What is the recommended treatment for erythema migrans?

From the Guidelines

The recommended treatment for erythema migrans is oral doxycycline, typically 100 mg twice daily for 10 days, as it is the most effective option with moderate-quality evidence. Alternative antibiotics include amoxicillin (500 mg three times daily) or cefuroxime axetil (500 mg twice daily) for 14 days, which are preferred for children under 8, pregnant women, or those with doxycycline allergies 1.

Key Considerations

• Treatment should begin promptly upon diagnosis, as early intervention prevents progression to later stages of Lyme disease.
• Erythema migrans is the characteristic expanding "bull's-eye" rash that appears at the site of a tick bite infected with Borrelia burgdorferi bacteria.
• The rash typically appears 3-30 days after the bite and may be accompanied by flu-like symptoms.
• Doxycycline is preferred because it effectively targets the spirochete bacteria and has good tissue penetration.
• Most patients experience resolution of symptoms within a few days of starting antibiotics, though the rash may take up to 2 weeks to completely disappear.
• No follow-up testing is typically needed if symptoms resolve with treatment 1.

Special Populations

• For children under 8, pregnant women, or those with doxycycline allergies, amoxicillin or cefuroxime axetil are recommended alternatives.
• Azithromycin may be used as a second-line agent, but its effectiveness is lower compared to doxycycline, amoxicillin, or cefuroxime axetil 1.

Duration of Treatment

• A 10-day course of doxycycline or a 14-day course of amoxicillin or cefuroxime axetil is recommended, as longer treatment courses do not provide additional benefits 1.

From the FDA Drug Label

Two adequate and well-controlled studies were performed in patients with early Lyme disease. In these studies all patients had to present with physician-documented erythema migrans, with or without systemic manifestations of infection Patients were randomized in a 1:1 ratio to a 20-day course of treatment with cefuroxime axetil 500 mg twice daily or doxycycline 100 mg 3 times daily.

The recommended treatment for erythema migrans is cefuroxime axetil 500 mg twice daily for 20 days or doxycycline 100 mg 3 times daily for 20 days 2.

• Cefuroxime axetil and doxycycline were effective in preventing the development of sequelae of late Lyme disease.
• The efficacy of cefuroxime axetil was comparable to doxycycline in treating early Lyme disease.

From the Research

Treatment Options for Erythema Migrans

• The recommended treatment for erythema migrans includes antibiotics such as doxycycline, amoxicillin, or cefuroxime axetil 3, 4, 5, 6, 7.
• Doxycycline is the primary treatment recommendation for erythema migrans, with a typical treatment duration of 10 days 3, 6.
• A study found that 7 days of oral doxycycline is non-inferior to 14 days in adults with solitary erythema migrans, allowing for less antibiotic exposure 3.
• Amoxicillin and cefuroxime axetil are also effective treatments for erythema migrans, with a typical treatment duration of 20 days 4, 5, 7.
• Cefuroxime axetil has been shown to be well tolerated and equally effective as doxycycline in the treatment of early Lyme disease 7.

Treatment Duration and Efficacy

• A study compared the efficacy of 10-day and 15-day doxycycline treatment in adult European patients with erythema migrans, finding that the 10-day regimen was not inferior to the 15-day regimen 6.
• Another study found that 20 days of oral doxycycline, amoxicillin, or cefuroxime axetil was effective in treating erythema migrans, with a satisfactory clinical outcome achieved in 90-95% of patients 4, 7.
• The efficacy of treatment is typically assessed based on clinical observations and microbiologic tests, with follow-up evaluations at 2,6, and 12 months after treatment 3, 6.

Special Considerations

• Children with erythema migrans can be treated with amoxicillin or cefuroxime axetil, as doxycycline is usually avoided in children due to toxicity 5.
• Patients with Lyme arthritis may require longer treatment durations, typically 28 days of oral doxycycline or amoxicillin 4.
• Antibiotic therapy for more than 8 weeks is not indicated for patients with Lyme disease, and chronic Lyme disease due to antibiotic-resistant infection has not been demonstrated 4.