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Brazilian Protocol for Sexually Transmitted Infections, 2020: infections that cause genital ulcers

Mauro Cunha Ramos José Carlos Sardinha Herculano Duarte Ramos de Alencar Mayra Gonçalves Aragón Leonor Henriette de Lannoy About the authors

Highlighted excerpt:

Approximately 70% of the genital ulcers attended in specialized clinics are due to sexually transmitted infections, particularly in adolescents and young adults.

Abstract

Infections that cause genital ulcers are one of the themes comprising the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health in 2020. The Protocol and Guidelines have been developed based on scientific evidence and validated in discussions with specialists. This article addresses clinical genital ulcer syndrome caused by sexually transmitted infections and its most common etiological agents: Treponema pallidum (syphilis), herpes simplex virus-2 (genital herpes) and herpes simplex virus-1 (perioral herpes), Haemophilus ducreyi (chancroid), Chlamydia trachomatis serotypes L1, L2 and L3 (lymphogranuloma venereum), and Klebsiella granulomatis (donovanosis). Epidemiological and clinical aspects of these infections and guidelines for their diagnosis and treatment are presented, including strategies for surveillance, prevention, and control actions to support health managers and professionals in the qualification of care.

Keywords:
Syphilis; Chancre; Genital herpes; Chancroid; Lymphogranuloma venereum; Granuloma inguinale

FOREWORD

This article addresses the infections that cause genital ulcers, a subject that comprises the Clinical Protocol and Therapeutic Guidelines (PCDT) for Comprehensive Care for People with Sexually Transmitted Infections (STI), published by the Health Surveillance Secretariat of the Brazilian Ministry of Health in 202011. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para atenção integral às pessoas com infecções sexualmente transmissíveis (IST) [Internet]. Brasília: Ministério da Saúde; 2020 [cited 2020 out 19]. 248 p. Available from: http://www.aids.gov.br/pt-br/pub/2015/protocolo-clinico-e-diretrizes-terapeuticas-para-atencao-integral-pessoas-com-infeccoes
http://www.aids.gov.br/pt-br/pub/2015/pr...
. To draft this document, a selection of available evidence was analyzed and discussed by a panel of specialists. The National Committee for Health Technology Incorporation in the Brazilian National Health System (Conitec) approved this document22. Brasil. Ministério da Saúde. Portaria MS/GM nº 42, de 5 de outubro de 2018. Torna pública a decisão de aprovar o Protocolo Clínico e Diretrizes Terapêuticas para Atenção Integral às Pessoas com Infecções Sexualmente Transmissíveis (IST), no âmbito do Sistema Único de Saúde - SUS [Internet]. Diário Oficial da União, Brasília (DF), 2018 out 8 [cited 2020 jul 31]; Seção 1:88. Available from: http://conitec.gov.br/images/Relatorios/Portaria/2018/Portaria_SCTIE_N42_05_10_2018.pdf
http://conitec.gov.br/images/Relatorios/...
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EPIDEMIOLOGICAL ASPECTS

Approximately 70% of the genital ulcers attended in specialized clinics are due to STI, particularly in adolescents and young adults33. Noda AA, Blanco O, Correa C, Pérez L, Kourí V, Rodríguez I. Etiology of genital ulcer disease in male patients attending a sexually transmitted diseases clinic: first assessment in Cuba. Sex Transm Dis [Internet]. 2016 Aug [cited 2020 Oct 19]; 43(8):494-7. Available from: https://doi.org/10.1097/OLQ.0000000000000470
https://doi.org/10.1097/OLQ.000000000000...
. As a syndrome, genital ulcers are not a compulsory reporting condition in Brazil, making it difficult to quantify their occurrence. They are, however, a frequent cause of consultations and are a significant cofactor for human immunodeficiency virus (HIV) transmission44. World Health Organization - WHO. Report on global sexually transmitted infection surveillance, 2018 [Internet]. Geneva: World Health Organization; 2018 [cited 2020 Oct 19]. Available from: https://www.who.int/reproductivehealth/publications/stis-surveillance-2018/en /
https://www.who.int/reproductivehealth/p...
. Genital ulcers can have different causes, such as other infections, trauma, inflammatory diseases (e.g., pemphigus, erythema multiforme, contact dermatitis, erosive lichen planus, or fixed drug eruption), and neoplastic lesions (e.g., squamous cell carcinoma or other neoplasms). The latter is particularly relevant in older adults and those with immunodepression11. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para atenção integral às pessoas com infecções sexualmente transmissíveis (IST) [Internet]. Brasília: Ministério da Saúde; 2020 [cited 2020 out 19]. 248 p. Available from: http://www.aids.gov.br/pt-br/pub/2015/protocolo-clinico-e-diretrizes-terapeuticas-para-atencao-integral-pessoas-com-infeccoes
http://www.aids.gov.br/pt-br/pub/2015/pr...
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Establishing the etiologic agent on a clinical basis is difficult due to polymorphism in presentations55. Moherdaui F, Vuylsteke B, Siqueira LF, Santos Jr MQ, Jardim ML, Brito AM, et al. Validation of national algorithms for the diagnosis of sexually transmitted diseases in Brazil: results from a multicenter study. Sex Transm Infect. 1998 Jun;74(Suppl 1):S38-43.. The availability of accurate and rapid diagnostic tests varies according to different agents and different health systems scenarios. For this reason, the World Health Organization has recommended the syndromic treatment, adopted by several countries33. Noda AA, Blanco O, Correa C, Pérez L, Kourí V, Rodríguez I. Etiology of genital ulcer disease in male patients attending a sexually transmitted diseases clinic: first assessment in Cuba. Sex Transm Dis [Internet]. 2016 Aug [cited 2020 Oct 19]; 43(8):494-7. Available from: https://doi.org/10.1097/OLQ.0000000000000470
https://doi.org/10.1097/OLQ.000000000000...
,66. González-Beiras C, Marks MY, Chen C, Roberts S, Mitjà O. Epidemiology of Haemophilus ducreyi infections. Emerg Infect Dis [Internet]. 2016 Jan [cited 2020 Oct 19]; 22(1):1-8. Available from: https://dx.doi.org/10.3201%2Feid2201.150425
https://doi.org/10.3201%2Feid2201.150425...
,77. Naveca FG, Sabidó M, Amaral TAP, Veras EA, Contreras Mejía MC, et al. Etiology of genital ulcer disease in a sexually transmitted infection reference center in Manaus, Brazilian Amazon. PLoS One [Internet]. 2013 [cited 2020 Oct 19]; 8(5):e63953. Available from: https://doi.org/10.1371/journal.pone.0063953
https://doi.org/10.1371/journal.pone.006...
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The most common agent found in genital ulcers is the herpes simplex virus (HSV), type 1 (HSV-1) and type 2 (HSV-2). They are DNA viruses that belong to the Herpesviridae family88. Patel R, Kennedy OJ, Clarke E, Geretti A, Nilsen A, Lautenschlager S, et al. 2017 European guidelines for the management of genital herpes. Int J STD AIDS [Internet]. 2017 [cited 2020 Oct 19]; 28(14):1366-79. Available from: https://doi.org/10.1177/0956462417727194
https://doi.org/10.1177/0956462417727194...
. The second most common agent is Treponema pallidum, which causes syphilis. These agents can also be found in association33. Noda AA, Blanco O, Correa C, Pérez L, Kourí V, Rodríguez I. Etiology of genital ulcer disease in male patients attending a sexually transmitted diseases clinic: first assessment in Cuba. Sex Transm Dis [Internet]. 2016 Aug [cited 2020 Oct 19]; 43(8):494-7. Available from: https://doi.org/10.1097/OLQ.0000000000000470
https://doi.org/10.1097/OLQ.000000000000...
,99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
. Brazil, similarly to other countries1010. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Sífilis | 2019. Bol Epidemiol [Internet]. 2019 out [cited 2020 out 19]; especial. Available from: http://www.aids.gov.br/pt-br/pub/2019/boletim-epidemiologico-sifilis-2019
http://www.aids.gov.br/pt-br/pub/2019/bo...
, faces a significant increase in syphilis cases since 2017. In 2018, the government reported a detection rate of acquired syphilis of 75.8 cases per 100,000 inhabitants1010. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Sífilis | 2019. Bol Epidemiol [Internet]. 2019 out [cited 2020 out 19]; especial. Available from: http://www.aids.gov.br/pt-br/pub/2019/boletim-epidemiologico-sifilis-2019
http://www.aids.gov.br/pt-br/pub/2019/bo...
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Chancroid is caused by Haemophilus ducreyi, a sexually transmitted Gram-negative bacterium. The condition, which occurs most frequently in men and in tropical regions11. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para atenção integral às pessoas com infecções sexualmente transmissíveis (IST) [Internet]. Brasília: Ministério da Saúde; 2020 [cited 2020 out 19]. 248 p. Available from: http://www.aids.gov.br/pt-br/pub/2015/protocolo-clinico-e-diretrizes-terapeuticas-para-atencao-integral-pessoas-com-infeccoes
http://www.aids.gov.br/pt-br/pub/2015/pr...
,1111. Lautenschlager S, Kemp M, Christensen JJ, Mayans MV, Moi H. 2017 European guideline for the management of cancroid. Int J STD AIDS [Internet]. 2017 Mar [cited 2020 Oct 19]; 28(4):324-9. Available from: https://doi.org/10.1177/0956462416687913
https://doi.org/10.1177/0956462416687913...
, has been significantly diminishing, possibly due to the syndromic approach introduction1212. O'Farrell N, Lazaro N. UK National guideline for the management of Chancroid 2014. Int J STD AIDS [Internet]. 2014 Dec [cited 2020 Oct 19]; 25(14):975-83. Available from: https://doi.org/10.1177/0956462414542988
https://doi.org/10.1177/0956462414542988...
. A systematic review carried out with publications from 1980 to 2014 revealed that after the year 2000, up to 15% of genital ulcers were chancroids, with 14 studies conducted in 13 countries66. González-Beiras C, Marks MY, Chen C, Roberts S, Mitjà O. Epidemiology of Haemophilus ducreyi infections. Emerg Infect Dis [Internet]. 2016 Jan [cited 2020 Oct 19]; 22(1):1-8. Available from: https://dx.doi.org/10.3201%2Feid2201.150425
https://doi.org/10.3201%2Feid2201.150425...
. Since 2000, chancroid cases have been sporadic in Europe1111. Lautenschlager S, Kemp M, Christensen JJ, Mayans MV, Moi H. 2017 European guideline for the management of cancroid. Int J STD AIDS [Internet]. 2017 Mar [cited 2020 Oct 19]; 28(4):324-9. Available from: https://doi.org/10.1177/0956462416687913
https://doi.org/10.1177/0956462416687913...
. In a Brazilian study at a specialized STI center in Manaus, no chancroid case was identified in 434 genital ulcers analyzed consecutively without prior selection77. Naveca FG, Sabidó M, Amaral TAP, Veras EA, Contreras Mejía MC, et al. Etiology of genital ulcer disease in a sexually transmitted infection reference center in Manaus, Brazilian Amazon. PLoS One [Internet]. 2013 [cited 2020 Oct 19]; 8(5):e63953. Available from: https://doi.org/10.1371/journal.pone.0063953
https://doi.org/10.1371/journal.pone.006...
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Lymphogranuloma venereum is caused by Chlamydia trachomatis, the highly invasive serotypes L1, L2, and L3. Transmission is also attributed to asymptomatic people1313. Buder S, Schöfer H, Meyer T, Bremer V, Kohl PK, Skaletz-Rorowski A, Brockmeyer N. Bacterial sexually transmitted infections. J Dtsch Dermatol Ges [Internet]. 2019 Mar [cited 2020 Oct 19]; 17(3):287-315. Available from: https://doi.org/10.1111/ddg.13804
https://doi.org/10.1111/ddg.13804...
,1414. Vries HJC, Barbeyrac B, De Vrieze NHN, Viset JD, White JA, Vall-Mayans M, et al. 2019 European guideline on the management of lymphogranuloma venereum. JEADV [Internet]. 2019 [cited 2020 Oct 19]; 33:1821-8. Available from: https://doi.org/10.1111/jdv.15729
https://doi.org/10.1111/jdv.15729...
. It is an endemic condition among men who have sex with men (MSM) in Europe, predominantly anogenital and rectal infections1414. Vries HJC, Barbeyrac B, De Vrieze NHN, Viset JD, White JA, Vall-Mayans M, et al. 2019 European guideline on the management of lymphogranuloma venereum. JEADV [Internet]. 2019 [cited 2020 Oct 19]; 33:1821-8. Available from: https://doi.org/10.1111/jdv.15729
https://doi.org/10.1111/jdv.15729...
. Lymphogranuloma venereum outbreaks in high-income countries and MSM (mainly by the L2b variant) have been associated with unprotected receptive anal exposure and HIV infection1515. Williamson DA, Chen MY. Emerging and reemerging sexually transmitted infections. N Engl J Med [Internet]. 2020 [cited 2020 Oct 19]; 382(21):2023-32. Available from: https://doi.org/10.1056/nejmra190719
https://doi.org/10.1056/nejmra190719...
. Sexual activity facilitated by global travel, online social networking, and pre-exposure prophylaxis of HIV infection is believed to have contributed to its reemergence1515. Williamson DA, Chen MY. Emerging and reemerging sexually transmitted infections. N Engl J Med [Internet]. 2020 [cited 2020 Oct 19]; 382(21):2023-32. Available from: https://doi.org/10.1056/nejmra190719
https://doi.org/10.1056/nejmra190719...
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Donovanosis is caused by Klebsiella granulomatis, a sporadic condition most commonly found in countries with tropical and subtropical climates. Associated with sexual transmission, it has low transmissibility, and its transmission mechanisms are not well known1616. O’Farrell N, Moi H. 2016 European guideline on donovanosis. Int J STD AIDS [Internet]. 2016 Feb [cited 2020 Oct 19]; 27(8):605-7. Available from: https://doi.org/10.1177/0956462416633626
https://doi.org/10.1177/0956462416633626...
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CLINICAL ASPECTS

The clinical aspects of genital ulcers are very varied and have low sensitivity and specificity regarding the etiological agent99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
. The diagnosis based on clinical impression showed positive predictive values of 30.9% for syphilis and 32.7% for chancroid, with no clinical correlation for cases with mixed chancre in Brazil99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
. Even so, the characteristics of genital ulcers should be evaluated and vary according to the etiological agent.

Herpes simplex virus 1 and 2

Infection caused by HSV-1 and HSV-2 sometimes presents a symptomatic primoinfection, which occurs with incubation of six days on average and a duration of approximately 20 days88. Patel R, Kennedy OJ, Clarke E, Geretti A, Nilsen A, Lautenschlager S, et al. 2017 European guidelines for the management of genital herpes. Int J STD AIDS [Internet]. 2017 [cited 2020 Oct 19]; 28(14):1366-79. Available from: https://doi.org/10.1177/0956462417727194
https://doi.org/10.1177/0956462417727194...
,1717. Garland SM, Steben M. Genital herpes. Best Pract Res Clin Obstet Gynaecol [Internet]. 2014 [cited 2020 Oct 19]; 28(7):1098-110. Available from: https://doi.org/10.1016/j.bpobgyn.2014.07.015
https://doi.org/10.1016/j.bpobgyn.2014.0...
,1818. Money D, Steben M. No. 207 - Genital herpes: gynaecological aspects. J Obstet Gynaecol Can [Internet]. 2017 Jul [cited 2020 Oct 19]; 39(7):e105-11. Available from: https://doi.org/10.1016/j.jogc.2017.04.015
https://doi.org/10.1016/j.jogc.2017.04.0...
. It is characterized by numerous vesicles that evolve into painful, ulcerated lesions, whose bottoms are covered with a yellowish coating. These lesions are accompanied by general malaise, fever, myalgia, painful regional enlarged lymph nodes, and severe urinary symptoms, especially in women1818. Money D, Steben M. No. 207 - Genital herpes: gynaecological aspects. J Obstet Gynaecol Can [Internet]. 2017 Jul [cited 2020 Oct 19]; 39(7):e105-11. Available from: https://doi.org/10.1016/j.jogc.2017.04.015
https://doi.org/10.1016/j.jogc.2017.04.0...
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Once the infection occurs, the virus is transported along the peripheral nerves' axons to sensitive ganglia. It enters latency, a state in which it can persist for life or suffer reactivations. Reactivated, the virus migrates to the mucous and cutaneous surfaces, again through the sensory nerves, and can be eliminated asymptomatically or cause episodes of recurrent lesions. The outbreaks, which may be the first manifestation, are spontaneous or induced by several factors (for example, exposure to ultraviolet radiation, infections, use of drugs, immunodeficiency, or physical or emotional stress). Recurrent manifestations are more frequent by HSV-2 than HSV-11717. Garland SM, Steben M. Genital herpes. Best Pract Res Clin Obstet Gynaecol [Internet]. 2014 [cited 2020 Oct 19]; 28(7):1098-110. Available from: https://doi.org/10.1016/j.bpobgyn.2014.07.015
https://doi.org/10.1016/j.bpobgyn.2014.0...
. Most infected individuals will experience a recurrence in less than one year, and with each subsequent year, their intensity and average number decrease by about one event per year. These recurrences are lighter and last less. They are often preceded by prodromal symptoms such as itching, paresthesia, or pain at the site of lesions near the primoinfection area. Initially, they consist of vesicles of citrine content grouped in clusters on an erythematous base. The vesicles are rarely found in the mucous membranes because they rupture more quickly and originate polycyclic ulcers that regress spontaneously in approximately seven to ten days1717. Garland SM, Steben M. Genital herpes. Best Pract Res Clin Obstet Gynaecol [Internet]. 2014 [cited 2020 Oct 19]; 28(7):1098-110. Available from: https://doi.org/10.1016/j.bpobgyn.2014.07.015
https://doi.org/10.1016/j.bpobgyn.2014.0...
,1818. Money D, Steben M. No. 207 - Genital herpes: gynaecological aspects. J Obstet Gynaecol Can [Internet]. 2017 Jul [cited 2020 Oct 19]; 39(7):e105-11. Available from: https://doi.org/10.1016/j.jogc.2017.04.015
https://doi.org/10.1016/j.jogc.2017.04.0...
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Syphilis

Chronic affection transmitted by sexual contact, whether genital, anal, or oral, or even by vertical transmission11. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para atenção integral às pessoas com infecções sexualmente transmissíveis (IST) [Internet]. Brasília: Ministério da Saúde; 2020 [cited 2020 out 19]. 248 p. Available from: http://www.aids.gov.br/pt-br/pub/2015/protocolo-clinico-e-diretrizes-terapeuticas-para-atencao-integral-pessoas-com-infeccoes
http://www.aids.gov.br/pt-br/pub/2015/pr...
,1919. Kingston M, French P, Higgins S, McQuillan O, Sukthankar A, Stott C, et al. UK national guidelines on the management of syphilis 2015. Int J STD AIDS [Internet]. 2016 May [cited 2020 Oct 19]; 27(6):421-46. Available from: https://doi.org/10.1177/0956462415624059
https://doi.org/10.1177/0956462415624059...
,2020. Janier M, Hegyi V, Dupin N, Unemo M, Tiplica GS, Potočnik M, et al. 2014 European guideline on the management of syphilis. J Eur Acad Dermatol Venereol [Internet]. 2014 Dec [cited 2020 Oct 19]; 28(12):1581-93. Available from: https://doi.org/10.1111/jdv.12734
https://doi.org/10.1111/jdv.12734...
. It alternates periods of latency and clinical manifestations, often cutaneo-mucous lesions, and can affect any organ with transitory or definitive manifestations, depending on the organ affected1313. Buder S, Schöfer H, Meyer T, Bremer V, Kohl PK, Skaletz-Rorowski A, Brockmeyer N. Bacterial sexually transmitted infections. J Dtsch Dermatol Ges [Internet]. 2019 Mar [cited 2020 Oct 19]; 17(3):287-315. Available from: https://doi.org/10.1111/ddg.13804
https://doi.org/10.1111/ddg.13804...
. The classic genital ulcer, called hard chancre, typically occurs as a single, painless ulcer with a clean bottom and an infiltrated base at the entrance site of T. pallidum99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
,2020. Janier M, Hegyi V, Dupin N, Unemo M, Tiplica GS, Potočnik M, et al. 2014 European guideline on the management of syphilis. J Eur Acad Dermatol Venereol [Internet]. 2014 Dec [cited 2020 Oct 19]; 28(12):1581-93. Available from: https://doi.org/10.1111/jdv.12734
https://doi.org/10.1111/jdv.12734...
. More common in genital organs, the ulcer can go unnoticed, especially when located in cavities such as the interior of the vagina, perianal and rectal regions, and oral cavity. The incubation period is from ten to 90 days, with an average of three weeks. The hard chancre disappears without scarring, with or without treatment, in approximately three to eight weeks. Increased regional lymph nodes typically accompany it, often unilateral, usually multiple, with one standing out for its larger size. They are painless, of elastic consistency, and nonsuppurative1919. Kingston M, French P, Higgins S, McQuillan O, Sukthankar A, Stott C, et al. UK national guidelines on the management of syphilis 2015. Int J STD AIDS [Internet]. 2016 May [cited 2020 Oct 19]; 27(6):421-46. Available from: https://doi.org/10.1177/0956462415624059
https://doi.org/10.1177/0956462415624059...
,2020. Janier M, Hegyi V, Dupin N, Unemo M, Tiplica GS, Potočnik M, et al. 2014 European guideline on the management of syphilis. J Eur Acad Dermatol Venereol [Internet]. 2014 Dec [cited 2020 Oct 19]; 28(12):1581-93. Available from: https://doi.org/10.1111/jdv.12734
https://doi.org/10.1111/jdv.12734...
,2121. Belda JW, Di Chiacchio N, Criado PR. Tratado de dermatologia. 2. ed. São Paulo: Atheneu; 2015. 2768p..

Chancroid

Very painful genital or perianal ulcers typically characterize soft chancre or Ducrey's chancre. It rarely occurs in the oral cavity or other regions of the tegument. It has an irregular border and unclean bottom, covered with a yellowish, necrotic, and fetid coating. When removed, it reveals friable granulation tissue and a non-infiltrated base. The most frequent locations in men are the frenulum and the balanoprepucial groove, and in women, the furcula and the inner face of the inner and outer lips1212. O'Farrell N, Lazaro N. UK National guideline for the management of Chancroid 2014. Int J STD AIDS [Internet]. 2014 Dec [cited 2020 Oct 19]; 25(14):975-83. Available from: https://doi.org/10.1177/0956462414542988
https://doi.org/10.1177/0956462414542988...
. Satellite lesions by autoinoculation are common, as well as disfiguring scars. It is accompanied by inguinal adenitis in 30% to 50% of cases, a unilateral inflammatory bubo that tends to fistulize through a single orifice. Tense and fluctuating lymph nodes can be relieved by needle aspiration. The drainage or excision of the affected lymph nodes is contraindicated. They may attack deep lymph node chains in the form of systemic disease1111. Lautenschlager S, Kemp M, Christensen JJ, Mayans MV, Moi H. 2017 European guideline for the management of cancroid. Int J STD AIDS [Internet]. 2017 Mar [cited 2020 Oct 19]; 28(4):324-9. Available from: https://doi.org/10.1177/0956462416687913
https://doi.org/10.1177/0956462416687913...
.

Lymphogranuloma venereum

It presents ulcers that usually go unnoticed by the infected person or the health professional. Its evolution occurs in three phases: inoculation, regional lymphatic dissemination, and sequelae.

The inoculation phase starts with a papule, a pustule, or a small painless ulcer, which disappears without leaving sequelae. It may occur in the rectum and rarely in the urethra or cervix. Depending on its location, it may present mucopurulent exudate1414. Vries HJC, Barbeyrac B, De Vrieze NHN, Viset JD, White JA, Vall-Mayans M, et al. 2019 European guideline on the management of lymphogranuloma venereum. JEADV [Internet]. 2019 [cited 2020 Oct 19]; 33:1821-8. Available from: https://doi.org/10.1111/jdv.15729
https://doi.org/10.1111/jdv.15729...
,2222. Stoner BP, Cohen SE. Lymphogranuloma venereum 2015: clinical presentation, diagnosis, and treatment. Clin Infect Dis [Internet]. 2015 Dec [cited 2020 Oct 19]; 61(Suppl 8):S865-73. Available from: https://doi.org/10.1093/cid/civ756
https://doi.org/10.1093/cid/civ756...
. The regional lymphatic dissemination phase develops from one to six weeks after infection. Especially in women, the affected ganglia chain depends on the location of the initial lesion. In men, inguinal lymphadenopathy represents the main reason for consultation and is unilateral in 70% of cases1414. Vries HJC, Barbeyrac B, De Vrieze NHN, Viset JD, White JA, Vall-Mayans M, et al. 2019 European guideline on the management of lymphogranuloma venereum. JEADV [Internet]. 2019 [cited 2020 Oct 19]; 33:1821-8. Available from: https://doi.org/10.1111/jdv.15729
https://doi.org/10.1111/jdv.15729...
,2222. Stoner BP, Cohen SE. Lymphogranuloma venereum 2015: clinical presentation, diagnosis, and treatment. Clin Infect Dis [Internet]. 2015 Dec [cited 2020 Oct 19]; 61(Suppl 8):S865-73. Available from: https://doi.org/10.1093/cid/civ756
https://doi.org/10.1093/cid/civ756...
. In the last clinical phase of the condition, called the sequelae phase, ganglia's involvement evolves with a fusion of lymph nodes into a large mass, with liquefaction and fistulation by multiple holes. Orogenital contact can cause ulcerative glossitis with regional lymphadenopathy. It may be accompanied by proctitis or proctocolitis, sometimes simulating rectal cancer. The illness may be accompanied by general symptoms such as fever, malaise, anorexia, weight loss, arthralgia, night sweats, and meningism. In case of initial lesions in the cervix or rectovaginal pouch, lymphatic drainage is performed by pararectal ganglia, with permanent damage to the lymphatic network. The chronic lymphatic obstruction leads to genital elephantiasis, which in women is called esthiomene. Rectal, vaginal, or bladder fistulas may occur, as well as orificial stenosis, events that should always suggest the diagnosis of lymphogranuloma venereum1414. Vries HJC, Barbeyrac B, De Vrieze NHN, Viset JD, White JA, Vall-Mayans M, et al. 2019 European guideline on the management of lymphogranuloma venereum. JEADV [Internet]. 2019 [cited 2020 Oct 19]; 33:1821-8. Available from: https://doi.org/10.1111/jdv.15729
https://doi.org/10.1111/jdv.15729...
,2222. Stoner BP, Cohen SE. Lymphogranuloma venereum 2015: clinical presentation, diagnosis, and treatment. Clin Infect Dis [Internet]. 2015 Dec [cited 2020 Oct 19]; 61(Suppl 8):S865-73. Available from: https://doi.org/10.1093/cid/civ756
https://doi.org/10.1093/cid/civ756...
.

Donovanosis

The original lesion may vary in appearance. It can start with a flat edge ulcer that evolves to hypertrophic or vegetating ulcer, with granular bottom, single or multiple, well delimited, that grows slowly and progressively. It has a bright red aspect and easy bleeding to manipulation. There is a predilection for skin or mucous folds, with frequent "mirror configuration"2323. Velho PE, Souza EM, Belda Junior W. Donovanosis. Braz J Infect Dis [Internet]. 2008 [cited 2020 Oct 19]; 12(6):521-5. Available from: https://doi.org/10.1590/s1413-86702008000600015
https://doi.org/10.1590/s1413-8670200800...
. Adenitis does not occur, but pseudobuboes may appear in the inguinal region (subcutaneous granulomatous nodules). Genital elephantiasis is a late sequel by obstructive lymphatic phenomena. The extragenital spread is rare and most often occurs from primary genital or perigenital lesions1616. O’Farrell N, Moi H. 2016 European guideline on donovanosis. Int J STD AIDS [Internet]. 2016 Feb [cited 2020 Oct 19]; 27(8):605-7. Available from: https://doi.org/10.1177/0956462416633626
https://doi.org/10.1177/0956462416633626...
,2323. Velho PE, Souza EM, Belda Junior W. Donovanosis. Braz J Infect Dis [Internet]. 2008 [cited 2020 Oct 19]; 12(6):521-5. Available from: https://doi.org/10.1590/s1413-86702008000600015
https://doi.org/10.1590/s1413-8670200800...
. The differential diagnosis of donovanosis includes syphilis, chancroid, tuberculosis, and other granulomatous diseases, cutaneous amebiasis, ulcerated neoplasms, and American tegumentary leishmaniasis11. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para atenção integral às pessoas com infecções sexualmente transmissíveis (IST) [Internet]. Brasília: Ministério da Saúde; 2020 [cited 2020 out 19]. 248 p. Available from: http://www.aids.gov.br/pt-br/pub/2015/protocolo-clinico-e-diretrizes-terapeuticas-para-atencao-integral-pessoas-com-infeccoes
http://www.aids.gov.br/pt-br/pub/2015/pr...
,1616. O’Farrell N, Moi H. 2016 European guideline on donovanosis. Int J STD AIDS [Internet]. 2016 Feb [cited 2020 Oct 19]; 27(8):605-7. Available from: https://doi.org/10.1177/0956462416633626
https://doi.org/10.1177/0956462416633626...
.

DIAGNOSIS

The assistance to people with lesions presents particularities. The interview must be conducted in an environment of privacy, in an empathetic manner, and without value judgments, either through speech or non-verbal language. Inquiries about sexual practices and identification of STI risk factors, such as age under 30, history of new or multiple sexual partnerships (especially in the past three months), sexual partnerships with STI, prior or concurrent STI, and irregular condom use are required99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
,2424. Gabrielson AT, Le TV, Fontenot C, Usta M, Hellstrom WJG. Male genital dermatology: a primer for the sexual medicine physician. Sex Med Rev [Internet]. 2019 Jan [cited 2020 Oct 19]; 7(1):71-83. Available from: https://doi.org/10.1016/j.sxmr.2018.09.004
https://doi.org/10.1016/j.sxmr.2018.09.0...
,2525. Wagenlehner FME, Brockmeyer NH, Discher T, Friese K, Wichelhaus TA. The presentation, diagnosis, and treatment of sexually transmitted infections. Dtsch Arztebl Int [Internet]. 2016 [cited 2020 Oct 19]; 113(1-2):11-22. Available from: https://doi.org/10.3238/arztebl.2016.0011
https://doi.org/10.3238/arztebl.2016.001...
. Psychoactive drugs, anonymous or group sexual encounters, professional sexual activity, sexual abuse, street situation, or liberty deprivation must be considered. Populations with difficult access to services, such as transexuals, deserve special attention.

The etiological diagnosis of genital ulcers based on anamnesis and physical examination can be imprecise; therefore, it is important to use diagnostic tests whenever they are available99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
,2626. World Health Organization - WHO. Diagnóstico laboratorial de doenças sexualmente transmissíveis, incluindo o vírus da imunodeficiência humana [Internet]. Brasília: Organização Mundial da Saúde; Ministério da Saúde; 2013 [cited 2020 out 19]. Available from: https://apps.who.int/iris/bitstream/handle/10665/85343/9789241505840_por.pdf?sequence=7
https://apps.who.int/iris/bitstream/hand...
. These tests only have value if the results are immediately available because treatment institution should not be postponed depending on the results. These tests' sensitivity is variable due to technical particularities and relies on the number of pathogens in the sample obtained99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
,2727. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância, Prevenção e Controle das Doenças Sexualmente Transmissíveis, HIV/Aids e Hepatites Virais. Manual para o diagnóstico da sífilis [Internet]. Brasília: Ministério da Saúde ; 2016 [cited 2020 out 19]. Available from: http://www.aids.gov.br/pt-br/pub/2016/manual-tecnico-para-diagnostico-da-sifilis
http://www.aids.gov.br/pt-br/pub/2016/ma...
.

Herpes simplex virus HSV-1 and HSV-2

Serological tests for HSV-1 and HSV-2 detections are available. Although they are of little help in diagnosis, identifying the viral type can help evaluate prognosis and counseling. It is estimated that HSV-2 has greater transmissibility, including transmission from the pregnant woman to the newborn99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
,2424. Gabrielson AT, Le TV, Fontenot C, Usta M, Hellstrom WJG. Male genital dermatology: a primer for the sexual medicine physician. Sex Med Rev [Internet]. 2019 Jan [cited 2020 Oct 19]; 7(1):71-83. Available from: https://doi.org/10.1016/j.sxmr.2018.09.004
https://doi.org/10.1016/j.sxmr.2018.09.0...
.

Viral culture, reserved for research environments and considered a gold standard exam, is being replaced by tests based on nucleic acid amplification test (NAAT), which have greater sensitivity and practicality2626. World Health Organization - WHO. Diagnóstico laboratorial de doenças sexualmente transmissíveis, incluindo o vírus da imunodeficiência humana [Internet]. Brasília: Organização Mundial da Saúde; Ministério da Saúde; 2013 [cited 2020 out 19]. Available from: https://apps.who.int/iris/bitstream/handle/10665/85343/9789241505840_por.pdf?sequence=7
https://apps.who.int/iris/bitstream/hand...
.

Treponema pallidum

Dark-field microscopy can allow the identification of spirochetes with characteristic shapes and movements. Lymph obtained by the expression is used, ideally without bleeding, which must be analyzed immediately. The use of material obtained from lesions of the oral cavity is inappropriate due to the presence of saprophytic spirochaetes unrelated to syphilis. Direct immunofluorescence or special stains require longer processing and will hardly be useful in clinical context. Identification of genital lesions indicates serological investigation for diagnostic clarification and screening of concomitant STI. There are two types of serological tests, treponemal and nontreponemal. Among the treponemal tests, the following can be mentioned: rapid tests by immunochromatography, treponemal fluorescent antibody-absorption (FTA-Abs), T. pallidum particle agglutination assay (TPHA), electrochemiluminescence, and the enzyme-linked immunosorbent assay (ELISA). Nontreponemal tests, such as the venereal disease research laboratory (VDRL) and rapid plasma reagin (RPR), have particular importance in the serological follow-up1919. Kingston M, French P, Higgins S, McQuillan O, Sukthankar A, Stott C, et al. UK national guidelines on the management of syphilis 2015. Int J STD AIDS [Internet]. 2016 May [cited 2020 Oct 19]; 27(6):421-46. Available from: https://doi.org/10.1177/0956462415624059
https://doi.org/10.1177/0956462415624059...
,2020. Janier M, Hegyi V, Dupin N, Unemo M, Tiplica GS, Potočnik M, et al. 2014 European guideline on the management of syphilis. J Eur Acad Dermatol Venereol [Internet]. 2014 Dec [cited 2020 Oct 19]; 28(12):1581-93. Available from: https://doi.org/10.1111/jdv.12734
https://doi.org/10.1111/jdv.12734...
,2626. World Health Organization - WHO. Diagnóstico laboratorial de doenças sexualmente transmissíveis, incluindo o vírus da imunodeficiência humana [Internet]. Brasília: Organização Mundial da Saúde; Ministério da Saúde; 2013 [cited 2020 out 19]. Available from: https://apps.who.int/iris/bitstream/handle/10665/85343/9789241505840_por.pdf?sequence=7
https://apps.who.int/iris/bitstream/hand...
. Treponemal tests become positive, on average, from one to three weeks from lesion onset, slightly earlier than nontreponemal tests. The rapid tests, distributed by the Ministry of Health, are practical, safe, and easy to perform by trained professionals. They provide results in up to 30 minutes and allow diagnostic support, decision making at the time of consultation, and immediate treatment2727. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância, Prevenção e Controle das Doenças Sexualmente Transmissíveis, HIV/Aids e Hepatites Virais. Manual para o diagnóstico da sífilis [Internet]. Brasília: Ministério da Saúde ; 2016 [cited 2020 out 19]. Available from: http://www.aids.gov.br/pt-br/pub/2016/manual-tecnico-para-diagnostico-da-sifilis
http://www.aids.gov.br/pt-br/pub/2016/ma...
.

Haemophilus ducreyi

Smear microscopy of lesions with abundant exudate may allow identification of organized streptobacilli two by two, a configuration compared to "train tracks". This examination has much lower sensitivity and specificity than culture, a procedure with many demands and challenging performance. DNA amplification techniques, such as NAAT, are now considered the gold standard for detecting H. ducreyi, with sensitivity up to 98.4%. Some kits for polymerase chain reaction (PCR) have the advantage of simultaneously testing other agents, such as T. pallidum and HSV99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
,1111. Lautenschlager S, Kemp M, Christensen JJ, Mayans MV, Moi H. 2017 European guideline for the management of cancroid. Int J STD AIDS [Internet]. 2017 Mar [cited 2020 Oct 19]; 28(4):324-9. Available from: https://doi.org/10.1177/0956462416687913
https://doi.org/10.1177/0956462416687913...
,1212. O'Farrell N, Lazaro N. UK National guideline for the management of Chancroid 2014. Int J STD AIDS [Internet]. 2014 Dec [cited 2020 Oct 19]; 25(14):975-83. Available from: https://doi.org/10.1177/0956462414542988
https://doi.org/10.1177/0956462414542988...
,2626. World Health Organization - WHO. Diagnóstico laboratorial de doenças sexualmente transmissíveis, incluindo o vírus da imunodeficiência humana [Internet]. Brasília: Organização Mundial da Saúde; Ministério da Saúde; 2013 [cited 2020 out 19]. Available from: https://apps.who.int/iris/bitstream/handle/10665/85343/9789241505840_por.pdf?sequence=7
https://apps.who.int/iris/bitstream/hand...
.

Chlamydia trachomatis

NAAT tests, which include PCR and ligase chain reaction, are the recommended methods for detecting C. trachomatis in material collected from ulcer specimens, rectum, bubo aspirates, pharynx, biopsy specimens, and urine samples, which are little available in the routine.1414. Vries HJC, Barbeyrac B, De Vrieze NHN, Viset JD, White JA, Vall-Mayans M, et al. 2019 European guideline on the management of lymphogranuloma venereum. JEADV [Internet]. 2019 [cited 2020 Oct 19]; 33:1821-8. Available from: https://doi.org/10.1111/jdv.15729
https://doi.org/10.1111/jdv.15729...
,2121. Belda JW, Di Chiacchio N, Criado PR. Tratado de dermatologia. 2. ed. São Paulo: Atheneu; 2015. 2768p.,2828. White J, O’Farrell N, Daniels D. 2013 UK National guideline for the management of lymphogranuloma venereum. Int J STD AIDS [Internet]. 2013 Jul [cited 2020 Oct 19]; 24(8):593. Available from: https://doi.org/10.1177/0956462413482811
https://doi.org/10.1177/0956462413482811...
Serological tests are of little importance for the identification of C. trachomatis99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
,2626. World Health Organization - WHO. Diagnóstico laboratorial de doenças sexualmente transmissíveis, incluindo o vírus da imunodeficiência humana [Internet]. Brasília: Organização Mundial da Saúde; Ministério da Saúde; 2013 [cited 2020 out 19]. Available from: https://apps.who.int/iris/bitstream/handle/10665/85343/9789241505840_por.pdf?sequence=7
https://apps.who.int/iris/bitstream/hand...
.

Klebsiella granulomatis

The diagnosis is established by identifying Donovan bodies in the microscopy of tissue fragment smears or their anatomopathological study, stained by Giemsa, Leishman's, Wright's, or Rapi-Diff methods. It is a microorganism of difficult culture, and NAATs are available, especially in research institutions99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
,1616. O’Farrell N, Moi H. 2016 European guideline on donovanosis. Int J STD AIDS [Internet]. 2016 Feb [cited 2020 Oct 19]; 27(8):605-7. Available from: https://doi.org/10.1177/0956462416633626
https://doi.org/10.1177/0956462416633626...
,2626. World Health Organization - WHO. Diagnóstico laboratorial de doenças sexualmente transmissíveis, incluindo o vírus da imunodeficiência humana [Internet]. Brasília: Organização Mundial da Saúde; Ministério da Saúde; 2013 [cited 2020 out 19]. Available from: https://apps.who.int/iris/bitstream/handle/10665/85343/9789241505840_por.pdf?sequence=7
https://apps.who.int/iris/bitstream/hand...
,2929. O’Farrell N, Hoosen A, Kingston M. 2018 UK national guideline for the management of donovanosis. Int J STD AIDS [Internet]. 2018 Sep [cited 2020 Oct 19]; 29(10):946-8. Available from: https://doi.org/10.1177/0956462418770319
https://doi.org/10.1177/0956462418770319...
.

TREATMENT

STIs are the main cause of genital ulcers and should invariably compose the diagnostic hypotheses, especially in the presence of epidemiological elements. Longer developing ulcers of more than four weeks in duration require a more careful evaluation since they may be related to neoplastic processes, chronic infectious diseases, or immunosuppression. Most of the time, these processes require specialized care, biopsy, and histopathological studies.

STIs' importance as a public health issue lies in their high frequency of occurrence and the need to interrupt transmission. The use of laboratory tests, although desirable, has limitations. In genital ulcers with STI suspicion, it is not acceptable to delay the treatment depending on laboratory test results. The use of combinations of therapeutic options to treat one or more agents is desirable in some scenarios99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
,1919. Kingston M, French P, Higgins S, McQuillan O, Sukthankar A, Stott C, et al. UK national guidelines on the management of syphilis 2015. Int J STD AIDS [Internet]. 2016 May [cited 2020 Oct 19]; 27(6):421-46. Available from: https://doi.org/10.1177/0956462415624059
https://doi.org/10.1177/0956462415624059...
,2020. Janier M, Hegyi V, Dupin N, Unemo M, Tiplica GS, Potočnik M, et al. 2014 European guideline on the management of syphilis. J Eur Acad Dermatol Venereol [Internet]. 2014 Dec [cited 2020 Oct 19]; 28(12):1581-93. Available from: https://doi.org/10.1111/jdv.12734
https://doi.org/10.1111/jdv.12734...
,2424. Gabrielson AT, Le TV, Fontenot C, Usta M, Hellstrom WJG. Male genital dermatology: a primer for the sexual medicine physician. Sex Med Rev [Internet]. 2019 Jan [cited 2020 Oct 19]; 7(1):71-83. Available from: https://doi.org/10.1016/j.sxmr.2018.09.004
https://doi.org/10.1016/j.sxmr.2018.09.0...
,2525. Wagenlehner FME, Brockmeyer NH, Discher T, Friese K, Wichelhaus TA. The presentation, diagnosis, and treatment of sexually transmitted infections. Dtsch Arztebl Int [Internet]. 2016 [cited 2020 Oct 19]; 113(1-2):11-22. Available from: https://doi.org/10.3238/arztebl.2016.0011
https://doi.org/10.3238/arztebl.2016.001...
,3030. Prabhakar P, Narayanan P, Deshpande GR, Das A, Neilsen G, Mehendale S, et al. Genital ulcer disease in india: etiologies and performance of current syndrome guidelines. Sex Transm Dis [Internet]. 2012 Nov [cited 2020 Oct 19]; 39(11):906-10. Available from: https://doi.org/10.1097/olq.0b013e3182663e22
https://doi.org/10.1097/olq.0b013e318266...
.

Figure 1 presents guidelines for the management of infections that cause genital ulcers11. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para atenção integral às pessoas com infecções sexualmente transmissíveis (IST) [Internet]. Brasília: Ministério da Saúde; 2020 [cited 2020 out 19]. 248 p. Available from: http://www.aids.gov.br/pt-br/pub/2015/protocolo-clinico-e-diretrizes-terapeuticas-para-atencao-integral-pessoas-com-infeccoes
http://www.aids.gov.br/pt-br/pub/2015/pr...
. Due to the significant reduction in the incidence of chancroid77. Naveca FG, Sabidó M, Amaral TAP, Veras EA, Contreras Mejía MC, et al. Etiology of genital ulcer disease in a sexually transmitted infection reference center in Manaus, Brazilian Amazon. PLoS One [Internet]. 2013 [cited 2020 Oct 19]; 8(5):e63953. Available from: https://doi.org/10.1371/journal.pone.0063953
https://doi.org/10.1371/journal.pone.006...
, the lack of epidemiological surveillance of this condition3131. Brasil. Ministério da Saúde. Portaria MS/GM nº 1.984, de 12 de setembro de 2014. Define a lista nacional de doenças e agravos de notificação compulsória, na forma do Anexo, a serem monitorados por meio da estratégia de vigilância em unidades sentinelas e suas diretrizes [Internet]. Diário Oficial da União, Brasília (DF), 2014 set 15 [cited 2020 maio 31]; Seção 1:59. Available from: http://www.acm.org.br/acm/acamt/documentos/emfoco/portaria-n-1984-12-09-2014.pdf .
http://www.acm.org.br/acm/acamt/document...
and the constant need to update the recommendations, the Ministry of Health instituted, in 2018, a project to identify the main etiological agents of genital ulcers (HSV type 1 and 2, T. pallidum, and H. ducreyi) using molecular tests in specific services. This project's findings may modify the current conduct flowchart regarding genital ulcers, as was the case for urethral discharge syndrome3232. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Coordenação-Geral de Vigilância das Infecções Sexualmente Transmissíveis. Vigilância epidemiológica das infecções sexualmente transmissíveis no Brasil. Bol Epidemiol [Internet]. 2020 fev [cited 2020 jun 9]; 51(8):11-5. Available from: https://www.saude.gov.br/images/pdf/2020/fevereiro/21/Boletim-epidemiologico-SVS-08.pdf .
https://www.saude.gov.br/images/pdf/2020...
,3333. Bazzo ML, Golfetto L, Gaspar PC, Pires AF, Ramos MC, Franchini M, et al. First nationwide antimicrobial susceptibility surveillance for Neisseria gonorrhoeae in Brazil, 2015-16. J Antimicrob Chemother [Internet]. 2018 [cited 2020 Oct 19]; 73(7):1854-61. Available from: https://doi.org/10.1093/jac/dky090
https://doi.org/10.1093/jac/dky090...
.

FIGURE 1:
Recommendations for the management of genital ulcer infections.

During the evaluation of genital ulcer complaints, given evidence or history of characteristic vesicular lesions, the treatment of genital herpes is indicated. In case of first episode, acyclovir 200mg, two pills, per os, three times a day, for seven to ten days, and, in the case of recurrence, acyclovir 200mg, two tablets, per os, three times a day, for five days. In cases of need of genital herpes suppression (six or more episodes per year), acyclovir 200mg, two pills, per os, twice a day, for up to six months, with the possibility of prolonging the treatment for up to two years.

For the treatment of other STI with genital ulcers and clinical pictures with less than four weeks of evolution, syphilis (hard chancre) must be treated with benzathine penicillin, a single dose of 2.4 million international units (IU), deep intramuscular (1.2 million IU in each gluteus), and chancroid with azithromycin 1g, single-dose, per os. In cases of lesions with more than four weeks of evolution, a biopsy must be performed. The institution of treatment for syphilis, chancroid, lymphogranuloma venereum, and donovanosis must be assessed. For lymphogranuloma venereum and donovanosis, more prolonged treatments are necessary. In the case of lymphogranuloma, doxycycline 100mg must be taken twice a day orally for 21 days as the first option, and azithromycin as an alternative. In the case of donovanosis, it is recommended to take azithromycin 500mg, two pills, per os, once a week, for at least three weeks or until the lesions heal, and, as an alternative treatment, the use of doxycycline, ciprofloxacin, or sulfamethoxazole-trimethoprim may be assessed11. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para atenção integral às pessoas com infecções sexualmente transmissíveis (IST) [Internet]. Brasília: Ministério da Saúde; 2020 [cited 2020 out 19]. 248 p. Available from: http://www.aids.gov.br/pt-br/pub/2015/protocolo-clinico-e-diretrizes-terapeuticas-para-atencao-integral-pessoas-com-infeccoes
http://www.aids.gov.br/pt-br/pub/2015/pr...
. The recommended treatments, including in special situations such as immunosuppression and pregnancy, are summarized in Figure 2 and Figure 3. It is important to emphasize that given a lesion with sudden evolution and a history of exposure to drugs, fixed drug eruption must be considered2424. Gabrielson AT, Le TV, Fontenot C, Usta M, Hellstrom WJG. Male genital dermatology: a primer for the sexual medicine physician. Sex Med Rev [Internet]. 2019 Jan [cited 2020 Oct 19]; 7(1):71-83. Available from: https://doi.org/10.1016/j.sxmr.2018.09.004
https://doi.org/10.1016/j.sxmr.2018.09.0...
,3434. Sehgal VN, Pandhi D, Khurana A. Nonspecific genital ulcers. Clin Dermatol [Internet]. 2014 Feb [cited 2020 Aug 6]; 32(2):259-74. Available from: https://doi.org/10.1016/j.clindermatol.2013.08.024
https://doi.org/10.1016/j.clindermatol.2...
.

FIGURE 2:
Treatment of genital herpes.

FIGURE 3:
Treatment of genital ulcers with a diagnosis of syphilis, chancroid, lymphogranuloma venereum, or donovanosis.

The sexual partners of the last three months must be oriented about exposure risks and evaluated and treated according to clinical, laboratory, or epidemiological findings88. Patel R, Kennedy OJ, Clarke E, Geretti A, Nilsen A, Lautenschlager S, et al. 2017 European guidelines for the management of genital herpes. Int J STD AIDS [Internet]. 2017 [cited 2020 Oct 19]; 28(14):1366-79. Available from: https://doi.org/10.1177/0956462417727194
https://doi.org/10.1177/0956462417727194...
,99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
,1212. O'Farrell N, Lazaro N. UK National guideline for the management of Chancroid 2014. Int J STD AIDS [Internet]. 2014 Dec [cited 2020 Oct 19]; 25(14):975-83. Available from: https://doi.org/10.1177/0956462414542988
https://doi.org/10.1177/0956462414542988...
,2424. Gabrielson AT, Le TV, Fontenot C, Usta M, Hellstrom WJG. Male genital dermatology: a primer for the sexual medicine physician. Sex Med Rev [Internet]. 2019 Jan [cited 2020 Oct 19]; 7(1):71-83. Available from: https://doi.org/10.1016/j.sxmr.2018.09.004
https://doi.org/10.1016/j.sxmr.2018.09.0...
,2525. Wagenlehner FME, Brockmeyer NH, Discher T, Friese K, Wichelhaus TA. The presentation, diagnosis, and treatment of sexually transmitted infections. Dtsch Arztebl Int [Internet]. 2016 [cited 2020 Oct 19]; 113(1-2):11-22. Available from: https://doi.org/10.3238/arztebl.2016.0011
https://doi.org/10.3238/arztebl.2016.001...
. Sexual partners of individuals with syphilis whose exposure occurred up to 90 days before the onset of symptoms must be evaluated1919. Kingston M, French P, Higgins S, McQuillan O, Sukthankar A, Stott C, et al. UK national guidelines on the management of syphilis 2015. Int J STD AIDS [Internet]. 2016 May [cited 2020 Oct 19]; 27(6):421-46. Available from: https://doi.org/10.1177/0956462415624059
https://doi.org/10.1177/0956462415624059...
,2020. Janier M, Hegyi V, Dupin N, Unemo M, Tiplica GS, Potočnik M, et al. 2014 European guideline on the management of syphilis. J Eur Acad Dermatol Venereol [Internet]. 2014 Dec [cited 2020 Oct 19]; 28(12):1581-93. Available from: https://doi.org/10.1111/jdv.12734
https://doi.org/10.1111/jdv.12734...
, performing their presumptive treatment with a single dose penicillin benzathine 2.4 million IU, single-dose, intramuscular. Sexual partners of individuals with chancroid whose exposure occurred up to ten days before the onset of symptoms should be evaluated and treated with azithromycin 500mg, two pills, per os, single dose99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
,1212. O'Farrell N, Lazaro N. UK National guideline for the management of Chancroid 2014. Int J STD AIDS [Internet]. 2014 Dec [cited 2020 Oct 19]; 25(14):975-83. Available from: https://doi.org/10.1177/0956462414542988
https://doi.org/10.1177/0956462414542988...
. For asymptomatic partners of people with HSV-1 and HSV-2, presumptive treatment is not recommended88. Patel R, Kennedy OJ, Clarke E, Geretti A, Nilsen A, Lautenschlager S, et al. 2017 European guidelines for the management of genital herpes. Int J STD AIDS [Internet]. 2017 [cited 2020 Oct 19]; 28(14):1366-79. Available from: https://doi.org/10.1177/0956462417727194
https://doi.org/10.1177/0956462417727194...
,3131. Brasil. Ministério da Saúde. Portaria MS/GM nº 1.984, de 12 de setembro de 2014. Define a lista nacional de doenças e agravos de notificação compulsória, na forma do Anexo, a serem monitorados por meio da estratégia de vigilância em unidades sentinelas e suas diretrizes [Internet]. Diário Oficial da União, Brasília (DF), 2014 set 15 [cited 2020 maio 31]; Seção 1:59. Available from: http://www.acm.org.br/acm/acamt/documentos/emfoco/portaria-n-1984-12-09-2014.pdf .
http://www.acm.org.br/acm/acamt/document...
,3535. Patel R, Green J, Clarke E, Seneviratne K, Abbt N, Evans C, et al. 2014 UK national guideline for the management of anogenital herpes. Int J STD AIDS [Internet]. 2015 Oct [cited 2020 Oct 19]; 26(11):763-76. Available from: https://doi.org/10.1177/0956462415580512
https://doi.org/10.1177/0956462415580512...
. Presumptive treatment of sexual partners of people with chlamydia, with exposure up to 60 days before the onset of symptoms is indicated99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
,1414. Vries HJC, Barbeyrac B, De Vrieze NHN, Viset JD, White JA, Vall-Mayans M, et al. 2019 European guideline on the management of lymphogranuloma venereum. JEADV [Internet]. 2019 [cited 2020 Oct 19]; 33:1821-8. Available from: https://doi.org/10.1111/jdv.15729
https://doi.org/10.1111/jdv.15729...
,2222. Stoner BP, Cohen SE. Lymphogranuloma venereum 2015: clinical presentation, diagnosis, and treatment. Clin Infect Dis [Internet]. 2015 Dec [cited 2020 Oct 19]; 61(Suppl 8):S865-73. Available from: https://doi.org/10.1093/cid/civ756
https://doi.org/10.1093/cid/civ756...
,2828. White J, O’Farrell N, Daniels D. 2013 UK National guideline for the management of lymphogranuloma venereum. Int J STD AIDS [Internet]. 2013 Jul [cited 2020 Oct 19]; 24(8):593. Available from: https://doi.org/10.1177/0956462413482811
https://doi.org/10.1177/0956462413482811...
with azithromycin 500mg, two pills, per os, single-dose, or doxycycline 100mg, one tablet, per os, twice a day for seven days (contraindicated in pregnant women, nursing mothers and children under nine). In the case of donovanosis, presumptive treatment of asymptomatic sexual partners is not recommended because of low infectivity1616. O’Farrell N, Moi H. 2016 European guideline on donovanosis. Int J STD AIDS [Internet]. 2016 Feb [cited 2020 Oct 19]; 27(8):605-7. Available from: https://doi.org/10.1177/0956462416633626
https://doi.org/10.1177/0956462416633626...
,2929. O’Farrell N, Hoosen A, Kingston M. 2018 UK national guideline for the management of donovanosis. Int J STD AIDS [Internet]. 2018 Sep [cited 2020 Oct 19]; 29(10):946-8. Available from: https://doi.org/10.1177/0956462418770319
https://doi.org/10.1177/0956462418770319...
.

Surveillance, prevention, and control

Counseling centered on the person and their sexual practices aim at recognizing riskier practices and establishing a risk reduction plan in light of combined prevention recommendations for STI, HIV, and viral hepatitis11. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para atenção integral às pessoas com infecções sexualmente transmissíveis (IST) [Internet]. Brasília: Ministério da Saúde; 2020 [cited 2020 out 19]. 248 p. Available from: http://www.aids.gov.br/pt-br/pub/2015/protocolo-clinico-e-diretrizes-terapeuticas-para-atencao-integral-pessoas-com-infeccoes
http://www.aids.gov.br/pt-br/pub/2015/pr...
. The use of barrier methods during oral, vaginal, and anal sexual activity must be indicated. Sexual accessories must be for individual use and sanitized before, and after use11. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para atenção integral às pessoas com infecções sexualmente transmissíveis (IST) [Internet]. Brasília: Ministério da Saúde; 2020 [cited 2020 out 19]. 248 p. Available from: http://www.aids.gov.br/pt-br/pub/2015/protocolo-clinico-e-diretrizes-terapeuticas-para-atencao-integral-pessoas-com-infeccoes
http://www.aids.gov.br/pt-br/pub/2015/pr...
,99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
. HIV infection prophylaxis on post-exposure or pre-exposure must be offered when indicated11. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para atenção integral às pessoas com infecções sexualmente transmissíveis (IST) [Internet]. Brasília: Ministério da Saúde; 2020 [cited 2020 out 19]. 248 p. Available from: http://www.aids.gov.br/pt-br/pub/2015/protocolo-clinico-e-diretrizes-terapeuticas-para-atencao-integral-pessoas-com-infeccoes
http://www.aids.gov.br/pt-br/pub/2015/pr...
.

Rapid testing for HIV, syphilis, and hepatitis B and C infection must invariably be recommended. Post-therapeutic serological follow-up tests are indicated for people with syphilis. Vaccination for HPV and hepatitis A and B prophylaxis should follow the recommendations99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
,2424. Gabrielson AT, Le TV, Fontenot C, Usta M, Hellstrom WJG. Male genital dermatology: a primer for the sexual medicine physician. Sex Med Rev [Internet]. 2019 Jan [cited 2020 Oct 19]; 7(1):71-83. Available from: https://doi.org/10.1016/j.sxmr.2018.09.004
https://doi.org/10.1016/j.sxmr.2018.09.0...
,2525. Wagenlehner FME, Brockmeyer NH, Discher T, Friese K, Wichelhaus TA. The presentation, diagnosis, and treatment of sexually transmitted infections. Dtsch Arztebl Int [Internet]. 2016 [cited 2020 Oct 19]; 113(1-2):11-22. Available from: https://doi.org/10.3238/arztebl.2016.0011
https://doi.org/10.3238/arztebl.2016.001...
. NAAT screening for C. trachomatis and Neisseria gonorrhoeae infections in urine samples, urethral or cervical exudate is recommended, despite its unavailability in most services11. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para atenção integral às pessoas com infecções sexualmente transmissíveis (IST) [Internet]. Brasília: Ministério da Saúde; 2020 [cited 2020 out 19]. 248 p. Available from: http://www.aids.gov.br/pt-br/pub/2015/protocolo-clinico-e-diretrizes-terapeuticas-para-atencao-integral-pessoas-com-infeccoes
http://www.aids.gov.br/pt-br/pub/2015/pr...
.

Syphilis cases with ulcers that present a reagent test (treponemal or nontreponemal) must be compulsorily reported as acquired syphilis3131. Brasil. Ministério da Saúde. Portaria MS/GM nº 1.984, de 12 de setembro de 2014. Define a lista nacional de doenças e agravos de notificação compulsória, na forma do Anexo, a serem monitorados por meio da estratégia de vigilância em unidades sentinelas e suas diretrizes [Internet]. Diário Oficial da União, Brasília (DF), 2014 set 15 [cited 2020 maio 31]; Seção 1:59. Available from: http://www.acm.org.br/acm/acamt/documentos/emfoco/portaria-n-1984-12-09-2014.pdf .
http://www.acm.org.br/acm/acamt/document...
, and partners will only be notified after investigation, depending on the test results and the presence of symptoms, as defined in the case definition of acquired syphilis11. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para atenção integral às pessoas com infecções sexualmente transmissíveis (IST) [Internet]. Brasília: Ministério da Saúde; 2020 [cited 2020 out 19]. 248 p. Available from: http://www.aids.gov.br/pt-br/pub/2015/protocolo-clinico-e-diretrizes-terapeuticas-para-atencao-integral-pessoas-com-infeccoes
http://www.aids.gov.br/pt-br/pub/2015/pr...
.

SPECIAL POPULATIONS

Pregnant women

Genital ulcers caused by STI deserve careful attention due to the potential for vertical transmission of some etiological agents, especially T. pallidum. The suspicion of syphilis in pregnant woman indicates treatment according to the clinical stage, in a mandatory way, independently of laboratory results. Post-treatment nontreponemal tests must be performed every 30 days99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
,1919. Kingston M, French P, Higgins S, McQuillan O, Sukthankar A, Stott C, et al. UK national guidelines on the management of syphilis 2015. Int J STD AIDS [Internet]. 2016 May [cited 2020 Oct 19]; 27(6):421-46. Available from: https://doi.org/10.1177/0956462415624059
https://doi.org/10.1177/0956462415624059...
,2020. Janier M, Hegyi V, Dupin N, Unemo M, Tiplica GS, Potočnik M, et al. 2014 European guideline on the management of syphilis. J Eur Acad Dermatol Venereol [Internet]. 2014 Dec [cited 2020 Oct 19]; 28(12):1581-93. Available from: https://doi.org/10.1111/jdv.12734
https://doi.org/10.1111/jdv.12734...
. HSV also presents specificities in its management during pregnancy. Its occurrence at the end of pregnancy increases the risk of fetal and neonatal complications. In the presence of active lesions in the genital area, a cesarean section is indicated88. Patel R, Kennedy OJ, Clarke E, Geretti A, Nilsen A, Lautenschlager S, et al. 2017 European guidelines for the management of genital herpes. Int J STD AIDS [Internet]. 2017 [cited 2020 Oct 19]; 28(14):1366-79. Available from: https://doi.org/10.1177/0956462417727194
https://doi.org/10.1177/0956462417727194...
,3636. Gnann JW, Whitley RJ. Genital herpes. N Engl J Med [Intenet]. 2016 Aug [cited 2020 Oct 19]; 375:666-74. Available from: https://doi.org/10.1056/NEJMcp1603178
https://doi.org/10.1056/NEJMcp1603178...
,3737. Foley E, Clarke E, Beckett VA, Harrison S, Pillai A, FitzGerald M, et al. Management of genital herpes in pregnancy [Internet]. London: BASHH; 2014 [cited 2020 Oct 19]. Available from: https://www.rcog.org.uk/globalassets/documents/guidelines/management-genital-herpes.pdf .
https://www.rcog.org.uk/globalassets/doc...
. The occurrence of adverse events in pregnancy due to chancroid and donovanosis is rare99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
. In the case of donovanosis, there are reports of perinatal transmission cases involving the otorhinolaryngological structures of the newborn3838. Govender D, Narddok K, Chetty R. Granuloma inguinale: an usual cause of otitis media and mastoiditis in children. Am J Clin Pathol [Internet]. 1997 Nov [cited 2020 Oct 19]; 108(5):510-4. Available from: https://doi.org/10.1093/ajcp/108.5.510
https://doi.org/10.1093/ajcp/108.5.510...

39. Scott CW, Harper D, Jason RS. Neonatal granuloma venereum. Am J Dis Child [Internet]. 1953 Mar [cited 2020 Oct 19]; 85(3):308-15. Available form: https://doi.org/10.1001/archpedi.1953.02050070320006
https://doi.org/10.1001/archpedi.1953.02...
-4040. Ramdial PK, Sing Y, Ramburan A, Naidu TK, Samuel EY, Bagratee JS, et al. Infantile donovanosis presenting as external auditory canal polyps. A diagnostic trap. Am J Dermatopathol [Internet]. 2012 Dec [cited 2020 Oct 19]; 34(8):818-21. Available from: https://doi.org/10.1097/DAD.0b013e3182540ccb
https://doi.org/10.1097/DAD.0b013e318254...
.

People with HIV infection

STI treatment regimens are the same as those recommended for people without HIV infection. Genital ulcers facilitate HIV transmission, increasing the importance of early treatment, and the higher risk is especially significant for genital herpes, syphilis, and chancroid99. Workowski KA. Centers for Disease Control and Prevention - CDC. Sexually transmitted diseases treatment guidelines. Clin Infect Dis [Internet]. 2015 [cited 2020 Oct 19]; 61(Suppl 8):S759-62. Available from: https://doi.org/10.1093/cid/civ7712015
https://doi.org/10.1093/cid/civ7712015...
,2323. Velho PE, Souza EM, Belda Junior W. Donovanosis. Braz J Infect Dis [Internet]. 2008 [cited 2020 Oct 19]; 12(6):521-5. Available from: https://doi.org/10.1590/s1413-86702008000600015
https://doi.org/10.1590/s1413-8670200800...
,2424. Gabrielson AT, Le TV, Fontenot C, Usta M, Hellstrom WJG. Male genital dermatology: a primer for the sexual medicine physician. Sex Med Rev [Internet]. 2019 Jan [cited 2020 Oct 19]; 7(1):71-83. Available from: https://doi.org/10.1016/j.sxmr.2018.09.004
https://doi.org/10.1016/j.sxmr.2018.09.0...
. Syphilis coinfection can alter the clinical course of this condition, with atypical and aggressive manifestations1919. Kingston M, French P, Higgins S, McQuillan O, Sukthankar A, Stott C, et al. UK national guidelines on the management of syphilis 2015. Int J STD AIDS [Internet]. 2016 May [cited 2020 Oct 19]; 27(6):421-46. Available from: https://doi.org/10.1177/0956462415624059
https://doi.org/10.1177/0956462415624059...
,2020. Janier M, Hegyi V, Dupin N, Unemo M, Tiplica GS, Potočnik M, et al. 2014 European guideline on the management of syphilis. J Eur Acad Dermatol Venereol [Internet]. 2014 Dec [cited 2020 Oct 19]; 28(12):1581-93. Available from: https://doi.org/10.1111/jdv.12734
https://doi.org/10.1111/jdv.12734...
. In HSV coinfection, lesions can be more painful, atypical, and longer-lasting and may require intravenous medication to control the symptoms88. Patel R, Kennedy OJ, Clarke E, Geretti A, Nilsen A, Lautenschlager S, et al. 2017 European guidelines for the management of genital herpes. Int J STD AIDS [Internet]. 2017 [cited 2020 Oct 19]; 28(14):1366-79. Available from: https://doi.org/10.1177/0956462417727194
https://doi.org/10.1177/0956462417727194...
,3535. Patel R, Green J, Clarke E, Seneviratne K, Abbt N, Evans C, et al. 2014 UK national guideline for the management of anogenital herpes. Int J STD AIDS [Internet]. 2015 Oct [cited 2020 Oct 19]; 26(11):763-76. Available from: https://doi.org/10.1177/0956462415580512
https://doi.org/10.1177/0956462415580512...
. Chancroid and lymphogranuloma venereum must be carefully monitored since they may need more prolonged treatment due to greater chance of response delay or therapeutic failure1414. Vries HJC, Barbeyrac B, De Vrieze NHN, Viset JD, White JA, Vall-Mayans M, et al. 2019 European guideline on the management of lymphogranuloma venereum. JEADV [Internet]. 2019 [cited 2020 Oct 19]; 33:1821-8. Available from: https://doi.org/10.1111/jdv.15729
https://doi.org/10.1111/jdv.15729...
,2121. Belda JW, Di Chiacchio N, Criado PR. Tratado de dermatologia. 2. ed. São Paulo: Atheneu; 2015. 2768p.,2727. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância, Prevenção e Controle das Doenças Sexualmente Transmissíveis, HIV/Aids e Hepatites Virais. Manual para o diagnóstico da sífilis [Internet]. Brasília: Ministério da Saúde ; 2016 [cited 2020 out 19]. Available from: http://www.aids.gov.br/pt-br/pub/2016/manual-tecnico-para-diagnostico-da-sifilis
http://www.aids.gov.br/pt-br/pub/2016/ma...
.

ACKNOWLEDGEMENTS

The authors thank the technical group of specialists responsible for elaborating the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with STI in 2020 and for their contribution to this work.

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Publication Dates

  • Publication in this collection
    17 May 2021
  • Date of issue
    2021

History

  • Received
    01 Feb 2021
  • Accepted
    10 Mar 2021
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