Could It Be Herpes?

[hindsight]

I’m a  28 yo male. I have a painless red sore on the tip of my penis. It does not look blistered or pus-filled. It has a red base with a slightly raised red interior(kind of like a tiny, squat mountain range). The whole thing has a glazed look to it. It developed 9-12 days ago. It is perhaps a third the size of a nickel. It appears to have shrunk a little in the last 24 hours, though overall it hasn’t really changed appearance that much. I last had sex on Sept 2 (almost 3 months before sore appeared) and used a condom.

Background:
A few weeks back I developed genital warts. My urologist proscribed podofilox and I started treating them on Nov 20. The first week I was excessive – heavily targeting the individual warts but also making sure I got it on the surrounding skin. The warts were all on the foreskin, near the top. The warts have responded pretty well to the treatment.

The sore developed in my second treatment week. Initially, it was just redness on the penis head – no apparent lesions or bumps – more or less corresponding to the area where the treated foreskin would roll onto the penis head. The redness would heal a little but then seem to push a little westwards. Where the sore now is, is directly above the area where I put on podofilox most on the foreskin, though it took a day or two for the redness to appear there and maybe a day more for it to take on the raised, bump appearance.

A few days (four or five) after that I started feeling itchy over small areas of my body and this developed into an outright, larger rash. There was some rash on the soles of my feet too, and some spots on my tongue. A few days after this I developed flu symptoms.

I went to a dermatologist who didn’t really think there was a chance of it being syphilis. He said the rash was too generalized to be sure, but he guessed it was eczema. He said the sore on my penis did not look like herpes but he wanted me to get tested anyway (blood test). In the last 24 hours the rash and flu symptoms have really healed up (though not totally). The sore also appears to have shrunk a little bit in this time frame.

Sexual history:
Active since 18. I’ve had vaginal intercourse with 12-15 women, for an aggregate of about 50 times total. 4 of these times were unprotected, each with a different woman, the last time a year ago (I’ve had protected anal sex a few times). I’ve also received unprotected male oral sex numerous times, rough guess 30-50, though not in the last six months, I think.

What are the chances of the sore being herpetic? Given the time lag in appearance since the last time I had sex, if it’s herpes it must be an old infection only now showing for the first time. What range of time would a herpes sore last for in that scenario? I'm presently at 9-12 days (I think 12, but can't be certain). Does this put me out of range? Also, just how risky was my prior sexual behavior?

Thanks. This is a great site, an invaluable resource.

[H. Hunter Handsfield, M.D.]

I believe you have syphilis; I could use your description of the penile sore to each medical students about chancres, the ulcerative primary stage of syphilis.  The same applies to parts of your skin rash description, especially lesions on the soles of the feet and in the mouth.  And  you clearly are at risk, by having sex with other men (oral sex easily transmits syphilis).  Usually the generalized rash of syphilis (the secondary stage) doesn't appear until the chancre has healed, but there are many exceptions.  Regardless of your dermatologist's opinion, you definitely need a syphilis blood test if not yet done.  (If s/he knew about your bisexual contacts, s/he should have jumped to the possibility of syphilis just as I have.)

Herpes is the most common cause of genital ulceration, but the lesion you describe doesn't sound like herpes, both from your description of the lesion and its duration.  From the timing, I can't tell whether inflammation from podofilox might be responsible.  Finally, every condition that can cause rash or other skin abnormalities anywhere on the body sometimes can affect the genitals, so the possibilities are broad.

So if you have an STD at all, it's syphilis.  Get that checked out right away if a blood test hasn't been done.  The most efficient way probably is to visit your local health department STD clinic for expert, confidential care.  They'll be able to make an accurate determination for or against syphilis within an hour, while you wait.  And if it's syphilis, have an HIV test as well.  But if/when syphilis is ruled out, follow the STD clinic's and/or your dermatologist's advice about other possibilities.

Good luck--  HHH, MD

[hindsight]

Thanks, Doctor. I'm about to take myself asap to a clinic (though it's Sunday, so I don't know if I'll find anyone open). What are the odds of contracting HIV through receptive unprotected male oral sex?

Thanks.

[hindsight]

Sorry, one more question: I told my dermatologist about receiving unprotected male oral sex and suggested syphilis myself but he didn't see that as a serious possibility. Should I change doctors?

[H. Hunter Handsfield, M.D.]

If I correctly recall a recent report, something like 40% of syphilis in gay/bi men in the US currently is being acquired by unprotected oral sex.  The oral lesions if secondary syphilis--such as the spots you have seen in your mouth, if you have syphilis--are teeming with syphilis bacteria and highly infectious.

There's not that much urgency.  Wait until Monday and visit your local health department.  Any place you could find open on Sunday (emergency room, urgent care clinic) is not likely to be staffed by people who know much about syphilis.

Most dermatologists are pretty well trained in STD and certainly should know the routes of syphilis transmission.  By itself, that doesn't need you need to change doctors.  But an STD clinic or other provider confirms syphilis, make sure you let the dermatologist know about it.

HHH, MD

[HHH,MD]

Maybe I misunderstood your question about oral sex.  You might not be using "receptive" the way I mean.  Performing fellatio (receptive) is lower risk that receiving it (insertive).  Given the penile lesion, you probably were infected by being the insertive partner.

HHH, MD

[hindsight]

Sorry, Doc: One final thing as I'm not sure if I had my terminology wrong regarding "receptive male oral sex." I was the one inserting the penis (not taking it in my mouth). I assume this doesn't change your opinion?

Thanks for all the great advice.

[H. Hunter Handsfield, M.D.]

Right.  Now we're on the same track.

HHH, MD