Overview

We understand that seeing a new rash, especially one that looks like a bull's-eye, can be quite alarming, particularly if it's on your child. Erythema Migrans is a distinctive skin rash that often appears in the early stage of Lyme disease. It's sometimes called a "bull's-eye" rash due to its characteristic appearance.

This rash is caused by the Borrelia burgdorferi bacteria, which is transmitted to people through the bite of an infected blacklegged tick (often called a deer tick). Anyone can get Lyme disease and develop Erythema Migrans if bitten by an infected tick, but it's more common in people who spend time in wooded or grassy areas where these ticks live, especially during warmer months. It's important to know that Erythema Migrans itself, and Lyme disease, are not contagious from person to person; you can't catch it from someone who has it. If Lyme disease isn't recognized and treated early, it can affect your joints, heart, and nervous system, which can significantly impact your daily life and well-being. Even the initial worry about the rash can be distressing, and we're here to help you understand what might be happening.

Symptoms

Knowing what to look for can help you seek care sooner. The most common symptoms include:

• A circular or oval-shaped red rash - that often looks like a bull's-eye: a central red spot, surrounded by clear skin, then another ring of redness. However, the rash can also be uniformly red or have a different appearance.
• The rash usually starts - as a small red spot at the site of the tick bite and expands slowly over days or weeks.
• It can grow quite large - sometimes up to 12 inches (30 cm) or more across.
• The rash is typically not painful or itchy - in most people, but it can sometimes feel warm to the touch or, less commonly, be slightly tender or itchy.
• You might also experience flu-like symptoms - such as fatigue, fever, chills, headache, muscle and joint aches, and swollen lymph nodes, even before or as the rash appears.
• The rash can appear - anywhere on the body but is often found in areas like the armpits, groin, back of the knees, scalp, or trunk.
• Some people may develop multiple Erythema Migrans rashes - at different sites on their body.
• It's important to note - that not everyone with Lyme disease develops or notices this characteristic rash.

Diagnosis

Diagnosing Erythema Migrans and early Lyme disease often starts with your doctor looking closely at the rash. They will likely ask about your medical history, including any recent tick bites you remember or if you've spent time in areas where ticks are common (like woods or areas with tall grass).

In many cases, if you have the typical rash and a history of possible tick exposure in an area where Lyme disease is prevalent, your doctor may diagnose it based on these findings alone. Blood tests are available to detect antibodies to the Lyme disease bacteria. However, these antibodies can take a few weeks to develop, so tests might be negative in the very early stages of infection, even when the Erythema Migrans rash is present. Sometimes, a follow-up test is needed.

Management & Treatment

Finding out you have Erythema Migrans can be unsettling, but the good news is that it's a clear sign that allows for early treatment of Lyme disease. Prompt and appropriate medical care is key to a swift and complete recovery.

The primary and most effective treatment for Erythema Migrans is a course of oral antibiotics prescribed by a healthcare professional. There are no over-the-counter (OTC) medications that can cure Lyme disease; antibiotics are essential to eliminate the underlying bacterial infection.

Prescription Antibiotics: The Standard of Care

Your doctor will prescribe a specific antibiotic based on your age, medical history, and other factors. The most common options include:

• Doxycycline: Often the first choice for adults and children over 8.
• Amoxicillin or Cefuroxime Axetil: Typically used for younger children and pregnant or breastfeeding women.

Treatment usually lasts for 10 to 14 days. It is incredibly important that you take the full course of antibiotics as prescribed, even if you start to feel better or the rash disappears. Stopping treatment early can allow the infection to persist and potentially lead to more serious complications later on.

What to Expect During Treatment

Most people begin to see their rash fade and feel an improvement in their symptoms within a few days of starting antibiotics. While the medication works to clear the infection, you can support your body's recovery by getting plenty of rest and staying hydrated.

Important Safety Note: Doxycycline can make your skin more sensitive to the sun. If you are prescribed this medication, be sure to use sunscreen and wear protective clothing when outdoors to prevent sunburn.

When to Follow Up With Your Doctor

If you have completed your full course of antibiotics but are not feeling better, or if you develop new symptoms, it's crucial to contact your healthcare provider. They can re-evaluate your condition and determine if a different treatment approach is needed. We are here to support you, and seeing a doctor ensures you get the most accurate and effective care for your situation.

Duration & Outlook

It's natural to worry about how long this might last and what to expect. The Erythema Migrans rash typically appears 3 to 30 days after an infected tick bite, with an average appearance around 7 days.

If left untreated, the rash itself usually fades on its own within a few weeks to a month. However, this does not mean the Lyme disease infection is gone. The infection can persist and spread throughout the body if not treated. Early Lyme disease, when Erythema Migrans is present, is generally considered an acute condition that responds well to appropriate treatment. If Lyme disease is not treated promptly, it can progress and potentially lead to more chronic problems affecting the joints, heart, or nervous system.

Warning signs for complications or progression of Lyme disease can include new or worsening symptoms like severe headaches, neck stiffness, additional rashes on other parts of your body, facial palsy (drooping on one side of the face), irregular heartbeat, dizziness, shortness of breath, or pain, swelling, and stiffness in large joints. If you notice any of these, it is very important to see a doctor right away.

Prevention

The most effective way to prevent Erythema Migrans is to prevent tick bites, which are the cause of Lyme disease. We know it can be challenging, but these steps can really help:

• When spending time outdoors - especially in wooded, grassy, or leafy areas, wear long-sleeved shirts and long pants. Tucking your pants into your socks can offer extra protection.
• Use an EPA-registered insect repellent - that is effective against ticks. Follow the product instructions carefully.
• Try to walk in the center of trails - and avoid brushing against tall grass, bushes, and leaf litter.
• After being outdoors - always perform a thorough tick check on yourself, your children, and your pets. Check common hiding spots like the scalp, behind the ears, in the armpits, around the waist, in the groin area, and behind the knees.
• If you find an attached tick - remove it promptly and correctly using fine-tipped tweezers. Grasp the tick as close to the skin's surface as possible and pull upward with steady, even pressure.

Causes & Triggers

The direct cause of Erythema Migrans is an infection with a type of bacteria called Borrelia burgdorferi (and in some cases, other Borrelia species).

• How it's caused: This bacterium is introduced into your body through the bite of an infected blacklegged tick (commonly known as a deer tick). The tick itself becomes infected by feeding on small animals, like mice and other rodents, that carry the bacteria. For the bacteria to be transmitted, the infected tick usually needs to be attached and feeding for 36 to 48 hours or more.
• Common Triggers: The primary "trigger" for developing Erythema Migrans is being bitten by an infected tick. This most often happens during outdoor activities in tick habitats.
• Who is most likely to develop it? People who live in or visit regions where Lyme disease is common are at higher risk. In the United States, these areas include the Northeast, mid-Atlantic, and upper Midwest. It's also found in parts of Europe and Asia.
• Risk Factors: Engaging in outdoor activities such as hiking, camping, hunting, fishing, or gardening in tick-prone areas increases your risk. Not using tick repellents, not wearing protective clothing, or not performing thorough tick checks after outdoor exposure are also significant risk factors. The risk is generally highest during warmer months (spring, summer, and early fall) when ticks are most active, but infections can occur whenever temperatures are above freezing.

When to see a doctor:

Your health is important, and it's always best to be cautious. Please remember, this information is for understanding, and a healthcare professional is the only one who can diagnose your condition.

You should see a doctor if:

• You develop a circular, expanding red rash, especially one that resembles a bull's-eye, even if you don't remember being bitten by a tick.
• You experience flu-like symptoms (such as fever, chills, headache, fatigue, muscle and joint aches) within several weeks of a known tick bite or after spending time in an area where ticks are common.
• You remove an attached tick from your skin, particularly if it appears engorged (swollen from feeding) or if you live in an area where Lyme disease is prevalent.
• You are simply concerned about a new skin rash or symptoms that might be related to a tick bite.

Early diagnosis and treatment of Lyme disease are crucial for preventing potential long-term complications. A primary care doctor can often diagnose and manage early Lyme disease. If there are concerns about more complicated or later-stage Lyme disease, they may refer you to a specialist, such as an infectious disease doctor or a rheumatologist.

Frequently Asked Questions (FAQs):

• Q: Does everyone with Lyme disease get the bull's-eye rash? A: No, not everyone. It's estimated that about 70-80% of people infected with Lyme disease develop the Erythema Migrans rash. Some people may have Lyme disease without ever noticing a rash, or the rash might look different from the classic "bull's-eye" or be in a location that's hard to see.
• Q: If the Erythema Migrans rash goes away on its own, does that mean the Lyme disease is gone? A: No, this is a common misconception. The rash can fade even if the Lyme disease infection is still active in your body. Without appropriate medical treatment, the infection can spread and potentially cause more serious health problems later on.
• Q: Can I get Lyme disease from my pet? A: You cannot get Lyme disease directly from your dog or cat, like you would catch a cold. However, pets can bring infected ticks into your home on their fur. These ticks can then detach and bite a person, potentially transmitting Lyme disease. That's why regular tick prevention for pets is so important.
• Q: What is the correct way to remove a tick? A: Use fine-tipped tweezers to grasp the tick as close to your skin's surface as possible. Pull upward with steady, even pressure. Don't twist or jerk the tick, as this can cause the mouth-parts to break off and remain in the skin. After removing the tick, thoroughly clean the bite area and your hands with rubbing alcohol, an iodine scrub, or soap and water. You may want to save the tick in a sealed bag or container to show your doctor, especially if you develop symptoms.
• Q: Is Erythema Migrans always a perfect circle? A: While the "classic" Erythema Migrans rash is a bull's-eye circle, it can also appear as a uniformly red, expanding patch, or it can be oval-shaped. Sometimes it can have a bluish hue in the center or even blistering. The key feature is that it expands over time.

References

• Infectious Diseases Society of America. (2020). AAN/ACR/IDSA 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. Retrieved from https://www.idsociety.org/practice-guideline/lyme-disease/
• Centers for Disease Control and Prevention. (n.d.). Clinical Treatment of Erythema Migrans Rash. Retrieved from https://www.cdc.gov/lyme/hcp/clinical-care/erythema-migrans-rash.html
• Medscape. (2023). Lyme Disease Treatment & Management. Retrieved from https://emedicine.medscape.com/article/330178-treatment
• WebMD. (n.d.). What to Know About Erythema Migrans. Retrieved from https://www.webmd.com/skin-problems-and-treatments/what-to-know-erythema-migrans