By Lisette Hilton | Reviewed by Ted Rosen, MD, FAAD, Editor-in-Chief
Sex happens, even during a pandemic.
Sexually transmitted diseases (STDs) persist despite the community containment and social distancing that occur during a pandemic, according to a paper by Italian researchers published December 2020 in the Journal of Public Health Research.1
The authors documented the case of a 58-year-old man who in late March 2020 was referred to their dermatology clinic with suspected SARS CoV-2 infection. He had a generalized, mildly pruritic exanthematous rash associated with systemic symptoms of 2-week duration, according to the paper.
A general practitioner had treated the patient with paracetamol and systemic steroids, which improved his symptoms initially. But the symptoms relapsed, and the skin eruption worsened.
While in the dermatologist’s care, the patient referred to a genital rash that spontaneously resolved 2 months earlier. Testing revealed the patient’s more generalized rash was related to secondary syphilis. The dermatologist treated the patient with penicillin, which resolved the skin rash.
“… [S]yphilis should never be forgotten,” the authors wrote. “As highlighted by present report, the potential impact on public health is substantial, considering that secondary syphilis is a highly contagious generalized bacteremic phase of the disease.”
STDs remain a common threat
STDs, in general, are on the rise in the US, according to Ted Rosen, MD, FAAD, Editor-in-Chief of The Dermatology Digest and Professor of Dermatology at Baylor College of Medicine.
“Between the years 2014 and 2019, there were high double-digit percent increases in STDs across the board in the US. More gonorrhea, more chlamydia, more syphilis. In the first 2 months of 2020, that trend continued,” said Dr. Rosen.
Combined cases of syphilis, gonorrhea, and chlamydia reached an all-time high nationally in 2018, according to the annual Sexually Transmitted Disease Surveillance Report released by the CDC in October 2019.2
CDC statistics show that from 2017 to 2018, the number of primary and secondary syphilis cases rose 14% to more than 35,000 cases, the highest number reported since 1991. Gonorrhea increased 5% to more than 580,000 cases and chlamydia increased 3% to more than 1.7 million cases. Provisional, unpublished data disclosed by the CDC indicates that these trends continued in 2019, according to Dr. Rosen.
One in 5 people in the US have an STD, according to the CDC.
STD statistics took an interesting turn from March 2020 and after, according to Dr. Rosen. “STDs seemingly took a plunge off a cliff, with a 33% decrease in STDs, including syphilis,” he said.
The numbers could reflect declining rates from wearing masks, social distancing, and closing places such as bars, where people might meet casual partners and acquire STDs. Perhaps public health messages stressing things such as self-pleasuring and virtual rather than in-person sex helped to decrease the numbers, according to Dr. Rosen.
But he is not convinced that the numbers reflect STD reality in the age of COVID-19.
“There are good reasons why STDs should have gone up, like a condom shortage. Three of the 4 largest worldwide manufacturers of condoms closed because a lot of their workers acquired COVID-19. So, there was a worldwide shortage of condoms. Among STD clinics in the US, for example, only about 8% have remained open and had normal hours of operation during the pandemic. Two-thirds, more or less, had very curtailed days or hours of operation because STD clinics are not configured for social distancing, for example. Moreover, they don’t have enough personal protective equipment.”
About a quarter of STD clinics in the US closed completely with the onset of the pandemic, according to Dr. Rosen.
It appears that less testing is being done. CBS News in Denver, for example, reported on January 21, 2021, that Colorado public health agencies had conducted 40% fewer tests for gonorrhea, chlamydia, and syphilis during the COVID-19 pandemic compared to the previous year.
Under those circumstances, one could and should wonder if the numbers are low because STD clinics are either shut down or not functioning properly to capture true numbers. Another potential issue, according to Dr. Rosen, is that many people are afraid to go to dermatologists, primary care physicians, and other doctors for fear of catching COVID-19.
“I honestly believe that the decline in STDs that has been reported is not real,” he said.
What we think we know and do not know about STDs and COVID-19
Dr. Rosen coauthored the SkinMed August 2020 article Sexually Transmitted Diseases in the COVID-19 Era, which looked at sexual transmission of COVID-19, as well as STD co-infection with COVID-19.3
He said that COVID-19 does not appear to alter facets of STDs.
“HIV causes a change in morphology. It often may institute recurrences of some diseases that tend to recur. And it can alter response to therapy,” Dr. Rosen said. “… COVID-19 to date has not caused more recurrence of those diseases that tend to recur like genital herpes or genital warts. It has not altered response to standard treatment protocols, and it has not really altered the morphology of STDs.”
Sexual transmission of COVID-19, however, seems a bit of an enigma, according to Dr. Rosen.
Some viruses, such as the Zika virus, can be sexually transmitted and are not considered STDs. Several reports of acutely infected as well as recovering COVID-19 patients have shown no detectable COVID-19 virus in genital secretions, like semen. But researchers in China found in a study of 38 patients that more than 26% of acutely infected and about 9% of recovering COVID-19 patients have some degree of COVID-19 in semen.4
“We have yet to determine whether the virus can be transmitted through sexual activity,” Dr. Rosen said.
Dermatologists’ roles
Dermatologists are STD experts and need to continue to care for STD patients through and after the pandemic, according to Dr. Rosen, who recently wrote an editorial on the topic [Ted Talks: Should dermatologists still be experts in sexually transmitted diseases? – The Dermatology Digest (thedermdigest.com)]5.
“If you are under the illusion that gynecologists or urologists understand or know STDs other than a very few genital lesions, disabuse yourself of that illusion. They do not. And the infectious disease people—there are not enough of them and they are mostly interested in HIV,” Dr. Rosen said.
Dermatologists are ideally trained to treat STDs, most of which occur on the skin.
“If we don’t do it, nobody else really will,” Dr. Rosen said.
Dermatologists should encourage patients to talk about genital health. Those conversations are particularly important with patients who may be at a high demographic risk, including gay men, bisexual men, those who might be intravenous drug abusers, people who have had past STDs, etc.
“I think this should be part of all of our routines. Whether there is a COVID-19 pandemic or not, it still is an important issue,” Dr. Rosen said. “The bottom line is STDs are here, they’ve been here, they’re going to be here, and we need to be aware of them and diagnose and treat them properly and in a timely fashion.”
REFERENCES
1. Di Buduo A, Atzori L, Pilloni L, et al. Don’t forget about syphilis: sexually transmitted diseases during COVID-19 pandemic. J Public Health Res. 2020 Dec 23;9(4):2040. doi: 10.4081/jphr.2020.2040.
2. CDC. STDs continue to rise in the US. https://www.cdc.gov/nchhstp/newsroom/2019/2018-STD-surveillance-report-press-release.html
3. Wiggins CJ, Rosen T. Sexually transmitted diseases in the COVID-19 era. Skinmed. 2020 Aug 1;18(4):210-212. PMID: 33032683
4. Li D, Jin M, Bao P, et al. Clinical characteristics and results of semen tests among men with coronavirus disease 2019. JAMA Netw Open. 2020 May 1;3(5):e208292. doi: 10.1001/jamanetworkopen.2020.8292. Erratum in: JAMA Netw Open. 2020 Jun 1;3(6):e2010845.
5. Rosen T. Ted talks: Should dermatologists still be experts in sexually transmitted diseases? The Dermatology Digest. 2021 Feb;2-4.