It’s the middle of summer and you’re out gravel riding with a group of buddies. At the top of a long climb onto a beautiful ridgeline you sprawl on the grass, relaxing, pondering life and watching the sunset. But a week later you start to feel unwell and you discover a rash which looks roughly like a ‘bulls eye.’ It’s possible that you’ve been bitten by a tick bearing Borrelia, a spirochete bacteria. If you get medical help promptly then it can be treated, but left untreated (or undiagnosed) then the risk is that you could develop Lyme Disease. If you would like to find out more then read on….

What is it Lyme Disease?

Lyme disease is a bacterial illness transmitted to humans through the bite of infected ticks. It is the most common human tick-borne infectious disease in the northern hemisphere and there are numerous strains of Borrelia.¹ Ticks are tiny spider-like creatures found in woodland and moorland areas, grassy places, parks and gardens. They feed on the blood of birds and mammals, including humans. ² Lyme infection can occur at any time of the year. Ticks are more active in the spring and summer months but temperatures need to drop below freezing to reduce tick activity. Lyme disease is known as the ‘Great Imitator’ as symptoms are nonspecific and can mimic so many other conditions. Lyme disease can look like ME/CFS, fibromyalgia, anxiety, depression, Alzheimer’s and Parkinson’s. When it comes to Lyme disease, the chance of misdiagnosis is high. ¹

What are ticks?

Image courtesy of Lyme Disease Action

Ticks are related to spiders, mites and scorpions. There are many different species of tick living in Britain, each preferring to feed on the blood of different animal hosts. The one most likely to bite humans in Britain is the Sheep tick, or Castor Bean tick, Ixodes ricinus. Despite its name, the sheep tick will feed from a wide variety of mammals and birds.

There are four stages to a tick’s life-cycle: egg, larva, nymph, and adult. Larvae, nymphs and adults spend most of the time on the ground protected by leaf litter, leaving this protection to find a meal. They feed only once in each stage, staying attached for a few days, then dropping to the ground to moult into the next stage. The adult male dies after mating. When the adult female finishes feeding it drops to the ground, releases eggs and dies. ³

 How to avoid being bitten by ticks

 There are some simple things you can do to reduce your chances of being bitten by ticks:

• Use insect repellent designed to repel ticks.
• Wear light coloured clothing so that you can spot and brush off any ticks [suddenly those white SPD shoes and roadie-length white socks seem like a good idea after all….]
• Try to avoid riding through long grass
• Check carefully for tick bites when you get home

Areas of the body that ticks may be found include skin folds, armpits, groin, waistband area, back of the neck and hairline. Data from UKHSA’s Tick Surveillance Scheme shows that adults are commonly bitten on the legs, whilst children are commonly bitten on the head or neck area. Bites can occur on any part of the body and more than one tick can be attached at one time. Wash your clothes at a high temperature (60 degrees C plus) and put all clothes in a tumble dryer on the highest heat possible to kill any ticks remaining on clothing. ¹

What to do if you’ve been bitten

If you find an embedded tick, remove it as quickly as possible using the correct tick removal technique. If you have difficulty removing a tick, contact your pharmacist or a GP.

Method One - Tweezer tick-removal technique

1. Grasp the tick as close to the skin as possible and pull upwards with steady, even pressure.
2. Do not twist or jerk the tick as this may leave its mouth parts embedded, or cause it to regurgitate disease-causing fluids. If any mouth parts do break off, they may be removed with a sterilised needle or tweezer points.
3. Do not squeeze or crush the body of the tick, because its fluids (saliva and gut contents) may contain disease-causing organisms and leak into the host’s body.
4. Do not handle the tick with bare hands, because certain disease-causing organisms may enter through breaks in the skin, or through mucous membranes (if you touch eyes, nostrils or mouth).
5. After removing the tick, disinfect the bite site with an antiseptic wipe or wound wash and wash your hands with soap and water.
6. The best way to dispose of it is to place it in a tissue and squash it between the tissue, ensuring no fluid touches your hands. Then flush away the tissue or dispose of it in the dustbin. This will prevent the tick from going on to bite another person or animal. Although not every tick carries disease, immediate removal of an attached tick is recommended.

Method Two: Tick Removal Tool

There are various brands of tick removal tool available that are designed to cradle the body of the tick and don’t exert pressure on either its mouth parts or its abdomen. It can therefore be safely twisted in one direction (either clockwise or counter-clockwise – the tick is not screw-threaded), which allows the barbs on the tick’s proboscis to be freed from the surrounding tissue. The twisting action also helps to crack the special saliva cement that most hard-tick species secrete in order to firmly attach themselves. The tool doesn’t cause any compression to the body of the tick and so it minimises the risk of back-flow of the tick’s saliva and gut contents, and  therefore helps to avoid disease transmission.

You should NEVER twist with tweezers.

If you use this tool to lever as you would a crow bar, the mouth parts are likely to break off. If you twist the tick one way and then the other, the mouth parts are also likely to break off. Twist in one direction only.

1. Choose the most suitable O’Tom Tick Twister ® tool, according to the size of the tick (each pack contains two sizes, one for adult ticks and one for the tiny nymph ticks).
2. Engage the tool by approaching the tick from the side (the body of the tick is flat when unfed) until it is held securely.
3. Lift the tool very lightly and TURN IT (clockwise or counter-clockwise). The tick detaches itself after 2-3 rotations.
4. After removing the tick, disinfect the bite site and wash hands with soap and water.
5.  The best way to dispose of it is to place it in a tissue and squash it between the tissue, ensuring no fluid touches your hands. Then flush away the tissue or dispose of it in the dustbin. This will prevent the tick from going on to bite another person or animal. Although not every tick carries disease, immediate removal of an attached tick is recommended.

Consult your GP if you’ve been bitten by a tick or visited an area where ticks are present within the past three months and are experiencing flu-like symptoms or a spreading round or oval rash. ¹

Images courtesy of Lyme Disease Action

• Ticks can be as small as a poppy seed. Bites are normally painless, so can easily be missed.
• Not everyone with Lyme disease develops a rash. It is important to look out for symptoms as well.
• The rash can appear up to 3 months after being bitten by an infected tick, but usually appears within 1 to 4 weeks. It can last for several weeks.
• Early symptoms can include fatigue, headaches, flu-like illness, facial palsy, migratory muscle and joint pain, nausea, and a stiff neck. ¹

Diagnosis 

Diagnosing Lyme disease can be difficult due to the wide range of symptoms and a blood test that can be unreliable for various reasons. GPs often miss a Lyme disease diagnosis and there are also many uncertainties surrounding the disease, as outlined by the James Lind Alliance findings and Independent Reviews commissioned by the Department of Health. ¹

Images courtesy of Lyme Disease Action

An infected tick bite can result in a rash known as erythema migrans (EM). This can be distinctive and resemble a bull’s-eye shape target, however it can also be atypical and some people discover multiple rashes. This EM rash is diagnostic of Lyme disease and treatment should start right away without the need for a blood test. The rash can often be mistaken for ringworm, cellulitis or an allergic reaction. ¹

 Blood tests can be used to confirm a suspected case of Lyme disease but they are not 100% reliable and a negative result cannot rule out Lyme disease. Testing for Lyme disease is a two tier process. The first tier is an ELISA test which is usually performed at your local hospital laboratory and takes a few days or possibly a week for the result to  come back. ¹

Treatment for acute/early Lyme disease

The NICE Guideline for Lyme disease was published in 2018 and sets out guidance on diagnosis and management of Lyme disease. It aims to raise awareness of when Lyme disease should be suspected and ensure that people have prompt and consistent diagnosis and treatment.

Acute Lyme disease is treated with antibiotics. Please note that the type of antibiotic varies depending on whether you are an adult or a child or pregnant. It is also important to ensure that you are receiving the maximum amount of treatment recommended by the NICE guideline (each course should be between 17-28 days depending on the age of the patient, the type of antibiotic prescribed and symptoms), as some doctors may not be familiar with the guideline and may inadvertently undertreat the infection. It is essential that you complete each course of antibiotics. Make sure you have an appointment with your doctor before the end of the course to review your progress as if symptoms persist, you may require a second course of treatment, which if necessary needs to be prescribed as quickly as possible after the initial course.¹

References and further reading

1. Lyme Disease UK
2. NHS Inform
3. Lyme Disease Action