Diagnose And Treat Lyme Disease If Bulls Eye Rash Is Present Says Nice
People presenting erythema migrans, the characteristic skin rash associated with Lyme disease, can be diagnosed and treated without the need for blood tests, NICE has said in a final quality standard published today.
10 July 2019
Lyme disease is a bacterial infection transmitted by the bite of a tick. Symptoms range from headaches and fever to joint pain and lethargy. Although most tick bites are harmless, they must be removed quickly and safely to reduce the risk of infection.
The updated quality standard emphasises the importance of a quick diagnosis and immediate treatment where appropriate. Its important that patients begin their treatment as soon as possible in order to reduce the risk of infection spreading and causing lasting damage to the body.
Laboratory tests, such as the enzyme-linked immunosorbent assay , check for antibodies in the blood. However, Lyme disease antibodies may first appear 6 to 8 weeks after a person has been bitten, so an early ELISA test may not detect the disease.
If the ELISA is positive or symptoms continue for 12 weeks of more, a more specific test called an immunoblot test should be used to confirm Lyme disease. People who do not have the rash and had a negative result from an early ELISA should have an ELISA repeated at the 4- to 6-week mark if Lyme disease is still suspected.
After a diagnosis of Lyme disease, a person will receive an appropriate course of antibiotics based on their symptoms.
Lyme Disease Rash Vs Other Rashes
Lyme disease diagnoses have been steadily increasing in the United States at alarming rates, especially the Maryland, DC, and Virginia area.
Below is a map from the Centers for Disease Control which shows reported cases of Lyme Disease in 2001 and 2014.
The trademark rash of Lyme disease is often described as a bull’s-eye with a round red rash that is dark in the center, and has dark outer edges.
It is formally called Erythema Chronicum Migrans or Erythema Migrans. This rash indicates the early stage of Lyme disease. Because of its growing awareness, many rashes are often mistaken for Lyme disease. Below are a few examples of Lyme disease rashes compared to other common rashes.
1. Erythema Migrans vs. Ringworm
To the left is how a Lyme disease rash, Erythema Migrans, usually appears with the trademark circular bull’s-eye center.
Ringworm is described as a circular rash that often has raised edges. Ringworm is caused by a fungus while Lyme disease is caused by the bacteria Borrelia burgdorferi.
2. Erythema Migrans vs. an Insect Bite Allergic Reaction
This version of Erythema Migrans on the left is slightly different than the characterized bull’s-eye rash.
It is a spread out rash with a scab in the center.
The insect bite allergic reaction on the right does look similar, but it was described as itchy. Erythema Migrans is mostly described as not itchy or painful, but warm to the touch.
3. Erythema Migrans vs. a Drug Allergic Reaction
Signs And Symptoms Of Untreated Lyme Disease
Seek medical attention if you observe any of these symptoms and have had a tick bite, live in an area known for Lyme disease, or have recently traveled to an area where Lyme disease occurs.
Untreated Lyme disease can produce a wide range of symptoms, depending on the stage of infection. These include fever, rash, facial paralysis, and arthritis.
The appearance of the erythema migrans rash can vary widely.
- Fever, chills, headache, fatigue, muscle and joint aches, and swollen lymph nodes may occur in the absence of rash
- Erythema migrans rash :
- Occurs in approximately 70 to 80 percent of infected persons
- Begins at the site of a tick bite after a delay of 3 to 30 days
- Expands gradually over several days reaching up to 12 inches or more across
- May feel warm to the touch but is rarely itchy or painful
- Sometimes clears as it enlarges, resulting in a target or bulls-eye appearance
- May appear on any area of the body
- Does not always appear as a classic erythema migrans rash
- Severe headaches and neck stiffness
- Additional EM rashes on other areas of the body
- Arthritis with severe joint pain and swelling, particularly the knees and other large joints.
- Intermittent pain in tendons, muscles, joints, and bones
- Heart palpitations or an irregular heart beat
- Episodes of dizziness or shortness of breath
- Inflammation of the brain and spinal cord
Links with this icon indicate that you are leaving the CDC website.
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Whos At Risk Of Lyme Disease
The risk of getting Lyme disease is higher:
- for people who spend time in woodland or moorland areas
- from March to October because more people take part in outdoor activities
Its thought only a small proportion of ticks carry the bacteria that cause Lyme disease. Being bitten doesnt mean youll definitely be infected. However, its important to be aware of the risk and speak to a GP if you start to feel unwell.
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Seek Medical Care Early To Prevent Lyme Disease From Progressing
Its easy to get bit by a tick and not know it. Most people dont feel a tick on their skin or the bite. Checking your skin for ticks after spending time outdoors can help you find a tick and remove it.
Removing a tick can prevent Lyme disease. A tick must be attached to your skin for at least 36 hours to infect you with the bacteria that cause Lyme disease.
Its not always possible to find a tick, so its important to pay close attention to your skin. If you notice any signs of Lyme disease or develop a rash, get medical care right away. Ticks can cause other serious diseases, such as Rocky Mountain spotted fever.
Related AAD resources
ImagesImage 1: Centers for Disease Control and Prevention, Public Health Image Library, Last accessed May 11, 2017.
Images 2, 3, and 7: Used with permission of the Journal of the American Academy of Dermatology. J Am Acad Dermatol. 2011 64:619-36.
Images 4 and 5: Getty Images
Image 6: Used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides.
ReferencesBhate C and Schwartz RA.
Lyme disease: Part I. Advances and perspectives. J Am Acad Dermatol. 2011 64:619-36.
Lyme disease: Part II. Management and prevention. J Am Acad Dermatol 2011 64:639-53.
Centers for Disease Control and Prevention:
Signs and symptoms of untreated Lyme disease. Page last updated October 26, 2016. Last accessed May 2, 2018.
Lyme disease: transmission. Page lasted updated March 4, 2015. Last accessed May 2, 2018.
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How To Prevent Lyme Disease
The deer ticks that carry the bacteria that transmit Lyme disease are most prevalent in New England, the mid-Atlantic states, and the upper Midwest of the United States. They live in moist and woody environments. If you’re going to be in an area like this, use an insect repellent that contains DEET, picaridin, IR3535, oil of lemon eucalyptus, para-menthane-diol, or 2-undecanone. You should also:
- Check your body for ticks after being outside.
- Check your clothing and pets for ticks.
- Place clothes in a dryer on high heat to kill ticks.
- Remove attached ticks with tweezers as soon as you notice them.
- Watch for symptoms of Lyme disease after you remove a tick.
- Contact your healthcare provider if you develop a fever or rash, even if you don’t remember being bitten.
- Treat your animals using veterinarian-prescribed tick prevention products to keep them from bringing ticks into your house.
- Discourage deer from coming into your yard by removing plants that attract them and putting up fences.
- Create a tick-safe zone in your yard by using chemical control agents and keeping the area clean of yard debris.
Does Everyone Get The Telltale Bullseye Rash
No. A certain kind of rash, called erythema migrans, is a telltale symptom of Lyme disease, and if you have it call your doctor immediately. But not everyone who has Lyme exhibits a rash, much less the bullseye rash so often associated with Lyme disease.
The chart below illustrates several of the forms these rashes might take.
The Centers for Disease Control and Prevention report that as many as 70% may exhibit the erythema migrans, but this can vary by region. For example, a 2010 study showed that in the state of Maine only 43% of Lyme patients exhibited this particular type of rash.
There are many symptoms of Lyme disease and it is critical that you are alert to all of them. See Lyme Disease Symptoms for more information.
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Diagnosis Testing And Treatment
You may have heard that the blood test for Lyme disease is correctly positive only 65% of the time or less. This is misleading information. As with serologic tests for other infectious diseases, the accuracy of the test depends upon how long youve been infected. During the first few weeks of infection, such as when a patient has an erythema migrans rash, the test is expected to be negative.
Several weeks after infection, FDA cleared tests have very good sensitivity.
It is possible for someone who was infected with Lyme disease to test negative because:
If you are pregnant and suspect you have contracted Lyme disease, contact your physician immediately.
* Silver HM. Lyme disease during pregnancy. Infect Dis Clin North Am. 1997 Mar 11:93-7.
The most common co-infections that occur with Lyme disease are anaplasmosis and babesiosis. In general:
Whats The Treatment For Later
There are a few options to treat the joint pain and swelling associated with Lyme disease. Pain-relievers and anti-inflammatories â such as ibuprofen â can help relieve symptoms. An in-office procedure called arthrocentesis can be used to withdraw fluid from swollen joints. Rarely, arthritis persists after antibiotic treatment. Some scientists believe that chronic joint inflammation can be triggered by the infection even after the successful elimination of Lyme bacteria.
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Lyme Disease Rashes And Look
Circular, expanding rash with target-like appearance.
Expanding rash with central crust
Expanding lesion with central crust on chest.
Expanding erythema migrans
Photo Credit: Reprinted from Bhate C, Schwartz RA. Lyme disease: Part I. Advances and perspectivesexternal icon. J Am Acad Dermatol 2011 64:619-36, with permission from Elsevier.
Description:Early, expanding erythema migrans with nodule.
Multiple rashes, disseminated infection
Early disseminated Lyme disease multiple lesions with dusky centers.
Red, oval plaque
Red, expanding oval-shaped plaque on trunk.
Expanding rash with central clearing
Circular, expanding rash with central clearing.
Bluish hued rash, no central clearing
Bluish hued without central clearing.
Expanding lesion, no central clearing
Expanding lesion without central clearing on back of knee.
Red-blue lesion with central clearing
Red-blue lesion with some central clearing on back of knee.
Insect bite hyper-sensitivity
Large itchy rash caused by an allergic reaction to an insect bite.
Fixed drug reaction
Description:A skin condition that occurs up to two weeks after a person takes a medication. The skin condition reappears at the same location every time a person takes that particular medication.
Description:Ringworm is a common skin infection that is caused by a fungus. Its called ringworm because it can cause a ring-shaped rash that is usually red and itchy with raised edges.
Pityriasis rosea rash
Granuloma annulare rash
Living With Lyme Disease
Most people treated in the early stages of Lyme disease make a quick and complete recovery. Some may experience symptoms for a few weeks after treatment. If you were treated for Lyme disease but you still dont feel well, call your family doctor. They can make sure there isnt something else wrong. They can help you find ways to ease your symptoms. Some patients have found relief with treatments typically used for chronic fatigue syndrome or fibromyalgia.
Other things you can do to help manage Lyme disease include:
- Educate yourself. There is a lot of inaccurate information to be sorted through, especially on the internet. Ask your doctor if you have questions.
- Track your symptoms. Keep a diary of your sleep patterns, eating habits, exercise routines, and how youre feeling. You or your doctor may be able to make connections between them.
- Take care of yourself. Eat a healthy diet. Exercise as regularly as you can. Get plenty of rest.
- Find support.It can be hard to not feel well and not know why. Some people may think your symptoms arent real. Talk to friends and family. If they cant offer support, talk with a counselor who can help you.
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Lyme Disease: Signs And Symptoms
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What Are The Symptoms And Signs Of Lyme Disease
There are three distinct phases of Lyme disease. Each phase involves different parts of the body.
- 1. Early localized disease causes skin rashes and redness.
- 2. Early disseminated disease affects the nervous system and heart. People in this stage may have palsies that exhibit paralysis and tremors. A rare but potentially life-threatening bacterial infection called meningitis may occur in this stage. Meningitis affects the tissue surrounding the brain and spinal cord .
- 3. Late disease involves arthritis and neurological issues. During this stage damage to nerves of sensation and movement can occur.
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Stage : Small Oval Rashes Or A Reddish Lump
When a tick that causes Lyme disease bites you, it infects you with bacteria. Without treatment, the bacteria can spread to other areas of your body. Stage 2 begins when the bacteria spread to other parts of your body.
During this stage, you may see small, oval rashes on your skin. Some people develop a bluish-red lump.
Where you see these signs: Because the infection has spread, small rashes can appear anywhere on your skin, except for your palms and soles. Most rashes appear on the arms, legs, and face.
Some people develop a lump, which your doctor may refer to as borrelial lymphocytoma. In children, this lump tends to appear on an earlobe. Adults often see a raised growth form around a nipple.
Borrelial lymphocytoma on a childs ear
This can appear in stage 2 of Lyme disease.
What you may see on your skin: The rashes that appear during stage 2 differ from the rash that can appear in stage 1. In stage 2, the rashes stay the same size rather than grow larger.
When the rashes, lump, and symptoms begin: About 30 to 45 days after the tick bites you, you may notice rashes or a lump. These can also take longer to appear, sometimes six months or more.
Some people develop symptoms, which make them feel ill, including:
Shortness of breath and dizzy spells
Bells palsy, which causes one half of the face to droop
Heart problems, such as chest pains or an irregular heartbeat
Does Bullseye Rash Mean Lyme Disease
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What You Need To Know About Lyme Disease
Lyme disease is an infection caused by the spiral-shaped bacteria Borrelia burgdorferi, which is most commonly transmitted by a tick bite.
There are over 300,000 estimated new cases of Lyme disease in the United States each year.
The symptoms of Lyme disease depend on the how long the infection has been present in the body. The first sign of Lyme disease is often an expanding round or oval red “bullseye” rash.
If left untreated, people may develop neurological symptoms and heart problems, and have an approximately 60 percent chance of developing Lyme arthritis.
What Causes Lyme Disease
Lyme disease is caused by bacteria that is spread to humans by tick bites. The ticks that carry the spirochete are:
Black-legged deer tick
Western black-legged tick
Ticks prefer to live in wooded areas, low-growing grasslands, and yards. Not all ticks carry the Lyme disease bacteria. Depending on the location, anywhere from less than 1% to more than 50% of the ticks are infected with it.
While most tick bites are harmless, several species can cause life-threatening diseases. Tick-borne diseases include:
Rocky Mountain spotted fever
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How Is Lyme Disease Diagnosed
A healthcare provider will diagnose Lyme disease based on symptoms, physical findings and whether or not youve been in an area populated by infected ticks.
Many people dont remember or know that theyve been bitten by a tick. This is because the tick is tiny, and its bite is usually painless.
Your provider will confirm the diagnosis using a blood test. If your first blood test is negative for Lyme disease, you wont need another test. If the first test is positive or equivocal, your provider will conduct the test again. You have to have two positive results to be diagnosed with Lyme disease.