Letters to the Editor

The Presence of Bull's Eye Lesion Is Not Required to Diagnose Lyme Disease


Am Fam Physician. 2018 Oct 15;98(8):474.

Original Article: Clinical Diagnosis of Lyme Disease Frequently Misses the “Bull's Eye” [POEMs]

Issue Date: April 1, 2018

Available online at: https://www.aafp.org/afp/2018/0401/p474.html

To the Editor: The title of this POEM1 may be misleading about the study and the synopsis appearing in American Family Physician. Specifically, the title suggests that diagnosing Lyme disease requires the bull's eye form of the erythema migrans rash. This suggestion is repeated in the Bottom Line section, which reads, “For children with suspected Lyme disease but without a classic bull's eye lesion (erythema migrans of at least 5 cm), check serology rather than rely on your clinical impression.”

In fact, the research study used the Centers for Disease Control and Prevention's (CDC's) definition of erythema migrans, which does not require a bull's eye lesion. Instead, the key portion of the CDC definition of erythema migrans is “a skin lesion that typically begins as a red macule or papule and expands over a period of days to weeks to form a large round lesion, often with partial central clearing. A single primary lesion must reach greater than or equal to 5 cm in size across its largest diameter.”2 Further, only 4% of the patients in the study had erythema migrans lesions that met the CDC definition.1

Central clearing is not needed to make the diagnosis of Lyme disease. It is often faint in appearance or not present, or it may not appear until the lesion grows larger or until more days have elapsed. A 1996 study found that only 37% of patients with Lyme disease had central clearing,3 and another article demonstrating variations on erythema migrans suggests that central clearing at the time of erythema migrans presentation occurs a minority of the time.4

Author disclosure: No relevant financial affiliations.


show all references

1. Nigrovic LE, Bennett JE, Balamuth F, et al.; Pedi Lyme Net. Accuracy of clinician suspicion of Lyme disease in the emergency department. Pediatrics. 2017;140(6):e20171975....

2. Centers for Disease Control and Prevention. National Notifiable Diseases Surveillance System. Lyme disease (Borrelia burgdorferi). 2017 case definition. https://wwwn.cdc.gov/nndss/conditions/lyme-disease/case-definition/2017/. Accessed June 12, 2018.

3. Nadelman RB, Nowakowski J, Forseter G, et al. The clinical spectrum of early Lyme borreliosis in patients with culture-confirmed erythema migrans. Am J Med. 1996;100(5):502–508.

4. Feder HM Jr, Abeles M, Bernstein M, Whitaker-Worth D, Grant-Kels JM. Diagnosis, treatment and prognosis of erythema migrans and Lyme arthritis. Clin Dermatol. 2006;24(6):509–520.

Editor's Note: This letter was sent to the authors of Clinical Diagnosis of Lyme Disease Frequently Misses the “Bull's Eye,” who declined to reply.


Send letters to afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680. Include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.



Copyright © 2018 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


Sep 2021

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article