Why do bulls-eye rashes look like they do?

Why do bulls-eye rashes look like they do?

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People infected with Lyme Disease often present with an erythema migrans ("migrating redness") rash. Most often, these rashes are in the shape of a bulls-eye.

Rash image.

Presumably, this is a reaction that many of our bodies have to the Borrelia burgdorferi pathogen.

Lyme disease also sometimes presents with different-looking rashes, and other pathogens also sometimes produce a bulls-eye-looking rash. CDC Link on Lyme Disease Rashes and Look-alikes.

What causes the bulls-eye shape of these rashes?

Thought process: A gradient of redness from the site of the tick bite makes sense--an immune response might be strongest at the bite site--but I'm still stumped on why there would be a spot of redness surrounded by a no-rash-ring surrounded by a rash-ring.

Note: If I remember correctly, external links to images are usually frowned upon. Although the images linked in this post aren't super graphic, I decided to make them external links for the sake of anyone who is sensitive to medical images.

The spreading of the rash is caused by dissemination (migration) of the Lyme spirochetes (Borrelia) through the skin out from the initial site of infection.

The spirochetes trigger a immune reaction that involves macrophages entering the skin and releasing pro-inflammatory factors.

The clear areas (when present) apparently represent areas where macrophages have been cleared from the skin and thus are no longer triggering a inflammatory response.

The different patterns associated with the rashes can be explained by differences in how fast macrophages are cleared from the skin.

Reference: Vig, D. K., & Wolgemuth, C. W. (2014). Spatiotemporal evolution of erythema migrans, the hallmark rash of Lyme disease. Biophysical journal, 106(3), 763-768.

Lyme Disease Rashes and Look-alikes

Circular, expanding rash with target-like appearance.

Expanding rash with central crust

Photo Credit: Bernard Cohen

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 201164:619-36, with permission from Elsevier.

Early, expanding erythema migrans with nodule.

Multiple rashes, disseminated infection

Photo Credit: Bernard Cohen

Early disseminated Lyme disease multiple lesions with dusky centers.

Red, oval plaque

Photo Credit: Alison Young

Red, expanding oval-shaped plaque on trunk.

Expanding rash with central clearing

Photo Credit: Taryn Holman

Circular, expanding rash with central clearing.

Bluish hued rash, no central clearing

Photo Credit: Yevgeniy Balagula

Bluish hued without central clearing.

Expanding lesion, no central clearing

Photo Credit: Gary Wormser

Expanding lesion without central clearing on back of knee.

Red-blue lesion with central clearing

Photo Credit: Robin Stevenson

Red-blue lesion with some central clearing on back of knee.

Insect bite hyper-sensitivity

Large itchy rash caused by an allergic reaction to an insect bite.

Fixed drug reaction

Photo Credit: Shahbaz A. Janjua

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

Ringworm is a common skin infection that is caused by a fungus. It&rsquos called &ldquoringworm&rdquo because it can cause a ring-shaped rash that is usually red and itchy with raised edges.

Pityriasis rosea rash

Photo Credit: Bernard Cohen

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

Reddish bumps on the skin arranged in a circle or ring.

Urticaria multiforme

Photo Credit: Bernard Cohen

Also known as hives. Often caused by an allergic reaction to food, an infection, or a medicine. May burn or itch.

Lyme Disease

Lyme disease is transmitted through a bite from a specific type of tick. The animals that most often carry these insects are white-footed field mice, deer, raccoons, opossums, skunks, weasels, foxes, shrews, moles, chipmunks, squirrels and horses. The majority of these ticks have been found in New York, Connecticut, New Jersey, Minnesota and Wisconsin.

In the early stages of Lyme disease, you will have a telltale bullseye rash that expands around the area of the tick bite. You may experience flu-like symptoms that can include a stiff neck, chills, fever, swollen lymph nodes, headaches, fatigue, muscle aches and joint pain. Joint and muscle pain are other early signs of Lyme disease. In more advanced disease, nerve problems and arthritis, especially in the knees may occur. Read more about symptoms, diagnosis, and treatments for Lyme disease.


Image: Photo courtesy of CDC

Text: "Arthritis: Lyme Disease", WebMD Medical Reference provided in collaboration with the Cleveland Clinic

What if I don&rsquot get a rash but still feel super sick?

Since you can&rsquot always rely on a rash to clue you in, pay attention to other signs of illness you experience after possible exposure. Dr. Mudassar says that tick-borne illnesses can cause fever, fatigue, loss of appetite, headache, muscle pain, and regional lymph node swelling in the early stages of the disease.

Dr. Schrading adds that you might simply have nonspecific viral illness symptoms, like malaise and myalgia&mdashso it helps to consider the time of year you&rsquore feeling sick. &ldquoMore people are outside and around ticks in the summer, which isn&rsquot flu season,&rdquo he says. &ldquoSo if you&rsquore feeling like you have the flu in the middle of summer, think about whether you could have been exposed to a tick.&rdquo Noted.

Don’t Be Fooled

Lyme disease is often referred to as the great imitator because so many of its symptoms resemble those of other diseases. Without a telltale skin rash, it can be very hard to diagnose Lyme disease. Many people never recall being bitten.

Below is a list of just some of diseases that many people have initially been diagnosed with, only to receive a Lyme diagnosis later:

  • Arthritis: typically manifesting as joint pain, swelling, redness, heat, and limitation of movement
  • Juvenile idiopathic arthritis: a childhood disease that causes joint inflammation and swelling
  • Fibromyalgia: especially widespread muscle and soft tissue pain
  • Chronic fatigue syndrome: severe and debilitating fatigue
  • Multiple sclerosis: leading to problems with muscle control and strength, vision, balance, sensation, and mental functioning
  • Lupus: joint pain, swelling, may affect kidneys, brain and other organs

If you suspect Lyme, even if you do not recall being bitten, try to recall where and when you might have been exposed to infected ticks, and discuss the situation and symptoms with your doctor.

Image courtesy of Emily M. Eng

What does the rash look like?

Most illnesses that manifest on the skin have distinct rashes, but COVID-related rashes can take on many different appearances. According to the American Academy of Dermatology (AAD), COVID rashes can manifest as "a patchy rash, itchy bumps, blisters that look like chickenpox, round, pinpoint spots on the skin, a large patch with several smaller ones, a lace-like pattern on the skin, or lat spots and raised bumps that join together." If your rash resembles any of these descriptions, you should talk to your doctor. And for more up-to-date COVID news delivered straight to your inbox, sign up for our daily newsletter.

Telehealth Rash Consultation Services

Tick bite and Lyme disease rash consultation* is available by telemedicine appointment at the Johns Hopkins Lyme Disease Research Center. A telehealth visit requires the ability to digitally photograph the patient’s skin rash for the evaluation and to meet certain State insurance parameters.

* Only available currently to patients in Maryland, Pennsylvania, Virginia, and Delaware.

If you are experiencing flu-like symptoms, please seek the advice of a healthcare practitioner.

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One important rule of thumb is to seek help if the rash came with other symptoms.

“The majority of rashes are not life threatening,” said Dr. Daniela Kroshinsky, an associate professor of dermatology at Harvard Medical School and director of inpatient dermatology and pediatric dermatology at Massachusetts General Hospital.


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“But, if you’re feeling generally unwell and having a rash, that would be a reason to seek medical attention. Your primary care physician or dermatologist should be able to help you triage whether it’s something that should be seen and whether it needs to be seen urgently.”

A rash can be a warning sign of a serious medical problem, such as an autoimmune disease or a Lyme infection, explained Dr. Laura Ferris, an associate professor of dermatology at the University of Pittsburgh Medical Center. Or it could simply be the result of a harmless, though vexing, insect bite or a brush past some poison ivy.

Bullseye Rash Tick Bite

It is the name given to a rash caused by tick bite that looks similar to a bull’s-eye. This is a red bumpy rash that can be seen in puppies, dogs and children. In humans, it can arise almost anywhere on the body such as face, neck, underarm, under the breasts, groin and the legs.

Picture 2 – Bullseye Rash
Source – canlyme

This condition is also commonly referred to as Lyme disease. It results from infection caused by a type of bacterium known as Borrelia Burgdorferi. It usually affects animals and is less common in humans.

8. Chigger bites

What it looks like: Tiny pink or flesh-colored bumps that itch—a lot.

Causes: Chiggers, small mites that live in tall grass and can latch onto skin, bite and leave behind itchy welts.

How to treat it: OTC anti-itch creams and oral antihistamines usually ease symptoms and help bumps to subside in about a week.

See a doc if: If a week goes by and your OTC regimen hasn’t stopped the itch.

Your best defense: Chiggers tend to be most active during the early evening and nighttime hours, so use DEET-based insect repellent if you’re hitting up a backyard barbecue or going for an after-dinner hike.

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