BULLSEYE AND OTHER RASHES IN LYME AND CO-INFECTIONS
Updated: 7 hours ago
I had a bullseye rash, and my doctor said it was either ringworm or an "odd" rash and suggested creams. That mistake caused years of unnecessary suffering.
Please know this: ILADS considers a Lyme rash, bullseye or not, a sure sign of Lyme in anyone who may have been exposed to ticks where Lyme is found. That means a doctor can diagnose Lyme and start treatment right away, without waiting for blood tests. And many people with Lyme never get a rash or never notice one, so not having one doesn't rule Lyme out.
Short on time or energy? A quick-view graphic with the key points is at the bottom of this post.
How Lyme is diagnosed without relying on one test:
CLINICAL DIAGNOSIS
THE LYME RASH (ERYTHEMA MIGRANS)
- The Lyme rash is called erythema migrans, or EM. It usually starts as a red area that slowly spreads outward. An older 2021 Johns Hopkins study found these rashes kept growing for up to about 14 days.
- It usually shows up 3 to 30 days after the infection, and sometimes sooner (Bay Area Lyme Foundation).
- It can show up somewhere other than the tick bite, and there can be more than one (Global Lyme Alliance).
- It is often warm to the touch and may burn. Less often it is a little painful or itchy (Bay Area Lyme Foundation).
- ILADS notes the rash usually doesn't cause symptoms, so it is easy to miss unless someone looks for it.
- In the 2022 Lyme Disease Biobank study, more than half of the rashes had been there a week or less when they were checked. The researchers think the bullseye look may be tied to a rash that has been there longer, which may be one reason so few bullseyes were seen. Dr. Richard Horowitz shares that the rash fades over time whether it is treated or not, but if it isn't treated, the infection can go on to become chronic. A fading rash doesn't mean the infection is gone.
THE MANY LOOKS OF A LYME RASH
- ILADS shares that fewer than 20% of Lyme rashes look like the classic bullseye. Most are one solid color, from faint pink to deep red.
- A 2022 study of Lyme Disease Biobank patients (a Bay Area Lyme Foundation program) found only 2 of 35 confirmed Lyme rashes (6%) had the bullseye pattern. Most were pink and oval, about half were one even color, and almost all had a clear, well-defined edge.
- A Lyme rash can have a bluish cast like a bruise, an oval or uneven shape, or a raised bump in the center (Bay Area Lyme Foundation).
- Dr. Horowitz shares that Lyme rashes in the US can also be solid spreading rashes that get mistaken for a skin infection (cellulitis), raised rashes, or bluish rashes with small blisters in the center that get mistaken for shingles or a spider bite.
- Multiple rashes: ILADS lists multiple red rashes as a sign of Lyme that has spread. Bay Area Lyme Foundation explains that more than one EM rash means the infection has traveled through the bloodstream, so take photos and contact your doctor right away.
- That same 2021 Johns Hopkins study of 271 adults found the rash can look different depending on age, sex, how long it has been there and where it is on the body. For example, the older the person, the less likely the rash was to have a clear center.
- Borrelia mayonii, a Lyme bacteria found in the Midwest, may cause a rash spread over the face, body, arms and legs that can look like an allergic reaction (Dr. Horowitz).
- Rarer skin signs, seen more in Europe (Dr. Horowitz): acrodermatitis chronica atrophicans (ACA), a reddish-purple skin change usually on the hands or feet that can show up years after the infection, and Borrelia lymphocytoma, a hard reddish lump on an earlobe or nipple, seen in children. Dr. Horowitz shares that the bacteria behind ACA (Borrelia afzelii) is now being found in US ticks too.
LYME RASHES ON DARKER SKIN
- Lyme rashes can look different on darker skin, and doctors see fewer examples of them in medical training, so they can be missed (Johns Hopkins, 2023).
- A 2023 Johns Hopkins study of 1,395 Lyme patients found that 52.1% of white patients came in with only a rash, compared with 18.6% of Black patients. Black patients had about twice the odds of coming in without a rash or other telltale signs, almost five times the odds of more advanced Lyme, and waited longer for antibiotics (35 days compared with 7).
- Dr. John Aucott of Johns Hopkins explains that the rash looks different on darker skin, and examples are rarely shown in medical textbooks.
- A 2026 study of 16 resources used at top US medical schools found only 3 of 47 Lyme rash pictures (6.4%) showed darker skin.
HOW MANY PEOPLE NEVER SEE A RASH
- Bay Area Lyme Foundation shares that in many studies, about half or fewer of Lyme patients had a rash that was seen or reported. State health department studies found 51% in Delaware, 43% in Maine and 33% in California.
- ILADS shares that fewer than 30% of people with Lyme in the US remember a tick bite.
- ILADS also reminds doctors that some people come in with flu-like symptoms and no rash, and Lyme should still be considered where it is found.
TESTS ARE OFTEN NEGATIVE EARLY
- In the 2022 Lyme Disease Biobank study, only 37% of people with a confirmed Lyme rash tested positive early on.
- A 2023 study of 192 children with a Lyme rash found standard two-tier testing was positive in only 38.1% of those with one rash, and 76.8% of those with multiple rashes. The researchers say a Lyme rash should be diagnosed by a careful exam, not lab tests.
- A 2026 study supported by the Bay Area Lyme Foundation found common FDA-cleared two-tier tests missed 64% to 78% of early Lyme cases, including people with the Lyme rash.
- Dr. Horowitz shares that an EM rash is proof of Lyme exposure and doesn't need a blood test to confirm it. If a rash doesn't look typical, he suggests seeing a Lyme-literate provider and a dermatologist, who may do a biopsy.
TAKE PHOTOS OF ANY RASH
- Take a photo next to a ruler so the size is clear, and draw a ring around the edges with a pen to see if it spreads (Bay Area Lyme Foundation).
- Date each photo and ask your doctor to put a copy in your medical records (Global Lyme Alliance).
- After a tick bite, take a photo of the bite and draw a circle around it (Global Lyme Alliance).
RASHES THAT CAN BE MISTAKEN FOR LYME (AND THE OTHER WAY AROUND)
- A tick bite can leave a small red spot, no bigger than a dime, that can last days to weeks. That spot alone doesn't mean infection, but it's a sign you were exposed, so write it down (IGeneX).
- In the 2022 Lyme Disease Biobank study, 30% of the suspected rashes looked like a very early Lyme rash or a tick bite reaction. These were usually under 5 cm (about 2 inches), and all had a visible bite mark. Others were thought to be ringworm, an allergic skin reaction or mosquito bites.
- A rash that looks like a bullseye can also come from a spider bite, a drug reaction, ringworm or an allergic reaction to an insect bite (Global Lyme Alliance). This is why a Lyme-literate doctor should look at any rash after a possible tick bite.
- Lyme rashes can be mistaken for cellulitis, shingles, spider bites and allergic reactions (Bay Area Lyme Foundation, Dr. Horowitz).
- Bay Area Lyme Foundation warns that when a Lyme rash is mistaken for something else, people may get the wrong antibiotic, none at all, or steroids, and that can make persistent Lyme more likely.
- STARI (Southern tick-associated rash illness) causes a Lyme-like rash after a Lone Star tick bite. ILADS explains that its cause hasn't been clearly found, that limited evidence supports treating it much like Lyme, and that the Lone Star tick now reaches much of the Northeast. For someone with a rash who may have been exposed to both blacklegged (deer) ticks and Lone Star ticks, ILADS says doctors should consider Lyme, STARI and other tick-borne infections.
BARTONELLA STRIAE - BARTONELLA STREAKS - BARTONELLA TRACKS
- Bartonella can cause a rash that looks like stretch marks. Its formal name is Bartonella striae, and it's also called Bartonella streaks or tracks.
Learn more and see pictures here:
- ILADEF (the International Lyme and Associated Diseases Educational Foundation) describes them as intensely red or purple stretch-mark-like lines that don't follow the skin's natural lines and aren't from weight gain.
- IGeneX describes the streaks as usually red or dark brown.
- Dr. Horowitz shares that the streaks may be dark red, may form a Christmas tree pattern, or may run across the skin's natural lines. He often sees white streaks instead, on the hips, thighs, lower back, breasts and upper chest, and their color can change over time. He explains that, just as an EM rash points to Lyme, these classic Bartonella rashes show exposure to Bartonella.
- Dr. Todd Maderis notes they are especially likely to run horizontally on the back and hips.
- Dr. Robert Mozayeni, a Bartonella specialist and past president of ILADS, says that when his team biopsied the red stretch-mark-like lesions, they turned out to be Bartonella every time, though larger studies are needed to prove it.
- Dr. Rosalie Greenberg shares that a regular skin biopsy may only show inflammation unless special stains are used, and that tests at large labs often aren't sensitive enough. If you or your child have unexplained skin marks along with neuropsychiatric symptoms (mental health and nerve symptoms), she suggests strongly considering Bartonella testing.
- Dr. Edward Breitschwerdt of NC State explains that these lesions can show up where nothing should be stretching, like the arm, and can run up and down or across the thigh. He notes this has become a controversy among doctors.
- An older 2020 NC State study found that 24 of 29 people with neuropsychiatric symptoms and signs of Bartonella exposure or infection (83%) reported skin lesions. Many looked like stretch marks, and most of these people didn't report the usual causes of stretch marks. The researchers say more studies are needed.
- Dr. Horowitz also lists other Bartonella skin signs, like small bumps where a cat scratched and raised dark lumps (bacillary angiomatosis). Dr. Breitschwerdt explains these lumps were first seen in people with weakened immune systems from AIDS.
BABESIA AND OTHER TICK-BORNE INFECTIONS
- Babesia: ILADEF and LymeDisease.org don't list a rash among the common symptoms of Babesia.
- Anaplasma: a rash is rare (under 10% of cases). ILADEF says a rash with Anaplasma may point to another co-infection.
- Ehrlichia: ILADEF shares that fewer than 30% of adults and about 60% of children get a rash.
- Rocky Mountain spotted fever: ILADEF explains that the classic signs (a tick bite, fever and a spotted rash) can't always be counted on to catch it early, and that it can get serious quickly. See a doctor right away if it could be RMSF.
- Tick-borne relapsing fever (TBRF) can cause a rash, and tularemia can cause a skin sore where the infection entered (ILADEF).
WHEN TO SEE A DOCTOR
- Any spreading rash after a possible tick bite, even if it isn't a bullseye or isn't where the bite was.
- More than one rash: contact your doctor right away.
- A fever with a spotted rash after a tick bite: get care right away.
- Flu-like symptoms after a possible tick bite, even with no rash (Global Lyme Alliance suggests seeing a Lyme doctor right away).
- Stretch-mark-like streaks you can't explain, especially with neuropsychiatric symptoms.
BEFORE YOU START
- Don't wait for a rash to turn into a bullseye. ILADS says a Lyme rash in someone who may have been exposed should be treated right away.
- Ask your doctor before using steroid creams on a rash that could be Lyme, since Bay Area Lyme Foundation warns steroids can make persistent Lyme more likely.
MY EXPERIENCE
- Rocky Mountain spotted fever didn't show up as a rash in either of us.
- A family member had the Bartonella rash up and down the spine, and it helped with the diagnosis.
- Many doctors will still tell patients that rash is just stretch marks.
RELATED POSTS
CLINICAL DIAGNOSIS
BARTONELLA MOST COMMON SYMPTOMS
NEW TICK BITE? WHAT TO ASK YOUR DOCTOR.
SOURCES
ILADS, Lyme Disease Basics for Providers (updated 2026)
ILADEF, Tick-Borne Diseases Other Than Lyme (2024)
Bay Area Lyme Foundation, Skin Rashes (updated 2026)
Bay Area Lyme Foundation, The Myth of the Bullseye (2024)
Bay Area Lyme Foundation, Tests miss 64-78% of early Lyme (2026)
Bay Area Lyme Foundation, Dr. Edward Breitschwerdt interview (2023)
Schotthoefer and others, The Spectrum of Erythema Migrans, Lyme Disease Biobank, Cureus (2022)
LymeDisease.org, A Lyme rash doesn't always look like a bull's-eye (2022)
LymeDisease.org, Dr. Horowitz, Medical Detective: Bartonella, Parts 1 and 2 (2025)
LymeDisease.org, Babesia (2022)
Global Lyme Alliance, Lyme Disease Diagnosis (no date shown)
Global Lyme Alliance, I Found a Tick on Me, Now What? (2023)
Global Lyme Alliance, Lyme Disease Symptoms (no date shown)
Global Lyme Alliance, Not All Lyme Rashes Are Created Equal (2019, older source, still worth reading)
Global Lyme Alliance, Dr. Rosalie Greenberg, Bartonella (2022)
IGeneX, Identifying Tick Bites (2024)
Johns Hopkins Medicine, Inequities in Lyme diagnosis for Black patients (2023)
Rebman and others, Erythema migrans characteristics, Johns Hopkins, Infection (2021, older source, still worth reading)
Baffoe-Mensah and others, Skin tone in Lyme teaching images, J Med Educ Curric Dev (2026)
Thompson and others, Lyme tests in children with a Lyme rash, J Pediatric Infect Dis Soc (2023)
Breitschwerdt and others, Bartonella skin lesions, NC State, Pathogens (2020, older source, still worth reading)
Dr. Richard Horowitz, Let's Talk About Testing for Lyme Disease, Part 1 - Rashes (2024)
Dr. Robert Mozayeni, interview with Better Health Guy, Episode 185 (2023)
Dr. Todd Maderis, Bartonella: More Problematic than Lyme Disease? (updated 2023)
Disclaimer: Rise Above Lyme makes no claims about any possible benefit of using any product mentioned within this site. Always consult with your doctor before adding anything. The information shared is based on personal experience, years of accumulated researched resources from Lyme Literate doctors and polls conducted within Lyme groups from actual patient experience using these solution ideas.
Comments