What is the appropriate management for a recent tick bite, including removal technique, indication for prophylactic doxycycline, and follow‑up care?

Tick Bite Management

Remove the tick immediately with fine-tipped tweezers by grasping as close to the skin as possible and pulling upward with steady pressure, then give prophylactic doxycycline (200 mg single dose for adults, 4.4 mg/kg up to 200 mg for children) ONLY if all three high-risk criteria are met within 72 hours of removal. 1

Immediate Tick Removal Technique

Proper removal method:

• Grasp the tick's head as close to the skin surface as possible using clean fine-tipped tweezers or a comparable tick removal device 1
• Pull upward with steady, even pressure perpendicular to the skin without twisting 2, 3
• Remove the tick as quickly as possible since disease transmission risk increases significantly after 24 hours of attachment 4

What NOT to do:

• Never burn the tick with matches or heat devices 1
• Never apply petroleum jelly, nail polish, gasoline, kerosene, or other chemicals 1, 2
• Never crush the tick with your fingers 2
• These methods can cause the tick to regurgitate infectious material into the wound 5, 4

Post-removal care:

• Clean the bite site thoroughly with soap and water, alcohol, or iodine scrub 2
• If tick mouthparts remain embedded, clean the area and leave them alone—the body will expel them naturally without increasing infection risk 2
• Wash hands thoroughly after handling the tick 2

Antibiotic Prophylaxis Decision Algorithm

Prophylactic doxycycline is indicated ONLY when ALL three criteria are met: 1, 6

1. Tick species identification: The tick is confirmed to be an Ixodes species (deer tick/black-legged tick) 1, 6
2. Geographic location: The bite occurred in a highly endemic area (parts of New England, mid-Atlantic states, Minnesota, Wisconsin with ≥20% tick infection rates) 1, 6
3. Duration of attachment: The tick was attached for ≥36 hours (estimated by degree of engorgement) 1, 6

If ANY criterion is not met with certainty, use a wait-and-watch approach instead of prophylaxis. 1, 7

Dosing when indicated:

• Adults: Single dose of 200 mg oral doxycycline 1, 6
• Children ≥8 years: Single dose of 4.4 mg/kg (maximum 200 mg) 1, 6
• Must be given within 72 hours of tick removal 1, 6, 7

Contraindications:

• Doxycycline is relatively contraindicated in pregnant women and children <8 years old 6, 7
• For these populations meeting high-risk criteria, consider infectious disease consultation 6

Laboratory Testing Guidance

Do NOT test asymptomatic patients:

• Routine serologic testing after a tick bite is NOT recommended for asymptomatic patients 1, 7
• Early antibody testing is unreliable as it takes weeks to develop 7
• Testing provides no clinical benefit and may lead to false positives 7

Do NOT test the tick itself:

• Presence or absence of B. burgdorferi in the tick does not reliably predict clinical infection 7
• However, submitting the tick for species identification is reasonable to help determine if prophylaxis criteria are met 1

Post-Bite Monitoring (Critical for All Patients)

Monitor the bite site and patient for 30 days: 2, 6, 7

Watch for erythema migrans (Lyme disease):

• Expanding "bullseye" or solid red rash at the bite site 2, 7
• If this develops, diagnose clinically without laboratory testing and treat with antibiotics 1, 7
• Treatment: 10-day course of doxycycline OR 14-day course of amoxicillin or cefuroxime axetil 1

Watch for other tick-borne diseases:

• Fever, headache, muscle pain, joint pain 2
• Petechial rash starting on wrists, forearms, and ankles (suggests Rocky Mountain Spotted Fever) 2
• Note that doxycycline prophylaxis may prevent Lyme disease but not necessarily other tick-borne infections 7

Seek immediate medical attention if:

• Erythema migrans develops at any bite site 2
• Systemic symptoms develop (fever, severe headache, muscle aches) 7

Prevention of Future Tick Bites

Repellents (strong recommendation): 1

• Apply EPA-registered repellents to exposed skin: DEET, picaridin, IR3535, oil of lemon eucalyptus (OLE), p-methane-3,8-diol (PMD), or 2-undecanone 1, 6
• Apply permethrin to clothing and gear (not directly to skin) 1, 6
• The combination of DEET on skin plus permethrin on clothing offers the best protection 8

Physical protective measures: 1, 6

• Wear long-sleeved shirts, long pants tucked into socks, and closed-toe shoes in tick-infested areas 2, 5
• Wear light-colored clothing to spot ticks more easily 8
• Perform full-body tick checks on yourself, children, and pets after outdoor activities 6

Common Pitfalls to Avoid

• Delaying tick removal: Risk of disease transmission increases significantly after 24 hours of attachment—remove immediately 4
• Giving antibiotics to all tick bites: Prophylaxis is only indicated for high-risk bites meeting ALL three specific criteria 1, 7
• Missing the 72-hour window: Prophylactic doxycycline is only effective if given within 72 hours of tick removal 1, 7
• Ordering unnecessary tests: Do not test asymptomatic patients or the tick itself for Borrelia 1, 7
• Assuming prophylaxis prevents all tick-borne diseases: A single dose of doxycycline may prevent Lyme disease but not other tick-borne infections—remain vigilant for symptoms 7