Am Fam Physician. 1998 Aug 1;58(2):354-357.
to the editor: A potential complication of tick removal is separation of the tick head from the body with retention of the head in the wound as a source of late infection. Several studies1,2 report a correlation between the duration of tick attachment and the likelihood of transmission of infection. Ticks embed themselves by inserting their hourglass-shaped hypostome (sucker) into the skin of the host and then secreting cement around it.3 When a tick is removed intact, the secreted adhesive material sometimes appears as a translucent white membrane attached to the tick's head. The dominant species of tick varies by geographic region, and some species are more difficult to remove intact than others.4 I suggest a mechanical rotation technique that removes the entire Demacentor variabilis (dog tick) more reliably than other common methods.
Two approaches to tick removal have been described4: (1) application of a noxious stimulus to induce the tick to withdraw spontaneously and (2) mechanical removal. An example of the first approach is suffocation with petroleum jelly. The low respiration rate of the tick (three to 15 times per hour) makes interruption of respiratory gas exchange a slow prospect at best. Touching a recently extinguished match to the abdomen of the tick has also been suggested, but this approach may precipitate regurgitation of infectious material into the host's tissues. I agree with other authors who have not found either of these methods to be reliable. Another unsuccessful approach involves subcutaneous injection of local anesthetic.5 Failure to dislodge ticks using this approach is not surprising since the mechanism of adherence to the host does not depend on a muscular action.
The most frequently reported mechanical method of removal involves grasping the tick thorax with forceps and applying gentle, constant traction.3,5 This “traction” method may leave body parts behind if impatiently applied or if the tick is a fragile variety, and this technique may not be tolerated by children. Some physicians advocate surgical removal of the involved host tissue with the tick by punch biopsy needle.6 This technique would remove the entire tick, but it may be unnecessarily traumatic.
I propose a technique of mechanical removal involving rotation, which may be more reliable for rapid removal of the entire tick, including the head. The tick thorax is gripped delicately with a fine forceps or hemostat. The abdomen should not be squeezed since this may cause regurgitation. Then, being careful not to apply traction to the host's skin, the tick is rotated approximately two revolutions about the long axis of its body. Concomitant rotation and traction, as suggested by some physicians,7 may flex the hypostome, leaving it embedded in the host. Micrography of the tick hypostome indicates a surface textured by rows of conical “denticles” pointing backward.5,11 Shearing forces applied by rotation might be more effective than tensile forces in removing this type of structure intact. My practice has been to rotate the tick counterclockwise, although the directionality or consistency of direction of rotation is probably unimportant.
My success rate of complete live tick removal using the rotational technique has been 100 percent in 23 efforts, compared with about 50 percent in approximately 40 previous attempts in adults, children and domesticated animals. It is important to note that the rotational technique is fast and painless compared with direct traction, which occasionally causes marked discomfort.
In summary, ticks should be removed as soon as possible to reduce the likelihood of transmission of infectious disease. Rotation of the tick without traction may prove to be a superior method to straight traction in facilitating complete removal of the tick.
1. Falco RC, Fish D, Piesman J. Duration of tick bites in a Lyme disease-endemic area. Am J Epidemiol. 1996;143:187–92.
2. Sood SK, Salzman MB, Johnson BJ, Happ CM, Feig K, Carmody L, et al. Duration of tick attachment as a predictor of the risk of Lyme disease in an area in which Lyme disease is endemic. J Infect Dis. 1997;175:996–9.
3. Needham GR. Evaluation of five popular methods for tick removal. Pediatrics. 1985;75:997–1002.
4. Crawford KL. Ticks. Md State Med J. 1971;20:95–6.
5. Lee MD, Sonenshine DE, Counselman FL. Evaluation of subcutaneous injection of local anesthetic agents as a method of tick removal. Am J Emerg Med. 1995;13:14–6.
6. Oteo JA, Martinez de Artola V, Gomez-Cadinanos R, Casas JM, Blanco JR, Rosel L. Evaluation of methods of tick removal in human ixodidiasis [Spanish]. Rev Clin Esp. 1996;196:584–7.
7. Pfenninger JL, Fowler GC. Procedures for primary care physicians. St. Louis: Mosby, 1994.
8. Sixl W, Dengg E, Waltinger H. Scanning electron microscopy studies of ticks. IV. Haemaphysalis inermis Birula, 1895 [German]. Acta Zool Pathol Antverp. 1972;55:67–9.
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