Clinical Treatment of Erythema Migrans Rash

What to know

People treated with appropriate antibiotics in the early stages of Lyme disease usually recover rapidly and completely. Early diagnosis and proper antibiotic treatment of Lyme disease can help prevent late Lyme disease.

Illustration of erythema migrans on different colored skin tones.

Erythema migrans rash

Treatment regimens listed in the following table are for the erythema migrans rash, the most common manifestation of early Lyme disease. These regimens may need to be adjusted depending on a person's age, medical history, underlying health conditions, pregnancy status, or allergies. Consult an infectious disease specialist regarding individual patient treatment decisions.

Treatment regimens for localized (early) Lyme disease.
Age Category Drug Dosage Maximum Duration, Days* References
Adults Doxycycline
OR		 100 mg, twice per day orally N/A 10-14 1 – 6
Amoxicillin
OR		 500 mg, three times per day orally N/A 14 1, 3, 6
Cefuroxime 500 mg, twice per day orally N/A 14 6, 10, 11
Children Doxycycline
OR		 4.4 mg/kg per day orally, divided into 2 doses 100 mg per dose 10–14 7,9
Amoxicillin
OR		 50 mg/kg per day orally, divided into 3 doses 500 mg per dose 14 7,8
Cefuroxime 30 mg/kg per day orally, divided into 2 doses 500 mg per dose 14 8, 10, 11

*When different durations of antibiotics are shown to be effective for the treatment of Lyme disease, the shorter duration is preferred to minimize adverse effects, including infectious diarrhea and antimicrobial resistance.

NOTE: For people intolerant of amoxicillin, doxycycline, and cefuroxime, the macrolide azithromycin may be used, although it is less effective. People treated with azithromycin should be closely monitored to ensure that symptoms resolve.

References

  1. Kowalski TJ, Tata S, Berth W, et al. Antibiotic treatment duration and long-term outcomes of patients with early Lyme disease from a Lyme disease-hyperendemic area. Clin Infect Dis. 2010 Feb 15;50(4):512-20.
  2. Nowakowski J, Nadelman RB, Forseter G, et al. Doxycycline versus tetracycline therapy for Lyme disease associated with erythema migrans. J Am Acad Dermatol. 1995;32(2 Pt 1):223-227.
  3. Smith RP, Schoen RT, Rahn DW, et al. Clinical characteristics and treatment outcome of early Lyme disease in patients with microbiologically confirmed erythema migrans. Ann Intern Med. 2002;136(6):421-428.
  4. Stupica D, Lusa L, Ruzić-Sabljić E,dt al. Treatment of erythema migrans with doxycycline for 10 days versus 15 days. Clin Infect Dis. 2012;55(3):343-350.
  5. Wormser GP, Brady KC, Cho MS, et al. Efficacy of a 14-day course of amoxicillin for patients with erythema migrans. Diagn Microbiol Infect Dis. 2019;94(2):192-194.
  6. Torbahn G, Hofmann H, Rücker G, et al. Efficacy and safety of antibiotic therapy in early cutaneous Lyme borreliosis. JAMA Dermatology 2018;154(11):1292-1303.
  7. Chason M, Monaghan M, Wang J, et al. Symptom resolution in pediatric patients with Lyme disease. J Ped Infect Dis Soc
  8. Eppes S, Childs J. Comparative study of cefuroxime axetil versus amoxicillin in children with early Lyme disease. Pediatrics 2002; 109:1173-1177.
  9. American Academy of Pediatrics. Red Book, 32nd Ed. 2021. Lyme disease (Lyme Borreliosis, Borrelia burgdorferi sensu lato Infection).
  10. Arnez M, Radsel-Medvescek A, Pleterski-Rigler D, et al. Comparison of cefuroxime axetil and phenoxymethyl penicillin for the treatment of children with solitary erythema migrans. Wien Klin Wochenschr. 1999 Dec 10;111(22-23):916-22.
  11. Cerar D, Cerar T, Ruzić-Sabljić E, et al. Subjective symptoms after treatment of early Lyme disease. Am J Med. 2010 Jan;123(1):79-86.
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Content Source:
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)