Tick Bites and Lyme Disease: How to Prevent Them and What to Do If You Find a Tick

Clinical presentation

An attached tick should be removed as soon as possible. However, finding a tick does not mean that someone has Lyme disease and does not, by itself, justify prescribing antibiotics. Here are six practical questions on how to prevent, recognise and manage these situations.

1. What is Lyme disease and what complications can it cause?

Lyme borreliosis is an infection caused by spirochetes belonging to the Borrelia burgdorferi complex, transmitted by certain tick species of the genus Ixodes. Its most characteristic early manifestation is erythema migrans: a reddish patch that gradually expands, appears days or weeks after the tick bite and does not necessarily have the classic bull’s-eye appearance.

Manifestation	Clinical findings	Clinical significance
Early cutaneous	Erythema migrans, sometimes accompanied by fatigue, headache, myalgia or arthralgia.	If the lesion is typical and the exposure is compatible, the diagnosis is clinical; do not wait for serology results.
Neurological	Facial palsy, painful radiculoneuritis, neuropathy or meningitis.	Requires specific investigation and treatment; some presentations can be serious.
Cardiac	Palpitations, breathlessness, presyncope or syncope; cardiac conduction disturbances.	Significant conduction block may require hospital admission and monitoring.
Articular	Arthritis, usually with obvious swelling of a large joint.	Requires a longer course of treatment than early cutaneous disease.

Diagnostic pearl: in typical erythema migrans, serology may be negative in the early stages. Do not delay treatment while awaiting serology, and do not order it routinely after a tick bite in an asymptomatic patient.

2. Which areas of Spain have the highest risk?

Risk is particularly concentrated in humid, wooded areas of northern mainland Spain, especially in Galicia and the Basque Country, with additional localised foci in Asturias, Cantabria, Navarre, the Pyrenees and other mountainous areas.

Do not equate “northern Spain” with “an area of high Lyme endemicity”. Exposure must be assessed locally: municipality, environment, presence of Ixodes ricinus, repeated detection of Borrelia and locally acquired human cases. Simply finding ticks, or living in a particular autonomous community, is not sufficient to justify prophylaxis.

What indicates local epidemiological risk?

1Vector

Presence of Ixodes ricinus, particularly nymphs, in local surveillance.

2Circulation of Borrelia

Repeated detection of the bacterium in ticks from the area.

3Human cases

Documented locally acquired disease, together with compatible habitat and exposure.

Conceptual diagram, not an endemicity map or a validated scoring system.

3. How can tick bites be prevented?

Infographic · Before, during and after outdoor activities

1BEFORE

Use clear paths; tuck long trousers into socks or boots; wear long sleeves, closed shoes and light-coloured clothing. Apply an approved tick repellent (DEET, icaridin/picaridin or IR3535) according to the product label.

2DURING

Avoid tall grass, scrub and leaf litter. Check your skin and clothing regularly, especially if you frequently brush against vegetation.

3AFTERWARDS

Perform a full-body tick check and shower, preferably within 2 hours. Wash or tumble-dry clothing using heat; check backpacks, footwear and pets.

For children, during pregnancy and in other special circumstances, strictly follow the repellent’s age restrictions and directions for use. Anti-tick bracelets have not been shown to be sufficiently effective.

4. Where and how should we look for ticks?

A tick bite may go unnoticed. Checks should be systematic and cover the whole body, using a mirror or another person’s help for areas that are difficult to see.

Infographic · Areas not to overlook

Scalp and hairline

Behind the ears

Armpits

Navel and waist

Groin

Behind the knees

Under socks

Skin folds and other hidden areas

In children: pay special attention to the head and neck

Also check clothing, shoes, backpacks and pets.

5. If we find an attached tick, how should we remove it?

The method recommended by the IDSA/AAN/ACR and AHA/American Red Cross guidelines is to remove it immediately using mechanical traction with fine-tipped tweezers or a dedicated tick-removal device.

Infographic · Five steps

1. Wash your hands and, if possible, clean the tweezers.
2. Place the tweezer tips between the skin and the tick’s body, gripping the mouthparts or the point of attachment, not the abdomen.
3. Pull straight upwards, slowly and steadily, with even pressure; do not twist or jerk.
4. Check that the tick has been completely removed.
5. Clean the bite area and your hands; record the date and location of exposure.

What NOT to do: do not burn the tick, apply oil, petroleum jelly, alcohol or other substances to make it detach, crush it or pull abruptly.

What about removing a tick by rotating it with a finger? Bucher and Gaide describe this technique in a brief dermatology report (published in 2026). It is interesting, but it should not be presented as equivalent to the guideline-recommended technique: the report is not a robust clinical comparison, and first-aid guidelines favour fine-tipped tweezers.

What should we watch for afterwards?

Over the following 4–6 weeks, watch for an expanding skin lesion, fever, headache, myalgia, arthralgia or general malaise. A mild local reaction that subsides within 24–48 hours is not the same as erythema migrans.

Urgent medical assessment: syncope, breathlessness, chest pain, confusion, marked neck stiffness, significant neurological symptoms or rapid deterioration. High fever, a widespread rash or a black eschar should also prompt consideration of other tick-borne diseases.

6. When and how should we treat?

It is essential to distinguish prophylaxis after a tick bite in an asymptomatic person from treatment of an established infection.

A. Asymptomatic tick bite: doxycycline prophylaxis?

Routine prophylaxis is not recommended. According to the US IDSA/AAN/ACR guidelines, a single dose may only be considered when all the following high-risk criteria are met:

Algorithm · Prophylaxis after a tick bite

Tick removed · ASYMPTOMATIC patient

↓

Was the tick identified as a vector species of Ixodes AND did the bite occur in a highly endemic local area AND was the tick attached for ≥36 hours AND has it been ≤72 hours since removal?

↓

NO / CANNOT BE CONFIRMEDNo routine prophylaxis. Document the exposure, counsel the patient and monitor for symptoms.

YES, ALL CRITERIA METConsider doxycycline on an individual basis as a single dose, after reviewing contraindications and local guidance.

If symptoms develop → this is no longer prophylaxis: clinical assessment and treatment according to the suspected disease.

Teaching adaptation of the 2020 IDSA/AAN/ACR guidelines. European recommendations vary, and some advise against routine prophylaxis; decisions in Spain should be individualised.

Prophylaxis after a high-risk tick bite	Regimen	Conditions
Adults	Doxycycline 200 mg orally, once	Administer within 72 hours of tick removal; assess tetracycline allergy, pregnancy, breastfeeding, drug interactions and adverse effects. Prophylaxis does not replace monitoring.
Children	Doxycycline 4.4 mg/kg orally, once (maximum 200 mg)

The single-dose recommendation comes from the IDSA/AAN/ACR guidelines; it is not a universal indication for tick bites in Spain. Take with plenty of water and not immediately before lying down, to reduce the risk of oesophagitis.

What NOT to order after an asymptomatic tick bite: routine Borrelia serology or microbiological testing of the tick to determine whether the person is infected. Identifying the tick species may help assess risk.

B. What if erythema migrans or compatible symptoms are already present?

Typical erythema migrans in the appropriate epidemiological setting is a clinical diagnosis and should be treated without waiting for serology results. The following regimens are those recommended for early localised Lyme disease (erythema migrans) by the IDSA/AAN/ACR guidelines:

Antibiotic	Adults	Children	Duration
Doxycycline	100 mg orally every 12 hours	4.4 mg/kg/day in 2 divided doses (max. 200 mg/day)	10 days
Amoxicillin	500 mg orally every 8 hours	50 mg/kg/day in 3 divided doses (max. 500 mg/dose)	14 days
Cefuroxime axetil	500 mg orally every 12 hours	30 mg/kg/day in 2 divided doses (max. 500 mg/dose)	14 days

Regimens are taken from Tables 3 and 4 of the 2020 IDSA/AAN/ACR guidelines. Adjust for age, clinical circumstances, allergies, pregnancy, renal function when appropriate and local protocols. Azithromycin is a second-line alternative when the preferred agents cannot be used.

If the disease extends beyond the skin…	Guideline-based approach
Neuroborreliosis without parenchymal involvement	Targeted treatment for 14–21 days, orally or intravenously depending on the manifestation and clinical circumstances.
Lyme carditis	14–21 days; consider admission, ECG and intravenous therapy in severe cases.
Lyme arthritis	Initial oral antibiotic treatment for 28 days.

Remember the differential diagnosis. After a tick bite, high fever, an inoculation eschar or a rash should not automatically be attributed to Lyme disease. The supplied material emphasises that if rickettsiosis is suspected, doxycycline should be started promptly without waiting for laboratory confirmation.

KEY TAKEAWAYS

1. Prevent: protective clothing, approved repellents and full-body tick checks.
2. Remove: as soon as possible with fine-tipped tweezers and steady upward traction.
3. Monitor: an expanding red skin lesion and systemic, neurological, cardiac or joint symptoms.
4. Avoid unnecessary medical intervention: an asymptomatic tick bite does not warrant routine serology or automatic antibiotic use.
5. Treat: prophylaxis only for selected high-risk situations; typical erythema migrans requires a full treatment course.

References

1. Lantos PM, et al. Clinical Practice Guidelines by IDSA, AAN and ACR: 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease. Clinical Infectious Diseases. 2021;72:e1–e48. DOI: 10.1093/cid/ciaa1215.
2. Hewett Brumberg EK, et al. 2024 American Heart Association and American Red Cross Guidelines for First Aid. Circulation. 2024;150:e519–e579. DOI: 10.1161/CIR.0000000000001281.
3. Bucher D, Gaide O. A simple method to remove ticks, no tools needed. J Eur Acad Dermatol Venereol. 2026;40:e187–e188. DOI: 10.1111/jdv.70145.