Published on 19/03/2015 by admin
Filed under Dermatology
Last modified 22/04/2025
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Anuradha Lele Mookerjee and Glenn C. Newell
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
(Courtesy of Dr Shyam Verma, Vadodra, India.)
Chancroid is a genital ulcer disease caused by the Gram-negative facultative anaerobic bacillus Haemophilus ducreyi. It is common in many parts of the world, including Africa, the Caribbean basin, and Southwest Asia. In more developed countries the incidence of chancroid appears to be decreasing. It is often seen in travelers who have had unprotected sex, returning from areas known to have high risk. Chancroid typically is described as a painful, ragged, deep genital ulcer 3–20 mm in diameter. There may be surrounding erythema, and the base is often covered with a yellow-gray exudate. The lesion may be single, but can be multiple as a result of autoinoculation (kissing lesions). Painful lymphadenitis occurs in 30–60% of patients, and approximately one-quarter of patients with lymphadenopathy may develop a suppurating bubo.
Diagnosis on clinical criteria alone is difficult. The painful ulcer of chancroid can easily be confused with genital herpes. Syphilis, especially if secondarily infected, can also mimic chancroid. Co-infection with herpes simplex virus (HSV) or Treponema pallidum occurs in as many as 10% of patients, making the diagnosis more difficult. Extra-anogenital chancroid has been reported and may further represent diagnostic challenge.
The combination of a painful genital ulcer with tender suppurative lymphadenopathy is the only clinical presentation that is nearly pathognomonic. Chancroid has been noted to increase the susceptibility to human immunodeficiency virus (HIV) infection, probably by disrupting mucosal integrity, thereby allowing a portal of entry for HIV.
A definitive diagnosis may be made by culturing the exudates from the ulcer base or by aspiration of a bubo. Gram stain of the ulcer base in chancroid may show Gram-negative coccobacilli in a ‘school of fish’ appearance. Special culture media should be used, and the specimen should be handled by laboratories familiar with H. ducreyi. It should be noted that sensitivity of culture as shown by DNA amplification techniques can be as low as 75%. The newer nucleic acid amplification tests (NAATs) show higher positivity rates than culture and do not depend on live bacteria, making the test especially useful. However, only few laboratories have established NAATs for the diagnosis of chancroid, due to the rare occurrence of H. ducreyi. Polymerase chain reaction testing has the advantage of simultaneous testing of H. ducreyi along with T. pallidum and HSV.
HIV prolongs the incubation period of H. ducreyi and increases the number of genital ulcers. These tend to heal slowly and poorly. Extragenital sites are also frequently found in co-infection with HIV. Notably, there are increased treatment failures with HIV co-infection. Treatment guidelines for patients co-infected with HIV are the same as for those without HIV, but closer follow-up and potentially a longer course of therapy may be recommended.
Chancroid is usually treated on a presumptive basis in endemic areas if clinical features are suggestive. Empiric therapy is also often used if patients fail to respond to treatment of syphilis and/or herpes genitalis.
Gram stain of ulcer base or bubo aspiration
Culture of ulcer base or bubo aspirate
NAATs (nucleic acid amplification tests)
Syphilis serology
HIV serology
Kemp M, Christensen JJ, Lautenschlager S, Vall-Mayans M, Moi H. Int J STD AIDS 2011; 22: 241–4.
An up-to-date and comprehensive review of chancroid diagnosis and management. The authors cite an unblinded prospective study which found that ceftriaxone versus azithromycin in doses noted above were equally efficacious.
Schmid GP. Clin Infect Dis 1999; 28: S14–20.
This source provides a comprehensive review of chancroid therapy. Single-dose quinolones may have failure rates approaching 10%. However, a regimen of azithromycin (1 g orally, once), or ceftriaxone (250 mg intramuscularly, once), remains effective for the treatment of chancroid in the US and is recommended.
Centers for Disease Control and Prevention, MMWR Recomm Rep 59 (RR-12), 1–110. 2010; 55: 14–30.
These guidelines agree with the above. Other special considerations mentioned are increased treatment failure rates in uncircumcised men and in patients with HIV infection (see above). Patients should be tested for HIV at the time chancroid is diagnosed. Patients should also be retested for HIV and syphilis 3 months after the diagnosis of chancroid if initial tests were negative.
Malonza IM, Tyndall MW, Ndinya-Achola JO, Maclean I, Omar S, MacDonald KS, et al. J Infect Dis 1999; 180: 1886–93.
This clinical trial compared single-dose therapy with ciprofloxacin to a 7-day course of erythromycin for the treatment of chancroid. Cure rates of 92% and 91% were reported with ciprofloxacin and erythromycin, respectively, for the 111 participants with chancroid. Failure rates were attributed to ulcer etiologies of HSV or syphilis.
Schmid GP, Clin Infect Dis 1999; 28: S14–20.
Single-dose ciprofloxacin therapy is less effective than multiple-dose therapy, probably owing to the short half-life of ciprofloxacin and inadequate peak serum levels. Single-dose therapy is recommended only in HIV-seronegative uncircumcised men with close follow-up.
Braz J, Infect Dis 2009; 13: 218–20.
For 54 patients with chancroid, cure rates with single-dose treatment were 73% with azithromycin and 89% with thiamphenicol. HIV seropositivity was found to be associated with treatment failure (p = 0.001). The treatment failed in all HIV positive patients treated with azithromycin (p = 0.002), and this drug should be avoided in these co-infected patients. In the view of the authors, thiamphenicol is the most indicated single-dose regimen for chancroid treatment.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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Azithromycin 1 g orally (one dose)
Ceftriaxone 250 mg intramuscularly (one dose)
Ciprofloxacin 500 mg twice a day for 3 days
Erythromycin 500 mg orally four times a day for 7 days
Fleroxacin 400 mg orally (one dose)
Spectinomycin 2 g intramuscularly (one dose)
Granulated thiamphenicol 5.0 g orally (one dose)
Ciprofloxacin 500 mg or 1000 mg orally (one dose)
