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What does a Lyme bullseye rash look like?

A Lyme disease bullseye rash, also called erythema migrans, is a key symptom of early Lyme disease. The rash occurs in approximately 70-80% of infected people and begins at the site of a tick bite. It is one of the telltale signs of Lyme disease and is important to recognize. If treated quickly with antibiotics, Lyme disease can be cured.

What is a Lyme bullseye rash?

The Lyme bullseye rash refers to the characteristic circular rash that occurs in many Lyme disease patients. It is called a “bullseye” rash because it resembles a bullseye target. The rash usually occurs at the site of the tick bite within 3 to 30 days after being bitten by an infected tick. It slowly expands over a period of days or weeks, forming a circular shape with a red ring surrounding a clear center.

The Lyme bullseye rash, known medically as erythema migrans, occurs when the Borrelia burgdorferi bacteria that causes Lyme disease begins to multiply and spread outwards from the site of the tick bite. As the bacteria spread, they produce inflammation and a rash in the skin. The clearing in the center of the rash is where the tick was attached and the highest concentration of bacteria remains. The red ring shows the leading edge of the spreading bacterial infection.

Key features

Some key features of the Lyme bullseye rash include:

  • Circular shape
  • Expands over time
  • Red ring around a pale center
  • Appears within 3-30 days of tick bite
  • Often (but not always) > 5 cm in diameter
  • Does not itch or cause pain
  • May feel slightly warm to the touch
  • Typically occurs at site of tick bite

Appearance

In some cases, the Lyme bullseye rash has a very classic textbook appearance – a red ring surrounding a clear center. However, the rash can vary greatly in appearance between individuals. Some features that may be present include:

  • Solid red rash instead of bullseye
  • Blue or purple tones
  • Central crusting or blistering
  • Central scabbing or ulceration
  • Raised or thickened on palpation
  • Varying shapes – oval, triangular, etc.

The rash may also feel warm to the touch but is typically not painful or itchy. Over time, as the rash expands it can grow to over 15 inches (38 cm) in diameter in some cases.

Where on the body does it occur?

The Lyme bullseye rash most commonly occurs at the site of the tick bite. However, the rash can show up anywhere on the body where an infected tick was attached. Common sites include:

  • Legs
  • Arms
  • Torso
  • Groin
  • Underarms
  • Neck
  • Head and scalp (hairline and behind ears in children)

In about 10% of cases, people may develop multiple bullseye rashes at different sites on their body. This can happen if they were bitten by multiple infected ticks. Alternatively, the bacteria can spread through the bloodstream and cause secondary rashes to appear elsewhere.

Duration

The Lyme bullseye rash usually appears between 3 to 30 days after an infected tick bite. Typically, the rash lasts for approximately 3 to 5 weeks. However, some rashes may persist for several months without treatment. Each case is unique.

In most cases, the rash will slowly expand over a period of several days or weeks, reaching its maximum size within about 5 weeks. As the rash expands, the center often clears, creating the bullseye pattern. Over time, the rash may stop expanding and simply look like a solid red patch on the skin.

Without treatment, the rash will eventually fade on its own. However, this does not mean the infection is gone. Symptoms like fatigue, joint pain, and neurological issues may follow weeks or months later as the infection spreads. Prompt antibiotic treatment during the rash phase can help prevent complications.

Is a bullseye rash definitive for Lyme disease diagnosis?

Although highly indicative of Lyme disease, the presence of a bullseye rash is not by itself sufficient to diagnose Lyme disease. Other infections like southern tick-associated rash illness (STARI) caused by the Amblyomma americanum tick can also produce similar rashes. Blood tests are recommended to confirm Lyme infection by detecting antibodies to Borrelia burgdorferi.

However, in regions where Lyme disease is very common, the characteristic bullseye rash is considered adequate grounds to start treatment, especially if the patient recalls a recent tick bite. Blood tests are still recommended though to complement the clinical diagnosis.

Can you have Lyme disease without a rash?

Yes, it is entirely possible to develop Lyme disease without having the bullseye rash. Studies show the rash only occurs in an estimated 70-80% of Lyme patients. Up to 30% of people may not develop any rash at all.

Some reasons why the rash may not occur include:

  • The rash was present but the patient did not notice it
  • The tick was attached in a hidden part of the body like the scalp or groin area
  • The patient did not recall being bitten by a tick so did not look for a rash
  • The rash occured but resolved quickly before being noticed
  • Differences between Borrelia strains and individual immune response

Therefore, while the bullseye rash is considered one of the hallmark symptoms of Lyme disease, a lack of rash does not rule out a Lyme diagnosis. Patients without a rash who have other symptoms and exposure to infected ticks should still be tested and treated if positive.

Lyme bullseye rash pictures

Here are some photos of Lyme disease bullseye rashes to see how they may appear:

These photos demonstrate the classic circular red rash with central clearing that is typical of many Lyme bullseye rashes. However, keep in mind the rash can vary greatly in appearance between individuals and may not always display this textbook pattern.

Prevention tips

To help prevent Lyme disease and associated bullseye rashes, some recommended tips include:

  • Avoid areas with lots of ticks – stick to the trail when hiking
  • Wear light-colored clothing to spot ticks more easily
  • Use EPA approved insect repellants like DEET on skin and clothes
  • Wear long sleeves and pants tucked into socks when in wooded areas
  • Check your whole body for ticks after being outdoors
  • Shower after exposure to remove unattached ticks
  • Talk to your vet about tick prevention products for dogs

Promptly removing attached ticks within 24 hours also greatly reduces your chance of contracting Lyme disease. Ticks require 24-48 hours of feeding to transmit the bacteria.

What to do if you find a tick

If you find a tick attached to your body, follow these steps:

  1. Use fine-tipped tweezers to grasp the tick close to your skin
  2. Gently pull straight up until the tick releases its grip
  3. Clean the bite area and your hands with soap and water
  4. Save the tick in a sealed container in case testing is needed later
  5. Watch for symptoms like rash or flu-like illness in the following 30 days
  6. Contact your doctor if any symptoms develop

Avoid squeezing or crushing the tick’s body during removal, as this may cause more pathogens to enter your bloodstream. Folk remedies like using petroleum jelly or hot matches do not work and may make things worse!

When to see a doctor

You should promptly contact a doctor if:

  • You develop a bullseye rash or other mysterious rash
  • You experience any symptoms of Lyme disease like fever, chills, headache, fatigue, joint pain or neurological issues
  • You were bitten by a tick and live in an area where Lyme disease is common

Early diagnosis and treatment of Lyme disease leads to much better outcomes. Even without a diagnostic rash, your doctor can order blood tests and prescribe antibiotics as needed.

Let your doctor know if you have been bitten by ticks, spend time in wooded areas, or have recently travelled to endemic areas. Prompt antibiotic treatment can help resolve Lyme disease at any stage, but is most effective in the early localized phase when the rash first appears.

Diagnostic testing

In addition to clinical diagnosis based on a bullseye rash, your doctor may order the following blood tests to help confirm Lyme disease:

Enzyme immunoassays (EIA)

This is usually the first test ordered to screen for Lyme disease antibodies. It is relatively inexpensive and fast, but misses up to 50% of true cases. If negative, a second more sensitive immunoblot test should be done.

Immunoglobulin M (IgM) immunoblot

Looks for antibodies produced in early stages of Lyme infection. A positive IgM indicates recent or current active infection.

Immunoglobulin G (IgG) immunoblot

Looks for antibodies that develop weeks or months after initial infection. Remains positive for months or years after infection. Indicates previous exposure to Lyme bacteria.

CDC criteria require both IgM and IgG immunoblots to be positive for diagnosis in the absence of a clear rash. However, talk to your doctor about diagnosis and treatment if symptoms are highly suggestive despite negative blood work.

Polymerase chain reaction (PCR)

Detects the genetic material of Borrelia burgdorferi rather than indirect antibodies. Helpful for early Lyme diagnosis before antibodies are produced. Best performed on skin biopsy of rash or synovial fluid if Lyme arthritis is present.

Culture

Tries to grow Borrelia bacteria from fluid or tissue samples. Low sensitivity limits usefulness and is not commonly performed.

Brain MRI

Sometimes done when neurological symptoms are present. May detect abnormalities suggestive of Lyme meningitis or encephalitis.

Talk to your doctor to determine which test(s) are appropriate for your individual situation. Two-tiered testing with EIA and immunoblots is most common. Serological tests for antibodies require 2-4 weeks after exposure for best accuracy.

Treatment

Treatment for Lyme disease aims to cure the active bacterial infection and resolve symptoms. Treatment guidelines endorsed by the Infectious Diseases Society of America include:

  • Early localized Lyme (rash only) – Doxycycline, amoxicillin, or cefuroxime for 14-21 days
  • Disseminated Lyme (multiple rashes or other symptoms) – Doxycycline, amoxicillin, or ceftriaxone for 14-28 days
  • Late Lyme arthritis or neurological symptoms – Ceftriaxone, cefotaxime, or penicillin IV for 2-4 weeks

Longer courses or additional antibiotics provide no added benefit once standard treatment is completed. The majority of patients have excellent outcomes when treated in the early stages. Delaying treatment can increase risk of developing more severe symptoms months or years later.

Prognosis and complications

With prompt antibiotic treatment in the early stages when the rash is present, most cases of Lyme disease can be cured without complication. However, the following problems can occur with untreated or delayed treatment:

  • Recurring rashes – Multiple secondary bullseye rashes may appear as bacteria spread through the bloodstream
  • Chronic Lyme arthritis – Painful swollen joints that can mimic rheumatoid arthritis
  • Neuroborreliosis – Neurological symptoms like facial palsy, meningitis, numbness and weakness
  • Lyme carditis – Rare heart symptoms like irregular rhythm, heart block, and shortness of breath
  • Post-treatment Lyme disease syndrome (PTLDS) – Debilitating fatigue, muscular pain, and cognitive issues lasting over 6 months after treatment

Approximately 10-20% of patients treated for Lyme still have lingering symptoms like fatigue and muscle aches that slowly resolve over 6-12 months. With early recognition and treatment of Lyme disease, long-term complications are unlikely.

Frequently asked questions

Can a Lyme rash disappear and come back?

An individual Lyme rash lesion usually continues expanding slowly once it first appears. However, some patients may develop multiple rashes over time as the infection spreads. The initial rash may have resolved by the time secondary rashes appear elsewhere.

Can you get a bullseye rash and not have Lyme disease?

It is possible, since other infections like STARI can also cause similar rashes. However, when acquired in Lyme endemic areas, the bullseye rash is strongly predictive of Lyme disease, especially when combined with other symptoms.

Is there a blood test for the Lyme rash?

There is no blood test specific for the Lyme rash itself. However, your doctor may order blood tests like Lyme antibody EIA and immunoblots to help confirm Lyme disease in suspected rash cases.

Can you get a Lyme rash but test negative?

Yes, false negative blood tests are common in the first few weeks of Lyme infection before antibodies are produced. Clinical diagnosis based on the rash remains valid even with negative blood work early on.

Can you have Lyme disease without the rash or other symptoms?

It is possible to be infected with Lyme bacteria but be entirely asymptomatic. A small proportion of people exposed to Lyme may never develop any symptoms at all. However, most cases will cause at least a fever and flu-like illness.

Conclusion

In summary, the Lyme disease bullseye rash is a key sign of early Lyme infection. It occurs at the site of the tick bite in 60-80% of Lyme patients. The rash expands slowly into a red ring with central clearing resembling a bullseye target, though the appearance can vary. While highly indicative of Lyme when present, up to 30% of people may not develop any rash at all.

If you develop a suspicious rash or other potential Lyme symptoms, prompt doctor evaluation and antibiotic treatment is recommended. Perform tick checks after time outdoors and remove attached ticks properly within 24 hours to reduce infection risk. With early diagnosis in the localized stage, most cases of Lyme disease can be treated successfully with a 14-28 day course of antibiotics like doxycycline.

Though Lyme disease cases are concentrated in the Northeast, Midwest and West Coast of the United States, increasing numbers are now being acquired across North America each year. Preventive measures like proper clothing, tick repellants, and careful tick removal remain your best defense against Lyme disease.