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Biett’s sign: a hallmark sign of secondary syphilis

Fred Bernardes Filho1 Ana Laura Rosifini Alves Rezende1 Marcos Davi Gomes de Sousa2

1Divisão de Dermatologia, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil. 2Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil.

DOI: 10.1590/0037-8682-0475-2018

A previously healthy 39-year-old man presented with a 2-week history of a painless diffuse erythematous rash (Figure 1). He had had multiple sexual partners and unprotected intercourse. Physical examination showed diffuse lymphadenopathy and multiple erythematous macules (diameter, 1-2 cm) with an off-white scaly peripheral collarette (Biett’s sign) (Figure 2), which are typical findings of syphilitic roseola. Screening for sexually transmitted infections revealed positive results on Venereal Disease Research Laboratory (titer 1:256) and Treponema pallidum hemagglutination tests; serologically, he tested negative for human immunodeficiency virus, hepatitis B, and hepatitis C. He received a total of 4.8 million units of penicillin G benzathine over two weeks. At the 1-month follow-up, cutaneous lesions were absent; he was asymptomatic.

FIGURE 1: Diffuse erythematous macules with collarette scales. 

FIGURE 2: Syphilitic roseolas with Biett’s sign. 

Syphilis is a sexually transmitted infection that is re-emerging with increasing prevalence worldwide1,2. Secondary syphilis shows two typical types of rash: one occurring early in this phase called syphilitic roseolas, characterized by light pink to erythematous macules, and one occurring later in this phase named syphilids, marked by erythematous papules2,3. Both have hallmark collarette scales, known as Biett’s sign. Additionally, cutaneous manifestations may demonstrate atypical morphology, such as nodulo-ulcerative, annular, and pustular lesions, among others1,3. Due to varied clinical presentations, secondary syphilis is recognized as “the great imitator” and must be considered as a differential diagnosis of all dermatoses with atypical presentation. All secondary syphilis cutaneous lesions contain highly contagious spirochetes; its non-recognition and late treatment favor an increased risk of disease transmission.


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2. Peeling RW, Mabey D, Kamb ML, Chen XS, Radolf JD, Benzaken AS. Syphilis. Nat Rev Dis Primers. 2017;3:17073. [ Links ]

3. Hook EW Rd. Syphilis . Lancet. 2017;389(10078):1550-57. [ Links ]

Received: November 06, 2018; Accepted: December 17, 2018

Corresponding author: Dr. Fred Bernardes Filho. e-mail:f9filho@gmail.com

Conflict of interest: The authors declare that there is no conflict of interest.