Lyme Disease Rashes and Look-alikes
A telling sign of Lyme disease is a red, circular or oval rash that expands over time like a bulls-eye. Doctors call it “erythema migrans.” But if you’re looking for a bulls-eye pattern and ignoring other types of skin rashes and lesions, you’re probably missing an important clue to the diagnosis. Surprise, surprise: Relatively few Lyme rashes mimic the concentric circles of a dart board.
What Does a Lyme Disease Rash Really Look Like? These Pictures Explain It
You know the classic bulls-eye rash—but Lyme disease causes other types, like these.
Karen is a senior editor at Health, where she produces health condition “explainers” backed by current science.
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William Truswell, MD, FACS, operates his own cosmetic and reconstructive facial surgery practice. Dr. Truswell was the first in his area in Western Massachusetts to have an accredited private office surgical suite.
A telling sign of Lyme disease is a red, circular or oval rash that expands over time like a bulls-eye. Doctors call it “erythema migrans.” But if you’re looking for a bulls-eye pattern and ignoring other types of skin rashes and lesions, you’re probably missing an important clue to the diagnosis. Surprise, surprise: Relatively few Lyme rashes mimic the concentric circles of a dart board.
The classic target pattern represents just 20% of Lyme-related skin lesions in North America, noted John Aucott, MD, associate professor of medicine at Johns Hopkins University School of Medicine in Baltimore and director of the Johns Hopkins Lyme Disease Research Center.
The problem isn’t a shortage of people wanting to be doctors, but rather, too few opportunities for training. Medical schools have increased class sizes by 30% since 2002, but federal funding for residency training – an essential step in the process of becoming a practicing physician – has not increased since 1997, according to Inside Higher Ed.
“Eighty percent don’t look like that, and they constantly get misdiagnosed as spider or bug bites,” Dr. Aucott told Health.
The fact is that Lyme disease rash can present itself in different ways, per the Centers for Disease Control and Prevention (CDC). How it appears on your body may depend, in part, on how long you’ve had it and where it shows up on your body.
Generally, erythema migrans is circular, because it spreads centrifugally (away from the center) from the point of the tick bite, said Dr. Aucott. But it can be more oval or elongated in shape if, for instance, the tick took its blood meal in the groove of your groin.
Its appearance may also depend on your skin tone, Andrea Swei, PhD, an associate professor specializing in tick-borne diseases at San Francisco State University, told Health. In fact, some research, like a 2019 article published in Biomedical Journal of Scientific & Technical Research, suggests that Lyme rashes may not always be obvious in darker-skinned individuals, which can lead to disparities in diagnosis and treatment.
Healthcare providers also point out that it’s possible to have Lyme disease with no visible rash, or a rash that clears up on its own before you notice it.
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Editor’s Note
This article contains sensitive medical imagery.
What Do the Rashes of Lyme Disease Look Like?
Uniformly Red Rash
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This is the most common Lyme disease rash. It can be circular or oval and appear anywhere on the body. The redness is evidence of inflammation, explained Dr. Aucott. And just because it doesn’t have a target appearance doesn’t mean it’s not Lyme disease. If you develop a solid rash during tick season in a Lyme-endemic area, chances are it’s not a spider bite, said Dr. Aucott.
Classic Bulls-Eye Pattern Rash
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This is the image you often see in articles and stories on Lyme disease: a concentric circle pattern consisting of a red bulls-eye dead center and a ring of “central clearing” bordered by an outer red ring.
“Sometimes it goes from red to white to red; sometimes it’s white to red, but any time you have central clearing, it gives that target appearance,” explained Dr. Aucott. Although it’s pretty indicative of Lyme, it’s not the most common Lyme rash; nor is it a foolproof sign of the disease, added Dr. Aucott. Another tick-borne disease, called southern tick-associated rash illness, can cause a circular lesion too.
Multiple Red Rashes
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Early Lyme disease that spreads, or “disseminates,” through the bloodstream can cause multiple red lesions, Jennie Johnson, MD, infectious diseases specialist, associate medical director at Infectious Disease and Immunology Center at The Miriam Hospital, and co-director at Lifespan Lyme Disease Center in Providence, Rhode Island, told Health. When this happens, it means bacteria are no longer isolated to the area of the skin where the tick bite occurred. The CDC describes these rashes as having “dusky centers.”
Red-Blue or Bluish Lesions
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These rashes may or may not have central clearing, according to the CDC. If there’s clearing, that portion of the person’s skin will take on a bluish tinge, observed Dr. Johnson. The trouble with these rashes is they can be mistaken for bruises due to their reddish-blue color, said Dr. Aucott.
Central Blistering Rash
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A vesicular rash, one that blisters in the center, is uncommon. These lesions account for just 2% of Lyme rashes, according to Dr. Aucott, but he says they’re really important. That’s because people don’t realize Lyme can cause rashes with central blistering—or even central crusting after the blisters have popped. Occasionally, a crusty black scab, called an eschar, will develop, noted Dr. Aucott, “and those [almost] always get misdiagnosed.”
Can Lyme Disease Rash Itch?
If you develop a Lyme disease rash, you probably won’t be scratching your skin until it’s raw. Still, Lyme disease rashes can be slightly itchy, even mildly painful, said Dr. Aucott, but they don’t itch like a case of poison ivy.
Lyme rashes often feel warm to the touch as well. Your healthcare provider may perform what’s called a “crossover test” to gauge whether the area feels warmer than the rest of your skin, said Dr. Johnson. Here’s what that involves: Let’s say the rash is behind one knee. You place one hand on the rash and your other hand in the same area of the unaffected knee, wait a few seconds, and then switch hands. If there’s a difference in temperature, you’ll notice it.
Lyme Disease Rashes and Look-alikes
Description:
Circular, expanding rash with target-like appearance.
Expanding rash with central crust
Photo Credit: Bernard Cohen
Description:
Expanding lesion with central crust on chest.
Expanding erythema migrans
Photo Credit: Reprinted from Bhate C, Schwartz RA. Lyme disease: Part I. Advances and perspectives external icon . J Am Acad Dermatol 2011;64:619-36, with permission from Elsevier.
Description:
Early, expanding erythema migrans with nodule.
Multiple rashes, disseminated infection
Photo Credit: Bernard Cohen
Description:
Early disseminated Lyme disease; multiple lesions with dusky centers.
Red, oval plaque
Photo Credit: Alison Young
Description:
Red, expanding oval-shaped plaque on trunk.
Expanding rash with central clearing
Photo Credit: Taryn Holman
Description:
Circular, expanding rash with central clearing.
Bluish hued rash, no central clearing
Photo Credit: Yevgeniy Balagula
Description:
Bluish hued without central clearing.
Expanding lesion, no central clearing
Photo Credit: Gary Wormser
Description:
Expanding lesion without central clearing on back of knee.
Red-blue lesion with central clearing
Photo Credit: Robin Stevenson
Description:
Red-blue lesion with some central clearing on back of knee.
Insect bite hyper-sensitivity
Photo Credit: Chris Ha
Description:
Large itchy rash caused by an allergic reaction to an insect bite.
Fixed drug reaction
Photo Credit: Shahbaz A. Janjua
Description:
A skin condition that occurs up to two weeks after a person takes a medication. The skin condition reappears at the same location every time a person takes that particular medication.
Ringworm (Tinea corporis)
Photo Credit: Bernard Cohen
Description:
Ringworm is a common skin infection that is caused by a fungus. It’s called “ringworm” because it can cause a ring-shaped rash that is usually red and itchy with raised edges.
Pityriasis rosea rash
Photo Credit: Bernard Cohen
Description:
A rash without a known cause that can be a round or oval, pink, and scaly with a raised border. It can sometimes itch. Larger patches than the one shown here are also common.
Granuloma annulare rash
Photo Credit: Bernard Cohen
Description:
Reddish bumps on the skin arranged in a circle or ring.
Urticaria multiforme
Photo Credit: Bernard Cohen
Description:
Also known as hives. Often caused by an allergic reaction to food, an infection, or a medicine. May burn or itch.
Page last reviewed: October 9, 2020
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Signs and Symptoms of Untreated Lyme Disease
Seek medical attention if you observe any of these symptoms and have had a tick bite, live in an area known for Lyme disease, or have recently traveled to an area where Lyme disease occurs.
Untreated Lyme disease can produce a wide range of symptoms, depending on the stage of infection. These include fever, rash, facial paralysis, and arthritis.
Early Signs and Symptoms (3 to 30 Days After Tick Bite)
The appearance of the erythema migrans rash can vary widely.
- Fever, chills, headache, fatigue, muscle and joint aches, and swollen lymph nodes may occur in the absence of rash
- Erythema migrans (EM) rash (see photos):
- Occurs in approximately 70 to 80 percent of infected persons
- Begins at the site of a tick bite after a delay of 3 to 30 days (average is about 7 days)
- Expands gradually over several days reaching up to 12 inches or more (30 cm) across
- May feel warm to the touch but is rarely itchy or painful
- Sometimes clears as it enlarges, resulting in a target or “bull’s-eye” appearance
- May appear on any area of the body
- Does not always appear as a “classic” erythema migrans rash
Later Signs and Symptoms (days to months after tick bite)
- Severe headaches and neck stiffness
- Additional EM rashes on other areas of the body
- Facial palsy (loss of muscle tone or droop on one or both sides of the face)
- Arthritis with severe joint pain and swelling, particularly the knees and other large joints.
- Intermittent pain in tendons, muscles, joints, and bones
- Heart palpitations or an irregular heart beat (Lyme carditis)
- Episodes of dizziness or shortness of breath
- Inflammation of the brain and spinal cord
- Nerve pain
- Shooting pains, numbness, or tingling in the hands or feet
More about rashes
- A small bump or redness at the site of a tick bite that occurs immediately and resembles a mosquito bite, is common. This irritation generally goes away in 1-2 days and is not a sign of Lyme disease.
- A rash with a very similar appearance to EM occurs with Southern Tick-associated Rash Illness (STARI), but is not Lyme disease
- Ticks can spread other organisms that may cause a different type of rash.
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Page last reviewed: January 15, 2021
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