Chancroid is a bacterial infection that is spread through sexual contact. It is caused by a type of bacteria called Haemophilus ducreyi. Chancroid is characterized by a small bump on the genital which becomes a painful ulcer. Men may have just one ulcer, but women often develop four or more. About half of the people who are infected with a chancroid will develop enlarged inguinal lymph nodes, the nodes located in the fold between the leg and the lower abdomen. In some cases, the nodes will break through the skin and cause draining abscesses. The swollen lymph nodes and abscesses are often called buboes. Chancroid infections can be treated with antibiotics, including azithromycin, ceftriaxone, ciprofloxacin, and erythromycin. Large lymph node swellings need to be drained, either with a needle or local surgery.

Chancroid is caused by the bacterium Haemophilus ducreyi and results in painful, superficial ulcers, often with regional lymphadenopathy. Chancroid occurs in Asia, Africa, and the Caribbean, and is an important cofactor of HIV transmission. The genital ulcer from chancroid is painful, tender, and nonindurated.

Symptoms usually occur 4-10 days after exposure. The lesion at the site of infection is, initially, a pustule that breaks down to form a painful, soft, ulcer with a necrotic base and irregular borders. Multiple lesions and inguinal adenopathy often develop. With lymph node involvement, fever, chills, and malaise may also develop. Other symptoms of chancroid include painful urination, vaginal discharge, rectal bleeding, pain with bowel movements, and dyspareunia.

The combination of a painful genital ulcer and tender suppurative inguinal adenopathy suggests the diagnosis of chancroid. A probable diagnosis of chancroid can be made if:

• One or more painful genital ulcers (regional lymphadenopathy is also typical)
• No evidence of T. pallidum infection by darkfield examination of ulcer exudate or by syphilis serologic testing performed at least 7 days after onset of ulcers
• Test for herpes simplex virus performed on the ulcer exudate is negative

A definitive diagnosis of chancroid requires the identification of H. ducreyi on special culture media. However, culture media for chancroid are not widely available. Nucleic acid amplification tests can be performed in clinical laboratories that have developed their own tests.

Successful antimicrobial treatment for chancroid cures the infection, resolves the clinical symptoms, and prevents transmission to others. In advanced cases, genital scarring and rectal or urogenital fistulas from suppurative buboes can result despite successful therapy.

Recommended Regimens

Azithromycin 1 gm orally in a single dose

OR

Ceftriaxone 250 mg IM in a single dose

OR

Ciprofloxacin 500 mg orally 2 times/day for 3 days

OR

Erythromycin base 500 mg orally 3 times/day for 7 days

Azithromycin and ceftriaxone offer the advantage of single-dose therapy. Worldwide, several isolates with intermediate resistance to either ciprofloxacin or erythromycin have been reported. However, because cultures are not routinely performed, and chancroid is uncommon, data are limited regarding prevalence of H. ducreyi antimicrobial resistance.

Other Management Considerations

Men who are uncircumcised and persons with HIV infection do not respond as well to treatment as persons who are circumcised or are HIV negative. Patients should be tested for HIV at the time chancroid is diagnosed. If the initial HIV test results were negative, the provider can consider the benefits of offering more frequent testing and HIV PrEP to persons at increased risk for HIV infection.

Follow-Up

Patients should be reexamined 3–7 days after therapy initiation. If treatment is successful, ulcers usually improve symptomatically within 3 days and objectively within 7 days after therapy. If no clinical improvement is evident, the clinician should consider whether the diagnosis is correct, another STI is present, the patient has HIV infection, the treatment was not used as instructed, or the H. ducreyi strain causing the infection is resistant to the prescribed antimicrobial. The time required for complete healing depends on the size of the ulcer; large ulcers might require >2 weeks. In addition, healing can be slower for uncircumcised men who have ulcers under the foreskin. Clinical resolution of fluctuant lymphadenopathy is slower than that of ulcers and might require needle aspiration or incision and drainage, despite otherwise successful therapy. Although needle aspiration of buboes is a simpler procedure, incision and drainage might be preferred because of reduced need for subsequent drainage procedures.

Management of Sex Partners

Regardless of whether disease symptoms are present, sex partners of patients with chancroid should be examined and treated if they had sexual contact with the patient during the 10 days preceding the patient’s symptom onset.

Special Considerations

Pregnancy

Data indicate ciprofloxacin presents a low risk to the fetus during pregnancy but has potential for toxicity during breastfeeding. Alternative drugs should be used if the patient is pregnant or lactating. No adverse effects of chancroid on pregnancy outcome have been reported.

HIV Infection

Persons with HIV infection who have chancroid infection should be monitored closely because they are more likely to experience chancroid treatment failure and to have ulcers that heal slowly (430,432). Persons with HIV might require repeated or longer courses of therapy, and treatment failures can occur with any regimen. Data are limited concerning the therapeutic efficacy of the recommended single-dose azithromycin and ceftriaxone regimens among persons with HIV infection.

Children

Because sexual contact is the major primary transmission route among U.S. patients, diagnosis of chancroid ulcers among infants and children, especially in the genital or perineal region, is highly suspicious of sexual abuse. However, H. ducreyi is recognized as a major cause of nonsexually transmitted cutaneous ulcers among children in tropical regions and, specifically, countries where yaws is endemic. Acquisition of a lower-extremity ulcer attributable to H. ducreyi in a child without genital ulcers and reported travel to a region where yaws is endemic should not be considered evidence of sexual abuse.