Genital ulcers — MSF Clinical guidelines — Médecins Sans Frontières 2026

MSFClinical guideline (chapter)Current edition

From Clinical guidelines — Diagnosis and treatment manual › Chapter 9: Genito-urinary diseases · Médecins Sans Frontières, Current online edition, 2026

Syndromic management and treatment protocols for sexually transmitted genital ulcers for clinicians in resource-limited settings.

In one sentenceGenital ulcers should be treated syndromically with simultaneous therapy for syphilis (benzathine benzylpenicillin 2.4 MIU IM) and chancroid (azithromycin 1 g PO); partners receive same treatment regardless of symptoms except herpes.

Issuer: Médecins Sans Frontières
Edition: Current online edition, 2026
Audience: Clinicians working in resource-limited and humanitarian settings
Evidence: Expert consensus based on MSF field experience
Reviewed: 21 Oct 2026 · GMJ

Read the original on MSF Whole guideline (PDF)

Summary by GMJ Guidelines Desk•Reviewed by Prof. Giorgi Pkhakadze, MD, MPH, PhD•Record updated 21 Oct 2026•Next check Apr 2027

What this guideline says

GMJ summary

This MSF clinical guideline provides syndromic management protocols for genital ulcers caused by sexually transmitted infections. It covers five principal aetiologies: syphilis (Treponema pallidum), chancroid (Haemophilus ducreyi), genital herpes (Herpes simplex), lymphogranuloma venereum (Chlamydia trachomatis), and donovanosis (Calymmatobacterium granulomatis).

The guideline emphasises that laboratory testing in the field is of limited value and recommends empirical treatment based on clinical presentation. A key principle is simultaneous treatment for both syphilis and chancroid, as both are frequent and cannot be reliably distinguished clinically. The guideline specifies detailed dosing regimens for each condition, alternative therapies for penicillin-allergic patients, and management of complications such as fluctuant lymph nodes.

Sexual partners receive the same treatment as the index patient regardless of symptoms, except in genital herpes where partners are treated only if symptomatic. Special considerations are provided for HIV-infected patients, pregnant women, and patients with recurrent episodes.

Key points

For clinicians — doses and thresholds as stated in the guideline

For genital herpes first episode: aciclovir 400 mg PO 3 times daily for 7 days (within 5 days of symptom onset); for recurrence: same dose for 5 days (only effective if started during prodrome or within 24 hours)
For early syphilis: benzathine benzylpenicillin 2.4 MIU IM single dose; for late latent syphilis: 2.4 MIU IM weekly for 3 weeks
Alternative for penicillin allergy in syphilis: erythromycin 1 g PO twice daily for 14 days (early) or 30 days (late latent); or doxycycline 100 mg PO twice daily for same durations
For chancroid: azithromycin 1 g PO single dose, or ceftriaxone 250 mg IM single dose, or erythromycin 1 g PO twice daily for 7 days
Treat simultaneously for syphilis AND chancroid as both are frequent and cannot be correctly distinguished clinically
For lymphogranuloma venereum: erythromycin 1 g PO twice daily for 14 days or doxycycline 100 mg PO twice daily for 14 days
For donovanosis: continue treatment until complete disappearance of lesions (usually several weeks); azithromycin 1 g on day 1 then 500 mg daily, with addition of gentamicin 6 mg/kg IM daily in HIV-infected patients
Sexual partners receive same treatment as patient (whether symptomatic or not), except genital herpes where partners treated only if symptomatic

Treatment protocols for genital ulcers by aetiology

Table extracted from the guideline

Condition	First-line treatment	Alternative treatment	Duration/notes
Genital herpes (first episode)	Aciclovir 400 mg PO 3 times daily	—	7 days (within 5 days of onset)
Genital herpes (recurrence)	Aciclovir 400 mg PO 3 times daily	—	5 days (within 24 hours of onset)
Early syphilis	Benzathine benzylpenicillin 2.4 MIU IM	Erythromycin 1 g PO twice daily OR doxycycline 100 mg PO twice daily	Single dose / 14 days
Late latent syphilis	Benzathine benzylpenicillin 2.4 MIU IM weekly	Erythromycin 1 g PO twice daily OR doxycycline 100 mg PO twice daily	3 weeks / 30 days
Chancroid	Azithromycin 1 g PO OR ceftriaxone 250 mg IM	Erythromycin 1 g PO twice daily	Single dose / 7 days
Lymphogranuloma venereum	Erythromycin 1 g PO twice daily	Doxycycline 100 mg PO twice daily	14 days
Donovanosis	Azithromycin 1 g then 500 mg daily	Erythromycin 1 g PO twice daily OR doxycycline 100 mg PO twice daily	Until lesions disappear

Source: Médecins Sans Frontières, Genital ulcers — MSF Clinical guidelines. Reproduced in summary form.

From the guideline

Verbatim

“Treat simultaneously for syphilis AND chancroid as both are frequent, and cannot be correctly distinguished on clinical grounds.”

— Médecins Sans Frontières, Genital ulcers — MSF Clinical guidelines, Treatment section (2026)

Editor’s perspective

Why this matters for Georgia and the region

Prof. Giorgi Pkhakadze, MD, MPH, PhD

Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration

As someone who has worked extensively on STI control in the South Caucasus, I recognise the value of MSF's pragmatic syndromic approach for settings where laboratory confirmation is unavailable or delayed. The recommendation I would stress to Georgian clinicians is the simultaneous treatment for syphilis and chancroid—this reflects field realities where clinical differentiation is unreliable and untreated infection carries serious sequelae. However, implementation in Georgia requires a realistic caveat: benzathine benzylpenicillin, the first-line agent for syphilis, has faced global supply shortages, and national programmes must ensure consistent availability or have robust protocols for alternative regimens such as doxycycline or erythromycin. The guideline's emphasis on partner treatment aligns well with Georgian STI control policy, but health system capacity for partner notification and treatment remains a challenge in rural areas.

ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 21 Oct 2026

Applicability

Georgia and the South Caucasus

This guideline is highly relevant for Georgia and the South Caucasus, where STI services often rely on syndromic management in primary care and remote settings. Georgian national STI programmes would need to consider local epidemiology—particularly the prevalence of specific aetiologies such as chancroid and donovanosis, which may differ from endemic regions mentioned in the guideline (East/West Africa, Southeast Asia, South America, Caribbean for lymphogranuloma venereum; South Africa, Papua New Guinea, India, Brazil, Caribbean for donovanosis). The emphasis on simultaneous treatment for syphilis and chancroid is practical for settings where laboratory confirmation is unavailable, though programmes should weigh this against antimicrobial stewardship concerns. Availability of benzathine benzylpenicillin and other first-line agents in Georgian essential medicines lists would need verification for implementation.

Questions this guideline answers

Quick answers

Why does the guideline recommend treating for both syphilis and chancroid simultaneously?

Both are frequent causes of genital ulcers and cannot be correctly distinguished on clinical grounds. Laboratory testing available in the field is of little value, so empirical dual treatment ensures adequate coverage.

When is aciclovir treatment for genital herpes recurrence effective?

Treatment is only effective if initiated during the prodromal phase or within 24 hours after the onset of symptoms. For recurrences, give aciclovir 400 mg PO 3 times daily for 5 days.

What should be done with fluctuant lymph nodes in chancroid or lymphogranuloma venereum?

Fluctuant lymph nodes may be aspirated through healthy skin as required, but do not incise and drain lymph nodes.

How long should donovanosis be treated?

Treatment should continue until the complete disappearance of the lesions, which usually takes several weeks. Stopping earlier risks recurrence. In HIV-infected patients, add gentamicin 6 mg/kg IM once daily to the chosen antibiotic regimen.

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Genital ulcers — MSF Clinical guidelines

What this guideline says

Key points

Treatment protocols for genital ulcers by aetiology

From the guideline