Hyperpigmented palmoplantar macules

A 25-year-old man presented to our outpatient department with a complaint of asymptomatic, hyperpigmented, flat lesions over the palms and soles for 5 months. He had no other cutaneous or systemic complaints. Cutaneous examination revealed multiple brownish-black macules of varying sizes, ranging from 1 × 1 cm to 2 × 2 cm, presented over the palms and soles [Figure 1a and b]. There was no lymphadenopathy, generalized rash, or oral mucosal lesions on examination. On detailed history taking, he revealed a history of unprotected sexual intercourse with multiple male and female partners. Genital examination revealed a healed scar over the prepuce of the penis [Figure 1c], suggestive of a previous chancre.

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Figure 1: (a-b) Multiple brownish-black macules over the palms and soles. (c) A healed scar over the prepuce of the penis (black arrow).

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Serological investigations revealed non-reactive results for human immunodeficiency virus (HIV) and hepatitis B and C, while the venereal disease research laboratory (VDRL) test was reactive with a titer of 1:128, confirmed by a positive treponema pallidum hemagglutination assay (TPHA) test. Based on clinical findings and serological evidence, a diagnosis of secondary syphilis was established. The patient was treated with intramuscular benzathine penicillin G, 2.4 million units administered once. He was counseled regarding safe sexual practices and the importance of consistent condom use. Partner notification was advised, and he was requested to bring his sexual partner(s) for counseling, clinical evaluation, and appropriate screening during the subsequent visit.^[1] The differential diagnosis of palmoplantar pigmentation includes post-inflammatory hyperpigmentation, tinea nigra, acral melanocytic lesions, and lichen planus. Hyperpigmented palmoplantar macules are a crucial diagnostic clue. As the “great imitator,” secondary syphilis exhibits a broad range of morphological variations, including macular, papular, papulosquamous, lichenoid, annular, nodular, pustular, follicular, and pigmentary.