Saturday, January 01, 2011
Infection with various Borrelia species will cause cutaneous and
systemic infections. Early Lyme disease (erythema migrans) and late
Lyme disease (acrodermatitis chronicum atrophicans) are the classic
cutaneous complications of these infections. In Europe, patients
may also develop lymphocytoma as a complication of borrelial
Erythema Chronicum Migrans - Primary Lyme Disease
Erythema migrans is the cutaneous eruption of early borreliosis
caused by the tickborne spirochete Borrelia burgdorferi.
The therapeutic strategy is to eradicate the pathogenic organism.
Solitary lesions are treated with shorter durations of therapy.
When patients have multiple erythema migrans lesions, they often
have paucisymptomatic involvement of the nervous system or other
sites and may require longer courses of treatment. Patients with
multiple erythema migrans lesions may require complete neurologic
evaluation and lumbar puncture prior to treatment, or they should
be treated as if they have neuroborreliosis.
- Doxycycline 100 mg orally twice daily for 10-21 days. (In a
comparative trial, 10 days of doxycycline was equivalent to 20
days, although rare treatment failures can occur with any duration
of oral therapy.)
- Amoxicillin, 500 mg three times daily for 14-21 days; in
children 250 mg 3 times daily or 50 mg/kg/day in 3 divided doses.
This is the preferred medication in pregnancy.
- Patients with first-degree heart block or facial palsy as their
only manifestation may be treated with 14-21 days of any of the
above antibiotic regimens.
- For lymphocytoma associated with borreliosis, use the standard
antibiotics above for 20-30 days.
- In patients allergic to or intolerant of doxycycline and
amoxicillin, use cefuroxime axetil 125 mg twice daily or 30 mg/kg
per day in two divided doses for 14-21 days.
- Only in patients unable to take all three of the above
medications, erythromycin 250 mg 3 times daily or 30 mg/kg/day in 3
divided doses for 14-21 days.
- Regular follow up of these patients for potential cardiac,
neurologic, or arthritic sequelae is important. For arthritis,
30-60 days of an oral regimen or intravenous treatment as below for
14-28 days is recommended. For neurologic involvement or cardiac
involvement of more than first-degree heart block, ceftriaxone 2 g
IV once a day for 14 days, cefotaxime 2 g IV every 8 hours for
14-21 days, or penicillin G sodium 3.3 million units IV every 4
hours (20 million U/day) for 14-28 days.
- In endemic areas, persons at risk may consider immunization
with 3 doses of L-OspA.
- A single dose of doxycycline 200 mg is effective prophylaxis
after a tick bite in high endemicity regions.
- Protective clothing and insect repellents containing DEET
should be worn in endemic areas.
Complications and Undesired Consequences
- Erythema migrans is a clinical diagnosis, as serologic testing
may be negative at this stage. Treatment should not be withheld if
the diagnosis is uncertain. Seek consultation or treat
- Once chronic musculoskeletal or neurocognitive symptoms or
fatigue develop in patients with documented borreliosis, prolonged
duration antibiotic therapy (beyond that listed above) is unlikely
to lead to symptomatic improvement.
Acrodermatitis Chronica Atrophicans and Solitary
Lymphocytoma Cutis - Cutaneous Late Lyme Disease
Occurring almost exclusively in Europe, this disorder is a late
sequel of infection with Borrelia afzelii, a spirochete
that is tick-transmitted by Ixodes ricinus.
Doxycycline 100 mg twice daily for 20-30 days.
For patients who fail to respond to oral doxycycline:
- Intravenous or intramuscular ceftriaxone 2 g daily for 14-28
- Intravenous penicillin 20 x 106 unit/day for 14-28
The atrophic lesions of acrodermatitis chronica atrophicans may