (L2b) causes perirectal inflammation (proctitis) and/or erosion—primarily in men who have sex with men.22 Granuloma inguinale (donovanosis) is also rarely seen in the United States; this destructive disease persists in Papua New Guinea, South Africa, and parts of India and Brazil. Although once common, chancroid is rarely seen in the United States.

“Grooming” pubic hair has become a trend in this country. Among those who vigorously remove pubic hair monthly, there is a substantial increase in risk of STI acquisition.23 This is likely due to macrotrauma and microtrauma, which accompanies pubic hair removal.24 Conversely, those who do not remove pubic hair are much more likely to acquire pubic louse infestation.23 

Finally, a new approach seems promising to prevent bacterial STIs. This consists of post-exposure ingestion of a single 200-mg dose of doxycycline within 24 hours after unprotected intercourse. A prospective, randomized, placebo-controlled French study showed that this approach halved the risk of acquiring a bacterial STD among a large cohort of men who have sex with men.25 

Dr Rosen is professor of dermatology at Baylor College of Medicine in Houston, TX.

Disclosure: The author reports no relevant financial relationships.

References

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3. Jena AB, Goldman DP, Kamdar A, Lakdawalla DN, Lu Y. Sexually transmitted diseases among uses of erectile dysfunction drugs: Analysis of claims data. Ann Intern Med. 2010;153(1):1-7.

4. Bosma-Bleeker MH, Blaauw E. Substance use disorders and sexual behavior: the effects of alcohol and drugs on patients’ sexual thoughts, feelings and behavior. Addict Behav. 2018;87:231-237.

5. Mackesy-Amiti ME, Fendrich M, Johnson TP. Symptoms of substance dependence and risky sexual behavior in a probability sample of HIV-negative men who have sex with men in Chicago. Drug Alcohol Depend. 2010;110(1-2):38-43.

6. Hutton E, McCaul ME, Santora PB, Erbelding EJ. The relationship between recent alcohol use and sexual behaviors: gender differences among sexually transmitted disease clinic patients. Alcohol Clin Exp Res. 2008;32(11):2008-215.

7. What’s your number? Superdrug Online Doctor website. https://onlinedoctor.superdrug.com/whats-your-number/. Accessed October 23, 2018.

8. STDs at record high, indicating urgent need for prevention [press release]. Atlanta, GA: Centers of Disease Control and Prevention; September 26, 2017. https://www.cdc.gov/media/releases/2017/p0926-std-prevention.html. Accessed August 17, 2018.

9. Sexually Transmitted Disease Surveillance 2016. Centers of Disease Control and Prevention website. http://www.cdc.gov/std/stats16/toc.htm. Updated September 26, 2017. Accessed September 23, 2018.

10. Costa MC, Peres AS, Queiróz AJR, Souza Medeiros N, Costa IMC. Nonspecific diffuse alopecia as a single manifestation of syphilis infection: clinical and trichoscopic features. Int J Dermatol. 2018;57(5):593-595.

11. Shao LL, Guo R, Shi WJ, et al. Could lengthening minocycline therapy better treat early syphilis? Medicine (Baltimore). 2016;95(52):e5773.

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13. Rosen T. Unusual presentations of gonorrhea. J Am Acad Dermatol. 1982;6(3):369-372.

14. Abraha M, Egli-Gany D, Low N. Epidemiological, behavioural and clinical factors associated with antimicrobial-resistant gonorrhea: a review. F1000Ressearch. 2018;7:400. doi:10.12688/f1000research.13600.1

15. Phipps W, Saracino M, Magaret A, et al. Persistent genital herpes simplex virus-2 shedding years following the first clinical episode. J Infect Dis. 2011;203(2):180-187.

16. Ramchandani M, Selke S, Magaret A, et al. Prospective cohort study showing persistent HSV-2 shedding in women with genital herpes 2 years after acquisition [published online November 25, 2017]. Sex Transm Infect. doi:10.1136/sextrans-2017-053244

17. Tandon S, Singh J, Sinha S, Sharma DP. Recalcitrant hypertrophic herpes genitalis in HIV-infected patient successfully treated with topical imiquimod. Dermatol Ther. 2017;30(3). doi:10.1111/dth.12479

18. Camasmie HR, Barbosa C, Lupi O, et al. Extensive and refractory genital herpes in human immunodeficiency virus-infected patient successfully treated with imiquimod: Case report and literature review. Indian J Dermatol Venereol Leprol. 2017;83(3):256-259.

19. St Laurent J, Luckett R, Feldman S. HPV vaccination and the effects on rates of HPV-related cancers [published online June 23, 2018]. Curr Probl Cancer. doi:10.1016/j.currproblcancer.2018.06.004

20. Maver PJ, Poljak M. Progress in prophylactic human papillomavirus (HPV) vaccination in 2016: a literature review. Vaccine. 2018;36(36): 5416-5423. 

21. Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human papillomavirus vaccination—updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2016;65(49):1405-1408.

22. Martin-Iguacel R1, Llibre JM, Nielsen H, et al. Lymphogranuloma venereum proctocolitis: a silent endemic disease in men who have sex with men in industrialised countries. Eur J Clin Microbiol Infect Dis. 2010;29(8):917-925.

23. Osterberg EC, Gaither TW, Awad MA, et al. Correlation between pubic hair grooming and STIs: results from a nationally representative probability sample. Sex Transm Infect. 2017;93(3):162-166.

24. Truesdale MD, Osterberg EC, Gaither TW, et al. Prevalence of pubic hair grooming-related injuries and identification of high-risk individuals in the United States. JAMA Dermatol. 2017;153(11):1114-1121.

25. Molina JM, Charreau I, Chidiac C, et al; ANRS IPERGAY Study Group. Post-exposure prophylaxis with doxycycline to prevent sexually transmitted infections in men who have sex with men: an open-label randomised substudy of the ANRS IPERGAY trial. Lancet Infect Dis. 2018;18(3):308-317.

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