Tick Bites and Lyme Disease
How to advise on tick removal, recognise erythema migrans and early Lyme disease, and know when to refer to a GP or A&E.
Why this matters
Lyme disease is the most common tick-borne illness in the UK. Confirmed cases are known to underestimate the true burden, with UKHSA estimates suggesting thousands of cases annually across the UK.1 The tick that transmits it (Ixodes ricinus, the sheep tick, also called the castor bean tick) is found throughout the UK in woodland, heathland, moorland, and parkland, with higher-risk areas including the Scottish Highlands, Lake District, New Forest, South Downs, and Thetford Forest. Cases peak between March and November, with the highest activity in spring and early autumn.
The pharmacist is often consulted immediately after someone discovers a tick, or weeks later when an unexplained rash or illness develops. The most useful thing a pharmacist can do at the counter is: confirm correct tick removal technique, describe erythema migrans (the earliest and most treatable sign of Lyme disease), and make clear that any expanding rash at a bite site requires same-day GP assessment because treatment should not wait for blood test confirmation. Early antibiotic treatment is highly effective; delayed diagnosis leads to more complex disease affecting the joints, nervous system, or heart.2
The UK does not recommend prophylactic antibiotics after a tick bite, unlike North America. This means the pharmacist cannot supply or recommend antibiotics to reduce transmission risk. The correct advice is: correct removal, monitoring for erythema migrans for up to 3 months, and GP referral if a rash appears or symptoms develop.2
Red flags vs more likely benign
| Feature | More likely benign | Red flag ⚠ |
|---|---|---|
| Skin at bite site | Small red mark at bite site fading within 48 hours | Expanding red ring or patch at or near the bite site, appearing 3 days to 3 months after the bite (erythema migrans): refer to GP same-day because treatment should not wait for blood test confirmation |
| Systemic symptoms | None, or mild localised itching only | Fever, fatigue, headache, widespread muscle aches, or migratory joint pain developing days to weeks after a tick bite |
| Nervous system | No neurological symptoms | Stable new facial nerve palsy, limb paraesthesia, or radicular pain after tick exposure: same-day urgent GP or 111 assessment. Severe headache with neck stiffness, altered consciousness, rapidly progressive neurological deficit, or stroke features: call 999 or go to A&E immediately |
| Heart | No cardiovascular symptoms | Palpitations with syncope or near-syncope, chest pain, breathlessness, or collapse after a tick bite: call 999 or arrange immediate A&E assessment (possible Lyme carditis with complete heart block) |
| Joints | No joint involvement | Swollen, painful large joint (particularly knee) weeks to months after a tick bite: refer to GP for Lyme arthritis assessment |
| Tick attachment | Tick removed promptly, appears unengorged | Higher-risk exposure: tick that appeared engorged or was attached for a prolonged period. This does not itself indicate antibiotics if the patient is well with no rash or systemic symptoms, but give clear monitoring advice. Retained mouthparts may cause local irritation; do not dig deeply to remove them |
Think Tick Bites and Lyme Disease if Your Patient Says...
Erythema migrans expanding beyond the immediate bite site is the single most important sign of early Lyme disease and requires same-day GP assessment because treatment should not wait for blood test confirmation.
- "I found a tick on me about two weeks ago and now there is a red ring spreading around where it was."
- "I pulled a tick off but I think it had been there for a couple of days - did I do it right?"
- "I was walking in the New Forest last month and now I have aching joints and I feel exhausted."
- "There is a bruise-like mark on my leg that seems to be getting bigger - I was in the woods last weekend."
- "I had a tick bite a few weeks ago and now my face is drooping on one side."
- "My son found a tick on him but it is still attached - what do I do?"
The bullseye appearance of erythema migrans (red ring with central clearing) is classic but not universal. Many cases appear as a uniform expanding red or pink oval patch. Unlike a simple bite reaction, erythema migrans is not usually itchy, hot or painful, and continues to expand over days. On darker skin tones it may appear as a bruise-like discolouration that expands gradually. Any expanding mark at a bite site warrants same-day GP review.
🛑 TICKS: Assessment Framework
Use for any patient who presents after discovering a tick bite or with a rash or illness following outdoor activity.
Ask how long the tick was attached and how it was removed. The longer a tick remains attached, the greater the potential risk of Lyme disease transmission. Remove it promptly and correctly. Attachment duration alone does not indicate antibiotics in UK practice.3 Twisting, burning, or applying petroleum jelly are incorrect removal methods. If the tick is still attached, advise: fine-tipped tweezers, grasp as close to the skin as possible, pull upward with steady even pressure without twisting.
Ask the patient to show you the bite area if possible. A local bite reaction appears quickly and typically settles within 48 hours. Erythema migrans appears later (3 days to 3 months after the bite), gradually expands over days, and is not usually itchy, hot or painful.2 Advise the patient to photograph the rash in good light and, if safe to do so, mark the edge with pen to show whether it is expanding while awaiting GP assessment.
Ask about fever, fatigue, headache, muscle aches, and joint pain since the bite. These may develop days to weeks later and indicate disseminating infection. Ask specifically about facial drooping, palpitations, syncope, chest pain, breathlessness, and limb numbness or tingling, which suggest neurological or cardiac involvement requiring urgent assessment.
Any expanding red rash at or near a tick bite site is erythema migrans until proven otherwise and requires same-day GP assessment because treatment should not wait for blood test confirmation.2 NICE NG95 states that Lyme disease should be diagnosed clinically in people with erythema migrans. Do not reassure and monitor: early treatment is highly effective.
Call 999 or arrange immediate A&E assessment if the patient has: syncope or near-syncope, chest pain, breathlessness, palpitations with collapse, altered consciousness, severe headache with neck stiffness, rapidly progressive neurological deficit, or stroke features after a tick bite. These may indicate complete heart block or central nervous system infection. Refer for same-day urgent GP or 111 assessment if: new stable facial nerve palsy, limb paraesthesia, radicular pain, or migratory joint pain develops after possible tick exposure and the patient is otherwise well. Children and young people under 18 with symptoms beyond a single erythema migrans lesion need specialist discussion via the GP or urgent paediatric route.
Prophylactic antibiotics after a tick bite are not recommended in the UK. Do not supply or recommend antibiotics to reduce the risk of Lyme disease following a bite, even if the tick was attached for a prolonged period.2 Pharmacy First note: tick bites, presentations suggestive of tick bite, and erythema migrans are excluded from the NHS Pharmacy First infected insect bite PGDs (4a flucloxacillin, 4b clarithromycin, 4c erythromycin) because of Lyme disease risk.6 Do not supply any of these antibiotics under the infected insect bite PGDs for a suspected tick bite or erythema migrans.
Presentations That Are Commonly Missed or Misunderstood
These presentations lead to delayed diagnosis and more complex disease if not recognised early.
- Erythema migrans without a bullseye: the bullseye appearance is classic but not universal. Erythema migrans may appear as a uniform expanding red or pink oval patch, with or without central clearing. Unlike a simple bite reaction, it is not usually itchy, hot or painful and continues to expand over days. On darker skin, the expanding border may be more visible than the central colour change, and the mark may look like an enlarging bruise.
- Lyme disease without a remembered tick bite: ticks in the nymph stage are very small (like a poppy seed) and bites are often painless. Up to a third of patients with confirmed Lyme disease do not recall a tick bite. Do not exclude the diagnosis on this basis.
- Post-exposure anxiety without infection: the majority of tick bites do not transmit Lyme disease, even in endemic areas. A patient who presents immediately after finding a tick, with no rash and no systemic symptoms, needs correct removal advice, a clear description of erythema migrans, and instructions to see a GP if any rash or symptoms develop within 3 months. They do not need antibiotics.
- Tick-borne encephalitis (TBE): rare in the UK but reported in some forested areas of England and Scotland. Presents with a biphasic illness: initial flu-like symptoms followed by neurological features. TBE vaccine is a pre-exposure travel vaccine recommended for people visiting endemic areas overseas, or where specialist travel advice indicates high exposure risk. It is not a treatment after a tick bite. Refer any patient with neurological symptoms following a tick bite in Europe or known UK TBE areas to A&E.4
- Children and young people under 18: children playing in woodland or long grass are a high-exposure group. Parents may not find a tick at all before the child develops a rash. Any child with an unexplained expanding red mark should be seen by a GP same-day. For children and young people under 18 with suspected Lyme disease and symptoms beyond a single erythema migrans lesion, specialist discussion should be arranged via the GP or urgent paediatric route.
- Pharmacy First governance: tick bites, presentations suggestive of tick bite, and erythema migrans are excluded from the NHS Pharmacy First infected insect bite PGDs (4a flucloxacillin, 4b clarithromycin, 4c erythromycin) because of Lyme disease risk.6 Do not supply any of these antibiotics under the infected insect bite PGDs for a suspected tick bite or erythema migrans. Refer and signpost for GP or urgent clinical assessment according to symptoms.
- Do not use private tick testing to guide treatment: testing of removed ticks for Borrelia is not recommended by UKHSA to inform diagnosis or treatment decisions. Diagnosis and treatment decisions are based on clinical symptoms and assessment, not tick test results.
- Tick bite prevention and post-removal advice: after outdoor activity in risk areas, check all skin including the scalp, behind ears, armpits, groin, and behind knees. Check children thoroughly. Remove attached ticks promptly using fine-tipped tweezers. After removal, clean the bite site with antiseptic or soap and water. Use DEET-based insect repellent, wear long sleeves and trousers tucked into socks, and stay on paths where possible.
- Photograph the rash and mark the border: advise any patient with a mark at a bite site to photograph it in good light and, where safe, draw around the edge with pen. This helps the GP assess whether the rash is expanding at the appointment and supports clinical decision-making.
Blood tests for Lyme disease (ELISA followed by immunoblot if positive) are unreliable in the first few weeks after infection. A negative test in this window does not exclude early Lyme disease. NICE NG95 recommends treating erythema migrans clinically without waiting for serology.2 If early serology is negative but clinical suspicion remains, NICE recommends a repeat ELISA 4 to 6 weeks after the first test.
What to do in pharmacy
Key takeaways
- Any expanding red rash at a tick bite site is erythema migrans until proven otherwise: refer same-day because treatment should not wait for blood test confirmation.
- Prophylactic antibiotics after a tick bite are not recommended in the UK: advise correct removal, describe erythema migrans, and tell the patient to see a GP if a rash appears or systemic symptoms develop within 3 months.
- For neurological or cardiac symptoms after a tick bite, use a two-tier approach: call 999 for collapse, syncope, chest pain, breathlessness, or altered consciousness; refer same-day to GP or 111 for stable facial nerve palsy, paraesthesia, or radicular pain.
📚 References
- UK Health Security Agency. Lyme disease epidemiology and surveillance. London: UKHSA; updated 2024. https://www.gov.uk/guidance/lyme-disease
- National Institute for Health and Care Excellence. Lyme disease. NICE guideline NG95. London: NICE; April 2018. https://www.nice.org.uk/guidance/ng95
- National Institute for Health and Care Excellence. Insect bites and stings. Clinical Knowledge Summary. London: NICE; updated 2023. https://cks.nice.org.uk/topics/insect-bites-stings/
- UK Health Security Agency. Tick-borne encephalitis: guidance, data and analysis. London: UKHSA; 2023. https://www.gov.uk/guidance/tick-borne-encephalitis
- National Institute for Health and Care Excellence. Lyme disease: differential diagnosis. Supporting guidance to NG95. London: NICE; 2018. https://www.gov.uk/guidance/lyme-disease-differential-diagnosis
- NHS England. Pharmacy First: infected insect bite clinical pathway: PGDs 4a (flucloxacillin), 4b (clarithromycin), and 4c (erythromycin). London: NHS England; 2025. https://www.england.nhs.uk/publication/pharmacy-first-clinical-pathways/