Atypical Lyme Rash in Children: When the Rash Changes Over Time
Lyme rashes do not always look typical
Rashes in children may evolve over days
Early symptoms are often missed
An atypical Lyme rash in children can make early diagnosis challenging—especially when the rash does not resemble the classic bull’s-eye pattern.
Case reports highlight how Lyme disease may present in unexpected ways. In a report by Banadyha and colleagues, an 11-year-old girl developed multiple evolving rashes before a classic erythema migrans lesion appeared.
Early Symptoms Did Not Suggest Lyme Disease
The child was admitted with fever, headaches, abdominal pain, and a progressing rash.
Her illness began with a small rash on her left foot that resolved with topical treatment.
Shortly after, a second rash appeared on her right foot and also disappeared after antihistamine therapy.
These early rashes were transient and initially did not raise suspicion for Lyme disease.
Studies suggest atypical erythema migrans lesions may be more common than many clinicians expect, contributing to delayed recognition and missed opportunities for early treatment. Researchers studying PCR-confirmed Lyme disease found that many patients with proven infection had nonclassic rashes, highlighting how reliance on textbook images may delay diagnosis.
Rash Progression Over Several Days
By the fourth day of illness, a maculopapular rash appeared on the trunk and limbs.
Over the following days:
- The rashes enlarged
- Fever and lethargy developed
- Headaches and abdominal pain worsened
Initial diagnoses included other conditions such as toxic erythema.
Evolving and migratory rashes may complicate recognition of Lyme disease, particularly when the appearance changes over time.
Research has shown that atypical erythema migrans may appear uniformly red, red-blue, or resemble insect bites, cellulitis, or other dermatologic conditions rather than classic target lesions. In one PCR-confirmed cohort, most patients had nonclassic rather than classic erythema migrans lesions.
Diagnosis Delayed by Atypical Features
The child’s parents did not recall a tick bite.
Lyme disease was not initially suspected because symptoms began during a colder season.
Absence of a known tick bite, atypical rashes, and seasonality can lower clinical suspicion and contribute to delayed Lyme disease diagnosis.
Studies of PCR-confirmed Lyme disease have emphasized that clinicians should focus on whether a rash is enlarging, evolving, or spreading rather than relying solely on classic appearance. Observation of symptom progression may be more informative than appearance at a single point in time.
When the Classic Rash Appears Late
Only on the seventh day of illness did a typical erythema migrans lesion appear on the chest.
At that point, Lyme disease became more apparent.
Serologic testing confirmed early disseminated Lyme disease.
The child was treated with doxycycline and recovered.
Why This Case Matters
The authors noted that the rash was extensive, multiple, and migratory—features that differ from classic teaching.
Recognition may depend on following symptom progression rather than relying on a single early finding.
Learn more about how erythema migrans may not have a bull’s-eye appearance.
Additional pediatric presentations are discussed in early signs of Lyme disease in children.
Frequently Asked Questions
Can Lyme rash in children look different from a bull’s-eye rash?
Yes. Some children develop atypical, evolving, or multiple rashes that do not initially resemble classic erythema migrans.
Can Lyme disease rash change over time?
Yes. Rashes may enlarge, migrate, or evolve over several days before becoming more recognizable.
Do children always remember a tick bite?
No. Many children and parents do not recall a tick bite before symptoms develop.
Can Lyme disease occur outside peak tick season?
Yes. Seasonal expectations may lower suspicion, but Lyme disease can still be diagnosed outside typical periods of concern.
Are multiple rashes a sign of disseminated Lyme disease?
Multiple lesions may raise concern for disseminated infection, although clinical context remains important.
Clinical Takeaway
Atypical Lyme rash in children may delay diagnosis because early symptoms often do not match the expected pattern.
Children with evolving, migratory, or multiple rashes plus systemic symptoms may warrant consideration of Lyme disease even without a known tick bite.
Related Articles
These related articles explore pediatric presentations, diagnostic challenges, and rash variability in Lyme disease.
Delayed Lyme disease diagnosis
Lyme disease symptoms guide
Giant erythema in a child with Lyme disease
Pediatric Lyme disease
Lyme disease misdiagnosis
References
- Banadyha K, et al. Giant erythema in a child with Lyme disease.
- Schutzer SE, Berger BW, Krueger JG, et al. Atypical erythema migrans in patients with PCR-positive Lyme disease. Emerg Infect Dis. 2013;19(5):815-817.
- Franco-Avecilla D, Yeung C, Baranchuk A. Lyme carditis presenting with an atypical rash. CMAJ. 2020;192(21):E584.
- Review discussing variability in erythema migrans presentation and diagnostic challenges.
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
