Clinical update

Updated Lyme disease guidance: what nurses need to know

NICE guidelines say erythema migrans rash should prompt diagnosis without a blood test

NICE guidelines say those with erythema migrans skin rash should be diagnosed with Lyme disease without a blood test

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Essential info

Erythema migrans is a skin rash associated specifically with Lyme disease and is present in approximately two thirds of all cases. Often described as looking like a ‘bullseye’, it is a spreading red rash that usually appears one to four weeks following a bite by an infected tick. 

Those who spend a lot of time in grassy or wooded areas are at increased risk of exposure. Infection is more likely if the tick is attached for more than 24 hours. The south of England and Scotland have higher incidence rates. Worldwide, infected ticks are mainly found in the northern hemisphere.

It is a distinctive red rash that increases in size, is generally at the site of the bite and is not usually itchy, hot or painful. Other early symptoms of Lyme disease are non-specific and similar to the symptoms of flu. These include aching, fever, headache, fatigue, joint pain, abnormal skin conditions and a stiff neck.

Different manifestations of Lyme disease infection, which typically occur weeks or months after the bite, include joint problems, nerve and brain problems, inflammation of the heart and skin rashes.

It is estimated that there are around 2,000-3,000 new cases of Lyme disease a year in England and Wales. Persistent symptoms can affect a person’s ability to continue day-to-day life, and they may need time to gradually return to usual activities.

What’s new

People showing erythema migrans should be diagnosed with Lyme disease without the need for blood tests, according to National Institute for Health and Care Excellence (NICE) guidance. The updated quality standard document says prompt diagnosis and early treatment with antibiotics helps reduce the risk of further symptoms developing.

Campaigners say that sometimes doctors choose tests to diagnose the condition, even when the rash is present, but early laboratory tests may not detect the disease and could slow diagnosis. This is because Lyme disease antibodies may not first appear until six to eight weeks after a person has been bitten by a tick.

NICE has set out four standards to improve the care for those with the potentially serious condition, which can be difficult to diagnose.

How you can help your patient

  • Be able to recognise the distinctive erythema migrans rash.
  • If this rash is present, healthcare professionals should feel confident in diagnosing Lyme disease.
  • In the absence of erythema migrans and presentation of other symptoms, an initial enzyme-linked immunosorbent assay (ELISA) laboratory test can be used. If this test is carried out too early for antibodies to have developed, people may have a negative result and the test may need to be repeated.
  • If the ELISA is positive or symptoms continue for 12 weeks or more, a more specific test called an immunoblot test should be used to confirm Lyme disease. People who do not have the rash and had a negative result from an early ELISA should have an ELISA repeated at the four to six week mark if Lyme disease is still suspected.

Expert comment

Saul Faust, professor of paediatric immunology and infectious diseases at the University of Southampton and chair of the guideline committee, says: ‘Prompt diagnosis of Lyme disease is essential for effective management and helps reduce the risk of further symptoms developing.

'Lab tests are necessary when a person’s symptoms are unclear, but they are not needed if a person presents with erythema migrans.

‘Nurses may encounter Lyme disease in primary care and public health settings, and can improve care by recognising typical erythema migrans and referring people for appropriate diagnosis and management. It is important to explain that Lyme disease is a bacterial infection treated with antibiotics. It may take time to get better, but symptoms should continue to improve in the months after antibiotic treatment. 

'A patient may need additional treatment to ease their symptoms and can speak to a doctor with any concerns. Nurses can also help by pointing people to the NHS, Public Health England and NICE resources for people with confirmed or suspected Lyme disease.’


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