Skin Signs of Lyme disease
Lyme disease - a multi system disorder
Lyme disease is characterized by a skin eruption, erythema chronicum migrans at the site of inoculation. Later on, the spread of infection may lead to the disease of nervous system, heart, and joints, in addition to other dermatoses.
The principal vector of Borrelia burgdorferi is the Ixodes tick, different species of which predominate in different parts of the world. People who live close to, or have visited woodland areas where small mammals are infested by immature stages in life cycle of the tick. Adult ticks infest larger mammals, especially the deer.
Infection may occur at any time of the year. Young nymphs feed in early summer while adult tick bites are more common in autumn.
Skin is one of the earliest and the most affected organ in our body. Skin manifestations during different stages of Lyme disease include the following:
Erythema Migrans Skin Rash is a Hallmark of Lyme disease
Early Stage (Localized Infection)
Erythema chronicum migrans
Around 50% of the affected individuals recall a tick bite; a bite by autumn and winter feeding adult ticks is more likely to be noticed than that by the summer feeding nymph.
In about 90% of individuals, a circular or elliptical eruption appears at the site of the tick bite after an incubation period of around 9 days and is due to a local spread of the infection.
The initial redness is homogeneous, and it remains so until it heals. In long standing patches, the center partly or totally fades, leaving behind a circular red ring. The size of this red patch may range from less than 1 decimeter to several decimeters.
The size of patch or the distance redness has migrated mostly corresponds to the duration of infection.
With time, its border also begins to fade and is sometimes visible only after the skin has been warmed up, as in a hot bath. An untreated lesion usually disappears within weeks or months.
It may appear anywhere on the skin surface, but the lower extremities are usually affected in adults and face in children.
Atypical appearances with blisters, or hemorrhagic or scaling lesions, small stationary erythemas or a localized swelling without an obvious redness, may develop at the site of the bite.
The affected person may at times not even realize the presence of this red ring, or it could be itchy and accompanied by irritation and heat.
At times, the lesion is accompanied by severe pain, pricking sensation and tingling, along with swelling of regional lymph nodes.
One may also suffer from a headache, low-grade fever, malaise, gastric upset and joint pains before the appearance of, or along with the skin lesion.
The person may become irritable or depressed and get tired easily. If the symptoms continue to increase in duration and intensity, then it suggests that the infection has disseminated and reached the meninges and the brain.
At or around the site of inoculation, develops a solitary, tender, itchy, bluish-red nodule, 1-5 cms in diameter, and often accompanied by lymph node enlargement.
It may be preceded, or accompanied by Erythema migrans. Sites of predilection of this lesion include the ear lobe, nose, and the areola mammae region.
Multiple Erythema migrans like lesions
Early Disseminated Infection
This stage presents as multiple erythema migrans-like skin lesions, along with early manifestations of neuroborreliosis, arthritis, carditis, or other organ involvement.
Multiple Erythem migrans-like lesions
The development of multiple secondary annular red lesions, similar to the initial lesion but much smaller in size, is an indication that the microbe has spread to distant places throughout the body via the bloodstream.
The spirochetes can be successfully cultivated from these secondary lesions.
Acrodermatitis Chronica Atrophicans - a Late Feature of Lyme disease
Late Lyme Borreliosis
The chronic or late stage of the disease is heralded by Acrodermatitis Chronica atrophicans, neurologic, rheumatic, or other organ manifestations - persistent or remitting for at least 12 months.
Acrodermatitis Chronica atrophicans
A connection between this skin condition and a preceding tick bite is rarely suspected. Around 20% of the affected individuals will recall a preceding untreated erythema migrans, usually on an extremity where acrodermatitis Chronica atrophicans lesions develop 6 months to 10 years later. Some of the affected persons have a history of preceding neurological or/and rheumatic conditions.
It usually begins on the front of an extremity, the most common site being the lower leg, with involvement of the foot, ankle, or knee region. The dorsum of hands, fingers, toes, and soles may also be affected.
This is generally a disease of the middle-aged or elderly, and the females (70%) are affected more commonly than males.
It begins as a bluish-red discoloration, often with swelling of the affected part, be that the hand or the foot. It might look like venous stasis or lymphedema, a typical feature is that one of the feet or just the heel gradually increases in size.
The lesions progress gradually and insidiously, and initially both redness and swelling may aggravate and then reduce on their own, at frequent intervals.
Fibrous thickening of the skin in the form of bands and nodules may develop. The most common bands are ulnar bands.
These bluish-red, swollen lesions persist for years or decades, with gradual conversion to atrophic skin lesions.
In advanced atrophic phase, the skin becomes thinned out, translucent, cigarette paper-like and wrinkled, the hair follicles and oil glands are lost, and blood vessels begin to show.
These skin lesions are accompanied by migrating and/or intermittent pain arising from impact against bony prominences, such as knuckles or malleoli, underlying the thinned out atrophic skin.
More than 50% of the individuals with this skin lesion also have a peripheral neuropathy, along with symptoms such as hyperesthesia (increased sensitivity to pain, and touch stimuli), muscular weakness, and a feeling of heaviness. Profound fatigue, emotional disturbances, and personality changes sometimes accompany this condition.
Subluxations of small joints of fingers and toes, knee or olecranon bursitis, Achilles tendinitis, and attacks of knee joint effusion, often accompany this condition.
Borrelia burgdorferi may also cause skin lesions indistinguishable from localized scleroderma presenting as circumscribed sclerotic plaques with ivory-colored centers.
Removal of the Lyme vector
Treatment and Course of Illness
For uncomplicated Erythema migrans the treatment of choice is Doxycycline (100 mg orally twice a day), or amoxicillin (500 mg orally thrice a day).
In order to treat borrelial Lymphocytoma, the same treatment regime is followed, as above, but a prolonged course for up to 20 to 30 days is required.
In order to treat Acrodermatitis Chronica atrophicans, antibiotic Doxycycline in a dose of 100 mg twice a day, is required for 20 to 30 days.
Mild to moderate reactions may appear after the institution of the therapy in the form of intensification of skin rash, or appearance of new signs and symptoms such as chills and fever. This occurs due to the disintegration of the Borrelia microorganism with the initiation of therapy that triggers an inflammatory response.
Treatment failures do occur with most of the different regimes. But in a vast majority of cases, antibiotic therapy results in healing of infection. Recovery may take many months, and be accompanied with persistent fatigue.
Reinfections are common in previously treated individuals.
The redness in Erythema migrans begins to fade within a few days of initiation of therapy; in the case of Lymphocytoma, it might take more than a month after antibiotic therapy before the lesion disappears completely; for Acrodermatitis Chronica migrans, the resolution process might extend up to one year. The first sign of improvement is a reduction in swelling of the affected extremity. The least satisfactory results are obtained in late stages.
Skin Lesions in Different Stages of Lyme disease
Acrodermatitis chronica atrophicans
Early stage lesion
Late stage lesion
Pinkish red circular or elliptical patch, changing into annular lesion
Solitary bluish red nodule
Bluish red discoloration with swelling that later transforms to skin atrophy
Occur at site of inoculation, common site being lower extremity
Predilection sites are ear lobe, nose, and areola
Common sites being front of lower leg, foot, knee,and dorsum of hands