Dermatologic Manifestations of Chancroid 

  • Author: Mark A Hall, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jun 9, 2010
 

Background

Chancroid is a sexually transmitted genital ulcer disease (GUD) caused by the gram-negative bacillus Haemophilus ducreyi. Chancroid is characterized by the presence of painful ulcers (see image below) and inflammatory inguinal adenopathy.

Chancroid usually starts as a small papule that raChancroid usually starts as a small papule that rapidly becomes pustular and eventually ulcerates. The ulcer enlarges, develops ragged undermined borders, and is surrounded by a rim of erythema. Unlike syphilis, lesions are tender and the border of the ulcer is not indurated. Courtesy of Hon Pak, MD.

Chancroid is often referred to as a soft chancre because the lesions are usually not indurated. In contrast, a syphilitic chancre is nontender and indurated. The identification of the causative agent of chancroid was first reported in 1889 by August Ducrey, following experiments in which he autoinoculated patients' forearms with pus from their genital ulcers.[1, 2, 3]

Next

Pathophysiology

H ducreyi produces a potent cytolethal distending toxin, which is an important virulence factor in the pathogenesis of chancroid, probably contributing to both the generation and the slow healing of ulcers.[4] [5]

Chancroid, or soft chancre, facilitates human immunodeficiency virus (HIV) transmission. The chemokine receptors CCR5 and CXCR4 belong to the class of 7 transmembrane G-protein–coupled receptors, and their natural ligands are key players in the recruitment of immune cells to sites of inflammation. CCR5 and CXCR4 are the 2 main co-receptors essential for HIV entry. Macrophages in chancroid lesions have significantly increased expression of CCR5 and CXCR4 compared with peripheral blood cells, and CD4 T cells have significant up-regulation of CCR5. The beta-chemokine RANTES (regulated on activation, normal T cell expressed and secreted) are important ligands for CCR5. RANTES is present throughout the papular and pustular stages of chancroid infection but is not present in uninfected control skin.[6]

Together with the disruption of mucosal and skin barriers, the presence of cells with up-regulated HIV-1 co-receptors in H ducreyi –infected lesions provides an environment that facilitates the acquisition of HIV-1 infection. Effective and early treatment of genital ulceration, and chancroid in particular, is an important part of any strategy to control the spread of HIV infection in tropical countries.[7]

Previous
Next

Epidemiology

Frequency

United States

Chancroid is rarely reported in the United States, but regional outbreaks and some endemic transmission occur, principally among migrant farm workers and poor inner-city residents.

International

Because of a lack of readily available, accurate diagnostic tests, the global incidence of chancroid is unknown. An estimated 6 million cases of chancroid occur each year. Chancroid is common in many of the world's poorest regions such as areas of Africa, Asia, and the Caribbean. These regions also have some of the highest rates of HIV infection in the world, and chancroid is common in all 18 countries where adult HIV prevalence surpasses 8%. In addition to regional outbreaks, individual cases are reported sporadically in the developed world, usually in individuals who have recently returned from chancroid-endemic areas or occasionally within the context of localized urban outbreaks, which may be associated with commercial sex work.

Mortality/Morbidity

  • Chancroid produces painful ulcers on the genitals, often (50%) associated with unilateral tender inguinal lymphadenitis (ie, a bubo). Left untreated, the buboes can form fluctuant abscesses that spontaneously rupture, resulting in a nonhealing ulcer.
  • Chancroid has been shown to be a major cofactor in the transmission of HIV-1 infection.[8] This relationship has been especially significant in the heterosexual spread of HIV in Africa.[7, 9]

Sex

Males develop chancroid most often, with a male-to-female ratio of 3-25:1.[10]

  • Uncircumcised men develop chancroid more often than circumcised men.[11] Patients who are uncircumcised do not respond to treatment as well as those who are circumcised.[12, 13]
  • Chancroid is more common in heterosexual men.[14]
  • Female prostitutes, either with active disease in the form of genital ulcers or as asymptomatic carriers, are an important reservoir for chancroid infection.

Age

Chancroid is most prevalent in sexually active and promiscuous males, with a mean patient age of 30 years.

Previous
Proceed to Clinical Presentation
 
 
Contributor Information and Disclosures
Author

Mark A Hall, MD  President/Founder, Central Oregon Dermatology, PC

Mark A Hall, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Janet Fairley, MD  Professor and Head, Department of Dermatology, University of Iowa

Janet Fairley, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Federation for Medical Research, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Paul Krusinski, MD  Director of Dermatology, Professor, Department of Internal Medicine, Fletcher Allen Health Care, University of Vermont

Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Joel M Gelfand, MD, MSCE  Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania

Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology

Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

Chief Editor

Dirk M Elston, MD  Director, Department of Dermatology, Geisinger Medical Center

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

  1. Ducrey A. Experimentelle Untersuchungen uber den Ansteckungsstof des weichen Schankers und uber die Bubonen. Monats Prakt Dermatol. 1889;9:387-405.

  2. Hammond GW. A history of the detection of Haemophilus ducreyi, 1889-1979. Sex Transm Dis. Mar-Apr 1996;23(2):93-6. [Medline].

  3. Lewis DA. Chancroid: clinical manifestations, diagnosis, and management. Sex Transm Infect. Feb 2003;79(1):68-71. [Medline]. [Full Text].

  4. Spinola SM, Fortney KR, Katz BP, Latimer JL, Mock JR, Vakevainen M, et al. Haemophilus ducreyi requires an intact flp gene cluster for virulence in humans. Infect Immun. Dec 2003;71(12):7178-82. [Medline].

  5. Kulkarni K, Lewis DA, Ison CA. Expression of the cytolethal distending toxin in a geographically diverse collection of Haemophilus ducreyi clinical isolates. Sex Transm Infect. Aug 2003;79(4):294-7. [Medline].

  6. Humphreys TL, Schnizlein-Bick CT, Katz BP, Baldridge LA, Hood AF, Hromas RA, et al. Evolution of the cutaneous immune response to experimental Haemophilus ducreyi infection and its relevance to HIV-1 acquisition. J Immunol. Dec 1 2002;169(11):6316-23. [Medline].

  7. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect. Feb 1999;75(1):3-17. [Medline].

  8. Mohammed TT, Olumide YM. Chancroid and human immunodeficiency virus infection--a review. Int J Dermatol. Jan 2008;47(1):1-8. [Medline].

  9. O'Farrell N. Targeted interventions required against genital ulcers in African countries worst affected by HIV infection. Bull World Health Organ. 2001;79(6):569-77. [Medline].

  10. Spinola SM, Bauer ME, Munson RS Jr. Immunopathogenesis of Haemophilus ducreyi infection (chancroid). Infect Immun. Apr 2002;70(4):1667-76. [Medline].

  11. Van Howe RS. Genital ulcerative disease and sexually transmitted urethritis and circumcision: a meta-analysis. Int J STD AIDS. Dec 2007;18(12):799-809. [Medline].

  12. Weiss HA. Male circumcision as a preventive measure against HIV and other sexually transmitted diseases. Curr Opin Infect Dis. Feb 2007;20(1):66-72. [Medline].

  13. Weiss HA, Thomas SL, Munabi SK, Hayes RJ. Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect. Apr 2006;82(2):101-9; discussion 110. [Medline].

  14. Kyriakis KP, Hadjivassiliou M, Paparizos VA, Flemetakis A, Stavrianeas N, Katsambas A. Incidence determinants of gonorrhea, chlamydial genital infection, syphilis and chancroid in attendees at a sexually transmitted disease clinic in Athens, Greece. Int J Dermatol. Nov 2003;42(11):876-81. [Medline].

  15. Peel TN, Bhatti D, De Boer JC, Stratov I, Spelman DW. Chronic cutaneous ulcers secondary to Haemophilus ducreyi infection. Med J Aust. Mar 15 2010;192(6):348-50. [Medline].

  16. Ballard RC. Syndromic case management of STDs in Africa. Afr Health. Mar 1998;20(3):13-5. [Medline].

  17. Bogaerts J, Vuylsteke B, Martinez Tello W, Mukantabana V, Akingeneye J, Laga M, et al. Simple algorithms for the management of genital ulcers: evaluation in a primary health care centre in Kigali, Rwanda. Bull World Health Organ. 1995;73(6):761-7. [Medline].

  18. Dallabetta GA, Gerbase AC, Holmes KK. Problems, solutions, and challenges in syndromic management of sexually transmitted diseases. Sex Transm Infect. Jun 1998;74 Suppl 1:S1-11. [Medline].

  19. Mackay IM, Harnett G, Jeoffreys N, et al. Detection and discrimination of herpes simplex viruses, Haemophilus ducreyi, Treponema pallidum, and Calymmatobacterium (Klebsiella) granulomatis from genital ulcers. Clin Infect Dis. May 15 2006;42(10):1431-8.

  20. Pillay A, Hoosen AA, Loykissoonlal D, Glock C, Odhav B, Sturm AW. Comparison of culture media for the laboratory diagnosis of chancroid. J Med Microbiol. Nov 1998;47(11):1023-6. [Medline].

  21. Alfa M. The laboratory diagnosis of Haemophilus ducreyi. Can J Infect Dis Med Microbiol. Jan 2005;16(1):31-4. [Medline].

  22. Patterson K, Olsen B, Thomas C, Norn D, Tam M, Elkins C. Development of a rapid immunodiagnostic test for Haemophilus ducreyi. J Clin Microbiol. Oct 2002;40(10):3694-702. [Medline].

  23. Orle KA, Gates CA, Martin DH, Body BA, Weiss JB. Simultaneous PCR detection of Haemophilus ducreyi, Treponema pallidum, and herpes simplex virus types 1 and 2 from genital ulcers. J Clin Microbiol. Jan 1996;34(1):49-54. [Medline].

  24. Mertz KJ, Weiss JB, Webb RM, Levine WC, Lewis JS, Orle KA, et al. An investigation of genital ulcers in Jackson, Mississippi, with use of a multiplex polymerase chain reaction assay: high prevalence of chancroid and human immunodeficiency virus infection. J Infect Dis. Oct 1998;178(4):1060-6. [Medline].

  25. World Health Organization. Management of sexually transmitted diseases. World Health Organization. Available at http://www.who.int/en/.

  26. World Health Organization. Syndromic Case Management of STD (Sexually Transmitted Diseases)- A Guide for Decision-makers, Health Care Workers, and Communicators. World Health Organization. Available at www.who.int/en/.

  27. Van der Veen F, Fransen L. Drugs for STD management in developing countries: choice, procurement, cost, and financing. Sex Transm Infect. Jun 1998;74 Suppl 1:S166-74. [Medline].

  28. Annan NT, Lewis DA. Treatment of chancroid in resource-poor countries. Expert Rev Anti Infect Ther. Apr 2005;3(2):295-306. [Medline].

  29. Ernst AA, Marvez-Valls E, Martin DH. Incision and drainage versus aspiration of fluctuant buboes in the emergency department during an epidemic of chancroid. Sex Transm Dis. Jul-Aug 1995;22(4):217-20. [Medline].

  30. Rosen T, Vandergriff T, Harting M. Antibiotic use in sexually transmissible diseases. Dermatol Clin. Jan 2009;27(1):49-61. [Medline].

  31. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006. MMWR [serial online]. 2006;55:Available at http://www.cdc.gov/std/treatment/2006/toc.htm.

  32. Belda Jr W, Di Chiacchio NG, Di Chiacchio N, Romiti R, Criado PR, Velho PE. A comparative study of single-dose treatment of chancroid using thiamphenicol versus Azithromycin. Braz J Infect Dis. Jun 2009;13(3):218-20. [Medline].

  33. Steen R. Sex, soap and antibiotics: the case for chancroid eradication. Int J STD AIDS. 2001;12(Suppl 2):147.

  34. Steen R. Eradicating chancroid. Bull World Health Organ. 2001;79(9):818-26. [Medline].

  35. Afonina G, Leduc I, Nepluev I, Jeter C, Routh P, Almond G, et al. Immunization with the Haemophilus ducreyi hemoglobin receptor HgbA protects against infection in the swine model of chancroid. Infect Immun. Apr 2006;74(4):2224-32. [Medline].

  36. Bong CT, Bauer ME, Spinola SM. Haemophilus ducreyi: clinical features, epidemiology, and prospects for disease control. Microbes Infect. Sep 2002;4(11):1141-8. [Medline].

  37. Cole LE, Toffer KL, Fulcher RA, San Mateo LR, Orndorff PE, Kawula TH. A humoral immune response confers protection against Haemophilus ducreyi infection. Infect Immun. Dec 2003;71(12):6971-7. [Medline].

  38. Fulcher RA, Cole LE, Janowicz DM, Toffer KL, Fortney KR, Katz BP, et al. Expression of Haemophilus ducreyi collagen binding outer membrane protein NcaA is required for virulence in swine and human challenge models of chancroid. Infect Immun. May 2006;74(5):2651-8. [Medline].

  39. Hollier LM, Workowski K. Treatment of sexually transmitted diseases in women. Obstet Gynecol Clin North Am. Dec 2003;30(4):751-75, vii-viii. [Medline].

  40. Htun Y, Morse SA, Dangor Y, Fehler G, Radebe F, Trees DL, et al. Comparison of clinically directed, disease specific, and syndromic protocols for the management of genital ulcer disease in Lesotho. Sex Transm Infect. Jun 1998;74 Suppl 1:S23-8. [Medline].

  41. Humphreys TL, Li L, Li X, Janowicz DM, Fortney KR, Zhao Q, et al. Dysregulated immune profiles for skin and dendritic cells are associated with increased host susceptibility to Haemophilus ducreyi infection in human volunteers. Infect Immun. Dec 2007;75(12):5686-97. [Medline].

  42. Leduc I, Banks KE, Fortney KR, Patterson KB, Billings SD, Katz BP, et al. Evaluation of the repertoire of the TonB-dependent receptors of Haemophilus ducreyi for their role in virulence in humans. J Infect Dis. Apr 15 2008;197(8):1103-9. [Medline].

  43. Lewis DA. Chancroid: from clinical practice to basic science. AIDS Patient Care STDS. Jan 2000;14(1):19-36. [Medline].

  44. Lewis DA. Diagnostic tests for chancroid. Sex Transm Infect. Apr 2000;76(2):137-41. [Medline].

  45. Lewis DA, Stevens MK, Latimer JL, Ward CK, Deng K, Blick R, et al. Characterization of Haemophilus ducreyi cdtA, cdtB, and cdtC mutants in in vitro and in vivo systems. Infect Immun. Sep 2001;69(9):5626-34. [Medline].

  46. Post DM, Gibson BW. Proposed second class of Haemophilus ducreyi strains show altered protein and lipooligosaccharide profiles. Proteomics. Sep 2007;7(17):3131-42. [Medline].

  47. Roy-Leon JE, Lauzon WD, Toye B, Singhal N, Cameron DW. In vitro and in vivo activity of combination antimicrobial agents on Haemophilus ducreyi. J Antimicrob Chemother. Sep 2005;56(3):552-8. [Medline].

  48. Schmid GP, Faur YC, Valu JA, Sikandar SA, McLaughlin MM. Enhanced recovery of Haemophilus ducreyi from clinical specimens by incubation at 33 versus 35 degrees C. J Clin Microbiol. Dec 1995;33(12):3257-9. [Medline].

  49. Steen R, Dallabetta G. Genital ulcer disease control and HIV prevention. J Clin Virol. Mar 2004;29(3):143-51. [Medline].

  50. Trager JD. Sexually transmitted diseases causing genital lesions in adolescents. Adolesc Med Clin. Jun 2004;15(2):323-52. [Medline].

 
Previous
Next
 
Chancroid usually starts as a small papule that rapidly becomes pustular and eventually ulcerates. The ulcer enlarges, develops ragged undermined borders, and is surrounded by a rim of erythema. Unlike syphilis, lesions are tender and the border of the ulcer is not indurated. Courtesy of Hon Pak, MD.
This patient shows the characteristic lesions of chancroid. The bubo on the right side drained spontaneously. The bubo in the left inguinal canal required needle aspiration.
Close-up view of chancroid ulcers.
Large fluctuant buboes should be drained with the patient under local anesthesia and a large-gauge needle inserted through surrounding healthy skin. The insertion site should be superior or lateral to the bubo to prevent chronic drainage from the site.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.