Lyme Disease Rash: Red Circles, Bullseyes, and Unusual Patterns
Lyme disease rashes do not always look typical
Red circles and circular rashes may signal Lyme disease
Unusual rashes can delay diagnosis and treatment
Lyme disease rash presentations vary widely. Many patients expect a classic bullseye pattern, but erythema migrans (EM) can appear circular, uniformly red, itchy, scaly, or atypical.
Some patients describe a Lyme disease rash as a red circle on skin, a ring-shaped rash, or a circular patch rather than the classic bullseye appearance.
Many Lyme disease rashes are mistaken for cellulitis, insect bites, allergic reactions, or skin infections because erythema migrans can appear in many forms.
In the case report, “A Non-Classical Presentation of Erythema Migrans in a 51-Year-Old Woman With Early Manifestation of Lyme Neuroborreliosis (Bannwarth Syndrome),” Lorquet et al. describe a 51-year-old female who presented with general malaise, headache, neck stiffness, and an expanding rash consistent with Lyme neuroborreliosis.2
The woman reported worsening symptoms over four days and an expanding rash on her upper back but did not recall a tick bite.
“She stated that [the rash] started as a small area of redness, spreading rapidly,” the authors wrote.
What do unusual Lyme disease rashes look like?
The patient initially presented with an atypical rash pattern rather than the classic bullseye rash many associate with Lyme disease.
Clinicians suspected cellulitis and prescribed cephalexin and valacyclovir. However, symptoms did not improve.
“The bull’s-eye appearance of erythema migrans is not the only cutaneous manifestation of acute Lyme disease. There can be multiple variations of the rash.”
Her rash continued expanding while headache severity worsened and pain radiated into her neck.
The erythema migrans rash eventually covered two-thirds of her back and included a 5 cm crusted plaque centrally. A second circular rash later appeared behind her right ear.
READ: The many presentations of the Lyme disease rash
Can erythema migrans mimic other skin conditions?
Yes. Lyme disease rash presentations are frequently confused with:
- Cellulitis
- Spider bites
- Allergic reactions
- Fungal infections
- Viral rashes
- Other skin infections
Learn more about Lyme disease mimicking cellulitis.
What happened after treatment?
Clinicians treated symptoms with intravenous ondansetron, ketorolac, pantoprazole, and saline while empirically treating Lyme disease with doxycycline.
After testing returned positive, clinicians diagnosed Lyme neuroborreliosis, also known as Bannwarth syndrome in Europe.
Bannwarth syndrome is a manifestation of early Lyme neuroborreliosis characterized by painful radiculopathy, neuropathy, weakness, facial nerve palsy, and cerebrospinal fluid lymphocytic pleocytosis.3
Several weeks later, the patient returned to baseline functioning.
Why unusual Lyme disease rash presentations matter
Missing an atypical erythema migrans rash may delay diagnosis and treatment.
Patients who do not recall tick bites or who lack classic bullseye rashes may still have Lyme disease.
Frequently Asked Questions
Does a Lyme disease rash always look like a bullseye?
No. Many erythema migrans rashes are uniformly red, oval, circular, scaly, or atypical rather than classic bullseye patterns.
Can Lyme disease cause a red circle on skin?
Yes. Some erythema migrans rashes appear as red circles, rings, or expanding circular patches rather than classic bullseye patterns.
Can a Lyme disease rash itch?
Some patients describe itching, burning, tenderness, or discomfort, although presentations vary.
Can Lyme disease rash be mistaken for cellulitis?
Yes. Lyme disease rash is commonly confused with cellulitis and other skin conditions.
Can you have Lyme disease without recalling a tick bite?
Yes. Many patients diagnosed with Lyme disease do not remember a tick bite.
What is erythema migrans?
Erythema migrans is the characteristic rash associated with early Lyme disease, although it has many appearances.
Clinical Perspective
Many clinicians and patients still expect a classic bullseye rash. However, Lyme disease rash presentations vary significantly, increasing the risk of delayed diagnosis when rashes appear atypical.
Clinical Takeaway
A Lyme disease rash does not need to look like a bullseye to warrant consideration of Lyme disease.
Recognizing unusual erythema migrans patterns may reduce missed diagnoses and delayed treatment.
Related Articles
The many presentations of the Lyme disease rash
Erythema migrans rash doesn’t always have a bull’s-eye appearance
Lyme disease mimics cellulitis skin infection
Neurologic Lyme disease symptoms
References
- Schotthoefer AM, Green CB, Dempsey G, et al. The Spectrum of Erythema Migrans in Early Lyme Disease: Can We Improve Its Recognition? Cureus. 2022;14(10):e30673.
- Lorquet JR, Pell R, Adams J, Tak M, Ganti L. A Non-Classical Presentation of Erythema Migrans in a 51-Year-Old Woman With Early Manifestation of Lyme Neuroborreliosis (Bannwarth Syndrome). Cureus. 2023;15(6):e39931.
- Shah A, O’Horo JC, Wilson JW, Granger D, Theel ES. An Unusual Cluster of Neuroinvasive Lyme Disease Cases Presenting With Bannwarth Syndrome in the Midwest United States. Open Forum Infect Dis. 2017;5(1):ofx276.
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
