Treponematosis (Endemic Syphilis, Yaws, and Pinta) Treatment & Management

Updated: Oct 19, 2021
  • Author: Steven M Fine, MD, PhD; Chief Editor: John L Brusch, MD, FACP  more...
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Medical Care

Treatment of treponematosis is based on single-dose antibiotic therapy with benzathine penicillin or azithromycin.

Treponemes are highly sensitive to azithromycin and penicillin, which are the drugs of choice.

The WHO revised policies for treating yaws in 2012. One oral dose of azithromycin (30 mg/kg, not to exceed 2 g) is now recommended as equivalent to benzathine benzylpenicillin. Because of the ease of administration and low cost, it is now considered the drug of first choice. [14]

Yaws, pinta, and endemic syphilis may also be treated with benzathine penicillin G. Children younger than 10 years should receive 600,000 U intramuscularly, and children older than 10 years should receive 1.2 million U intramuscularly.

Alternatives are appropriate only if azithromycin or benzathine penicillins cannot be used. Tetracycline (25 mg/kg/d for 10-14 d) and chloramphenicol (25 mg/kg/d for 10-14 d) have been used successfully, as has a 10-day course of doxycycline. Other penicillins, cephalosporins, and macrolides are probably active against the treponemes; however, quinolones, aminoglycosides, and sulfa antibiotics are ineffective.

Treatment failures with penicillin have been reported, [15] but reinfection could not be ruled out.

Other important measures from the perspective of the individual patient and for public health include avoiding contact with others with cutaneous lesions and careful follow-up care to identify and to re-treat initial treatment failures.



With antibiotic treatment, the primary and secondary lesions usually resolve. Bone involvement can be a late complication of untreated yaws. Rarely, it can cause malformation of the long bones (eg, tibia), subcutaneous nodules, and ulcers in the palate and nose.



In 2012, the WHO developed a strategy for eradicating yaws, involving treatment of all eligible at-risk members of the community with one dose of oral azithromycin. Intramuscular penicillin G is substituted in patients in whom azithromycin is contraindicated. Active surveillance at 6-month intervals was then performed, especially in children, who represent the major reservoir of active infection. In one area of the community, the prevalence of yaws decreased from 2.4% before therapy to 0.3% a year after. [16] This approach is being scaled up in many affected areas.


Long-Term Monitoring

By extrapolation from the treatment of syphilis, follow-up testing with a nontreponemal test, usually RPR, can be performed 6 and 12 months posttreatment and should show a fourfold decrease in titer levels by 12 months in most patients.


Further Inpatient Care

Conscientious follow-up care to detect treatment failures and reinfection is recommended. Treatment failures or reinfections should be treated again. If azithromycin was initially used, penicillin should be considered. [17]  Resistance to penicillin is considered unlikely, but resistance to azithromycin in syphilis has been described.