Tick Removal and Tick-Borne Disease Recognition

Tick Removal

The goal is complete removal of the tick without squeezing its body. Squeezing can force gut contents — including pathogens — into the bite wound.

You need: Fine-tipped tweezers or a tick removal tool.

The technique:

What not to do:

• Do not use petroleum jelly, nail polish, or heat to make the tick back out — this is ineffective and may cause the tick to regurgitate into the wound
• Do not use your fingers to pull the tick — even with gloves, the chance of contamination and the inability to get close to the mouthparts makes this a poor method
• Do not use a lit match near the tick

Estimating Attachment Time

Knowing how long a tick has been attached informs both your treatment decision and your risk level.

Unengorged tick: Flat, small (seed tick size). If found and removed promptly, likely less than 24 hours. For deer ticks: transmission risk is low.

Partially engorged: Body slightly rounded and larger. Rough estimate: 24-36 hours. Moderate risk for Lyme if a deer tick.

Fully engorged: Body rounded, swollen, grape-like. Likely 48-72+ hours. Higher transmission risk. Also: much more likely to have already transmitted disease agents.

Tick Identification

Knowing what species of tick bit you informs which diseases are possible.

Blacklegged (Deer) Tick — Ixodes scapularis (East) / Ixodes pacificus (West)

• Very small — nymph is poppy seed sized, adult sesame seed sized
• Adults: reddish-brown body with black legs and shield
• Range: Northeast, upper Midwest, Pacific Coast forests
• Diseases: Lyme disease, anaplasmosis, babesiosis, Powassan virus

American Dog Tick — Dermacentor variabilis

• Larger, brown with white/silver markings on shield
• Range: East of the Rockies, Pacific Coast
• Diseases: Rocky Mountain Spotted Fever, tularemia

Rocky Mountain Wood Tick — Dermacentor andersoni

• Similar to American dog tick
• Range: Rocky Mountain region
• Diseases: RMSF, Colorado tick fever, tularemia

Lone Star Tick — Amblyomma americanum

• Reddish-brown; female has a distinctive single white spot on the back
• Range: Southeast and south-central US, expanding north
• Diseases: Ehrlichiosis, tularemia, STARI; alpha-gal syndrome (red meat allergy)

Gulf Coast Tick — Amblyomma maculatum

• Southeast coastal areas
• Diseases: Rickettsia parkeri (mild spotted fever)

Major Tick-Borne Diseases

Lyme Disease (Borrelia burgdorferi)

Vector: Deer tick (Ixodes), 36-48 hours attachment typically required

Early localized (3-30 days post-bite):

• Erythema migrans (EM) rash in 70-80% of cases — expanding red oval or bull's-eye pattern, usually greater than 5cm diameter, at the bite site
• Fatigue, fever, headache, muscle aches
• Does not look like a typical infection wound — it's usually painless and not hot

Early disseminated (days to weeks after EM):

• Multiple EM lesions at sites distant from original bite
• Bell's palsy (facial nerve paralysis) — unilateral facial drooping
• Meningitis, carditis (heart block)

Late disseminated (weeks to months):

• Arthritis — most commonly knee; swollen, painful joints
• Neurological symptoms (peripheral neuropathy, cognitive symptoms)

Treatment:

• Doxycycline 100mg twice daily for 10-21 days (depending on stage)
• Amoxicillin 500mg three times daily is an alternative for children under 8 and pregnant women
• Early treatment is far more effective than late treatment — do not delay

Prophylaxis: Single 200mg dose of doxycycline within 72 hours of a high-risk deer tick bite reduces Lyme risk by 87%.

Rocky Mountain Spotted Fever (Rickettsia rickettsii)

The most dangerous common tick-borne illness in the US

Vector: American dog tick (East), Rocky Mountain wood tick (West, Midwest). Transmission can begin in 4-6 hours.

Range: Despite the name, RMSF is most prevalent in the Southeast (North Carolina, Tennessee, Arkansas, Oklahoma, and Missouri account for the majority of cases).

Presentation (appears 2-14 days after bite):

• Abrupt onset of fever, severe headache, muscle pain
• Rash: typically appears day 2-5, starting as small flat red spots on wrists and ankles, spreading to the trunk — this centripetal spread pattern is distinctive. The rash may become petechial (pinpoint hemorrhages that do not blanch on pressure).
• Approximately 10-15% of cases have no rash (spotless RMSF) — this is the most dangerous presentation because diagnosis is delayed

The critical window: RMSF is fatal in 20-25% of untreated cases. Antibiotic treatment within the first 5 days of illness dramatically reduces mortality. Do not wait for laboratory confirmation to begin treatment.

Treatment: Doxycycline 100mg twice daily is the only recommended first-line treatment for all age groups including children — the risk of fatal RMSF outweighs the risk of dental staining from doxycycline in children. Treat for 3 days after fever resolves (minimum 5-7 days).

Ehrlichiosis and Anaplasmosis

Two separate but similar tick-borne rickettsial diseases:

Human Monocytic Ehrlichiosis (HME) — Lone Star tick, Southeast US Human Granulocytic Anaplasmosis (HGA) — Deer tick, Northeast and upper Midwest

Presentation: Fever, headache, muscle aches, nausea appearing 1-2 weeks after bite. Unlike RMSF, rash is less common (< 30% for ehrlichiosis, < 10% for anaplasmosis).

Laboratory clue: Both cause low white blood cell count and low platelet count — if a CBC is available, this pattern plus tick exposure is strongly suggestive.

Treatment: Doxycycline 100mg twice daily for 5-10 days. Response to doxycycline is typically rapid — improvement within 24-48 hours of starting treatment is expected and confirms the diagnosis.

Post-Treatment Syndrome

Some Lyme disease patients report persistent symptoms (fatigue, cognitive difficulties, joint pain) after completing a course of antibiotics — sometimes called "chronic Lyme disease." Multiple randomized controlled trials have found that prolonged additional antibiotic treatment does not improve outcomes compared to placebo. The cause of persistent symptoms is not established. Do not continue antibiotics indefinitely based on persistent symptoms alone — the risk of antibiotic complications without proven benefit is significant.

Tick Prevention

Daily tick checks are the most effective prevention after exposure. Run your fingers through hair, check the scalp, behind ears, around the neck, armpits, belly button, groin, and behind the knees. Engorged nymphal deer ticks are the size of a sesame seed — look carefully.

DEET (20-30%) applied to skin and clothing repels ticks effectively.

Permethrin applied to clothing (not skin) is highly effective and remains active through multiple washes. Factory-treated permethrin clothing is available. Permethrin kills ticks on contact with treated fabric.

Tick tubes (permethrin-treated cotton for rodent nesting) are an environmental control option for areas with high deer tick density.

After outdoor activities: shower within 2 hours of coming inside (reduces unattached tick risk), and tumble dry clothing on high heat for 10 minutes (heat kills ticks on clothing).