Skin manifestations Lyme disease

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Apr 3, 2016, 1:51:15 PM4/3/16

Here are some references about the different skin manifestations.

".....The differential diagnosis of erythema migrans includes cellulitis ,
tinea, (ringworm) contact dermatitis, fixed drug reaction. granuloma annulare,
reaction to an insect bite, or a Brown recluse spider bite (48)...."

from: Clinical Manifestations of Lyme Disease in the United States authors:
Trock, et al
Source: Connecticut Medicine June 1989 Volume 53, No. 6
"....Although the bite (and subsequent erythema migrans) may occur
anywhere, the tick has a predilection for the thigh, groin, or axilla. Facial
erythema migrans is more common among children. Atypical forms of erythema
migrans occur: ealy lesions may have indurated or vesicular centers , or MIMIC
and be misdiagnosed as a bite of the brown-recluse spider. Rarely, transient
eruptions are seen in early Lyme disease and include, maculopapular rashes,
urticaria, " (hives)"malar rash, septal panniculitis (erythema nodosum), and/or
localized granuloma annulare. Although B. burgdorferi has been isolated from
the perimeter of erythema migrans, skin biopsy is a low-yeild procedure.
Histologically, erythema migrans has a non-specific appearance with a
perivascular infiltrate comprised of lymphocytes, plasma cells, eosinophils,
and histiocytes.
" In addition to erythema migrans, many patients with early disease will
have a flu-like syndrome characterized by fatigue, fever, malaise, headache,
arthralgias, myalgias, regional or generalized lymphadenopathy, and/or
conjunctivitis." My LLD said that conjunctivitis in both eyes is a as
diagnostic of Lyme as a bull's eye rash. "One-third of patients will have such
symptoms in the absence of erythema migrans. These symptoms are typically
intermittent and changing, with the exception of fatigue, which is often
persistent and may be debilitating. Right upper-quadrant tenderness and a mild
hepatitis may occur (hepatitis has also been reported in later disease), as
well as cases of rare myositis "- maybe rarely recognized- " and adult
respiratory distress syndrome. During this early phase of disease, laboratory
findings are nonspecific........."

from: Annals of Internal Medicine--Vol. 114--Number 6--March 15, 1991 pg.
title: Diagnosis of Lyme Disease Based on Dermatologic Manifestations
authors: Malane, MD, et al

"Erythema migrans occurs in 60 to 83 % of patients with Lyme disease
(8-10). Classic erythema migrans starts as a red macule or papule at the site
of the tick bite, which then expands, forming an erythematous, annular lesion
with partial clearing center (11, 42). An erythematous central punctum or a
larger macule will often remain at the bite site. Many patients with erythema
migrans are unable to recall the tick bite. The lesion is generally found in
body areas where ticks characteristically feed. Such areas include those where
tight fitting clothing begins (for example at underwear lines ) and
interiginous" (superficial inflammation of two skin surfaces taht are in
contact) "locations such as the axilla, groin, thigh, and buttocks (11). Ticks
infrequently feed on the palms, the soles, or the mucous membranes, Erythema
migrans begins approximately 3 to 30 days after a tick bite (11, 12, 42) The
inflamed border will migrate cenrifugally over days to weeks. The average size
of the lesion is 15 cm, but lesions as large as 68 cm in diameter have been
reported (11). Erythema migrans is usually flat; however , the edges may be
elevated or indurated (11, 42). Although erythema migrans is usually
asymptomatic , burning, prutitus" (itchy)", pain, tenderness, hyperesthesia, or
dysesthesia may occur (11, 12, 12, 43). In more than 50% of patients, the
lesion is associated with a flu-like illness characterized by fever, myalgia,
arthralgias, malaise, fatigue or headache(11, 43). When left untreated, the
lesion fades weeks to months later, with an average duration of 1 month (8, 11,
12). On fading there may be residual scaling or pigmentary change in the skin
(11, 12)..........
"The histologic findings associated with erythema migans are relatively
nonspecific; thus for histopathologic confirmation , the presence of
B.burgdoreferi needs to be shown by silver stain, labeled antibody staining or
culture(23). Spirochetes are most frequently found in the dermis of the
advancing margin of the lesion (34, 45) Histopathologic findings in specimens
from the periphery of the lesion include a superficial and deep perivascular
lymphocitic infiltrate that may contain plasma cells, histiocytes, and, less
commonly mast cells or neutrophils. (11, 42, 43, 45). Histopathologic findings
in specimens from the center of the lesion are consistent with a reaction to an
arthropod bite, with eosinophils within the dermal infiltrate. Occasionaly
vasculitis" (patchy inflammation of walls of small blood vessles)" or
vesicular" (having blisters)" changes are also seen(11). "Other, less
classic presentations of the erythema migrans are common. The central area of
the lesion may show equal or greater erythema than the periphery(11, 13, 43).
A European study (12) found that the homogeneous erythematous lesions persist
for shorter duration than those with central clearing. An erythema migrans
lesion can have alternating rings of erythema and clearing, thereby creating
target configuration(11). Additionally, the central portion of the erythema
migrans lesion may show blue discoloration or frank purpura,"(a skin rash
resulting from bleeding into the skin from small blood vessles-capillaries;
the individual purple spots of the rash are called petechiae.)" induration,
"(hardening) "vesiculation," (blistering)" necrosis," (death of cells in organ
or tissue) "or ulceration (11-13, 43, 44, 46) . Uncommonly, petechiae, have
also been seen within erythema migrans lesions (46). Lesions may also have
different shape or textures. Lesions may appear oval or triangular in shape,
especially when they follow the lines of the clevage.
(Langer lines ) or are in intertriginous areas (34, 43, 47). Lesions may also
be more linear in configuration, especially when located on the scalp or when
expanding on an extremity (11,47). Scaling has been identified occasionally on
some lesions (13, 34, 43, 47).....The differential diagnosis of erythema
migrans includes cellulitis , tinea, (ringworm) contact dermatitis, fixed drug
reaction. granuloma annulare, reaction to an insect bite, or a Brown recluse
spider bite (48).

Secondary (Multiple) Erythema Migrans Lesions
"One or more secondary erythema migrans lesions may develop. Secondary
erythema migrans can appear within several days to weeks after onset of the
initial erythema migrans lesion and has been reported in 6% to 48% of patients
with Lyme disease (11, 12, 43). Secondary erythema migrans may result from
spirochetemia" (spirochetes in the blood)" or lymphatic spread and subsequent
seeding of the skin.
(49). Lesions often occur at sites away from the original lesion, but a single
secondary lesion may occur at the site of a primary lesion that has
disappeared. When many lesions are present, they can become confluent "
(meeting) "or intersecting, forming complicated patterns. The secondary lesions
are often similar to the intial erythema migrans lesion, but they tend to lack
indurated centers. (11). Secondary lesions are often asymptomatic. If
untreated, the lesions usually disappear within a month, but they may persist
for months to over a year, or there may be relapses. In patients receiving
therapy, secondary lesions resolve over several days (11). The differential
diagnosis of secondary erythema migrans includes erythema multiform, erythema
annulare cetrifugum, secondary syphilis, erythema marginatum, and drug
Acrodermatitis Chronica Atrophicans
"Acrodermatitis Chronica Atrophicans is a unique late complication of Lyme
disease, which was first recognized in 1883 (54) . .......It has been reported
as the first manifestation of Lyme disease; for example, one asymptomatic
patient, on screening had a high serum titer of B. burgdorferi antibodies and
he developed acrodermatitis chronica atophicans 4 years later (13, 54,
56)....Classically, there is an intial erythematous or violaceous discoloration
in doughy and swollen skin, appearing as plaques or nodules (13, 54). ....The
lesion expands and may have a waxing and waning course ((13, 58). This stage
will continue for weeks to years before becoming atrophic......There may be
hypopigmentation or hyperpignmentation as well as scaling (54, 57). The lesion
may be associated with pain, pruritis,"(itching)" hyperesthesias, or
paresthesias (55, 57)." (esthesia--from Taber's Cyclopedic Medical Dictionary--
1. Perception ; feeling; sensation 2. Any disease that affects sensations and
perceptions.----para is a prefix meaning near, beside, past, opposite,
abnormal, irregular, two like parts-----hyper is a prefix meaning above,
excessiive or beyond) "Regional lymphadenopathy," (a disease of the lymph
nodes---pathy is a combining form indicating disease.---While I was looking
this up I noticed that Taber's 18 th edition has a computer glossary included.)
" as well as neurological and musculoskeletal signs or symptoms, may be
localized to the same extremity as the acrodermatitis chronica atrophicans
lesion (13, 57). An associated sclerotic or fibrotic lesion may be found in
patients with acrodermatitis chronica atrophicans (13, 28, 57). The
differential diagnosis includes thrombophlebitis, venous insufficiency,
eczematous dermatitis, cold injury or aging......

"Fibrotic lesions, such as ulnar (or tibial) bands and ulnar nodules, have
been asssociated with acrodermatitis chronica atrophicans lesions....Ulnar (or
tibial ) bands are fibrotic, dense, linear bands taht occur in association with
atrophic plaques over the respective bones. .......periarticular fibrous
nodules ...These nodules can be confused with rheumatoid nodules, gouty tophi,
or erythema nodosum, especially if the acrodermatitis achronica atrophicans
lesion has gone unnoticed. (13).......

".......Morphea (Localized Scleroderma) and Other Scleradermatous Lesions
"Various types of sclerotic lesions, which are characterized by a thickened
dermis, develope in about 10% of... patients with acrodermatitis chronica
atrophicans and Borrelia lymphocytoma........Sclerodermatous lesions were first
reported in association with acrodermatitis chronica atrophicans in the 1930's.
The best described of these lesions are those that are both clinically and
pathologically identical to morphea (localized scleroderma). Even Morphea
lesions that occur in patients without
a history of Borrelia lymphocytoma or acrodermatitis chronica atrophicans may
be of spirochetal origin;..........
"Plaque-type morphea" ( from Mosby's Medical, Nursing and Allied Health
Morphea--localized scleroderma consisting of patches of yellowish or
ivory-colored, rigid, dry, smooth skin. It is more common in females. Also
called Addison's keloid, circumscribed scleroderma localized scleroderma.)
"manifests as a well-demarcated, indurated, round or
oval plaque with two stages. It begins as an edematous, erythematous lesion
that may have a violaceous or lilac tinged border. As the lesion ages, it
becomes a sclerotic plaque with a smooth and shiny surface that is white or
yellow in the center. The lesions can expand in size and are found on the
trunk or extremities. Although they are often painless, they have been
associated with dysesthesias, hypoesthesias, and hyperesthesias. Biopsy
specimens taken from the early lesion, especially from the violaceous border,
show a mixed superficial and deep perivascular lymphohistiocytic infiltrate
with plasma cells and occasional eosinophils. The dermis is thickened with
sclerosis and hylanization of collagen bundles. As the lesion ages, the dermis
becomes more sclerotic, and the inflammatory infiltrate begins to disappear.
Morphea may resolve spontaneously after months to years, leaving pigmentary or
atrophic changes, or both. Data about treatment are inconsistent. Early
lesions and lesions associated with acrodermatitis chronica atrophicans have
responded to antibiotics, and some late lesions have STOPPED PROGRESSING when
"Atrophoderma of Pasini and Pierini is rare and probably an atrophic
variant of morphea. Spirochetes have been cultured from one lesion.
Atrophoderma, a lesion of dermal atrophy progressing to sclerosis, presents as
a grey or pigmented lesion with sharp peripheral margins that appear to drop
into a depression. Atrophoderma appears most often on the back. A histologic
examination done early in the course of the lesion will show a mild diffuse
lymphocytic infiltrate and a slight thickening of collagen bundles. As lesions
age, the inflammatory infiltrate may disappear
and the thickened collagen bundles may increase, appearing tightly packed. Data
on therapy are not currently available.......
"The diagnosis of Lyme disease is based on recognizing the characteristic
clinical presentations. Serologic testing is an adjunct to clinical diagnosis.
Primary and secondary erythema migrans, Borrelia lymphocytoma, and
acrodermatitis chronica atrophicans are characteristic dermatologic lesions
that establish the diagnosis of Lyme diseasse. Less specific cutaneous
manifestations of Lyme disease include benign lymphocytic infiltration,
morphea, lichen sclerosis et atrophicus, eosinophilic fasciitis, and
progressive facial hemiatrophy................Recognizing and treating the
cutaneous manifestations of Lyme disease is INVALUABLE for preventing
progression of this multisystem infection."

from: California Lyme Disease Symposium 1994
Lyme Disease Resource Center of California
reported by Jean Hubbard

"Dermatologic Manifestations of Lyme Disease------

"Dermatologist Rudy Scrimenti, the first physician to identify EM in the United
States, noted that cutaneous manifestations of Lyme disease have served as
hallmarks of the disease., but agreed with Dr. Katzel that 'the classical
lesion with central clearing and red bands, although most diagnosable and most
readily recognizable, is far from being the most common lesion of EM, with
triangular lesions being quite common..' .....There is another lesion with
varieagated redness throughout, but in the central portion there are blisters
or vesicles. Sometimes these become crusted and highly inflammed. When
inflammatory changes occur in EM they are always focally placed in the central
portion and not throughout the lesion. They will eventually scale, but scaling
occurs only in the center and is not a particularly consipicuous feature at the
peripheral margins. 90% of the cultures are negative in such lesions, and one
of the reasons is that some of the inflammatory lesions probably show a
hypersensitivity reaction to the tick parts, possibly to the tick salivary
gland substances......
"There are Lyme disease rashes of sorts not yet documented well in the United
States, but present in Europe. These include a reddened breast nipple areola,
which is a Lyme borrelial lymphocytoma: this is the most common location in
adults, males and females. The most common site in children is the lobe of the
ears.; thus far this has not been successfully cultured in the United States. "
(this might have changed at this time) " Coalescent papules on the entire rim
of the auricle are also compatible with lymphocytoma. There are also
lymphocytomas that remain, sometimes for years, after the more typical EM rash
resorbs; these do improve with tetracycline and I am SURE I HAVE SEEN THESE IN
MY PRACTICE IN WISCONSIN, but thus far I've been unable to obatain a positive
culture. The most important alternative diagnosis for such lymphocytomas are
malignant lymphoma........"

".....The differential diagnosis of erythema migrans includes cellulitis ,
tinea, (ringworm) contact dermatitis, fixed drug reaction. granuloma annulare,
reaction to an insect bite, or a Brown recluse spider bite (48)...."

From Lyme Disease 1991
Patient/Physician Perspectives from the U.S. and Canada

Skin Manifestations of Lyme Disease by John Drulle M.D.

"Since Lyme disease is a widely disseminated, multi-organ system disease, skin
involvement is common, and occurs in about half of those infected.......

"The pathognomonic (diagnostic) rash of early Lyme is called EM(erythema
migrans--in Latin LErythema means redness, and migrans means migratory or
expanding). It usually appears at the site of the tick, flea, fly, or mosquito
bite several days to a year or more later. (It was recently reported that 18%
of the cases of Lyme in Austria are due to bites of non-tick vectors such as
flies and perhaps mosquitos. Borrelia burgdorferi -Lyme spirochete- has been
isolated from these insects.) The fact that one half of people who develope
Lyme do not recall a tick bite may be partially explained by non-tick vectors.
The EM rash is usually circular or oval, but irregularly shaped rashes are
common. They may spread or enlarge rapidly, but we have seen where pressure on
the skin from a tight garment impedes the progression of the rash causing
irregularity of shape. There may or may not be central clearing, and
concentric rings of different shades are often seen within the rash. There may
be necrosis (death of areas of tissue) or a blue violet shading at the site of
the bite. These rashes are rarely painful, as brown recluse spider bites
almost always are, and often itch. They are usually warm to the touch. The
rash may be completely flat, but occasionally the edges may be elevated and be
scaly or contain vesicular components. Ten variations of the EM rash have been
described by Dr Alan McDonald. Some of these are very recognizable or
"classic" in their appearance, but others may be confused with other common
skin infections such as ringworm, cellulitis, erythema multiforme, eczema, or

"......I feel that the best approach in an endemic area would be to assume that
the rash is Lyme and treat accordingly. It's better to err on the side of
overdiagnosis than to miss the diagnosis and have it haunt you months or years
later." (my own words-this Dr. obviously has a conscience) " Waiting for other
symptoms to develope may delay treatment and result in persistence of symptoms
or even more serious problems in the future.

"........I must note that a treatment effective in one person may not work in
another. This is generally true for any particular symptom of Lyme.

"Another type of chronic Lyme rash we have seen, occurs in some small
children. These tend to be widely disseminated, blotchy plaques, pink in
color. They do not spare the face. They have been seen in children born with
Lyme, especially if the mother was a bit late in pregnancy. These rashes are
usually misdiagnosed as eczema, and they do not respond to topical or systemic
steroids. They do respond quite well to oral or IV antibiotics ....

"In summary, I believe the current official description of Lyme skin
manifestations is quite incomplete. We are anxiously awaiting the PCR test to
become more readily available, since I feel that we will find evidence of
active infection in many of these chronic skin rashes."

Update to Lyme Disease 1991 4/93
A new "telltale rash" of Lyme disease: " A blistering rash easily mistaken for
poison ivy, an allergic reaction, herpes simplex or a variety of other
conditions is also associated with Lyme" (from an article by Dr. Neil
CKKGoldberg et al., Nov. 1992 Archives of Dermatology.)


Jul 12, 2021, 4:53:58 AMJul 12
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