Skin Challenge: Lyme Disease


Cutaneous manifestations are collectively called as “dermatoborreliosis.”

  • Stage 1: Localized (1–3 weeks)—primary erythema migrans
  • Stage 2: Disseminated (weeks to months)—secondary erythema migrans
  • Stage 3: Chronic (months to years)—acrodermatitis chronic atrophicans


Erythema migrans is the most common cutaneous manifestation of Lyme disease, which occurs at the site of a tick bite. It develops on lower extremities or the upper trunk in about 80% of people infected. When looking for this lesion, you will find various hues of erythema (redness) that can spread outward from the center which is a “bull’s eye,” in which the tick bite mark is at the exact center. The appearance is that of a target lesion and diameter must be at least 5cm (average size is 15cm) to qualify as erythema migrans.

The elongation of these lesions may relate to the direction of collagen fibers along which the organisms move in the ground substance of the skin. The surface is usually smooth; however, scaling or crusting may be present. Burning, itching, or pain can occasionally occur.

The characteristic rash is usually associated with viral infection-like symptoms, including malaise, fever, headache, and muscle pain, all of which may occur prior to the onset of the rash by a few days. Lesions typically resolve spontaneously within weeks to months.

What is the cause of primary erythema migrans in your client? Erythema migrans is not a reaction to a tick bite, but rather an outward sign of an actual Lyme disease infection in the skin. As with any infection, it can feel warm to the touch. In people with darker complexions, erythema migrans can look like a bruise.

Treatments that can be offered:

  • If the rash is itchy or uncomfortable, the client can try using an antihistamine to relieve itching.
  • Cold compress to cool the rash area with anti-itch ingredients such as menthol, calamine, colloidal oatmeal.
  • Peppermint hydrosol can relieve any itching/burning temporarily.
  • If the discoloration on the skin is a concern for the client, it can be disguised with camouflage makeup.


Secondary erythema migrans lesions occur at sites distant from the site of tick bite, indicating dissemination of B. burgdorferi via blood or lymph. These lesions vary from 17%-57% with the most common distant sites being the face and extremities with the exception of the palms, soles and mucous membranes. The lesions are few in number and they appear in one or two areas of similarly sized and shaped lesions.  These secondary lesions are lighter in color, smaller in size, less swollen and have less symptoms.

About 5% of people with Lyme disease will develop some degree of sudden facial weakness (or “facial palsy”), where one or both sides of the face droop. 

What is the cause of secondary erythema migrans and sudden facial weakness in your client? Humans and animals are infected with the bacteria through hard-tick bites. The borrelia survive in the midgut of the ticks. The immature nymphs are most likely to transmit the infection. The ticks feed on infected animals and then on humans. The bacteria that cause Lyme disease can affect the nervous system, and it can sometimes cause dysfunction of the facial nerve (the nerve that controls how a person moves their face to smile, pucker their lips, blink and more).

Treatments that can be offered:

  • Soothing, anti-inflammatory topical products over any skin lesions (note these are smaller with less symptoms and swelling).
  • DermoTaping and microcurrent can be used for facial palsy.
  • Client can also partake in facial yoga to stimulate the facial muscles.


Acrodermatitis chronica atrophicans develops in 2 stages. Initial inflammation is followed by progressive fibrosis and cutaneous atrophy within several months or years.

  • Inflammatory stage: reddish discolouration and swelling of the affected area that is not clearly defined. The skin may be tender or painful.
  • Atrophic stage: thin skin, loss sweat glands and hair, the disappearance of elastic fibres, and dilation of blood vessels. The skin can tear and ulcerate after minor trauma as it is tissue paper-like.

ACA usually presents as a unilateral violet discolouration of the outside of joints on legs and arms, however, it can appear anywhere on the body and can be bilateral.

Less common features of ACA include fibrous papules and plaques, and skin coloured nodules.

About 2/3 of people have an associated peripheral neuropathy of the affected extremity, manifesting primarily as local sensory loss.

What is the cause of ACA in your client? It is caused by chronic borrelial infection which is persistent with tissue loss in the extremities.

Treatments that can be offered:

  • ACA is treated with antibiotics. The choice of antibiotic and length of the treatment depends on which other organs are involved and the severity of symptoms so be aware of side effects from the antibiotics.
  • If the violet discoloration on the skin is a concern for the client it can be disguised with camouflage makeup.
  • Peripheral neuropathy in a mild form may benefit from gentle massage.  Sometimes it can be too painful to have a treatment

DISCLAIMER: Determine any medications; contraindications and cautions before proceeding with any spa treatment. Work within the scope of your license/certification.

Portrait of Mórag Currin. About the Author

Mórag Currin is a highly sought-after esthetic educator with more than 27 years of spa industry experience and more than twelve years of training and training management experience. She travels around the globe with her training and expertise, helping to raise the bar in the spa industry and to open the door to all people, regardless of skin type or health condition. To learn more about this topic and many other skin challenges, diseases, and symptoms, check out Mórag’s book, Health Challenged Skin: The Estheticians’ Desk Reference.

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