Early vs Late Syphilis Symptoms: What You Need to Know

Why Understanding Syphilis Stages Matters

Syphilis is unlike most other STIs. It progresses through distinct stages over months to years, with symptoms that come and go. This makes it both tricky to diagnose and potentially dangerous if left untreated.

The good news: syphilis is completely curable with antibiotics at any stage. But treatment is most straightforward in early stages, and late-stage syphilis can cause serious, irreversible damage.

Understanding the stages helps you recognise symptoms early and seek timely treatment.

The Four Stages of Syphilis

Stage 1: Primary Syphilis

When it appears: 10-90 days after infection (typically around 3 weeks)

The defining feature: A painless sore called a "chancre" (pronounced SHANG-ker)

Characteristics of the chancre:

• Usually single (but can be multiple)
• Round or oval with raised edges
• Firm, with a clean base
• Painless – this is why it's often missed
• Appears at the site of infection

Where chancres appear:

• Men: Penis, scrotum, around the anus, lips, mouth, throat
• Women: Vulva, vagina, cervix, around the anus, lips, mouth, throat
• Internal chancres (vagina, cervix, throat) often go completely unnoticed

Duration: The chancre heals on its own within 3-6 weeks, even without treatment

Critical point: Just because the sore heals doesn't mean the infection is gone. Without treatment, syphilis progresses to the next stage.

Stage 2: Secondary Syphilis

When it appears: 4-10 weeks after the primary chancre (may overlap with healing chancre)

Duration: Symptoms may come and go for 1-2 years

Classic symptoms:

Rash:

• The hallmark of secondary syphilis
• Typically appears on palms of hands and soles of feet (distinctive location)
• May cover entire body or appear in patches
• Usually not itchy
• Can be faint or pronounced
• May look like many other conditions

Mucous membrane lesions:

• Grey or white patches in mouth, throat, or genital area
• Called "mucous patches"
• Highly infectious

Condylomata lata:

• Large, raised, grey-white lesions in warm, moist areas
• Groin, under breasts, armpits
• Highly infectious

Flu-like symptoms:

• Fever
• Fatigue
• Swollen lymph nodes (throughout the body)
• Headaches
• Muscle aches
• Weight loss

Other possible symptoms:

• Patchy hair loss
• Sore throat
• Swollen joints

Critical point: Like primary syphilis, secondary symptoms resolve on their own – but the infection remains. This is why syphilis is called "the great imitator"; symptoms can mimic many other conditions.

Stage 3: Latent Syphilis

When it begins: After secondary symptoms resolve

Duration: Can last years or even decades

Symptoms: None – this is the "hidden" stage

What's happening:

• The bacteria remain in the body
• The immune system keeps the infection somewhat in check
• The person is usually not infectious (except possibly early latent)

Categories:

• Early latent: Less than 2 years since infection; may still be infectious
• Late latent: More than 2 years since infection; generally not infectious sexually

Critical point: Although symptomless, the infection can progress to tertiary syphilis at any point. This is also the only stage where syphilis can be detected solely by blood test, with no visible signs.

Stage 4: Tertiary (Late) Syphilis

When it appears: Years to decades after initial infection (typically 10-30 years)

Who develops it: About 15-30% of untreated syphilis cases

Types and symptoms:

Cardiovascular syphilis (affects heart and blood vessels):

• Aneurysm of the aorta
• Heart valve damage
• Inflammation of the aorta
• Can be fatal

Gummatous syphilis (soft tissue damage):

• "Gummas" – rubbery masses that can appear anywhere
• Skin, bones, liver, other organs
• Can be disfiguring
• Usually not infectious

Neurosyphilis (affects the nervous system):

• Can occur at any stage, but most serious in late syphilis
• Symptoms include:
• Severe headaches
• Difficulty coordinating movements
• Paralysis
• Numbness
• Dementia
• Blindness
• Deafness

Critical point: Tertiary syphilis can cause permanent damage and death. While treatment can stop progression, it cannot reverse damage already done.

Neurosyphilis: A Special Concern

Syphilis can affect the brain and nervous system at any stage:

Early Neurosyphilis

• Occurs within first few months to years
• May cause meningitis (headache, stiff neck, confusion)
• Eye involvement (ocular syphilis) – vision changes
• Ear involvement (otosyphilis) – hearing loss, tinnitus

Late Neurosyphilis

• General paresis – personality changes, dementia
• Tabes dorsalis – movement problems, loss of coordination
• Can be devastating and irreversible

Congenital Syphilis

Syphilis during pregnancy is particularly concerning:

• Can be transmitted to the baby at any stage of pregnancy
• Can cause miscarriage, stillbirth, or death shortly after birth
• Surviving babies may have serious health problems
• Routine antenatal screening in the UK helps prevent this

When to Seek Testing

You should be tested for syphilis if you have:

Symptoms Suggesting Syphilis

• Painless genital, anal, or oral sore
• Unexplained rash, especially on palms or soles
• Flu-like symptoms with rash
• Patchy hair loss
• Any combination of the above

Risk Factors

• Unprotected sex with a new partner
• Multiple sexual partners
• Partner diagnosed with syphilis
• Men who have sex with men (higher rates)
• Previous STI diagnosis
• HIV positive

Testing and Diagnosis

Blood Tests

• Screen for antibodies to syphilis
• May not detect very early infection (within first few weeks)
• Different tests confirm active vs past infection

Direct Testing

• Swabbing chancres or rash can detect bacteria
• Useful in early stages when blood tests may be negative

Testing Timeline

• Test 4-6 weeks after potential exposure for initial screen
• Repeat at 3 months for definitive result

Treatment at Each Stage

Early Syphilis (Primary, Secondary, Early Latent)

• Single intramuscular injection of penicillin
• Highly effective
• Usually curative

Late Latent Syphilis

• Three penicillin injections, one week apart
• Prevents progression to tertiary

Tertiary/Neurosyphilis

• More intensive treatment (often IV penicillin)
• Stops progression but cannot reverse damage
• May require expert involvement

Penicillin Allergy

• Alternative antibiotics are available
• Discuss with your clinician

The Jarisch-Herxheimer Reaction

• Flu-like reaction within 24 hours of treatment
• Fever, chills, headache, muscle aches
• Caused by bacteria dying off
• Not an allergic reaction
• Self-limiting – resolves within a day
• Common in early syphilis treatment

The Bottom Line

Syphilis is a sneaky infection that progresses through stages, with symptoms that come and go. Without treatment, it can eventually cause serious complications including heart disease, brain damage, and death.

The good news: it's easily detected with a blood test and easily cured with antibiotics. Early treatment prevents complications entirely.

If you have any risk factors or symptoms, don't wait. Get tested.

Get Tested Today

Our confidential syphilis testing provides fast, accurate results. If you're concerned about exposure or have noticed any symptoms, book your test now.