discrete and symmetrically distributed, particularly over the trunk, where they follow the lines of cleavage in a pattern similar to pityriasis rosea Secondary syphilis can be distinguished from pityriasis rosea by papular lesions on the palms ( Fig 66.10 ) and soles, and the presence of systemic symptoms, such as general malaise, fever, headaches, sore throat, rhinorrhea, lacrimation, and generalized lymphadenopathy The exanthem extends rapidly and is usually pronounced and may be short-lived or last months One needs a high level of suspicion when viewing rashes in sexually active (or sexually abused) children to make the diagnosis of secondary syphilis Acquired syphilis is sexually contracted from direct contact with ulcerative lesions of the skin or mucous membranes of an infected individual Diagnosis may be presumed after a positive nontreponemal test, such as the VDRL slide test, rapid plasma reagin test, or automated reagin test Diagnosis should be confirmed by a treponemal test, such as the fluorescent treponemal antibody absorption test, the microhemagglutination test for Treponema pallidum, or the T pallidum immobilization test Penicillin is the treatment of choice unless contraindicated, in which case tetracycline, doxycycline, ceftriaxone, or erythromycin may be substituted Length of therapy should be based on duration and stage of infection Concomitant sexually transmitted diseases should be sought and treated empirically HIV testing is recommended for patients with secondary syphilis