Lyme Disease on Black Skin: Why Diagnosis May Be Missed
Lyme disease rashes may appear differently on darker skin tones
Delayed recognition may increase the risk of advanced Lyme disease
Improved awareness may help reduce missed diagnoses and complications
A major study analyzing more than 168,000 Lyme disease cases identified significant racial disparities in diagnosis and outcomes across the United States.
The findings, published in Emerging Infectious Diseases, showed that non-White patients were more likely to experience delayed diagnosis, disseminated infection, hospitalization, and advanced disease at presentation.
One important contributor may involve the difficulty recognizing Lyme disease rashes on darker skin tones.
Lyme Disease on Black Skin May Look Different
The erythema migrans rash associated with Lyme disease does not always appear as a classic bright red “bull’s-eye” lesion.
On darker skin tones, Lyme disease rashes may appear:
- Darker brown or violaceous
- Less visibly red
- Faint or poorly demarcated
- Bruise-like or hyperpigmented
These differences may contribute to delayed recognition in both patients and clinicians.
Patients with Lyme disease symptoms may still develop fatigue, headaches, fever, muscle pain, neurologic symptoms, or joint pain even when the rash is subtle or missed entirely.
Racial Disparities in Lyme Disease Diagnosis
Researchers examining Medicare and Medicaid data from 16 high-incidence states identified several concerning disparities.
The study found:
- Non-White children were 77% more likely to develop disseminated Lyme disease
- Black children experienced significantly higher hospitalization rates
- Black Medicare patients under age 65 more often presented with advanced disease
- Non-White patients were more frequently diagnosed outside peak tick season
These findings suggest delayed recognition may contribute to more severe disease at diagnosis.
These findings
These findings suggest delayed recognition may contribute to more severe disease at diagnosis.
These findings highlight important healthcare inequities that may contribute to delayed Lyme disease diagnosis in patients with darker skin tones.
Why Lyme Disease May Be Missed on Darker Skin
Several overlapping factors may contribute to delayed diagnosis in patients with darker skin tones.
Potential contributors include:
- Difficulty identifying erythema migrans on darker skin
- Limited clinician training using diverse skin images
- Diagnostic bias during non-peak tick season
- Greater reliance on emergency departments rather than early outpatient evaluation
- Multiple healthcare visits before diagnosis
These diagnostic delays may increase the likelihood of neurologic Lyme disease, Lyme carditis, arthritis, or persistent post-treatment symptoms.
Delayed Diagnosis May Increase Complications
When Lyme disease is not recognized early, patients may present later with more advanced manifestations involving the joints, nervous system, or heart.
Delayed Lyme disease diagnosis may increase the risk of:
- Lyme arthritis
- Neurologic Lyme disease
- Lyme carditis
- Persistent fatigue and cognitive symptoms
These cases overlap with broader concerns regarding delayed Lyme disease diagnosis when early signs are missed or attributed to other conditions.
Can Black People Get Lyme Disease?
Yes. Black patients, Hispanic patients, Asian patients, and individuals of all skin tones can develop Lyme disease.
Ticks do not selectively target one racial or ethnic group.
However, differences in rash visibility, clinician recognition, access to care, and diagnostic pathways may influence how quickly Lyme disease is identified and treated.
Improving Recognition Across All Skin Tones
The study authors emphasized the importance of improving clinician education and diagnostic awareness across diverse patient populations.
Potential improvements include:
- Training clinicians using images of Lyme disease on darker skin tones
- Improving awareness of non-rash Lyme presentations
- Encouraging early evaluation of suspicious symptoms
- Reducing diagnostic delays in endemic regions
Early treatment remains important because Lyme disease is often most responsive during the initial stages of infection.
Frequently Asked Questions
Can Lyme disease appear differently on Black skin?
Yes. Lyme disease rashes on darker skin tones may appear less visibly red, bruise-like, violaceous, or more difficult to recognize.
Can Black people get Lyme disease?
Yes. Lyme disease can affect people of all racial and ethnic backgrounds.
Why is Lyme disease sometimes diagnosed later in Black patients?
Delayed diagnosis may result from differences in rash visibility, limited clinician training with darker skin tones, healthcare access barriers, and diagnostic bias.
Can Lyme disease occur without a visible rash?
Yes. Some patients never develop a recognized erythema migrans rash or may have rashes that are difficult to detect.
What complications can occur with delayed Lyme diagnosis?
Delayed diagnosis may increase the risk of Lyme arthritis, neurologic Lyme disease, Lyme carditis, and persistent post-treatment symptoms.
Clinical Takeaway
Lyme disease may be more difficult to recognize on darker skin tones, particularly when erythema migrans rashes appear faint, hyperpigmented, or atypical.
Delayed recognition may contribute to higher rates of disseminated disease, hospitalization, and advanced complications in non-White patients.
Improving clinician awareness of Lyme disease across all skin tones may help reduce diagnostic delays and improve outcomes for diverse patient populations.
Related Articles
These related articles explore delayed Lyme diagnosis, neurologic complications, persistent symptoms, and diagnostic challenges in Lyme disease.
Black Children More Likely to Be Diagnosed Later With Lyme Disease
Could Race Affect the Diagnosis and Treatment of Lyme Disease?
Lyme Disease Misdiagnosis
Neurologic Lyme Disease
Lyme Carditis
References
- Gould LH, Willis SJ, Prener CG, et al. Differences in Lyme disease diagnosis among Medicaid and Medicare beneficiaries, United States, 2016–2021. Emerg Infect Dis. 2025;31(9).
- Centers for Disease Control and Prevention. Lyme Disease.
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
This is so important! I have thought about this for years, as an engorged tick can look like a benign skin tag on darker skin.
Knowing from experience how poor diagnosis is for white people makes this all the more horrific! 🙁