<prompt> A female presents with 3 cm painless ulcer with raised edges on labia majora. Most common cause is: E. REPEAT 2013SyphilisGonorrheaHerpesChlamydia trachomatis  <response>: Ref: E s sent to Is in Dermatology, 1st editionExplanation: Presence of 3 cm ulcer with raised edges in the labia majora suggests Syphilis. See the following table SyphilisGranuloma Inguinale DonovanosisChancroidSoft sore. Soft Chancre, Ulcus molleLymphogranulomaVenereumEtiologyTreponema pallidumCalymmatobacteriumdonovaniGram negative Obligate intracellularHemophilus ducreiChlamydia trachomatis LI, L2 and L3 typesIncubationPeriodPrimary syphilis: 1-3 weeks Secondary syphilis: 6-12 weeks8-12 days17 days average3 days - 2 weeks 1-5 days average3-30 daysClinicalSigns Painless indurated Single punched out Usually non-bleeding Lymph nodes are rubbery Dark field microscopy FTA-ABS - Most sensitive test and Earliest lest to become positive VDRL RPR liters TPT - Most specific TPH - 2nd most sensitive test Painless genital ulcer Soft. Beefy Clean friable base Distinct raised rolled margins Massive scarring Lymphatic obstruction PseudobubosSubcutaneous granulomas not nodes Extremely painful. Suppurative ulcers of genital mucosa Soft friable, non- indurated, ragged undermined edges Foul smelling yellow grey exudate Suppurative inguinal lymph nodes Bubo Ito-Reenstierna test - Intradermal test Skin or mucosal ulcer followed by ulcerated inguinal lymph nodes Sign of the groove Freis Test: Intradermal test Genital elephantiasis EsthiomenePathology Hypertrophic ulcers Donovan Bodies Safety pin shapedPyogenic ulcerationNecrotising granulomatous inflammation with stricture formationTreatmentPenicillin G -Drug of Choice forall stages of syphilisDoxycycline 100 mgBD for 3 weeksAzithromycin 1 gsingle oral dose orCeftriaxone 250 mg1M single dose orCiprofloxacin 500 mgbd for 3 daysDoxycycline 100 mgBD for 3 weeks 