Erythema migrans

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Erythema migrans
Bullseye Lyme Disease Rash.jpg
An erythema migrans rash.
SpecialtyInfectious disease Edit this on Wikidata

Erythema migrans (New Latin, literally, "migrating redness") refers to a rash often seen in the early stage of Lyme disease, and can also (but less commonly) be caused by southern tick-associated rash illness (STARI).[1][2] It can appear anywhere from one day to one month after a tick bite. This rash does not represent an allergic reaction to the bite, but rather an actual skin infection of one of the Lyme bacteria species from the genus Borrelia.

Lyme disease[edit]

"Erythema migrans is the only manifestation of Lyme disease in the United States that is sufficiently distinctive to allow clinical diagnosis in the absence of laboratory confirmation."[3] It is a pathognomonic sign:[4] a physician-identified rash warrants an instant diagnosis of Lyme disease and immediate treatment without further testing, even by the strict criteria of the Centers for Disease Control and Prevention. Such target lesions (bull's-eye rashes) are characteristic of Borrelia infections, and no other pathogens are known that cause this form of rash. It is also true, though, that the rash in Lyme disease may also be solid rather than bullseye-shaped,[5] so self-diagnosis cannot rule out Lyme disease, and a doctor visit is advisable.[5]


This rash did not present as a typical erythema migrans at first presentation.
Only after 8 weeks did it form a more typical erythema migrans.

The erythema migrans rash is classically 5 to 6.8 cm (1.97-2.69 in) in diameter, appearing as an annular homogenous erythema (59%), central erythema (30%), central clearing (9%), or central purpura (2%).[6] Because of the "bull's-eye" description to describe the Lyme disease rash, the condition commonly called ringworm is sometimes confused with Lyme disease.[6] Uncommonly, EM may be less than 5 cm (1.97 in) in diameter.[7] Multiple painless EM rashes may occur, indicating disseminated infection.

The EM rash occurs in 80%[8] to 90%[9] of those infected with Borrelia. A systematic review of the medical literature[10] showed 80% of patients have an expanding EM rash, at the site of the tick bite,[11] although some patients with EM do not recall a tick bite. In endemic areas of the United States, homogeneously red rashes are more frequent.[12][13]

Visible part of the Lyme disease rash showing its characteristic asymmetrical cross-section

Southern tick-associated rash illness[edit]

Erythema migrans by STARI.

Southern tick-associated rash illness (STARI) produces a similar rash pattern although it develops more quickly and is smaller.[14] This erythema is also sometimes called erythema migrans[15] or EM. The associated infectious agent has not been determined. Antibiotic treatment resolves the illness quickly.[1][2]


Both lyme disease and STARI can be treated with antibiotics, particularly doxycycline.[16][17][18]


In a 1909 meeting of the Swedish Society of Dermatology, Arvid Afzelius first presented research about an expanding, ring-like lesion he had observed. Afzelius published his work 12 years later and speculated the rash came from the bite of an Ixodes tick, meningitic symptoms and signs in a number of cases and that both sexes were affected. This rash was known as erythema chronicum migrans, the skin rash found in early-stage Lyme disease.[19]

In the 1920s, French physicians Garin and Bujadoux described a patient with meningoencephalitis, painful sensory radiculitis, and erythema migrans following a tick bite, and they postulated the symptoms were due to a spirochetal infection. In the 1940s, German neurologist Alfred Bannwarth described several cases of chronic lymphocytic meningitis and polyradiculoneuritis, some of which were accompanied by erythematous skin lesions.[citation needed]

See also[edit]


  1. ^ a b "Lone star tick a concern, but not for Lyme disease". U.S. Centers for Disease Control and Prevention (CDC). Retrieved 2017-10-06. Page last reviewed: October 22, 2015
  2. ^ a b Naktin, Jaan Peter (2017). "Diagnostic Utility of Erythema Migrans". Clinical Infectious Diseases. doi:10.1093/cid/cix544. ISSN 1058-4838.
  3. ^ Wormser GP, Dattwyler RJ, Shapiro ED, et al. (November 2006). "The clinical assessment, treatment, and prevention of Lyme disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America". Clin. Infect. Dis. 43 (9): 1089–134. doi:10.1086/508667. PMID 17029130. "pp. 1101–2 Background and Diagnosis of Erythema Migrans
  4. ^ Ogden NH, Lindsay LR, Morshed M, Sockett PN, Artsob H (January 2008). "The rising challenge of Lyme borreliosis in Canada". Can. Commun. Dis. Rep. 34 (1): 1–19. PMID 18290267.
  5. ^ a b Juckett, G (2014), "In reply: Comment on 'Identifying erythema migrans rash in patients with Lyme disease'", Am Fam Physician, 89 (6): 424, PMID 24818260.
  6. ^ a b Feder HM, Abeles M, Bernstein M, Whitaker-Worth D, Grant-Kels JM (2006). "Diagnosis, treatment, and prognosis of erythema migrans and Lyme arthritis". Clin. Dermatol. 24 (6): 509–20. doi:10.1016/j.clindermatol.2006.07.012. PMID 17113969.
  7. ^ Weber K, Wilske B (2006). "Mini erythema migrans—a sign of early Lyme borreliosis". Dermatology. 212 (2): 113–6. doi:10.1159/000090650. PMID 16484816.
  8. ^ CDC Lyme Disease Erythema Migrans Disease Retrieved May 13 2007
  9. ^ Dandache P, Nadelman RB (2008). "Erythema migrans?". Infect Dis Clin North Am. 22 (2): 235–60. doi:10.1016/j.idc.2007.12.012. PMID 18452799.
  10. ^ Rational Clinical Examination
  11. ^ Tibbles CD, Edlow JA (2007). "Does this patient have erythema migrans?". JAMA. 297 (23): 2617–27. doi:10.1001/jama.297.23.2617. PMID 17579230.
  12. ^ Smith RP, Schoen RT, Rahn DW, Sikand VK, Nowakowski J, Parenti DL, Holman MS, Persing DH, Steere AC (2002). "Clinical characteristics and treatment outcome of early Lyme disease in patients with microbiologically confirmed erythema migrans" (PDF). Ann Intern Med. 136 (6): 421–8. doi:10.7326/0003-4819-136-6-200203190-00005. PMID 11900494.
  13. ^ Edlow JA (2002). "Erythema migrans". Med Clin North Am. 86 (2): 239–60. doi:10.1016/S0025-7125(03)00085-3. PMID 11982300.
  14. ^ Goddard J (2017) Not all erythema migrans lesions are Lyme disease. The American journal of medicine, 130(2), 231-233.
  15. ^ Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology. St. Louis: Mosby. ISBN 1-4160-2999-0.
  16. ^ Wright WF, Riedel DJ, Talwani R, Gilliam BL; Riedel; Talwani; Gilliam (June 2012). "Diagnosis and management of Lyme disease". Am Fam Physician. 85 (11): 1086–93. PMID 22962880. Archived from the original on 27 September 2013.
  17. ^ James AM, Liveris D, Wormser GP, Schwartz I, Montecalvo MA, Johnson BJ (June 2001). "Borrelia lonestari infection after a bite by an Amblyomma americanum tick". J. Infect. Dis. 183 (12): 1810–4. doi:10.1086/320721. PMID 11372036.
  18. ^ Blanton L, Keith B, Brzezinski W (June 2008). "Southern Tick-Associated Rash Illness: Erythema Migrans Is Not Always Lyme Disease". South. Med. J. 101 (7): 759–760. doi:10.1097/SMJ.0b013e31817a8b3f. PMID 18580719.
  19. ^ Lipschütz, B. (1931). "Zur Kenntnis der "Erythema chronicum migrans"". Acta dermato-venereologica. Stockholm. 12: 100–2.

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