Can Lyme disease be mistaken for herpes?

Photo of Lyme disease rash that appears to be herpes lesions.

Only 1 in 4 Lyme disease rashes present in a Bull’s-eye pattern. In fact, lesions can appear as a flat red rash, a blistering rash, and a rash that resembles cellulitis. Investigators describe a woman with Lyme disease who presented with a rare variant of an erythema migrans (EM) rash, which appeared with a herpetiform center.

In their article “Disseminated Lyme disease with a herpetiform center,” Zhang et al.¹ described a patient who presented with a Lyme disease rash that could have been mistaken for herpes. The woman in her 30’s developed a herpetiform rash, which resembles herpes lesions.

Initially, the patient developed a “small red bump and surrounding swelling on her back,” along with a rash in her left armpit and left ipsilateral swollen lymph node.

She was prescribed cephalexin for a presumed cellulitis. However, the bumps became larger, warm and more painful.

“Skin examination showed a large, circular, well-demarcated erythematous plaque on the back with a central cluster of herpetiform vesicles, bullae, and purple necrotic puncta,” wrote the authors.

“This case showcases early disseminated Lyme disease with a herpetiform center, a rare cutaneous presentation, as well as an example of Jarisch-Herxheimer reaction in response to initiating treatment of Lyme.”

There were two additional erythematous patches on the breast and chest consistent with disseminated Lyme disease.

“She ultimately completed the full course of doxycycline with complete resolution,” the authors wrote.

The woman was diagnosed with vesiculobullous EM in the setting of early disseminated Lyme disease, systemic symptoms and a Jarisch-Herxheimer reaction after start of treatment.

A Lyme antibody screen was positive 6 weeks after treatment and confirmed with a Western blot test.

READ: Single dose doxycycline for treatment of tick bite only prevents Lyme disease rash

Others have also described blistering rashes in Lyme disease patients. “Vesiculobullous Lyme may be more common than previously thought, representing 8% of Lyme cases in a study of one diagnostic center in New York,” wrote the authors.

Authors’ Conclusion

“While classic EM with central clearing is more recognizable, it is important to keep Lyme on the differential for atypical presentations of EM with central necrosis, hemorrhagic crusting, or vesiculobullous changes as observed in this case.”

  1. Zhang ZZ, Hashemi DA, Kroshinsky D. Disseminated Lyme disease with a herpetiform center. JAAD Case Rep. 2022 Mar 12;29:46-47. doi: 10.1016/j.jdcr.2022.02.034. PMID: 36193244; PMCID: PMC9525727.

8 Replies to "Can Lyme disease be mistaken for herpes?"

  • Eva S.
    11/28/2022 (11:34 am)

    Good morning, Thank you so much for helping people all over the world with Lyme.
    May you consider evaluating the sufferings of a teenager who is expected to undergo surgery soon to remove “under the arm skin complications”? She has suffered for years. She has been diagnosed with hidradenitis suppurativa which is a rare disease of which there is not a lot of information. She suffers pain, besides all the complications of numerous skin lesions, etc. physically, emotionally and mentally.
    Is it possible that Lyme disease could be the underlying issue?
    I know you cannot diagnose over the Internet, but any feedback will help.
    I appreciate your expertise and support to the population dealing with Lyme disease. I have been diagnosed with Lyme disease – June 2021.

    • Dr. Daniel Cameron
      11/30/2022 (7:22 am)

      I have not seen a case of Hidradenitis suppurativa in my Lyme disease patients. Their painful skin condition would typically be followed by a dermatologist. I have had patients with Lyme disease that has been overlooked while being treated for another condition.

  • Mary Beth Olah
    11/17/2022 (5:56 pm)

    Also looks like bacillary angiomatosis from bartonella spp

  • Phyllis Freeman
    11/13/2022 (1:16 pm)

    What an interesting case to highlight. Thank you.

  • Sydney Hampton
    11/08/2022 (12:58 am)

    bless you for continuing to look for the real cause.
    This disease is mind boggling when we put all of our symptoms out there. Some of which can be embarrassing when it comes to look like an std. who wants to go tell a doctor that we have issues in this area but we know we’ve never done anything to cause. Seems like an unending problem.
    I do wish for all who go through Lymes/coinfections to be healed in the Name of Jesus and lord please really soon😀

  • Diana Taylor
    11/07/2022 (10:39 am)

    My daughter went through this, but vaginal and buttocks. She was told it’s herpes and EBV . A couple of months later we finally found a specialist who diagnosed her with Lyme/Morgellons.

      11/14/2022 (4:44 am)

      Who was the specialist

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