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To the Editor: In their Rational Clinical Examination article, Drs Tibbles and Edlow¹ reviewed the accuracy of history and physical examination findings for the diagnosis of erythema migrans. There are 2 issues that are important to consider.

First, Table 2 states that erythema migrans is accompanied by mild pain or itch. However, in most cases erythema migrans is entirely asymptomatic.² Pruritus, when present, may be due to a hypersensitivity reaction to the tick bite, irrespective of the presence of borrelial pathogens.³ This pruritus lasts about a week, resolving around the time that most cases of erythema migrans begin to appear.² Moreover, a study conducted in Rhode Island suggests that patients with significant pruritus after a tick bite are less likely to develop Lyme disease than those who experience mild or no itch.³ An explanation offered is that individuals with prominent itch at the bite site are more likely to be . . . [Full Text of this Article]

Scott A. Norton, MD, MPH
norton@usuhs.edu
Dermatology Department
Uniformed Services University
Bethesda, Maryland

RELATED LETTER

Diagnosis of Erythema Migrans—Reply
Carrie Tibbles and Jonathan Edlow
JAMA. 2007;298(10):1160.
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RELATED ARTICLE

Does This Patient Have Erythema Migrans?
Carrie D. Tibbles and Jonathan A. Edlow
JAMA. 2007;297(23):2617-2627.
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