It is important to be aware of the early signs and symptoms of Lyme disease, including how to recognize the rash if it appears. It is also helpful to understand the varied symptoms of disseminated Lyme disease and when to seek medical care.
Early signs and symptoms
In the early localized stage of Lyme disease, the skin at the site of the tick bite can become infected with Borrelia burgdorferi. This can cause an expanding round or oval red skin lesion called erythema migrans, sometimes along with flu-like symptoms that may appear days to a month after the bite. Early symptoms can include achiness, chills, fever, sweats, extreme fatigue, severe headache, stiff neck, muscle soreness, joint pain, swollen lymph nodes, and sore throat.
The skin rash and flu-like symptoms are common early signs of Lyme disease, but they are not always present. Acute Lyme disease is not usually associated with a runny nose, prominent cough, or prominent diarrhea.
Recognizing the rash
A rash is not always present or easy to recognize in early Lyme disease, which can delay diagnosis and treatment.
Most Lyme disease rashes do NOT look like a “target” or bull’s-eye rash.
The most common appearance is a uniformly red, round or oval rash that expands to more than 2 inches across. Some rashes do have a bull’s-eye pattern, but this is less common.
This poster of varied Lyme disease rash manifestations is a helpful rash identification tool.
It is helpful to take dated photos of any suspicious rash, since an erythema migrans rash should prompt urgent medical evaluation. Lyme disease is most successfully treated in this early stage.
Lyme rash characteristics
- Round or oval and enlarges over days to weeks
- Usually larger than 2 inches across, often 6-8 inches
- Usually uniformly red
- Sometimes a bull’s-eye appearance, but this is not the most common pattern
- May appear 3 to 10 days after the bite, but can take up to 30 days
- Usually only mildly tender or itchy, if at all
- Often mistaken for a spider bite
- Sometimes blisters develop in the center (shown below)
- Can spread through bloodstream, leading to new lesions elsewhere
A tick bite reaction (below) can be confused with the rash of Lyme disease, but it usually stays small and does not keep enlarging. It often appears as a red bump smaller than 1 to 2 inches, may feel warm or tender, and can last for days or even weeks. Unlike erythema migrans, it does not steadily expand over 24 to 48 hours and is not typically associated with fever or other systemic symptoms.
Sex-based and menopause-related differences
Studies show that there are sex-based and menopause status differences in Lyme disease. Males were more likely than females to have a positive two-tier antibody test for acute Lyme disease. Males also showed more pronounced and more severe early disease based on objective clinical markers such as larger rashes, more frequent elevations in routine laboratory measures including liver function tests and white blood cell ratios, and a higher overall disease severity score.
Post-menopausal females resembled males more closely than pre-menopausal females in both test positivity and acute disease severity. This suggests that menopause related changes in hormones may influence immune response and clinical presentation.
Males and females reported a similar number of symptoms overall, but the types of symptoms differed. Females more often reported heart palpitations, vomiting, and sensitivity to light, while males more frequently reported sleep disruption.
Later signs and symptoms of Lyme disease
If Lyme disease is not recognized and treated early, it can spread to other parts of the body and have a major impact on patient’s health and quality of life. Symptoms may involve the joints, nervous system, heart, muscles, and brain and include severe fatigue, fever, intermittent body aches, joint pain, numbness, headaches, vision changes, and trouble concentrating or remembering. Some people develop more distinctive signs, such as facial palsy, meningitis, Lyme carditis, severe headache and stiff neck, or swollen joints, especially the knees. Cardiac manifestations can include fainting from an abnormally slow heart rate, irregular heart palpitations, or difficulty tolerating exercise. Some symptoms may also be related to autonomic nervous system dysfunction such as dizziness, heart palpitations, exercise intolerance, nausea, slow motility, or temperature sensitivity.
Late Lyme arthritis is a late stage manifestation that involves fluid accumulation and pain in joints, particularly in the knees. Late disseminated neurologic symptoms include numbness in the extremities, mental fogginess and concentration problems, slower processing speed, and difficulty following conversations.
When to seek medical care
People who have been bitten by a black-legged tick or who live in or visit Lyme-endemic areas should contact a healthcare provider if they develop a round, expanding greater than 2 inch wide red rash or a summer-flu-like illness, especially during peak tick season. The highest risk of acute illness occurs in late spring through summer, but Lyme disease can be contracted year-round, including on the West Coast and in other more temperate regions.
Seek prompt medical care for a suspicious rash, prolonged fever or viral-like symptoms, severe fatigue, facial weakness, severe headache, stiff neck, neurological symptoms, fainting, irregular heartbeat, heart symptoms, or painful swollen joints.
Meningitis and Lyme carditis are both potentially serious and warrant immediate medical attention.
IF YOU ARE DEPRESSED OR HAVE SUICIDAL TENDENCIES
- Call 911
- Go to the nearest emergency room
- Call 988 – The Suicide & Crisis Lifeline. Available 24 hours/day
- Visit 988lifeline.org for more resources
