Chancre and Cold Sores: Ulcers that One Should Not Ignore

Not all genital ulcers are due to herpes! While Herpes Simplex virus remains one of the common causes of genital ulcers, there are other differentials that one should consider if there is exposure to potential STDs. 

In this article, we discuss two types of ulcers seen in the setting of STD exposure, similarities, differences, and confusion between chancre and cold sores. The aim is to improve awareness among readers and physicians on the importance of seeking medical treatment in such instances. 

What is a Chancre?

Chancre is a skin ulcer due to syphilis infection. Syphilis is a sexually transmitted disease due to a spirochete pathogen known as Treponema Pallidum with significant health co-morbidities if left untreated. In the early stage (primary stage) of syphilis infection, a person can present with a chancre over the skin of the penis, vulva, vaginal tract/cervix, mouth/ lips, anal/rectal region. Typically, a chancre occurs about 3 weeks after infection. The lesion can start as a red pimple-like papule that progressively erodes, turning into an erosion or ulcer. The size of a chancre can be as small as a few subcentimetres to a centimetre.

If the chancre is left unattended, over time the lesion can take up to 6 weeks to heal without treatment. Having said that, a person remains infective, and the disease will continue to progress into subsequent secondary and tertiary stages of syphilis.

Main implication of syphilis includes progression of syphilis to later stages (tertiary syphilis), resulting in cardiovascular diseases such as aneurysm of the blood vessels, neurosyphilis complications such as stroke, gait and coordination disorders, cognitive, behavioral and personality disorders. Untreated syphilis during pregnancy can lead to vertical transmission of infection to the unborn infant, leading to miscarriage, stillbirth, blindness, deafness, central nervous system defects, and congenital diseases of the infant. 

What are Cold Sores?

Cold sores are small fluid-filled blisters. These blisters gradually turn into a group or patch of erosions and shallow ulcers. Over time, the sores will dry up and scab over. Cold sores usually heal without leaving a scar. Cold sores are caused by a virus known as Herpes Simplex Virus (HSV). There are 2 types of HSV. HSV-1 is the more common strain in comparison to HSV-2. In the past, HSV-1 was found exclusively over the oral region, and HSV-2 was found exclusively over the genital region, though over the years, due to various sexual orientations, the location of lesions no longer determines the type of HSV. 

There is currently no cure for cold sores or HSV infections. There are effective medications to manage the disease and suppress outbreaks of disease.

HSV cold sores can be associated with mild viral symptoms such as fever, flu-like symptoms, and lymph node swelling over the affected area. Cold sores tend to be painful and can be slightly itchy as well.

What are the Incubation Periods of Herpes Simplex Virus and Syphilis Before the Presentation of Sores and Chancre?

Upon infection with syphilis, one can have an incubation period up to 90 days, though symptoms including chancre tend to present 10-21 days following exposure.

In Herpes viral infection, the incubation period is shorter; typically cold sore symptoms surface 1-2 weeks from the time of contact. Having said that, due to the individual immune system, one can even take up to 3-4 weeks or months later before developing cold sores.

In both conditions, one can miss the initial presentation, as symptoms may be mild or one may ignore the symptoms completely until the lesions are gone. (This does not mean one is free from infection!)

Similarities between Chancre and Cold Sores

Both conditions can be transmitted during sexual intercourse- via direct skin-to-skin or direct skin-to-mucosal transfer. 

Both appear as sores and ulcers over the mucosal region of the genitals, mouth, and anus.

Both can be associated with swelling and inflammation of surrounding lymph nodes.

Both can resolve with time- though without treatment, the underlying infection is still present and is contagious.

Often, both appearances can be indistinguishable and confusing even to trained professionals.

Differences between Chancre and Cold Sores

Syphilis has a nickname of being the great mimic to various medical conditions. Often the ulcers are indistinguishable (even among clinicians) between the two, or both can occur simultaneously in the same person. In such situations, laboratory tests are useful in confirming and eliminating the diagnosis.

Why Should We Treat Chancre and Cold Sores?

Both underlying infections, if left unattended, can result in long-term health comorbidities. In particular, syphilis, when left undetected and untreated, can further progress into secondary and tertiary syphilis with potential irreversible health complications. In herpes, unknown infections result in poor management and recurring flares and outbreaks of cold sore symptoms.

As both conditions are highly contagious, there is a risk of spreading to others if the conditions are not managed appropriately.

Management of Chancre and Cold Sores Differs

As chancre and cold sores are two completely different infectious diseases with entirely different treatment antidotes, it is imperative to diagnose and treat the conditions without further delay.

• In syphilis, first-line treatment remains penicillin. In those who are allergic to penicillin, other antibiotics may be considered.
• In herpes infections, outbreaks and recurrence can be controlled with antiviral medications.

Do consult with your healthcare providers about your symptoms and treatment options. 

In the Presence of Genital Chancre and Sores, It Is Important to Consider a Comprehensive STD Test

The presence of chancre and sores is suggestive of a higher-risk sexual encounter with possible concurrent exposure to other forms of STDs.

If you are concerned about possible exposure or symptoms, STD testing can help assess for potential sexually transmitted infections based on your symptoms, exposure history, and doctor's assessment.

Furthermore, untreated sores and ulcers increase the risk of transmission of STDs due to

• Direct portal entry of infection from an open wound and broken skin barrier
• Local inflammation over the sores increases susceptibility of a person to contact other STDs

Studies have shown untreated genital ulcers increase a person's chance of acquiring HIV from HIV individuals during intercourse.

Co-infections with bacterial STDs are also more common and higher among those with genital ulcers. 

Other Causes of Genital Sores and Ulcers

STD-related

• Haemophilus ducreyi
• Lymphogranuloma venereum
• Cytomegalovirus

Non-STD related

• Tuberculosis (TB)
• Drug Allergy
• Covid Infection
• Shingles

You may wish to consult your healthcare providers on your ulcer symptoms. Based on your history, presentation of rash, and risk factors, your healthcare provider can advise you further on the necessary tests to evaluate your symptoms and thereafter advise on an appropriate management plan.

Concerned about a genital sore or possible STD exposure? Contact Dr Ben Medical to discuss your symptoms and whether an STD test may be appropriate. 

References:

1. Whiting C, Schwartzman G, Khachemoune A. Syphilis in Dermatology: Recognition and Management. Am J Clin Dermatol. 2023 Mar;24(2):287-297
2. Omarova S, Cannon A, Weiss W, Bruccoleri A, Puccio J. Genital Herpes Simplex Virus-An Updated Review. Adv Pediatr. 2022 Aug;69(1):149-162.
3. Cunha Ramos M, Nicola MRC, Bezerra NTC, Sardinha JCG, Sampaio de Souza Morais J, Schettini AP. Genital ulcers caused by sexually transmitted agents. An Bras Dermatol. 2022 Sep-Oct;97(5):551-565.
4. Roett MA. Genital Ulcers: Differential Diagnosis and Management. Am Fam Physician. 2020 Mar 15;101(6):355-361. 
5. Maliyar K, Mufti A, Syed M, Selk A, Dutil M, Bunce PE, Alavi A. Genital Ulcer Disease: A Review of Pathogenesis and Clinical Features. J Cutan Med Surg. 2019 Nov/Dec;23(6):624-634.