Medical Care
Local therapy for chancroid includes gentle topical cleansing, soaks, and measures to reduce edema.
Patients with nonfluctuant buboes respond well to antibiotics, and the chancroid lesions do not need to be drained.
If appropriate chancroid therapy is provided and no clinical improvement is evident, the clinician must consider whether the diagnosis is correct, whether the patient is co-infected with another sexually-transmitted disease (STD), whether the patient is infected with HIV, whether the treatment instructions were followed properly, and whether the H ducreyi strain is resistant to the prescribed antimicrobial.
In resource-poor settings, where diagnostic facilities are not readily available, the World Health Organization advocates the use of a syndromic approach for the therapy of GUD. [8, 9, 42, 43]
The syndromic approach for the therapy of STDs delivers effective treatment quickly to people when they first come in for care and is focused on the most common STDs that can be cured, including syphilis, gonorrhea, chlamydia, chancroid, trichomoniasis, and candidiasis.
The syndromic approach does not require the use of expensive tests, which often are not available. People who may have more than 1 STD infection are treated with the most effective drug available. In some undeveloped regions, 6 of every 10 patients with an STD have 2 or more different infections at the same time. This approach also emphasizes treatment during the first visit. Treating curable STDs as soon as possible limits the future spread of STDs, including HIV.
STD syndromes that cause similar signs and symptoms are included in a simple flow chart to help healthcare workers use the syndromic approach to make a diagnosis and begin appropriate therapy.
Using the syndromic approach is as follows:
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Men who present with a urethral discharge are treated for both gonorrhea and chlamydia.
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Women who present with lower abdominal pain are treated for gonorrhea, chlamydia, and other bacterial infections.
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Women who present with vaginal discharge and cervicitis are treated for gonorrhea and chlamydia.
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Women who present with vaginal discharge and vaginitis are treated for trichomoniasis and candidiasis.
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Men or women who present with genital ulcers are treated for syphilis, chancroid, and genital herpes.
Treating people with STDs in this way is less expensive long term because more people are cured the first time they come for care and because the spread of STD may be limited.
The recommended drugs for STDs should be selected based on cost, availability, and local resistance patterns. [44, 45] A proper supply of STD drugs and training programs for health care workers are essential.
With the syndromic approach, less emphasis is placed on identifying the cause of a particular STD. This may be difficult for some healthcare workers to accept when they have been trained to identify the specific cause of a disease before starting therapy. However, in a setting where rapid therapy is of utmost importance and sophisticated laboratories are not available, the syndromic approach provides effective treatment.
Prompt, effective therapy and education of patients helps them decide to use condoms, change their risky sexual behavior, and convince their partner to seek treatment.
Surgical Care
Fluctuant buboes should be drained with the patient under local anesthesia. Insert a large-gauge needle into the bubo, passing through normal tissue from the side or the top of the lesion rather than the bottom, thus avoiding continuous dependent drainage and fistula formation, as demonstrated in the image below.
Large fluctuant buboes should be drained with the patient under local anesthesia and a large-gauge needle inserted through surrounding healthy skin. The insertion site should be superior or lateral to the bubo to prevent chronic drainage from the site.
Incision and drainage is an effective method for treating fluctuant buboes and may be preferable to traditional needle aspiration, considering the frequency of required repeat aspirations in some studies. [46]
If circumcision is needed, it should be completed after the patient successfully completes treatment with antibiotics.
Activity
Patients should refrain from sexual activity until ulcers are healed. Untreated chancroid ulcers may persist for 1-3 months. Chancroid ulcers treated with the appropriate antibiotic agent resolve within 7-14 days.
Prevention
Eradication of chancroid is a feasible public health objective. H ducreyi has a short duration of infectivity and requires frequent contacts to spread within a population. Humans are the only reservoir for H ducreyi, and rates of infection can be easily reduced through a variety of methods. Simple washing with soap and water within a few hours of sexual exposure is effective in reducing the risk of contracting chancroid. [47] Male circumcision is also moderately protective against H ducreyi. [29]
Instituting a condom policy directed at protecting sex workers and their clients from exposure to sexually-transmitted diseases (STDs) and improving curative services are among the most effective strategies.
Offering regular examinations and treatment for registered sex workers or monthly presumptive antibiotic treatment to women at risk have both been shown to dramatically reduce the prevalence of chancroid. Antibiotic treatment of the highest-risk populations can reduce chancroid transmission in the short term and can lead to a rapid decline in chancroid prevalence in a community.
Breaking the chancroid transmission cycle in any of these ways can markedly reduce the prevalence of chancroid, even when other conditions favor its spread. [28, 48]
The American College of Obstetricians and Gynecologists (ACOG) has released guidelines on expedited partner therapy for chlamydial and gonorrheal STDs. [49, 50] While designed to prevent reinfection with chlamydia and gonorrhea, the recommendations can also be applied to other STDs. The ACOG recommendations include the following:
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Expedited partner therapy to prevent reinfection, with legalization of expedited partner therapy
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Counsel partners to undergo screening for HIV infection and other STDs
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Expedited partner therapy contraindicated in cases of suspected abuse or compromised patient safety; pretreatment evaluation for abuse potential recommended
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Expedited partner therapy medications and protocols based on CDC, state, and/or local guidelines
Notably, preliminary work has begun on possible vaccines for H ducreyi. Two genetic targets for vaccination were identified by de Sarom et al in an encouraging development. [51]
Long-Term Monitoring
Chancroid patients should receive follow-up care to ensure resolution of the disease. Clinical improvement of chancroid should occur over 7 days, and, with appropriate antibiotic therapy, healing should be complete in 2 weeks. Healing is slower for some uncircumcised men who have ulcers under the foreskin. Lymphadenopathy may be slow to resolve and may require needle aspiration if a significant bubo is present.
Because of the highly infectious nature of chancroid, routine treatment of contacts of men with chancroid is recommended even if they are asymptomatic. All sexual contacts during the 10 days prior to the development of the genital lesion should be treated.
Empirical chancroid treatment of high-risk women has been shown to significantly decrease the prevalence of disease.
Isolation or quarantine is not required for chancroid, but patients must avoid sexual contact until all lesions, including discharging regional lymph nodes, are healed.
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Chancroid usually starts as a small papule that rapidly becomes pustular and eventually ulcerates. The ulcer enlarges, develops ragged undermined borders, and is surrounded by a rim of erythema. Unlike syphilis, lesions are tender and the border of the ulcer is not indurated. Courtesy of Hon Pak, MD.
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This patient shows the characteristic lesions of chancroid. The bubo on the right side drained spontaneously. The bubo in the left inguinal canal required needle aspiration.
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Close-up view of chancroid ulcers.
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Large fluctuant buboes should be drained with the patient under local anesthesia and a large-gauge needle inserted through surrounding healthy skin. The insertion site should be superior or lateral to the bubo to prevent chronic drainage from the site.
