How to Treat Acute Tick Bites

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Safely Remove The Tick

The best way to remove a tick is to grab the tick at the head using tweezers. Pull up slowly and carefully. This method limits the chances that an attached tick will vomit Lyme germs into the tick bite area. Other methods, like burning a tick off, increase the chances of Lyme disease transmission from an infected tick.

Decide if You Should Take Antibiotics for a Tick Bite

The reason to use antibiotics for a tick bite is to prevent acute or chronic Lyme disease from the bite of a black legged deer tick.

Decide if The Tick Can Carry Lyme

All families of ticks do not carry Lyme (see CDC.gov). Lyme is transmitted by black legged deer ticks. Lyme is not transmitted by Lone star ticks, dog ticks or wood ticks. Dog and wood ticks can transmit other types of tick borne infections like anaplasma, ehrlichia, or rocky mountain spotted fever, but there is no evidence that preventing these infections with antibiotics after an asymptomatic bite works. In addition, these other infections are treated effectively with antibiotics when symptoms develop.

When to Treat an Acute Tick Bite:
My Recommendation

Asymptomatic Tick Bite Lyme Disease Prevention

Because chronic Lyme can cause severe life-long problems for a person, anyone who has a black legged tick bite of any length of attachment in any area of the country should receive antibiotic prophylaxis. The problems created by chronic Lyme disease far outweigh any risk of using preventive antibiotics. My recommendation is similar to the position of The International Lyme and Associated Disease Society (ILADS). I also recommend this approach if someone is unable to tell if the tick was a black legged deer tick or another type of tick. If the tick is identified as a wood tick, dog tick, or a Lone star tick, I do not support prophylactic antibiotics.

Any decision to treat a tick bite must weigh risks and benefits. The risk of not treating a tick bite is the development of Lyme disease which can result in chronic health problems. The earliest intervention after a tick bite results in the best outcomes. Even when antibiotics are given for acute Lyme disease where someone has symptoms or positive testing, there is a treatment failure rate of 15 to 20 percent. This risk of harm for not treating is greater than the risk of taking a short course of an antibiotic as I describe in the treatment recommendation section below. To put this in context, physicians regularly use antibiotics to treat teenage acne for months to years with minimal negative effects. Teenage acne is far from life threatening, yet we take risks in prescribing antibiotics to treat it. On the other hand, if Lyme becomes chronic, it has devastating consequences. Surely, we should do as much to prevent chronic Lyme as we do to treat teenage acne.

Symptomatic Tick Bite Lyme Disease Treatment

I agree with the United States Centers for Disease Control and Prevention/Infectious Disease Society of America (CDC/IDSA) position that someone with symptoms or a rash from a tick bite should receive antibiotics. These symptoms include flu-like symptoms, fever, and or marked neurologic symptoms. This is also the position of ILADS.

About the Bullseye Rash

Here are some points about the rash. Some with acute Lyme do develop the classic bullseye looking rash. However, sometimes the acute rash is only a red circular area that does not have a bullseye pattern. And 30 percent or more people who acquire Lyme from an acute black legged deer tick do not develop a rash at all. The lack of presence of the classic bullseye rash does not mean Lyme is not present.

When to Treat an Acute Tick Bite:
CDC/IDSA Recommendation

Acute Asymptomatic Tick Bites

The CDC/IDSA only recommend antibiotics for an asymptomatic tick bite without a rash when the following conditions are met:

  • The black legged deer tick is attached for 36 hours or more and
  • The tick bite occurs in a state or county with large amounts of Lyme in ticks. For practical purposes this means CT, DE, DC, MA, MD, ME, MN, NH, NJ, NY, PA, RI, VA, VT, WI, WV.
  • Treatment is started within 72 hours of the bite.

I strongly disagree with the CDC/IDSA position for the person who has a tick bite without symptoms or a rash. It is true that the longer a tick is attached, the greater the odds of getting Lyme. For instance, studies on transmission rates of infected ticks feeding on mice show no transmission of Lyme at 24 hours, 11% by 48 hours, 44% by 60 hours, and 94% by 96 hours. However, many ILADS physicians, including me, report Lyme disease from ticks attached less than 24 hours. In addition, Lyme spreads from ticks even in areas of the country where Lyme is rare. When it is followed, the CDC/IDSA position results in too many cases of chronic Lyme disease.

Symptomatic Tick Bites

If a person has a black legged deer tick bite and develops flu-like symptoms, neurologic symptoms, a bulls eye rash, or an illness with a fever, CDC/IDSA do agree that a person should receive antibiotics. I agree with this position.

How to Take Antibiotics for an Acute Tick Bite

First decide based on my recommendations above whether you need to treat the acute tick bite. Then decide how long to use the antibiotics.

  • I suggest treating with antibiotics for at least 20 days for an asymptomatic tick bite without a bullseye rash.
  • If a person has a bullseye rash or symptoms such as increased temperature, flu-like symptoms or neurologic symptoms then they should be treated for a minimum of four to six weeks and reassessed.
  • If there are any remaining symptoms, then treatment should continue with antibiotics until the symptoms are gone.

My position is similar to the ILADS position.

The best antibiotic to use is Doxycycline because it treats Lyme and can treat the other tick borne infections like anaplasma, ehrlichia, babesia, bartonella, and Rocky Mountain Spotted Fever if they are present. For an adult I recommend 100 mg 2 times a day. For a child of any age I recommend 2.2 mg/kg 2 times a day. I use this dose in children of any age for up to three weeks. In children under 8 years of age, I change to a different antibiotic at 3 weeks due to a concern of possible tooth staining. Recent studies show that using doxycycline for 3 weeks or less does not cause tooth staining.

If someone cannot take doxycycline, the alternative antibiotics include amoxicillin, cefuroxime, and azithromycin. However, there are no studies showing the proper dose or duration of these alternatives.

I do not recommend herbal antibiotics of any kind for an acute tick bite because there is no research evidence showing they work for an acute tick bite. 

CDC/IDSA recommend a single course of 200 mg of doxycycline for an adult and similar dose based on weight in children. I strongly disagree with this recommendation. This recommendation is based on one small study which lasted six weeks only. The goal in the study was to prevent the development of Lyme disease by measuring whether or not a bullseye rash developed. No other Lyme symptoms or signs were followed. Remember that 30 percent of people who develop Lyme never have a bulls eye rash. So this is not an accurate way to determine if Lyme develops. In addition, six weeks is not enough time to determine if Lyme disease will develop.

Mice studies that looked for Lyme tissue damage show 20 days of doxycycline prevent Lyme disease. So it seems appropriate to treat for at least this period of time. The truth is we do not have any human studies that document the best length of time to treat asymptomatic tick bites or the proper length of antibiotics to use. My recommendations for treatment duration are based on my clinical experience of what works and the one mouse study showing 20 days prevents Lyme disease in infected mice.

Disclaimer

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References

View Citations

  1. Cameron DJ, Johnson LB, Maloney EL. Evidence assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease. Expert Rev Anti Infect Ther. 2014;12(9):1103-1135. doi:10.1586/14787210.2014.940900 (View)
  2. Cameron DJ, Maloney EL. Insufficient evidence to advise a single dose of doxycycline to prevent Lyme disease from an Ixodes tick bite [published online ahead of print, 2020 Jul 15]. J Infect. 2020;S0163-4453(20)30472-2. doi:10.1016/j.jinf.2020.07.014 (View)
  3. Eisen L. Pathogen transmission in relation to duration of attachment by Ixodes scapularis ticks. Ticks Tick Borne Dis. 2018;9(3):535-542. doi:10.1016/j.ttbdis.2018.01.002 (View)
  4. Maloney EL. The management of Ixodes scapularis bites in the upper Midwest. WMJ. 2011;110(2):78-85. (View)
  5. Maloney EL. Reducing the burden of Lyme disease. Minnesota Family Physician. Spring 2020; 16-18. (View)
  6. Nadelman RB, Nowakowski J, Fish D, et al. Prophylaxis with single-dose doxycycline for the prevention of Lyme disease after an Ixodes scapularis tick bite. N Engl J Med. 2001;345(2):79-84. doi:10.1056/NEJM200107123450201 (View)
  7. Todd SR, Dahlgren FS, Traeger MS, et al. No visible dental staining in children treated with doxycycline for suspected Rocky Mountain Spotted Fever. J Pediatr. 2015;166(5):1246-1251. doi:10.1016/j.jpeds.2015.02.015 (View)

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About the Author

Marty Ross, MD is a passionate Lyme disease educator and clinical expert. He helps Lyme sufferers and their physicians see what really works based on his review of the science and extensive real-world experience. Dr. Ross is licensed to practice medicine in Washington State where he has treated thousands of Lyme disease patients in his Seattle practice. 

Marty Ross, MD is a graduate of Indiana University School of Medicine and Georgetown University Family Medicine Residency. He is a member of the International Lyme and Associated Disease Society (ILADS) and The Institute for Functional Medicine.

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