🧭 When to suspect

Syphilis is a systemic infection caused by the spirochaete Treponema pallidum (subspecies pallidum), acquired through direct contact with an infectious lesion or vertically in pregnancy. It is often called "the great imitator" because it progresses through stages whose features are easily mistaken for other conditions – and a large minority of people have no symptoms at all. After years of decline it has returned forcefully: there were 9,513 diagnoses of infectious syphilis in England in 2023 (up 9.4% on 2022), with more than 8,000 again in 2025. Most cases remain in gay, bisexual and other men who have sex with men (GBMSM) aged 25–34, but the steepest recent rises are in heterosexual men and women.

The GP's task is threefold: think of it across its protean presentations, test or refer every plausible case to sexual health services, and never miss the dangerous forms – neurological, ocular, otic, cardiovascular, and syphilis in pregnancy. Caught early, it is entirely curable.

Stage	Typical timing	Key features
Primary	9–90 days (mean ~21)	Single, painless, indurated, clean-based ulcer (chancre) at the site of entry; regional lymphadenopathy. A minority are painful or multiple.
Secondary	6 weeks–6 months	Non-itchy maculopapular rash including the palms and soles; mucous patches; condylomata lata (moist, highly infectious anogenital warts); generalised lymphadenopathy; systemic flu-like illness.
Early latent	< 2 years	Asymptomatic but seropositive; infection acquired within 2 years – still potentially infectious sexually.
Late latent	> 2 years / unknown	Asymptomatic, seropositive; no longer sexually infectious, but vertical transmission in pregnancy remains possible.
Tertiary	Years–decades	Gummatous (skin/bone), cardiovascular (aortitis, aortic aneurysm/regurgitation), and neurosyphilis; ocular and otic involvement can occur at any stage.

Source: BASHH 2024 · UKHSA

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