Ask a Doc: A Disease with a Bull’s-Eye Rash

July 17, 2016

Submitted by Michael R. Jordan, MD, MS-HQSM, FAAP, Chief of Pediatrics Newark-Wayne Community Hospital

“I'd like to kiss you way back in the sticks. I'd like to walk you through a field of wildflowers and I'd like to check you for ticks.” Lyrics to the Song “Ticks” by Brad Paisley - 2007.

A big black bear may not be the most dangerous creature in the northern woodlands. That distinction could go to a tiny “vampire” of an arachnid known as the tick. This being a hot summer, we are reminded that this danger is lurking in our lawns, in our woods and on our pets. Ticks have adapted and flourished in the warmer temperatures and on the backs of our local deer herd.

We think the mosquito is dangerous because of its ability to transmit Malaria, Zinka virus, and some forms of Encephalitis, but it is remarkable how many different types of infectious disease this tiny tick can transmit. Consider Black-legged Deer Tick (Ixodes scapularis), a smaller tick as ticks go (about the size of a poppy seed), silent and with a painless bite it is the vector that can introduce Lyme disease. Other common ticks cause a variety of serious diseases; Rocky Mounted Spotted Fever (more common in New York than any Rocky Mountain state), Babesiosis, Powassan Fever, Borrelia, Tularemia and Tick Borne Relapsing Fever (TBRF).

How a minuscule eight-legged tick can transmit such a plethora of infectious illness is interesting. Perhaps it is because the tick is a stealthy hunter, perched on a blade of grass, “questing” motionless with outstretched pincers waiting for a bird or a mammal to pass. Perhaps it is because it enters the skin with a painless bite and can remain attached with its head buried for days. It even secretes an anticoagulant to keep the trickle of blood flowing. This prolonged attachment is needed for the tick to multiply but also allows for an exchange of bacterial pathogens.

Ticks prefer the soft skin of the scalp, around the ears and the inner thighs and often go unnoticed until gorged and swollen. It’s that new mole in the scalp but with eight tiny moving legs! The most well-known tick-borne disease of course, is Lyme's disease, but in the 1980s it was not even on our local public health radar. I recall it was the veterinarians who first reported its arrival. I was skeptical when our vet told me of his many canine cases in Eastern Monroe and Western Wayne counties. Today I’m a believer and our office has treated at least 20 cases of early disease in the past two summers.

The first cases were described near the town of Lyme, in Connecticut. There was an unusually high number of children developed juvenile arthritis with swollen joints. Some of these early cases had a rash and most were children who had played in woodland areas. The number of new cases far exceeded the number of Juvenile Arthritis cases expected. Eventually, it was linked to a bacteria found in the Deer Tick by a young researcher named Dr. Burgdorfer. A passionate researcher, he continued his work while on vacation in Switzerland and noted that the Deer Ticks carried a corkscrew shaped bug that other ticks did not. He then came back to the states and furthered this study supported by the New York State Department of Health with hundreds of live Deer Ticks gathered from downstate deer. This pathogen is now known as Borrelia Burgdorferi in “honor” of this scientist.

Often, but not always, the first sign of Lyme Disease is a rash near the site of the tick bite. The sign of early Lyme is very distinct; a red painless slowly spreading target shaped rash. The arthritis and other complications of Lyme Disease occur weeks after the initial rash and include severe headaches, arthritis, heart disease and a variety of neurologic signs including sudden facial paralysis. Physicians don't hesitate to begin treatment for Lyme Disease in a patient with this type of rash, especially when seen in the summer months. Testing for Lyme disease is tricky and made difficult because it takes two to three weeks for the development of antibodies which is what we measure in the blood to detect the disease. The antibody tests do have very high amount of sensitivity, meaning they are intended to pick up all cases of antibody-positive Lyme Disease but unfortunately not very specific and can have false positive or equivocal results. Treatment of early Lyme Disease is much more successful than treatment of later stages of the arthritis.

Lyme Disease is not the only disease we see in children from ticks. Rocky Mountain Spotted Fever (RMSF) is been a known disease of children for over 100 years. Perhaps it should be called Tennessee Carolina fever since 60 percent of all RMSF cases occur in the southern Mid-Atlantic Region. Like many other tick related diseases, RMSF starts with headache, nausea, fever, photophobia (eye pain from light) and even sudden deafness. A rash then appears about three to five days into the illness with pink spots on the wrists and ankles which then turn dark and spread inward. Most tick-borne diseases can be successfully treated with antibiotics, but require a closed followed treatment plan.

This time of year, it is most important to prevent tick disease:

  1. Avoiding ticks; the best prevention is to wear long pants when hiking in the woods to use a DEET insecticide, especially on your lower extremities. It helps to pretreat woodland clothing with a spray Permethrin when planning a camping trip.
  2. Early removal; which decreases the likelihood of any tick-borne disease. Shower and inspect children and pets with a total body check, especially in the hair and behind the ears.
  3. Remove the tick correctly since the tick will have its head embedded. The CDC advice is to use a fine-toothed tweezers, grasp the tick as close to the skin as possible, use a steady pull upward and don’t twist. Pick out any remaining mouth parts, clean the bite area well and dispose of the tick down the toilet or wrapped in tape. Don’t squeeze the tick body or resort to a hot flame or nail polish to get the tick. Those methods only increase the risk of disease. After removing the tick, thoroughly clean the bite area and your hands with rubbing alcohol, iodine scrub or soap and water.

Ticks are hardy, adaptable and have been around for thousands of years. Their range is increasing as are the number of diseases they carry. A controlled deer herd has been shown to reduce the incidence of Lyme Disease but prevention before and inspection after being outside are the best defense against this woodland danger.

JordanMichaelMichael Jordan, MD, MS-HQSM, CPE, FAAP, Chief of Pediatrics at Newark-Wayne Community Hospital is board-certified in Pediatric Medicine. He attended the College of Human Medicine at Michigan State University and completed his residency training at the University of Rochester. In addition to his leadership role as chief of Pediatrics at Newark-Wayne, he is the medical director of Rochester Regional Medical Group and is also chair of Rochester General Medical Group’s Quality Committee. He works in the Sodus Rochester General Medical Group Pediatric office. To send questions on children’s health, please email Wendy Fisher, Pediatric Practice Manager at and write “Ask a Doc” in the subject line. To schedule an appointment, call 315-483-3214.

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Rochester Regional Health is an integrated health services organization serving the people of Western New York, the Finger Lakes and beyond. The system includes 150 locations: five hospitals; more than 100 primary and specialty practices, rehabilitation centers and ambulatory campuses; innovative senior services, facilities and independent housing; a wide range of behavioral health services; and ACM Medical Laboratory, a global leader in patient and clinical trials. Rochester Regional Health, the region’s second-largest employer, was named one of “America’s Best Employers” by Forbes in 2015. Learn more at