Classic Lyme Rash
(From the website of the Canadian Lyme Disease Foundation: http://canlyme.com/lyme-basics/symptoms/classic-lyme-rash/)
An “Erythema Migrans” skin rash is more often incorrectly referred to as the “bull’s eye” rash. Current research has shown that only a small subset of the strains/species of bacteria that cause Lyme disease will cause a rash of any kind. Of the few that do cause a rash only 9% of those will take the over-emphasized ‘bull’s eye’ form. The vast majority will get no rash and those that do most rashes are more generalized in appearance.
It is important to compare your rash with other known skin rashes that are not Lyme related. ie. ringworm (Tinea), a fungal infection that your physician should test for by scraping a little material off the rash area and having it tested for the fungus. Ringworm can be treated with anti-fungal creams.
Many doctors tell patients that what they have is a spider bite … the only spider bites that leave rashes that may be confused with Lyme disease will very quickly (within hours) become extremely painful, unlike a Lyme disease rash.
Overall a rash of any kind from Lyme disease occurs or is recalled in only 30% + cases so no evidence or recall of a rash does NOT mean no Lyme Disease to the clinician. It is not always a bull’s eye and can be generalized in appearance.
A Lyme disease rash is not always at the site of the tick bite. Many myths about the rash have resulted in misdiagnosis. One such myth is that the rash is usually the size of a quarter or silver dollar. The rash may vary greatly in both size and appearance. There may be more than one on the body (several at one time).
The most damaging myth is that all patients who have Lyme disease or at least the large majority get a rash of any kind. This has been proven to not be the case yet far too many physicians use this as the main diagnostic criteria rendering a negative diagnosis.
Pix of the Lyme rash you might get, if you are lucky enough to get a rash
Below are photos from the website of the Centers for Disease Control of variations on the EM rash that is an indicator of Lyme Disease. All of the CDC photos are shown below but I have provided the link so that CDC photos of rashes that are not Lyme can be viewed. I provide the photos here so that I can comment on them.
Above is what might be called the classic rash. In the center is a bug bite. No tick is shown because this rash evolves and by the time it gets to this stage, the tick would be engorged and either fallen off on its own or been noticed and removed. In this photo, the bug bite part is just a bump, but it can be an open lesion in the middle of the bump. The absolutely crucial diagnostic of Lyme EM rash is that it starts small and then expands, usually slowly but possibly rapidly. The average time, according to most sources, is 7 days after the bite for it to begin. Pink will appear to come out from under the red bug bite in the center, then expand into a pink circle, then clear between the outer edge and the center to form a ring. It may last a month or more, but with or without treatment, the rash itself will eventually disappear. This does not mean you’re cured. It means that you have Lyme disease.
This rash probably does not itch or burn and is not painful, unless it includes a lesion, which sometimes it does. It can be, however, very dramatic in appearance. There may be more than one ring. It may be triangular rather than round. It may be part-circle, part-something else. My largest one was a huge half-circle on the front of my thigh, from knee to groin, the edges meeting on the back of my thigh. If flattened out, it would have been a perfect half-circle. The upper half was stripes on my torso up to the bra line.
If the rash appears within hours of the tick bite, with or without other symptoms, it indicates that you already were infected with Lyme disease at some prior time, perhaps with no symptoms at all and no awareness even of a tick bite. Recent research indicates what was mentioned 30 years ago by Polly Murray, the “mother of Lyme disease” in her book The Widening Circle, is true. An infected person receiving another tick bite, may develop early Lyme symptoms overnight. It was unclear to me from Murray’s book when I read it, whether that had to be a tick carrying Lyme disease. What recent research shows is that it can be a bite from any tick, even an non-Lyme bearing species, that causes the symptoms because the Borrelia bacteria already in the person’s body are reacting to, becoming excited by, the tick saliva. This is a reason to not allow a non-Lyme doctor to dismiss you as a Lyme case because “the rash appeared too soon.”
Until recent years, this rash was the single symptom completely unique to Lyme disease and if you were lucky enough to get one, even the super cautious CDC would accept you as a Lyme case on the basis of the rash alone, not requiring a positive test. That policy changed officially for political reasons and the CDC now will only accept as an official case, one with positive tests. There was no scientific reason the stop using the rash as a unique diagnostic and it is rumored that individual doctors associated with the CDC will still say if you got this rash, you have Lyme disease.
However, the rash only looks “classic” some of the time. It may vary greatly depending on the body part involved and co-infections and possibly the strain of Borrelia. Some variations are shown below. In my case, my first EM rash was in my armpit and I only noticed it when I saw the edge expanding down my inner arm. There were no other symptoms at the time and Lyme disease had not yet been named or described, so I did not seek medical attention. My second EM rash, years later, was on the inner side of my breast and appeared within hours of my removing a tick from that area. The tick was tiny, not engorged, and not identifiable as to species, so it may not have even been a Lyme tick. Again, there were no other symptoms with the rash and I did not seek medical attention. I was not at that time, aware of Lyme disease, though it had by then been named and was being studied.
My third EM rash was from a tick bite in my groin. In this case, I damaged the tick removing it, the rash and symptoms appeared within a day. I was still not thinking about Lyme disease, but when red stripes began climbing up my lower torso, in conjunction with a circular rash expanding down my thigh, near-delirium, all-over body pain and extreme weakness, I feared blood poisoning and went to the doctor. I had not left the tick head in, but by the time I got to the doctor, I was remembering what I by now had heard about Lyme disease. My doctor insisted that I could not possibly have Lyme disease because the rash was “too big, not round enough and appeared too soon,” but he prescribed me not enough of the wrong antibiotic “just in case.”
It is now suggested by some researchers that a striped rash with a tick bite is an indication of Bartonella, a common co-infection of Lyme. I tested negative for Bartonella many years later when I finally went to a Lyme doctor, but he said that it was entirely possible that the antibiotics I got before I got to him could have killed off the Bartonella or that I had a strain that does not show up on the tests.
Multiple circles that have not yet cleared. It is unclear to me if these are the result of one tick bite or several.
Bluish and pink rings around a bug bite. The size of this is unclear, but my Lyme doctor told me a Lyme rash is a minimum of 3″ in diameter. I have no idea what he was basing that on, but would reiterate that, regardless of size, or what the bite is doing, the important thing is did it start small, then expand. It does not always necessarily clear and make a definite ring, but if it does, probability goes up that it is a Lyme EM rash.
The ring without the center. The CDC does not explain what happened to the center, but I would suggest, from my reading of the literature, that this is either a secondary rash or that it is very late in the evolution of the rash and the bug bite has healed but the edge of the rash remains. That might happen if the person was not very allergic to the tick saliva and the tick was removed early on. Early removal does not necessarily mean there was no time to transmit the disease, since damaging the tick means instant transmission. A secondary rash is one that appears some time, perhaps a long time, after initial infection and looks like an EM rash without a tick bite.
The rash can be bluish and only vaguely round. Here, the position on the body is probably distorting the ring. You can, however, see irregular concentric bands of different color. There is no red central bug bite, that appears to be a white area instead. If I saw a rash like this, I would really want to know if a tick was actually seen and/or removed from the white area and did it expand outward, before calling it an EM rash. It should be noted that the darker the skin, the bluer the shades of the rings. I have seen an expanding circle of near-black around a known tick bite on a mixed-race person about the shade of President Obama.
Photos from online, not CDC
Below are photos of rashes I downloaded from websites but did not note which websites I got them from.
A triangular rash with no red “bug bite” in the center.
EM rash with a lesion that has not yet started clearing in the center.
EM rash with a double center and no obvious bug bite. This could be a secondary rash or one from which the tick bite has already disappeared. Or, since the circle is not always centered around the bite, there is a dark area on the left that could be a disappearing tick bite.
EM rash that is starting to clear and make a ring. The clearing may or may not start as a complete, evenly sized ring. It may start as a patch of whiter skin that grows into a ring. I believe the dark spot is not the tick or the bite, but a skin blemish. I think the bite was off-center, in the lower left quadrant. The outer ring is becoming visible everywhere but there.
Photos of my own rashes
Below, photos I have taken of some of the rashes I have had during the course of my own case. None of the below are the EM rash that is an early sign. They are all lesions or rashes that came much later. The rashes I get that I’m calling secondary rashes do not expand outward. The remain the size they were when they appeared. It is the clearing into a ring that suggests they are Lyme-related. The photos below were taken by me and have been somewhat enhanced in an attempt to compensate for the white areas caused by the camera flash bouncing off skin.
Above, two angles on a rash I get maybe once a year that I am assuming is a secondary Lyme rash. It starts out as an imperfectly round blue solid circle about the size of a quarter. It does not hurt or itch. I cannot feel it at all. Even though it looks like a bruise, it is not at all tender and I have no memory of injuring it. I do bruise easily and get many bruises that are slightly tender that I cannot remember doing anything that would have caused them. But, these are darker than those and always between dime-size and quarter-size. After a few days, a small white area appears in the center and begins to expand, ultimately leaving a ring, which then gradually disappears. This one is starting to disappear, which is why there is a gap in the ring.
An earlier photo of the secondary rash shown in the two preceding photos. The round bruise-like area is just beginning to clear in the center. These rashes always appear close to the joints that have been most painful. This is my right elbow, which has been so painful I’ve had to put my arm in a sling to avoid trying to straighten it, thereby causing excruciating pain. This photo was taken by a friend, so I was able to get my arm into a position where the flash did not cause an unnatural white area. It has not been enhanced. The color and contrast values are true to the original photo.
This is a rash that I’ve only had a few times in 30 years. It does not hurt or itch, appeared overnight and lasted a day or two. It looks like I crashed through briars or scratched an itch too hard or was scratched by an animal. None of the above are true. As far as I can determine, nothing caused it. The only theory I have is that, since the common-name of Bartonella is “Cat-scratch fever” and I now know a striped EM rash is an indication of Bartonella, it is possible I still have a latent case or low-level case of Bartonella and every once in a while it causes a rash that looks like a cat-attack. There is no increase in other symptoms when I have had this rash.
This is the back of a friend’s right elbow, showing what I believe to be an EM rash with an off-center tick bite near the center of the upper edge. The area was actually more circular than the photo indicates because, again, the flash on my camera is bouncing off her skin, making a white area that obscures part of the circle. Though the total area was not very dark, the edge is distinct on the left side, near the bend of her elbow, and different shades of pink can be seen.
The dark spot in the center is not a tick. My friend never saw a tick, but felt a bite while visiting the Arcata Marsh in Humboldt County CA, an area that is crawling with deer ticks and in which many people, to my knowledge, have contracted Lyme disease. She awoke at 4 am the next day, scratching violently at this area and with a fever and aches. She got up, looked at the back of her arm with a mirror and noted how big the red circular area was. She did not see a tick, but did see the bite. She called me at 7 am, suspecting Lyme, and asked me to look at it. By that time it had expanded outward from the size it was at 4 am and my friend was feeling very sick. I went with her to the emergency room of the local hospital, where she was given a prescription for doxycyclene, only because we both insisted.
The rash continued to expand and did clear in the center and become a ring. It was never very dark, always shades of pink. It did not last very long. I went with her to our mutual doctor about 3 days after we went to the ER and the doctor claimed she could not see the rash, even though I could still see it, probably because I had seen it before and knew what I was looking for. My friend sometime later tested positive for Lyme disease by Igenex’s Lyme panel. (You can’t test until 6 weeks after the bite, because, if it is a new infection, the tests are not accurate until then. Doctors assume, in the case of testing, that it is a new case, not an old case in which a tick bite is causing rapid early symptoms.)
I believe what happened is that my friend, who had had many health problems consistent with Lyme disease for years, already had Lyme disease when a tick attached to her at the marsh. That tick may or may not have been a Lyme-bearing species, and if it was, may or may not have been carrying Borrelia. In reaction to tick saliva, the Borrelia already in her system produced an EM rash and flu-like symptoms much more rapidly than a new infection would have. She was allergic to the tick saliva (most people are not), so that the bite itched a lot and she scratched the tick out of her skin in her sleep, which is why she never saw it. It happens. What made me sure this was a Lyme rash, in addition to its expanding outward from a bug bite, was seeing it in the context of other information–the location where my friend got the bite, the flu-like symptoms and my knowledge that a rapid appearance of early symptoms is an indication that the person was already infected.