• Skin manifestations Lyme disease

    From georgia@21:1/5 to All on Sun Apr 3 10:51:14 2016
    OLD POST
    Here are some references about the different skin manifestations.

    ".....The differential diagnosis of erythema migrans includes cellulitis , tinea, (ringworm) contact dermatitis, fixed drug reaction. granuloma annulare, reaction to an insect bite, or a Brown recluse spider bite (48)...."

    from: Clinical Manifestations of Lyme Disease in the United States authors: Trock, et al
    Source: Connecticut Medicine June 1989 Volume 53, No. 6
    "....Although the bite (and subsequent erythema migrans) may occur anywhere, the tick has a predilection for the thigh, groin, or axilla. Facial erythema migrans is more common among children. Atypical forms of erythema migrans occur: ealy lesions may have indurated or vesicular centers , or MIMIC STREPTOCOCCAL OR STAPHYLOCCAL CELLULITIS. Central necrosis also may occur and be misdiagnosed as a bite of the brown-recluse spider. Rarely, transient eruptions are seen in early Lyme disease and include, maculopapular rashes, urticaria, " (hives)"malar rash, septal panniculitis (erythema nodosum), and/or localized granuloma annulare. Although B. burgdorferi has been isolated from the perimeter of erythema migrans, skin biopsy is a low-yeild procedure. Histologically, erythema migrans has a non-specific appearance with a perivascular infiltrate comprised of lymphocytes, plasma cells, eosinophils, and histiocytes.
    " In addition to erythema migrans, many patients with early disease will have a flu-like syndrome characterized by fatigue, fever, malaise, headache, arthralgias, myalgias, regional or generalized lymphadenopathy, and/or conjunctivitis." My LLD said that conjunctivitis in both eyes is a as diagnostic of Lyme as a bull's eye rash. "One-third of patients will have such symptoms in the absence of erythema migrans. These symptoms are typically intermittent and changing, with the exception of fatigue, which is often persistent and may be debilitating. Right upper-quadrant tenderness and a mild hepatitis may occur (hepatitis has also been reported in later disease), as well as cases of rare myositis "- maybe rarely recognized- " and adult respiratory distress syndrome. During this early phase of disease, laboratory findings are nonspecific........."

    from: Annals of Internal Medicine--Vol. 114--Number 6--March 15, 1991 pg. 490-498
    title: Diagnosis of Lyme Disease Based on Dermatologic Manifestations
    authors: Malane, MD, et al

    "Erythema migrans occurs in 60 to 83 % of patients with Lyme disease (8-10). Classic erythema migrans starts as a red macule or papule at the site of the tick bite, which then expands, forming an erythematous, annular lesion with partial clearing center (11, 42). An erythematous central punctum or a larger macule will often remain at the bite site. Many patients with erythema migrans are unable to recall the tick bite. The lesion is generally found in body areas where ticks characteristically feed. Such areas include those where tight fitting clothing begins (for example at underwear lines ) and interiginous" (superficial inflammation of two skin surfaces taht are in contact) "locations such as the axilla, groin, thigh, and buttocks (11). Ticks infrequently feed on the palms, the soles, or the mucous membranes, Erythema migrans begins approximately 3 to 30 days after a tick bite (11, 12, 42) The inflamed border will migrate cenrifugally over days to weeks. The average size of the lesion is 15 cm, but lesions as large as 68 cm in diameter have been reported (11). Erythema migrans is usually flat; however , the edges may be elevated or indurated (11, 42). Although erythema migrans is usually asymptomatic , burning, prutitus" (itchy)", pain, tenderness, hyperesthesia, or dysesthesia may occur (11, 12, 12, 43). In more than 50% of patients, the lesion is associated with a flu-like illness characterized by fever, myalgia, arthralgias, malaise, fatigue or headache(11, 43). When left untreated, the lesion fades weeks to months later, with an average duration of 1 month (8, 11, 12). On fading there may be residual scaling or pigmentary change in the skin (11, 12)..........
    "The histologic findings associated with erythema migans are relatively nonspecific; thus for histopathologic confirmation , the presence of B.burgdoreferi needs to be shown by silver stain, labeled antibody staining or culture(23). Spirochetes are most frequently found in the dermis of the advancing margin of the lesion (34, 45) Histopathologic findings in specimens from the periphery of the lesion include a superficial and deep perivascular lymphocitic infiltrate that may contain plasma cells, histiocytes, and, less commonly mast cells or neutrophils. (11, 42, 43, 45). Histopathologic findings in specimens from the center of the lesion are consistent with a reaction to an arthropod bite, with eosinophils within the dermal infiltrate. Occasionaly vasculitis" (patchy inflammation of walls of small blood vessles)" or vesicular" (having blisters)" changes are also seen(11). "Other, less classic presentations of the erythema migrans are common. The central area of the lesion may show equal or greater erythema than the periphery(11, 13, 43).
    A European study (12) found that the homogeneous erythematous lesions persist for shorter duration than those with central clearing. An erythema migrans lesion can have alternating rings of erythema and clearing, thereby creating target configuration(11). Additionally, the central portion of the erythema migrans lesion may show blue discoloration or frank purpura,"(a skin rash resulting from bleeding into the skin from small blood vessles-capillaries;
    the individual purple spots of the rash are called petechiae.)" induration, "(hardening) "vesiculation," (blistering)" necrosis," (death of cells in organ or tissue) "or ulceration (11-13, 43, 44, 46) . Uncommonly, petechiae, have also been seen within erythema migrans lesions (46). Lesions may also have different shape or textures. Lesions may appear oval or triangular in shape, especially when they follow the lines of the clevage.
    (Langer lines ) or are in intertriginous areas (34, 43, 47). Lesions may also be more linear in configuration, especially when located on the scalp or when expanding on an extremity (11,47). Scaling has been identified occasionally on some lesions (13, 34, 43, 47).....The differential diagnosis of erythema migrans includes cellulitis , tinea, (ringworm) contact dermatitis, fixed drug reaction. granuloma annulare, reaction to an insect bite, or a Brown recluse spider bite (48).

    Secondary (Multiple) Erythema Migrans Lesions
    "One or more secondary erythema migrans lesions may develop. Secondary erythema migrans can appear within several days to weeks after onset of the initial erythema migrans lesion and has been reported in 6% to 48% of patients with Lyme disease (11, 12, 43). Secondary erythema migrans may result from spirochetemia" (spirochetes in the blood)" or lymphatic spread and subsequent seeding of the skin.
    (49). Lesions often occur at sites away from the original lesion, but a single secondary lesion may occur at the site of a primary lesion that has disappeared. When many lesions are present, they can become confluent " (meeting) "or intersecting, forming complicated patterns. The secondary lesions are often similar to the intial erythema migrans lesion, but they tend to lack indurated centers. (11). Secondary lesions are often asymptomatic. If untreated, the lesions usually disappear within a month, but they may persist for months to over a year, or there may be relapses. In patients receiving therapy, secondary lesions resolve over several days (11). The differential diagnosis of secondary erythema migrans includes erythema multiform, erythema annulare cetrifugum, secondary syphilis, erythema marginatum, and drug reaction..."
    Acrodermatitis Chronica Atrophicans
    "Acrodermatitis Chronica Atrophicans is a unique late complication of Lyme disease, which was first recognized in 1883 (54) . .......It has been reported as the first manifestation of Lyme disease; for example, one asymptomatic patient, on screening had a high serum titer of B. burgdorferi antibodies and he developed acrodermatitis chronica atophicans 4 years later (13, 54, 56)....Classically, there is an intial erythematous or violaceous discoloration in doughy and swollen skin, appearing as plaques or nodules (13, 54). ....The lesion expands and may have a waxing and waning course ((13, 58). This stage will continue for weeks to years before becoming atrophic......There may be hypopigmentation or hyperpignmentation as well as scaling (54, 57). The lesion may be associated with pain, pruritis,"(itching)" hyperesthesias, or paresthesias (55, 57)." (esthesia--from Taber's Cyclopedic Medical Dictionary-- 1. Perception ; feeling; sensation 2. Any disease that affects sensations and perceptions.----para is a prefix meaning near, beside, past, opposite, abnormal, irregular, two like parts-----hyper is a prefix meaning above, excessiive or beyond) "Regional lymphadenopathy," (a disease of the lymph nodes---pathy is a combining form indicating disease.---While I was looking this up I noticed that Taber's 18 th edition has a computer glossary included.) " as well as neurological and musculoskeletal signs or symptoms, may be localized to the same extremity as the acrodermatitis chronica atrophicans lesion (13, 57). An associated sclerotic or fibrotic lesion may be found in patients with acrodermatitis chronica atrophicans (13, 28, 57). The differential diagnosis includes thrombophlebitis, venous insufficiency, eczematous dermatitis, cold injury or aging......

    "Fibrotic lesions, such as ulnar (or tibial) bands and ulnar nodules, have been asssociated with acrodermatitis chronica atrophicans lesions....Ulnar (or tibial ) bands are fibrotic, dense, linear bands taht occur in association with atrophic plaques over the respective bones. .......periarticular fibrous nodules ...These nodules can be confused with rheumatoid nodules, gouty tophi, or erythema nodosum, especially if the acrodermatitis achronica atrophicans lesion has gone unnoticed. (13).......

    ".......Morphea (Localized Scleroderma) and Other Scleradermatous Lesions "Various types of sclerotic lesions, which are characterized by a thickened dermis, develope in about 10% of... patients with acrodermatitis chronica atrophicans and Borrelia lymphocytoma........Sclerodermatous lesions were first reported in association with acrodermatitis chronica atrophicans in the 1930's. The best described of these lesions are those that are both clinically and pathologically identical to morphea (localized scleroderma). Even Morphea lesions that occur in patients without
    a history of Borrelia lymphocytoma or acrodermatitis chronica atrophicans may be of spirochetal origin;..........
    "Plaque-type morphea" ( from Mosby's Medical, Nursing and Allied Health dictionary.
    Morphea--localized scleroderma consisting of patches of yellowish or ivory-colored, rigid, dry, smooth skin. It is more common in females. Also called Addison's keloid, circumscribed scleroderma localized scleroderma.) "manifests as a well-demarcated, indurated, round or
    oval plaque with two stages. It begins as an edematous, erythematous lesion that may have a violaceous or lilac tinged border. As the lesion ages, it becomes a sclerotic plaque with a smooth and shiny surface that is white or yellow in the center. The lesions can expand in size and are found on the trunk or extremities. Although they are often painless, they have been associated with dysesthesias, hypoesthesias, and hyperesthesias. Biopsy specimens taken from the early lesion, especially from the violaceous border, show a mixed superficial and deep perivascular lymphohistiocytic infiltrate with plasma cells and occasional eosinophils. The dermis is thickened with sclerosis and hylanization of collagen bundles. As the lesion ages, the dermis becomes more sclerotic, and the inflammatory infiltrate begins to disappear. Morphea may resolve spontaneously after months to years, leaving pigmentary or atrophic changes, or both. Data about treatment are inconsistent. Early lesions and lesions associated with acrodermatitis chronica atrophicans have responded to antibiotics, and some late lesions have STOPPED PROGRESSING when treated.
    "Atrophoderma of Pasini and Pierini is rare and probably an atrophic variant of morphea. Spirochetes have been cultured from one lesion. Atrophoderma, a lesion of dermal atrophy progressing to sclerosis, presents as a grey or pigmented lesion with sharp peripheral margins that appear to drop into a depression. Atrophoderma appears most often on the back. A histologic examination done early in the course of the lesion will show a mild diffuse lymphocytic infiltrate and a slight thickening of collagen bundles. As lesions age, the inflammatory infiltrate may disappear
    and the thickened collagen bundles may increase, appearing tightly packed. Data on therapy are not currently available.......
    "Conclusion----
    "The diagnosis of Lyme disease is based on recognizing the characteristic clinical presentations. Serologic testing is an adjunct to clinical diagnosis. Primary and secondary erythema migrans, Borrelia lymphocytoma, and acrodermatitis chronica atrophicans are characteristic dermatologic lesions that establish the diagnosis of Lyme diseasse. Less specific cutaneous manifestations of Lyme disease include benign lymphocytic infiltration, morphea, lichen sclerosis et atrophicus, eosinophilic fasciitis, and progressive facial hemiatrophy................Recognizing and treating the cutaneous manifestations of Lyme disease is INVALUABLE for preventing progression of this multisystem infection."

    from: California Lyme Disease Symposium 1994
    Lyme Disease Resource Center of California
    reported by Jean Hubbard

    "Dermatologic Manifestations of Lyme Disease------

    "Dermatologist Rudy Scrimenti, the first physician to identify EM in the United States, noted that cutaneous manifestations of Lyme disease have served as hallmarks of the disease., but agreed with Dr. Katzel that 'the classical lesion with central clearing and red bands, although most diagnosable and most readily recognizable, is far from being the most common lesion of EM, with triangular lesions being quite common..' .....There is another lesion with varieagated redness throughout, but in the central portion there are blisters or vesicles. Sometimes these become crusted and highly inflammed. When inflammatory changes occur in EM they are always focally placed in the central portion and not throughout the lesion. They will eventually scale, but scaling occurs only in the center and is not a particularly consipicuous feature at the peripheral margins. 90% of the cultures are negative in such lesions, and one of the reasons is that some of the inflammatory lesions probably show a hypersensitivity reaction to the tick parts, possibly to the tick salivary gland substances......
    "There are Lyme disease rashes of sorts not yet documented well in the United States, but present in Europe. These include a reddened breast nipple areola, which is a Lyme borrelial lymphocytoma: this is the most common location in adults, males and females. The most common site in children is the lobe of the ears.; thus far this has not been successfully cultured in the United States. " (this might have changed at this time) " Coalescent papules on the entire rim of the auricle are also compatible with lymphocytoma. There are also lymphocytomas that remain, sometimes for years, after the more typical EM rash resorbs; these do improve with tetracycline and I am SURE I HAVE SEEN THESE IN MY PRACTICE IN WISCONSIN, but thus far I've been unable to obatain a positive culture. The most important alternative diagnosis for such lymphocytomas are malignant lymphoma........"

    ".....The differential diagnosis of erythema migrans includes cellulitis , tinea, (ringworm) contact dermatitis, fixed drug reaction. granuloma annulare, reaction to an insect bite, or a Brown recluse spider bite (48)...."


    From Lyme Disease 1991
    Patient/Physician Perspectives from the U.S. and Canada

    Skin Manifestations of Lyme Disease by John Drulle M.D.

    "Since Lyme disease is a widely disseminated, multi-organ system disease, skin involvement is common, and occurs in about half of those infected.......

    "The pathognomonic (diagnostic) rash of early Lyme is called EM(erythema migrans--in Latin LErythema means redness, and migrans means migratory or expanding). It usually appears at the site of the tick, flea, fly, or mosquito bite several days to a year or more later. (It was recently reported that 18% of the cases of Lyme in Austria are due to bites of non-tick vectors such as flies and perhaps mosquitos. Borrelia burgdorferi -Lyme spirochete- has been isolated from these insects.) The fact that one half of people who develope Lyme do not recall a tick bite may be partially explained by non-tick vectors. The EM rash is usually circular or oval, but irregularly shaped rashes are common. They may spread or enlarge rapidly, but we have seen where pressure on the skin from a tight garment impedes the progression of the rash causing irregularity of shape. There may or may not be central clearing, and concentric rings of different shades are often seen within the rash. There may be necrosis (death of areas of tissue) or a blue violet shading at the site of the bite. These rashes are rarely painful, as brown recluse spider bites almost always are, and often itch. They are usually warm to the touch. The rash may be completely flat, but occasionally the edges may be elevated and be scaly or contain vesicular components. Ten variations of the EM rash have been described by Dr Alan McDonald. Some of these are very recognizable or "classic" in their appearance, but others may be confused with other common skin infections such as ringworm, cellulitis, erythema multiforme, eczema, or hives.

    "......I feel that the best approach in an endemic area would be to assume that the rash is Lyme and treat accordingly. It's better to err on the side of overdiagnosis than to miss the diagnosis and have it haunt you months or years later." (my own words-this Dr. obviously has a conscience) " Waiting for other symptoms to develope may delay treatment and result in persistence of symptoms or even more serious problems in the future.

    "........I must note that a treatment effective in one person may not work in another. This is generally true for any particular symptom of Lyme.

    "Another type of chronic Lyme rash we have seen, occurs in some small
    children. These tend to be widely disseminated, blotchy plaques, pink in color. They do not spare the face. They have been seen in children born with Lyme, especially if the mother was a bit late in pregnancy. These rashes are usually misdiagnosed as eczema, and they do not respond to topical or systemic steroids. They do respond quite well to oral or IV antibiotics ....

    "In summary, I believe the current official description of Lyme skin manifestations is quite incomplete. We are anxiously awaiting the PCR test to become more readily available, since I feel that we will find evidence of active infection in many of these chronic skin rashes."

    Update to Lyme Disease 1991 4/93
    A new "telltale rash" of Lyme disease: " A blistering rash easily mistaken for poison ivy, an allergic reaction, herpes simplex or a variety of other conditions is also associated with Lyme" (from an article by Dr. Neil CKKGoldberg et al., Nov. 1992 Archives of Dermatology.)

    --- SoupGate-Win32 v1.05
    * Origin: fsxNet Usenet Gateway (21:1/5)
  • From lipanj7@21:1/5 to georgia on Mon Jul 12 01:53:57 2021
    On Sunday, April 3, 2016 at 1:51:15 PM UTC-4, georgia wrote:
    OLD POST
    Here are some references about the different skin manifestations.

    ".....The differential diagnosis of erythema migrans includes cellulitis , tinea, (ringworm) contact dermatitis, fixed drug reaction. granuloma annulare,
    reaction to an insect bite, or a Brown recluse spider bite (48)...."

    from: Clinical Manifestations of Lyme Disease in the United States authors: Trock, et al
    Source: Connecticut Medicine June 1989 Volume 53, No. 6
    "....Although the bite (and subsequent erythema migrans) may occur
    anywhere, the tick has a predilection for the thigh, groin, or axilla. Facial erythema migrans is more common among children. Atypical forms of erythema migrans occur: ealy lesions may have indurated or vesicular centers , or MIMIC
    STREPTOCOCCAL OR STAPHYLOCCAL CELLULITIS. Central necrosis also may occur
    and be misdiagnosed as a bite of the brown-recluse spider. Rarely, transient eruptions are seen in early Lyme disease and include, maculopapular rashes, urticaria, " (hives)"malar rash, septal panniculitis (erythema nodosum), and/or
    localized granuloma annulare. Although B. burgdorferi has been isolated from the perimeter of erythema migrans, skin biopsy is a low-yeild procedure. Histologically, erythema migrans has a non-specific appearance with a perivascular infiltrate comprised of lymphocytes, plasma cells, eosinophils, and histiocytes.
    " In addition to erythema migrans, many patients with early disease will
    have a flu-like syndrome characterized by fatigue, fever, malaise, headache, arthralgias, myalgias, regional or generalized lymphadenopathy, and/or conjunctivitis." My LLD said that conjunctivitis in both eyes is a as diagnostic of Lyme as a bull's eye rash. "One-third of patients will have such
    symptoms in the absence of erythema migrans. These symptoms are typically intermittent and changing, with the exception of fatigue, which is often persistent and may be debilitating. Right upper-quadrant tenderness and a mild
    hepatitis may occur (hepatitis has also been reported in later disease), as well as cases of rare myositis "- maybe rarely recognized- " and adult respiratory distress syndrome. During this early phase of disease, laboratory findings are nonspecific........."

    from: Annals of Internal Medicine--Vol. 114--Number 6--March 15, 1991 pg. 490-498
    title: Diagnosis of Lyme Disease Based on Dermatologic Manifestations authors: Malane, MD, et al

    "Erythema migrans occurs in 60 to 83 % of patients with Lyme disease
    (8-10). Classic erythema migrans starts as a red macule or papule at the site of the tick bite, which then expands, forming an erythematous, annular lesion with partial clearing center (11, 42). An erythematous central punctum or a larger macule will often remain at the bite site. Many patients with erythema migrans are unable to recall the tick bite. The lesion is generally found in body areas where ticks characteristically feed. Such areas include those where
    tight fitting clothing begins (for example at underwear lines ) and interiginous" (superficial inflammation of two skin surfaces taht are in contact) "locations such as the axilla, groin, thigh, and buttocks (11). Ticks
    infrequently feed on the palms, the soles, or the mucous membranes, Erythema migrans begins approximately 3 to 30 days after a tick bite (11, 12, 42) The inflamed border will migrate cenrifugally over days to weeks. The average size
    of the lesion is 15 cm, but lesions as large as 68 cm in diameter have been reported (11). Erythema migrans is usually flat; however , the edges may be elevated or indurated (11, 42). Although erythema migrans is usually asymptomatic , burning, prutitus" (itchy)", pain, tenderness, hyperesthesia, or
    dysesthesia may occur (11, 12, 12, 43). In more than 50% of patients, the lesion is associated with a flu-like illness characterized by fever, myalgia, arthralgias, malaise, fatigue or headache(11, 43). When left untreated, the lesion fades weeks to months later, with an average duration of 1 month (8, 11,
    12). On fading there may be residual scaling or pigmentary change in the skin (11, 12)..........
    "The histologic findings associated with erythema migans are relatively nonspecific; thus for histopathologic confirmation , the presence of B.burgdoreferi needs to be shown by silver stain, labeled antibody staining or
    culture(23). Spirochetes are most frequently found in the dermis of the advancing margin of the lesion (34, 45) Histopathologic findings in specimens from the periphery of the lesion include a superficial and deep perivascular lymphocitic infiltrate that may contain plasma cells, histiocytes, and, less commonly mast cells or neutrophils. (11, 42, 43, 45). Histopathologic findings
    in specimens from the center of the lesion are consistent with a reaction to an
    arthropod bite, with eosinophils within the dermal infiltrate. Occasionaly vasculitis" (patchy inflammation of walls of small blood vessles)" or vesicular" (having blisters)" changes are also seen(11). "Other, less
    classic presentations of the erythema migrans are common. The central area of the lesion may show equal or greater erythema than the periphery(11, 13, 43). A European study (12) found that the homogeneous erythematous lesions persist for shorter duration than those with central clearing. An erythema migrans lesion can have alternating rings of erythema and clearing, thereby creating target configuration(11). Additionally, the central portion of the erythema migrans lesion may show blue discoloration or frank purpura,"(a skin rash resulting from bleeding into the skin from small blood vessles-capillaries; the individual purple spots of the rash are called petechiae.)" induration, "(hardening) "vesiculation," (blistering)" necrosis," (death of cells in organ
    or tissue) "or ulceration (11-13, 43, 44, 46) . Uncommonly, petechiae, have also been seen within erythema migrans lesions (46). Lesions may also have different shape or textures. Lesions may appear oval or triangular in shape, especially when they follow the lines of the clevage.
    (Langer lines ) or are in intertriginous areas (34, 43, 47). Lesions may also be more linear in configuration, especially when located on the scalp or when expanding on an extremity (11,47). Scaling has been identified occasionally on
    some lesions (13, 34, 43, 47).....The differential diagnosis of erythema migrans includes cellulitis , tinea, (ringworm) contact dermatitis, fixed drug
    reaction. granuloma annulare, reaction to an insect bite, or a Brown recluse spider bite (48).

    Secondary (Multiple) Erythema Migrans Lesions
    "One or more secondary erythema migrans lesions may develop. Secondary erythema migrans can appear within several days to weeks after onset of the initial erythema migrans lesion and has been reported in 6% to 48% of patients
    with Lyme disease (11, 12, 43). Secondary erythema migrans may result from spirochetemia" (spirochetes in the blood)" or lymphatic spread and subsequent seeding of the skin.
    (49). Lesions often occur at sites away from the original lesion, but a single
    secondary lesion may occur at the site of a primary lesion that has disappeared. When many lesions are present, they can become confluent " (meeting) "or intersecting, forming complicated patterns. The secondary lesions
    are often similar to the intial erythema migrans lesion, but they tend to lack
    indurated centers. (11). Secondary lesions are often asymptomatic. If untreated, the lesions usually disappear within a month, but they may persist for months to over a year, or there may be relapses. In patients receiving therapy, secondary lesions resolve over several days (11). The differential diagnosis of secondary erythema migrans includes erythema multiform, erythema annulare cetrifugum, secondary syphilis, erythema marginatum, and drug reaction..."
    Acrodermatitis Chronica Atrophicans
    "Acrodermatitis Chronica Atrophicans is a unique late complication of Lyme disease, which was first recognized in 1883 (54) . .......It has been reported
    as the first manifestation of Lyme disease; for example, one asymptomatic patient, on screening had a high serum titer of B. burgdorferi antibodies and he developed acrodermatitis chronica atophicans 4 years later (13, 54, 56)....Classically, there is an intial erythematous or violaceous discoloration
    in doughy and swollen skin, appearing as plaques or nodules (13, 54). ....The lesion expands and may have a waxing and waning course ((13, 58). This stage will continue for weeks to years before becoming atrophic......There may be hypopigmentation or hyperpignmentation as well as scaling (54, 57). The lesion
    may be associated with pain, pruritis,"(itching)" hyperesthesias, or paresthesias (55, 57)." (esthesia--from Taber's Cyclopedic Medical Dictionary--
    1. Perception ; feeling; sensation 2. Any disease that affects sensations and perceptions.----para is a prefix meaning near, beside, past, opposite, abnormal, irregular, two like parts-----hyper is a prefix meaning above, excessiive or beyond) "Regional lymphadenopathy," (a disease of the lymph nodes---pathy is a combining form indicating disease.---While I was looking this up I noticed that Taber's 18 th edition has a computer glossary included.)
    " as well as neurological and musculoskeletal signs or symptoms, may be localized to the same extremity as the acrodermatitis chronica atrophicans lesion (13, 57). An associated sclerotic or fibrotic lesion may be found in patients with acrodermatitis chronica atrophicans (13, 28, 57). The differential diagnosis includes thrombophlebitis, venous insufficiency, eczematous dermatitis, cold injury or aging......

    "Fibrotic lesions, such as ulnar (or tibial) bands and ulnar nodules, have been asssociated with acrodermatitis chronica atrophicans lesions....Ulnar (or
    tibial ) bands are fibrotic, dense, linear bands taht occur in association with
    atrophic plaques over the respective bones. .......periarticular fibrous nodules ...These nodules can be confused with rheumatoid nodules, gouty tophi,
    or erythema nodosum, especially if the acrodermatitis achronica atrophicans lesion has gone unnoticed. (13).......

    ".......Morphea (Localized Scleroderma) and Other Scleradermatous Lesions "Various types of sclerotic lesions, which are characterized by a thickened dermis, develope in about 10% of... patients with acrodermatitis chronica atrophicans and Borrelia lymphocytoma........Sclerodermatous lesions were first
    reported in association with acrodermatitis chronica atrophicans in the 1930's.
    The best described of these lesions are those that are both clinically and pathologically identical to morphea (localized scleroderma). Even Morphea lesions that occur in patients without
    a history of Borrelia lymphocytoma or acrodermatitis chronica atrophicans may be of spirochetal origin;..........
    "Plaque-type morphea" ( from Mosby's Medical, Nursing and Allied Health dictionary.
    Morphea--localized scleroderma consisting of patches of yellowish or ivory-colored, rigid, dry, smooth skin. It is more common in females. Also called Addison's keloid, circumscribed scleroderma localized scleroderma.) "manifests as a well-demarcated, indurated, round or
    oval plaque with two stages. It begins as an edematous, erythematous lesion that may have a violaceous or lilac tinged border. As the lesion ages, it becomes a sclerotic plaque with a smooth and shiny surface that is white or yellow in the center. The lesions can expand in size and are found on the trunk or extremities. Although they are often painless, they have been associated with dysesthesias, hypoesthesias, and hyperesthesias. Biopsy specimens taken from the early lesion, especially from the violaceous border, show a mixed superficial and deep perivascular lymphohistiocytic infiltrate with plasma cells and occasional eosinophils. The dermis is thickened with sclerosis and hylanization of collagen bundles. As the lesion ages, the dermis
    becomes more sclerotic, and the inflammatory infiltrate begins to disappear. Morphea may resolve spontaneously after months to years, leaving pigmentary or
    atrophic changes, or both. Data about treatment are inconsistent. Early lesions and lesions associated with acrodermatitis chronica atrophicans have responded to antibiotics, and some late lesions have STOPPED PROGRESSING when treated.
    "Atrophoderma of Pasini and Pierini is rare and probably an atrophic
    variant of morphea. Spirochetes have been cultured from one lesion. Atrophoderma, a lesion of dermal atrophy progressing to sclerosis, presents as
    a grey or pigmented lesion with sharp peripheral margins that appear to drop into a depression. Atrophoderma appears most often on the back. A histologic examination done early in the course of the lesion will show a mild diffuse lymphocytic infiltrate and a slight thickening of collagen bundles. As lesions
    age, the inflammatory infiltrate may disappear
    and the thickened collagen bundles may increase, appearing tightly packed. Data
    on therapy are not currently available.......
    "Conclusion----
    "The diagnosis of Lyme disease is based on recognizing the characteristic clinical presentations. Serologic testing is an adjunct to clinical diagnosis.
    Primary and secondary erythema migrans, Borrelia lymphocytoma, and acrodermatitis chronica atrophicans are characteristic dermatologic lesions that establish the diagnosis of Lyme diseasse. Less specific cutaneous manifestations of Lyme disease include benign lymphocytic infiltration, morphea, lichen sclerosis et atrophicus, eosinophilic fasciitis, and progressive facial hemiatrophy................Recognizing and treating the cutaneous manifestations of Lyme disease is INVALUABLE for preventing progression of this multisystem infection."

    from: California Lyme Disease Symposium 1994
    Lyme Disease Resource Center of California
    reported by Jean Hubbard

    "Dermatologic Manifestations of Lyme Disease------

    "Dermatologist Rudy Scrimenti, the first physician to identify EM in the United
    States, noted that cutaneous manifestations of Lyme disease have served as hallmarks of the disease., but agreed with Dr. Katzel that 'the classical lesion with central clearing and red bands, although most diagnosable and most
    readily recognizable, is far from being the most common lesion of EM, with triangular lesions being quite common..' .....There is another lesion with varieagated redness throughout, but in the central portion there are blisters or vesicles. Sometimes these become crusted and highly inflammed. When inflammatory changes occur in EM they are always focally placed in the central
    portion and not throughout the lesion. They will eventually scale, but scaling
    occurs only in the center and is not a particularly consipicuous feature at the
    peripheral margins. 90% of the cultures are negative in such lesions, and one of the reasons is that some of the inflammatory lesions probably show a hypersensitivity reaction to the tick parts, possibly to the tick salivary gland substances......
    "There are Lyme disease rashes of sorts not yet documented well in the United States, but present in Europe. These include a reddened breast nipple areola, which is a Lyme borrelial lymphocytoma: this is the most common location in adults, males and females. The most common site in children is the lobe of the
    ears.; thus far this has not been successfully cultured in the United States. "
    (this might have changed at this time) " Coalescent papules on the entire rim of the auricle are also compatible with lymphocytoma. There are also lymphocytomas that remain, sometimes for years, after the more typical EM rash
    resorbs; these do improve with tetracycline and I am SURE I HAVE SEEN THESE IN
    MY PRACTICE IN WISCONSIN, but thus far I've been unable to obatain a positive culture. The most important alternative diagnosis for such lymphocytomas are malignant lymphoma........"

    ".....The differential diagnosis of erythema migrans includes cellulitis , tinea, (ringworm) contact dermatitis, fixed drug reaction. granuloma annulare,
    reaction to an insect bite, or a Brown recluse spider bite (48)...."


    From Lyme Disease 1991
    Patient/Physician Perspectives from the U.S. and Canada

    Skin Manifestations of Lyme Disease by John Drulle M.D.

    "Since Lyme disease is a widely disseminated, multi-organ system disease, skin
    involvement is common, and occurs in about half of those infected.......

    "The pathognomonic (diagnostic) rash of early Lyme is called EM(erythema migrans--in Latin LErythema means redness, and migrans means migratory or expanding). It usually appears at the site of the tick, flea, fly, or mosquito
    bite several days to a year or more later. (It was recently reported that 18% of the cases of Lyme in Austria are due to bites of non-tick vectors such as flies and perhaps mosquitos. Borrelia burgdorferi -Lyme spirochete- has been isolated from these insects.) The fact that one half of people who develope Lyme do not recall a tick bite may be partially explained by non-tick vectors.
    The EM rash is usually circular or oval, but irregularly shaped rashes are common. They may spread or enlarge rapidly, but we have seen where pressure on
    the skin from a tight garment impedes the progression of the rash causing irregularity of shape. There may or may not be central clearing, and concentric rings of different shades are often seen within the rash. There may
    be necrosis (death of areas of tissue) or a blue violet shading at the site of
    the bite. These rashes are rarely painful, as brown recluse spider bites almost always are, and often itch. They are usually warm to the touch. The rash may be completely flat, but occasionally the edges may be elevated and be
    scaly or contain vesicular components. Ten variations of the EM rash have been
    described by Dr Alan McDonald. Some of these are very recognizable or "classic" in their appearance, but others may be confused with other common skin infections such as ringworm, cellulitis, erythema multiforme, eczema, or hives.

    "......I feel that the best approach in an endemic area would be to assume that
    the rash is Lyme and treat accordingly. It's better to err on the side of overdiagnosis than to miss the diagnosis and have it haunt you months or years
    later." (my own words-this Dr. obviously has a conscience) " Waiting for other
    symptoms to develope may delay treatment and result in persistence of symptoms
    or even more serious problems in the future.

    "........I must note that a treatment effective in one person may not work in another. This is generally true for any particular symptom of Lyme.

    "Another type of chronic Lyme rash we have seen, occurs in some small children. These tend to be widely disseminated, blotchy plaques, pink in color. They do not spare the face. They have been seen in children born with Lyme, especially if the mother was a bit late in pregnancy. These rashes are usually misdiagnosed as eczema, and they do not respond to topical or systemic
    steroids. They do respond quite well to oral or IV antibiotics ....

    "In summary, I believe the current official description of Lyme skin manifestations is quite incomplete. We are anxiously awaiting the PCR test to become more readily available, since I feel that we will find evidence of active infection in many of these chronic skin rashes."

    Update to Lyme Disease 1991 4/93
    A new "telltale rash" of Lyme disease: " A blistering rash easily mistaken for
    poison ivy, an allergic reaction, herpes simplex or a variety of other conditions is also associated with Lyme" (from an article by Dr. Neil CKKGoldberg et al., Nov. 1992 Archives of Dermatology.)

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