History

After an incubation period of 3-7 days, the patient develops painful, erythematous papules at the site of contact. The chancroid papules become pustular and then rupture, usually forming 1-3 painful ulcers.

Men usually have chancroid symptoms directly related to the painful genital lesions or inguinal tenderness. Perianal lesions may also occur.^[34]Most females are asymptomatic but may present with less obvious symptoms, such as dysuria, dyspareunia, vaginal discharge, pain on defecation, or rectal bleeding. In females, 1-2 weeks after the onset of ulcers, development of a bubo is the rule in most women.^[4]Constitutional symptoms of chancroid, such as malaise and low-grade fevers, may be present.

Most commonly, males with chancroid report a history of recent contact with a prostitute. In addition, men who are infected are less likely to have used condoms and more likely to report a history of more than 2 sexual partners in the preceding 3 months.

Oral sex has also been documented in the transmission of chancroid.

Reports of nonsexually-transmitted H ducreyi infection have also been described, most recently from Australia in expatriates visiting from Papua New Guinea and Vanuatu. Infection led to chronic lower-limb ulcers.^{[35, 36]}

Physical Examination

With chancroid, a small papule is the initial lesion at the site of infection. The papule rapidly becomes pustular and eventually ulcerates. The ulcer enlarges, develops ragged undermined borders, and is surrounded by a rim of erythema. The border of the chancroid ulcer is not indurated as in syphilis. A grayish fibrinous membrane covers the base of the ulcer. Autoinoculation results in multiple sites of infection in various stages of evolution.

In men, the most common site of the chancroid infection is the foreskin, but it may also occur less commonly on the shaft, the glans, or the meatus of the penis. In women, chancroid ulcers most commonly occur on the labia majora, but they may also occur on the labia minora, the thighs, the perineum, or the cervix.

As many as 50% of chancroid patients have tender, fixed, inguinal lymphadenopathy, usually unilaterally, that when fluctuant is called a bubo and is highly specific for chancroid, as seen in the images below. Additional ulceration may be seen from lymph node sites suppurating and draining to the skin.^[4]

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.

View Media Gallery

Close-up view of chancroid ulcers.

View Media Gallery

Differential Diagnoses

Brothwell JA, Griesenauer B, Chen L, Spinola SM. Interactions of the Skin Pathogen Haemophilus ducreyi With the Human Host. Front Immunol. 2020. 11:615402. [QxMD MEDLINE Link]. [Full Text].
Ndzomo Ngono JP, Tchatchouang S, Noah Tsanga MV, et al. Ulcerative skin lesions among children in Cameroon: It is not always Yaws. PLoS Negl Trop Dis. 2021 Feb. 15 (2):e0009180. [QxMD MEDLINE Link]. [Full Text].
Copeland NK, Decker CF. Other sexually transmitted diseases chancroid and donovanosis. Dis Mon. 2016 Aug. 62 (8):306-13. [QxMD MEDLINE Link].
Sand FL, Thomsen SF. Skin diseases of the vulva: Infectious diseases. J Obstet Gynaecol. 2017 Apr 11. 1-9. [QxMD MEDLINE Link].
Ducrey A. Experimentelle Untersuchungen uber den Ansteckungsstof des weichen Schankers und uber die Bubonen. Monats Prakt Dermatol. 1889. 9:387-405.
Hammond GW. A history of the detection of Haemophilus ducreyi, 1889-1979. Sex Transm Dis. 1996 Mar-Apr. 23(2):93-6. [QxMD MEDLINE Link].
Lewis DA. Chancroid: clinical manifestations, diagnosis, and management. Sex Transm Infect. 2003 Feb. 79(1):68-71. [QxMD MEDLINE Link]. [Full Text].
Ballard RC. Syndromic case management of STDs in Africa. Afr Health. 1998 Mar. 20(3):13-5. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Dallabetta GA, Gerbase AC, Holmes KK. Problems, solutions, and challenges in syndromic management of sexually transmitted diseases. Sex Transm Infect. 1998 Jun. 74 Suppl 1:S1-11. [QxMD MEDLINE Link].
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. 2006 May 15. 42(10):1431-8.
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. 2003 Dec. 71(12):7178-82. [QxMD MEDLINE Link].
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. 2003 Aug. 79(4):294-7. [QxMD MEDLINE Link].
Roett MA, Mayor MT, Uduhiri KA. Diagnosis and management of genital ulcers. Am Fam Physician. 2012 Feb 1. 85(3):254-62. [QxMD MEDLINE Link].
Kemp M, Christensen JJ, Lautenschlager S, Vall-Mayans M, Moi H. European guideline for the management of chancroid, 2011. Int J STD AIDS. 2011 May. 22(5):241-4. [QxMD MEDLINE Link].
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. 2003 Dec. 71(12):7178-82. [QxMD MEDLINE Link]. [Full Text].
Janowicz DM, Cooney SA, Walsh J, et al. Expression of the Flp proteins by Haemophilus ducreyi is necessary for virulence in human volunteers. BMC Microbiol. 2011 Sep 22. 11:208. [QxMD MEDLINE Link]. [Full Text].
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. 2002 Dec 1. 169(11):6316-23. [QxMD MEDLINE Link].
Singer M, Li W, Morré SA, Ouburg S, Spinola SM. Host Polymorphisms in TLR9 and IL10 Are Associated With the Outcomes of Experimental Haemophilus ducreyi Infection in Human Volunteers. J Infect Dis. 2016 Aug 1. 214 (3):489-95. [QxMD MEDLINE Link].
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. 1999 Feb. 75(1):3-17. [QxMD MEDLINE Link].
Mutua FM, M'imunya JM, Wiysonge CS. Genital ulcer disease treatment for reducing sexual acquisition of HIV. Cochrane Database Syst Rev. 2012 Aug 15. 8:CD007933. [QxMD MEDLINE Link].
Johnson LF, Dorrington RE, Bradshaw D, Coetzee DJ. The role of sexually transmitted infections in the evolution of the South African HIV epidemic. Trop Med Int Health. 2012 Feb. 17(2):161-8. [QxMD MEDLINE Link].
Bhunu CP, Mushayabasa S. Chancroid transmission dynamics: a mathematical modeling approach. Theory Biosci. 2011 Dec. 130(4):289-98. [QxMD MEDLINE Link].
Irizarry L, Velasquez J, Wray AA. Chancroid. 2022 Jan. [QxMD MEDLINE Link]. [Full Text].
Gangaiah D, Spinola SM. Haemophilus ducreyi Cutaneous Ulcer Strains Diverged from Both Class I and Class II Genital Ulcer Strains: Implications for Epidemiological Studies. PLoS Negl Trop Dis. 2016 Dec. 10 (12):e0005259. [QxMD MEDLINE Link]. [Full Text].
Rob F, Jilich D, Lásiková Š, Křížková V, Hercogová J. First reported case of chancroid in the Czech Republic. Int J STD AIDS. 2018 Nov. 29 (11):1127-1129. [QxMD MEDLINE Link].
Spinola SM, Bauer ME, Munson RS Jr. Immunopathogenesis of Haemophilus ducreyi infection (chancroid). Infect Immun. 2002 Apr. 70(4):1667-76. [QxMD MEDLINE Link].
Van Howe RS. Genital ulcerative disease and sexually transmitted urethritis and circumcision: a meta-analysis. Int J STD AIDS. 2007 Dec. 18(12):799-809. [QxMD MEDLINE Link].
Weiss HA. Male circumcision as a preventive measure against HIV and other sexually transmitted diseases. Curr Opin Infect Dis. 2007 Feb. 20(1):66-72. [QxMD MEDLINE Link].
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. 2006 Apr. 82(2):101-9; discussion 110. [QxMD MEDLINE Link].
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. 2003 Nov. 42(11):876-81. [QxMD MEDLINE Link].
Mohammed TT, Olumide YM. Chancroid and human immunodeficiency virus infection--a review. Int J Dermatol. 2008 Jan. 47(1):1-8. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Cologne KG, Hsieh C. Nonviral Sexually Transmitted Diseases. Clin Colon Rectal Surg. 2019 Sep. 32 (5):358-363. [QxMD MEDLINE Link]. [Full Text].
Peel TN, Bhatti D, De Boer JC, Stratov I, Spelman DW. Chronic cutaneous ulcers secondary to Haemophilus ducreyi infection. Med J Aust. 2010 Mar 15. 192(6):348-50. [QxMD MEDLINE Link].
Lewis DA, Mitjà O. Haemophilus ducreyi: from sexually transmitted infection to skin ulcer pathogen. Curr Opin Infect Dis. 2016 Feb. 29 (1):52-7. [QxMD MEDLINE Link].
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. 1998 Nov. 47(11):1023-6. [QxMD MEDLINE Link].
Alfa M. The laboratory diagnosis of Haemophilus ducreyi. Can J Infect Dis Med Microbiol. 2005 Jan. 16(1):31-4. [QxMD MEDLINE Link].
Patterson K, Olsen B, Thomas C, Norn D, Tam M, Elkins C. Development of a rapid immunodiagnostic test for Haemophilus ducreyi. J Clin Microbiol. 2002 Oct. 40(10):3694-702. [QxMD MEDLINE Link].
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. 1996 Jan. 34(1):49-54. [QxMD MEDLINE Link].
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. 1998 Oct. 178(4):1060-6. [QxMD MEDLINE Link].
World Health Organization. Management of sexually transmitted diseases. World Health Organization. Available at http://www.who.int/en/.
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 http://www.who.int/en/.
Van der Veen F, Fransen L. Drugs for STD management in developing countries: choice, procurement, cost, and financing. Sex Transm Infect. 1998 Jun. 74 Suppl 1:S166-74. [QxMD MEDLINE Link].
Annan NT, Lewis DA. Treatment of chancroid in resource-poor countries. Expert Rev Anti Infect Ther. 2005 Apr. 3(2):295-306. [QxMD MEDLINE Link].
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. 1995 Jul-Aug. 22(4):217-20. [QxMD MEDLINE Link].
Steen R. Sex, soap and antibiotics: the case for chancroid eradication. Int J STD AIDS. 2001. 12(Suppl 2):147.
Steen R. Eradicating chancroid. Bull World Health Organ. 2001. 79(9):818-26. [QxMD MEDLINE Link].
Barclay L. ACOG recommends expedited partner therapy for STIs. Medscape Medical News. Available at http://www.medscape.com/viewarticle/845221. May 22, 2015; Accessed: June 24, 2015.
[Guideline] American College of Obstetricians and Gynecologists. Committee opinion no 632: expedited partner therapy in the management of gonorrhea and chlamydial infection. Obstet Gynecol. 2015 Jun. 125 (6):1526-8. [QxMD MEDLINE Link].
de Sarom A, Kumar Jaiswal A, Tiwari S, de Castro Oliveira L, et al. Putative vaccine candidates and drug targets identified by reverse vaccinology and subtractive genomics approaches to control Haemophilus ducreyi, the causative agent of chancroid. J R Soc Interface. 2018 May. 15 (142):[QxMD MEDLINE Link]. [Full Text].
Rosen T, Vandergriff T, Harting M. Antibiotic use in sexually transmissible diseases. Dermatol Clin. 2009 Jan. 27(1):49-61. [QxMD MEDLINE Link].
Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006. MMWR. 2006. 55:[Full Text].
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. 2009 Jun. 13(3):218-20. [QxMD MEDLINE Link].

Media Gallery

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.

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Author

Katherine H Fiala, MD Clinical Associate Professor, Department of Dermatology, Baylor Scott and White Health, Texas A&M University College of Medicine

Katherine H Fiala, MD is a member of the following medical societies: American Academy of Dermatology, American Society for MOHS Surgery, Association of Professors of Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Ritu Swali Texas A&M Health Science Center College of Medicine

Ritu Swali is a member of the following medical societies: American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster 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, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

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

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

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

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

Disclosure: Nothing to disclose.

Additional Contributors

Janet Fairley, MD Professor and Head, Department of Dermatology, University of Iowa, Roy J and Lucille A Carver College of Medicine

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

Disclosure: Nothing to disclose.

Ivan D Camacho, MD Dermatologist, Private Practice; Voluntary Assistant Professor of Dermatology, Department of Dermatology and Cutaneous Surgery, University of Miami, Leonard M Miller School of Medicine

Ivan D Camacho, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Florida Medical Association, International Society of Dermatology, Women's Dermatologic Society

Disclosure: Nothing to disclose.

Joshua R Freedman, MD, MS Resident Physician, Department of Dermatology and Cutaneous Surgery, Jackson Memorial Hospital, University of Miami, Leonard M Miller School of Medicine

Joshua R Freedman, MD, MS is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

Mark A Crowe, MD Assistant Clinical Instructor, Department of Medicine, Division of Dermatology, University of Washington School of Medicine

Mark A Crowe, MD is a member of the following medical societies: American Academy of Dermatology and North American Clinical Dermatologic Society

Disclosure: Nothing to disclose.

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.