STI Trends and a Dermatologist's Role With Ted Rosen, MD

“There are 2.5 million new [sexually transmitted infection] cases diagnosed per year in the United States. Putting that in perspective, that's twice as many as there are new cases of diabetes in the United States,” Ted Rosen, MD, said to kick off the session “Sexually Transmitted Infections” during the 2023 Fall Clinical Dermatology Conference in Las Vegas, Nevada October 19-22.¹

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The professor and vice chair of the dermatology department at Baylor College of Medicine in Houston, Texas reviewed the latest STI data, current trends, and what dermatologists should consider in the management of STIs.

Uptick in Syphilis

According to CDC data, the number of syphilis cases continue to rise at an alarming rate. 133,954 cases were reported in 2020 and that jumped to 176,713 reported cases in 2021. The numbers from 2017 to 2021 are shown in Figure 1.²

Figure 1. Reported STI case numbers from the CDC

“2022 results are not available quite yet, but my friends at the CDC are telling me that it's going to be even worse. So we're in the middle of an epidemic of STDs, HIV, syphilis. has gone absolutely wild,” explained Rosen.

There has also been a sharp increase in congenital syphilis cases. 2157 cases were reported in 2020 and that rose to 2855 cases in 2021. The number of cases from 2017 to 2021 are shown in Figure 2.²

Figure 2. Congenital syphilis case reports from the CDC

Considerations for Dermatology Clinicians

Alopecia syphilitica (AS) is a rare occurrence in secondary syphilis, affecting roughly 3% to 7% of cases. It manifests as a type of hair loss that doesn't result in permanent scarring and can appear in various patterns, including diffuse, patchy, or a combination of both. Given its infrequency and resemblance to other types of hair loss like alopecia areata, telogen effluvium, and tinea capitis, dermatologists should maintain a high level of suspicion for timely identification. Diagnosis of AS involves taking a thorough patient history, conducting serologic tests, and examining tissue or dermatoscope findings. The initial treatment of choice involves administering a benzathine penicillin G injection, which typically leads to hair regrowth within weeks to months after administration.³

In contemporary literature, there has been an increased occurrence of psoriasiform syphilis cases, which often imitates the presentation of palmoplantar psoriasis. This has been observed both in individuals with concurrent HIV infection and those without HIV. In the majority of instances, syphilis was initially misdiagnosed, leading to patients being treated for psoriasis instead.⁴

Education is Key

“We must educate the young,” Rosen emphasized. CDC data shows that 15 to 24 year olds account for nearly half of all new STIs. Both clinicians and consumers are encouraged by the CDC to consider the social, cultural, and economic conditions that make it more difficult for sexually active individuals to stay healthy including poverty, unstable housing, drug use, and lack of insurance or access to care.²

Good News: Increased Access to Testing

Rosen pointed out the increased accessibility to find free or low cost STI testing in the US. Anyone can find clinics nearby with a quick zip code search on https://gettested.cdc.gov/.

There are also home testing kits consumers can order from the brands Let’s Get Checked, Everlywell, and myLAB BOX. At-home testing kits range in price from $149 to $199, with a higher cost including more conditions to test for.

References

1. Rosen T. Sexually Transmitted Infections. Presented at: 2023 Fall Clinical Dermatology Conference; October 19-22, 2023, Las Vegas, NV.

2. Sexually transmitted disease surveillance, 2021. Centers for Disease Control and Prevention. April 11, 2023. Accessed October 22, 2023. https://www.cdc.gov/std/statistics/2021/default.htm.

3. Mohammad K Shalabi M, Burgess B, Khan S, Ehrsam E, Khachemoune A. Alopecia syphilitica, from diagnosis to treatment. Proc (Bayl Univ Med Cent). 2022;35(2):180-183. Published 2022 Jan 26. doi:10.1080/08998280.2021.2021761

4. Schettini AP, Sardinha JC, Marques EA, Massone C. Psoriasiform syphilis: A challenge. Dermatol Reports. 2021;13(3):8830. Published 2021 Oct 6. doi:10.4081/dr.2021.8830