Can Lyme Disease Be Mistaken for Herpes or Shingles?
Rare Lyme rashes can resemble herpes or shingles
Blistering erythema migrans may delay diagnosis
Early recognition and treatment can lead to complete recovery
Can Lyme disease be mistaken for herpes or shingles? Yes. Although uncommon, Lyme disease can occasionally cause a blistering form of erythema migrans (EM) that resembles herpes simplex or herpes zoster (shingles). Recognizing these atypical rashes is important because delayed diagnosis can postpone appropriate antibiotic treatment.
In their article “Disseminated Lyme disease with a herpetiform center“, Zhang et al.1 described a woman whose Lyme disease rash closely resembled herpes lesions, highlighting one of the less common skin manifestations of early disseminated Lyme disease.
A Lyme disease rash that mimicked herpes
The patient, a woman in her 30s, initially developed a small red bump with surrounding swelling on her back. She also had a rash in her left armpit and swelling of a nearby lymph node.
She was initially treated with cephalexin for presumed cellulitis. Instead of improving, the skin lesions became larger, warmer, and increasingly 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,” the authors wrote.
This case highlights early disseminated Lyme disease with a rare herpetiform rash and a Jarisch-Herxheimer reaction after antibiotic treatment was started.
Two additional erythematous patches on the breast and chest were consistent with early disseminated Lyme disease rather than a localized infection.
The patient completed a full course of doxycycline, and her skin lesions resolved completely. The patient’s improvement with doxycycline further supported the diagnosis of Lyme disease.
Can Lyme disease be mistaken for shingles?
Yes. Although shingles is far more common than blistering Lyme disease, rare cases of vesiculobullous erythema migrans may resemble herpes simplex or herpes zoster (shingles). Both conditions can present with painful skin lesions, making the diagnosis challenging early in the illness.
Several clinical features may help distinguish them. Shingles typically follows a single dermatome, while erythema migrans often expands over time and may be accompanied by additional skin lesions in patients with early disseminated Lyme disease. Lyme disease often follows a tick bite and may be accompanied by fever, fatigue, or multiple erythema migrans lesions, whereas shingles results from reactivation of the varicella-zoster virus and usually affects a single dermatome. A history of tick exposure or travel to an endemic area can also provide important diagnostic clues.
Can Lyme disease cause blisters?
Although most erythema migrans rashes are flat and non-blistering, uncommon vesiculobullous erythema migrans has been described. These blistering lesions may resemble herpes, shingles, cellulitis, or other skin disorders and can lead to an initial misdiagnosis.
In this case, the patient was ultimately diagnosed with vesiculobullous erythema migrans associated with early disseminated Lyme disease, systemic symptoms, and a Jarisch-Herxheimer reaction shortly after beginning treatment.
A Lyme antibody screen became positive six weeks after treatment and was confirmed with Western blot testing.
Related: Single-dose doxycycline after a tick bite only prevents some Lyme disease rashes
Other investigators have also reported blistering Lyme rashes. Zhang and colleagues noted that “vesiculobullous Lyme may be more common than previously thought,” representing approximately 8% of Lyme disease cases evaluated at one diagnostic center in New York.
What is a Jarisch-Herxheimer reaction?
A Jarisch-Herxheimer reaction is a temporary inflammatory response that may occur shortly after antibiotic treatment is started for certain bacterial infections, including Lyme disease. Symptoms may include fever, chills, muscle aches, headache, and temporary worsening of existing symptoms. Although uncomfortable, the reaction generally resolves within 24 to 48 hours with supportive care.
In this case, the patient’s clinical course was consistent with a Jarisch-Herxheimer reaction after doxycycline was initiated, supporting the diagnosis of early disseminated Lyme disease.
Authors’ conclusion
Zhang and colleagues emphasized the importance of recognizing these uncommon Lyme disease rashes.
“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.”
Frequently Asked Questions
Can Lyme disease be mistaken for herpes?
Yes. Rare blistering forms of erythema migrans can resemble herpes lesions. In patients with possible tick exposure or travel to an endemic area, Lyme disease should be considered among the possible causes of an atypical blistering rash.
Can Lyme disease be mistaken for shingles?
Yes. Vesiculobullous erythema migrans may resemble shingles because both conditions can produce painful skin lesions. However, shingles typically follows a single dermatome, while Lyme disease may produce an expanding rash or multiple skin lesions in early disseminated infection.
Does Lyme disease cause blisters?
Most Lyme disease rashes do not blister. However, uncommon vesiculobullous erythema migrans has been reported and may resemble herpes, shingles, or cellulitis.
Can Lyme disease cause cold sores?
No. Lyme disease does not cause cold sores, which are caused by the herpes simplex virus. However, rare blistering Lyme disease rashes can resemble cold sores or other herpes infections, making diagnosis more challenging.
Can a tick bite trigger shingles?
There is no evidence that a tick bite directly causes shingles. However, Lyme disease following a tick bite may produce an atypical rash that can initially be mistaken for shingles.
What other conditions can be mistaken for Lyme disease?
Lyme disease can resemble cellulitis, insect bites, contact dermatitis, fungal infections, shingles, herpes, and other skin disorders. Because treatment differs, persistent or expanding rashes should be evaluated by a healthcare professional familiar with Lyme disease.
Clinical Takeaway
Classic erythema migrans with central clearing is the best-known Lyme disease rash, but it is not the only presentation. Rare vesiculobullous forms can resemble herpes, herpes zoster (shingles), cellulitis, or other blistering skin disorders, increasing the risk of delayed diagnosis.
In patients with possible tick exposure, expanding skin lesions, systemic symptoms, or multiple rashes, clinicians should include Lyme disease in the differential diagnosis—even when the rash is atypical.
Recognizing atypical Lyme disease rashes can help avoid misdiagnosis, allowing earlier antibiotic treatment and improving the likelihood of complete recovery.
Related Articles
What Does a Lyme Disease Rash Look Like?
Erythema Migrans Rash Doesn’t Always Have a Bull’s-eye Appearance
Lyme Disease Skin Rash Puzzles Doctors, Leads to Misdiagnoses
Jarisch-Herxheimer Reaction in Lyme Disease
References:
- Zhang ZZ, Hashemi DA, Kroshinsky D. Disseminated Lyme disease with a herpetiform center. JAAD Case Rep. 2022;29:46-47. doi:10.1016/j.jdcr.2022.02.034. PMID:36193244; PMCID:PMC9525727.
Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.
Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention
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.
Diane,
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
What an interesting case to highlight. Thank you.
Thanks. And thanks for your work.
Who was the specialist
Also looks like bacillary angiomatosis from bartonella spp
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.
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.
I was treated for Lyme for 10 days with Doxycycline Hyclate 100 MG CAP, two days after taking the last cap I got a tiny tick behind my knee. I developed a rash over practically my entire leg with little swelling, redness and itching worst than I can describe. Called my doctor and he said I was probably still protected from taking the meds ending two days ago, and did not need to see me. I called my GP again and they told me to go to Urgent Care if I was conserned and gave me an appointment for Tuesday, a week after calling them. I did go to UC because it was not getting better, it was red, swollen some and a rash that wouldn’t stop. At the UC I was prescribed Triamicinolone Acetinide Ointmrnt USO and 14 days Doxycycline Mono 100MC CAP. I was told to use the ointment and take the meds in 2 days if it doesn’t improve.The rash is not quite as bad after 1 day but the red around the bite still there, swelling gone down. I don’t know whether I should take the meds or not, as too much taking antibiotics can also cause problems. I still have an appointment with my GP in 3 days. This is rediculouse…..I know Lyme is in my system, will I ever get rid of it?
I am sorry to hear how complicated things have become. It typically use an individualized plan. I also consider Babesia, a coinfection