THE MULTIPLE MANIFESTATIONS of syphilis often mimic many other diseases; however, there are distinctive findings for each of the three stages of syphilis. The classic physical findings of secondary syphilis (macular, maculopapular, and papular eruptions of the trunk, palms, and soles of the feet; oral mucosal patches; moth-eaten alopecia; typical condylomata lata) were well recognized by earlier generations of physicians because of the relatively high incidence of syphilis. The incidence of primary and secondary syphilis is at its lowest point since reporting began in 1941, 1 and today’s physicians have considerably less experience with the manifold presentations of secondary syphilis. Condylomata lata of the toe webs are uncommon manifestations of secondary syphilis that have been highlighted infrequently in recent medical publications. In the last 60 years, there have been only five published reports in the English language that describe condylomata lata of the toe webs in a total of 20 patients. 2–6 In an effort to increase awareness of this unusual finding, a case of interdigital condylomata lata is presented and various other parameters pertaining to these lesions are analyzed. Previously reported cases are also reviewed.
During routine blood screening, a 42-year-old black man was found to have a positive rapid plasma reagin result in a titer of 1:128. The patient was subsequently referred to a dermatology service for evaluation. The patient admitted to multiple episodes of unprotected sexual intercourse with anonymous partners within the preceding 6 months and gave a vague history of a transient, painless penile lesion of approximately 2 months duration, but was otherwise asymptomatic. Physical examination disclosed oozing papulonodular lesions located in interdigital web spaces between the third and fourth and the fourth and fifth toes on one foot, and in the webspace between the third and fourth toes on the other foot (Fig. 1). Results of darkfield examination of the serous exudate obtained from one of these lesions were positive, confirming the diagnosis of secondary syphilis. The remainder of the physical examination was unremarkable, and screening HIV serology was negative. One month after treatment with intramuscular benzathine penicillin 2.4 million U, the pedal lesions had entirely resolved, and the rapid plasma reagin titer had decreased to 1:4.
Condylomata lata are extremely infectious, moist papules commonly seen in secondary syphilis. These lesions often occur in areas of opposing skin surfaces associated with heat, moisture, and friction (e.g., the genitalia, perianal area, and axilla). Less frequently, these lesions may occur in toe webs. Gram-negative toe web infections and tinea pedis may predispose patients to the development of condylomata lata. In 1940, Thomas and Bluefarb described six patients who were affected by both chronic dermatophytosis of the toe webs and interdigital condylomata lata. 2 It has also been observed that interdigital condylomata lata have a propensity for involvement of the lateral toe webs, particularly the interdigital spaces between the third and fourth and the fourth and fifth toes. 6
There are 20 previously reported cases of condylomata lata of the toe webs in the English literature from 1940 to 1996, 17 of which contain detailed demographic and clinical descriptions. (Table 1) These detailed cases involved patients who were described as black (71%) or white (29%). 2–6 The greater frequency of black patients in published cases of interdigital condylomata lata may simply correspond to the disproportionately higher rate of syphilis in this population, or may reflect a different tissue response to syphilis in this racial or ethnic group, as has been noted with the annular syphilid.
According to the literature, condylomata lata may be found in single, multiple, or all web spaces. More than half (53%) of the previously reported patients with available descriptions of physical findings had involvement of only one toe web. Therefore, it is important to maintain a high index of suspicion even with an apparently minimal number of lesions. In contrast, 47% of reported patients presented with involvement of multiple toe web spaces.
Of the cases with interdigital condylomata lata, 88% involved other cutaneous lesions more commonly seen with secondary syphilis, such as a generalized maculopapular eruption. However, in a few cases, including the one reported herein, condylomata lata of the web spaces were the only cutaneous manifestation. Thus, the absence of a typical truncal eruption, mucous patches, alopecia, or palmar-plantar lesions does not reliably exclude syphilis.
As mentioned previously, interdigital condylomata lata are infrequent findings in syphilis. Such lesions carry an extensive differential diagnosis, including interdigital tinea pedis, erythrasma, macerated corns, ulcerated verruca, verrucous carcinoma, chromomycosis, mycetoma, and other fungal and gram-negative toe web infections. Thus, when moist interdigital lesions of the foot fail to respond to the typical effective therapy for a presumed diagnosis, a high index of suspicion for condylomata lata of secondary syphilis is needed. Because these lesions are moist and contain abundant spirochetes within lesional exudate, darkfield examination, if available, is diagnostic. Serologic test results for syphilis are also expected to be positive.
A new case of interdigital condylomata lata is presented with a review of the literature. Similar to most patients whose cases were previously reported, this patient is also black; however, the significance of ethnicity in relation to condylomata lata of the toe webs needs more study. Although this patient had multiple toe web lesions, no other manifestations of secondary syphilis were present, and positive darkfield examination results confirmed the diagnosis. The diagnosis of condylomata lata should be considered when evaluating toe web lesions, particularly if lesions are unresponsive to typical therapy, because these may be the only manifestation of a disease with known effective treatment.
1. Centers for Disease Control and Prevention. Primary and secondary syphilis–United States, 1998. MMWR Morb Mortal Wkly Rep 1999; 48: 873–878.
2. Thomas EW, Bluefarb SM. Early syphilitic lesions mistaken for dermatophytosis. Arch Dermatol Syphilol 1940; 42: 11–14.
3. Dexter HT. Interdigital infectious syphilitic lesions simulating dermatophytosis. Arch Dermatol 1951; 63: 581–585.
4. Minkin W, Landy SF, Cohen HJ. An unusual solitary lesion of secondary syphilis. Arch Dermatol 1967; 95: 217.
5. Hira SK. Condylomata lata of the toewebs: a case report of an unusual manifestation of syphilis. Sex Transm Dis 1984; 11: 167–168.
6. Templeton SF. Condyloma latum of the toe webs: an unusual manifestation of secondary syphilis. A report of two cases. Cutis 1996; 57: 38–40.