Chancroid

Anthony Sciscione, D.O.

Basic Information

Definition

Chancroid is a sexually transmitted disease characterized by painful genital ulceration and inflammatory inguinal adenopathy.

Synonyms

Soft chancre
Ulcus molle

ICD-10CM CODES
A57	Chancroid

Epidemiology & Demographics

•

Most frequent cause of genital ulcer disease worldwide.
•

Exact incidence in U.S. is unknown. The prevalence of chancroid has declined in the United States and is currently rare (1 per 2 million in the developed world). When infection occurs, it is usually associated with sporadic outbreaks and in association with trading sex for drugs, particularly crack cocaine.
•

Occurs more frequently in men (male:female ratio of 5:1 to 10:1).
•

Clinical infection is rare in women.
•

There is a higher incidence in uncircumcised men and in tropical and subtropical regions.
•

Incubation period is 4 to 7 days but may take up to 3 wk.
•

High incidence of HIV infection associated with chancroid.

Physical Findings & Clinical Presentation

•

One to three extremely painful ulcers (Fig. E1) accompanied by tender inguinal lymphadenopathy (especially if fluctuant). The chancre is typically soft in comparison with the hard, painless chancre of syphilis.
•

May present with inguinal bubo and several ulcers.
•

In women: initial lesion in the fourchette, labia minora, urethra, cervix, or anus; inflammatory pustule or papule that ruptures, leaving a shallow, nonindurated ulceration, usually 1 to 2 cm in diameter with ragged, undermined edges.
•

Unilateral lymphadenopathy develops 1 wk later in 50% of patients.

FIG.E1

Chancroid.

From James WD, et al.: *Andrews’ diseases of the skin*, ed 12, Philadelphia, 2016, Elsevier.

Etiology

Haemophilus ducreyi, a bacillus

Diagnosis

Differential Diagnosis

•

Other genitoulcerative diseases such as syphilis, herpes, lymphogranuloma venereum (LGV), granuloma inguinale.
•

A clinical algorithm for the initial management of genital ulcer disease is described in Section III.

Workup

Diagnosis based on history and physical examination is often inadequate. Must rule out syphilis in women because of the consequences of inappropriate therapy in those who are pregnant. Practitioner can base initial diagnosis and treatment recommendations on clinical impression of appearance of ulcer and most likely diagnosis for population. Definitive diagnosis is made by isolation of organism from ulcers by culture or Gram stain. Special culture media for H. ducreyi is not widely available commercially, and even when these media are used, sensitivity is <80%.

The CDC criteria for clinical diagnosis include all of the following:

1.

Single or multiple painful genital ulcers
2.

No evidence to support a diagnosis of syphilis (no evidence of T. pallidum infection by darkfield examination or ulcer exudate or by a serologic test for syphilis performed at least 7 days after onset of ulcers)
3.

A typical clinical presentation and appearance of the ulcer and, if present, regional lymphadenopathy are typical for chancroid
4.

A negative test (HSV PCR test or HSV culture) for the presence of HSV in the ulcer exudate

Laboratory Tests

•

Darkfield microscopy, RPR, HSV cultures, H. ducreyi culture, HIV testing recommended
•

No FDA-cleared PCR test for H. ducreyi is available in the U.S.

Treatment

Nonpharmacologic Therapy

Fluctuant nodes should be aspirated through healthy adjacent skin to prevent formation of draining sinus. Incision and drainage not recommended because it delays healing. Use warm compresses to remove necrotic material.

Acute General Rx

•

Azithromycin 1 g PO (single dose) or
•

Ceftriaxone 250 mg IM (single dose) or
•

Ciprofloxacin 500 mg PO bid for 3 days or
•

Erythromycin 500 mg PO qid for 7 days

NOTE: Ciprofloxacin is contraindicated in patients who are pregnant, lactating, or <18 yr.

•

HIV-infected patients may need more prolonged therapy.
•

In HIV-positive patients, failures have been reported with single-dose azithromycin and ceftriaxone regimens.

Disposition

•

All sexual partners should be treated with a 10-day course of one of the regimens (see “Acute General Rx”).
•

Patients should be reexamined 3 to 7 days after initiation of therapy. Ulcers should improve symptomatically within 3 days and objectively within 7 days after initiation of successful therapy.

Pearls & Considerations

Comments

•

In the U.S. HSV-1 and syphilis are the most common causes of genital ulcers followed by chancroid, LGV, and granuloma inguinale.
•

The combination of a painful genital ulcer and tender suppurative inguinal adenopathy suggests the diagnosis of chancroid.

Ferri – Chancroid