Crawling Skin Sensation: A Hidden Symptom of Lyme Disease

Crawling skin sensation is among the most distressing—and most dismissed—symptoms patients report. The feeling of insects moving beneath the skin can be constant, unpredictable, and impossible to ignore. Yet when patients describe these symptoms, they are often met with skepticism or immediate psychiatric referral.

Crawling skin sensation is a recognized neurologic symptom with multiple medical causes, including Lyme disease. Before concluding that symptoms are psychiatric, comprehensive medical evaluation should occur.

When Crawling Sensations Led to Psychiatric Referral—Then Lyme Diagnosis

A 52-year-old woman described constant crawling sensations beneath her skin. She had begun scratching repeatedly and was convinced something was emerging from her body. She collected fibers she found on her skin and brought them to appointments.

Dermatology found excoriation but no infestation. She was referred to psychiatry for delusional parasitosis.

The psychiatrist, however, took a detailed history. Symptoms had started six months earlier alongside severe fatigue, joint pain, and numbness in her hands. She recalled a tick bite the previous summer.

Neurologic evaluation revealed small fiber neuropathy. Lyme testing was positive. Treatment led to gradual improvement in both the sensory symptoms and her concerns about their cause.

What changed was not convincing her the sensations were imagined. What changed was identifying and treating the underlying neurologic condition.

What Crawling Skin Sensation Feels Like

Patients describe crawling skin sensation in many ways:

1. Insects crawling on or beneath the skin
2. Stinging, biting, or prickling feelings
3. Movement under the skin surface
4. Electric or vibrating sensations
5. Itching with no visible cause

The sensations may migrate, intensify at night, or worsen with stress or fatigue. These features often lead clinicians to suspect a psychiatric cause—but they are also characteristic of small fiber and autonomic nerve involvement.

Why Crawling Skin Sensation Occurs in Lyme Disease

In Lyme disease, crawling skin sensation often arises from small sensory nerve dysfunction rather than structural nerve damage detectable on standard testing.

Small sensory fibers regulate pain perception, temperature sensation, and aspects of autonomic function. When these fibers become irritated or hypersensitive—whether from infection, inflammation, or immune activation—they can produce intense sensory symptoms without any visible skin findings.

This pattern has been described in Lyme disease and other post-infectious conditions.. The nervous system is processing sensation incorrectly, not because the patient is imagining symptoms, but because neurologic changes have lowered the threshold for sensory signaling.

Standard nerve conduction studies and EMG do not reliably assess small fibers. A normal result does not rule out the symptom—it reflects the limits of the test.

For related neurologic context, see: Autonomic dysfunction, small fiber neuropathy and Lyme disease

The Problem: Psychiatric Labeling Before Medical Workup

When patients describe crawling skin sensation—especially if they bring collected samples or express concern about infestation—the clinical response is often immediate psychiatric referral.

This approach can delay diagnosis of treatable conditions:

1. Small fiber neuropathy may not be considered
2. Lyme disease may be overlooked, particularly when patients don’t recall tick exposure
3. Standard nerve testing may be treated as definitive even though it doesn’t assess the relevant fibers
4. Psychiatric diagnosis should follow exclusion of medical causes, not precede it.This pattern of premature dismissal reflects broader misconceptions about Lyme disease that delay appropriate care.

Some patients may encounter the term “Morgellons” when searching for answers. Regardless of terminology, the underlying question remains the same: what is causing these sensations, and has that question been fully evaluated?

Medical Conditions That Cause Crawling Skin Sensation

Crawling skin sensation—medically termed formication—is a documented neurologic symptom with multiple causes:

Small fiber neuropathy Damage or dysfunction of small sensory fibers produces crawling, burning, or prickling sensations. Standard nerve tests do not detect it.

Lyme disease Lyme disease affects peripheral nerves and can produce crawling skin sensation and other dysesthesias. These may occur without classic Lyme manifestations.

Tick-borne coinfections Bartonella, Babesia, and other coinfections produce neurologic symptoms that overlap with crawling sensation complaints.

Vitamin B12 deficiency Causes peripheral neuropathy with sensory disturbances. Easily tested and treatable.

Other causes Medications, hormonal changes, autoimmune conditions, and post-infectious neuropathy can all produce similar symptoms.

When Further Evaluation Is Appropriate

In patients with persistent crawling skin sensation, further assessment may focus on:

Small fiber involvement

1. Autonomic symptoms
2. Tick-borne infection history
3. Inflammatory or immune triggers
4. Post-infectious neurologic patterns

The goal is not to chase abnormal tests, but to match symptoms with the correct biologic framework.

For many patients, naming the mechanism provides relief. It replaces uncertainty with understanding and opens the door to appropriate management.

Clinical Takeaway

Crawling skin sensation is a hidden symptom of Lyme disease and other neurologic conditions that deserves thorough medical evaluation before psychiatric conclusions are reached.

Recognizing this pattern prevents dismissal, restores clinical clarity, and supports more individualized care.

Frequently Asked Questions

What causes crawling skin sensation? Medical evaluation can identify neurologic, metabolic, or infectious causes including Lyme disease, small fiber neuropathy, and B12 deficiency.

Can Lyme disease cause crawling skin sensation? Yes. Lyme disease can affect small sensory and autonomic nerve fibers, producing crawling, stinging, or movement sensations beneath the skin.

Should medical workup happen before psychiatric referral? Yes. Comprehensive medical and neurologic evaluation should occur before assuming symptoms are psychiatric in origin.

Why do doctors sometimes dismiss crawling skin sensation? These symptoms can seem implausible, and standard nerve tests may be normal. This leads some clinicians to conclude symptoms are not neurologic—when in fact the relevant fibers were never tested.

What is formication? Formication is the medical term for crawling skin sensation. It is a recognized neurologic symptom with many documented causes, including Lyme disease.

Resources

1. Can J Infect Dis Med Microbiol. Laupland, Louis Valiquette. Delusional Infestation  2016
2. Psychopathology. Trabert W.  Epidemiology of delusional parasitosis. 1995;28(4):238–246.
3. Clinical, Cosmetic and Investigational Dermatology Middelveen MJ, et al. History of Morgellons disease: from delusion to definition. . 2013;6:1–21.
4. Halperin JJ. Nervous system Lyme disease. Infect Dis Clin North Am. 2015;29(2):241–253.

5. Autonomic Dysfunction, Small Fiber Neuropathy and Lyme Disease

6. Neurologic Manifestations of Lyme Disease

7. When Normal Sensations Start to Hurt: Allodynia in Lyme Disease