21. Describe the rash seen in patients with Lyme disease and two of the most common variations of that rash.

There is no 'typical rash' that all patients get when infected with Lyme disease. Many people do not remember a rash or even a tick bite. If a rash does appear, it may be anywhere from a light pink color to blazing red, to blue, to purple depending on the skin color, the type of rash, and possible co-infections. The ECM rash can be as small as a quarter, be present in several locations, or be large enough to cover the entire back of an adult. The rash may be mistaken for an insect bite reaction or even ringworm. It may be hot, it may flake or swell. It may be well formed and expanding or have uneven or raised edges. It may disappear and return later and it may be slightly itchy in some individuals. Borrelial lymphocytoma may appear on the earlobe, the scrotum, or on the nipple of the breast. It may be bright red to a bluish color and may disappear and return later. The ACA rash (acrodermatitis chronica atrophicans) may have the appearance of a scleroderma rash and is often noticed on the feet and ankles and/or the hands. It may appear elsewhere on the body and may affect organs.

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