Tick Removal

Ticks can carry and transmit a remarkable array of pathogens, including bacteria, spirochetes, rickettsiae, protozoa, viruses, nematodes, and toxins. A single tick bite can transmit multiple pathogens, a phenomenon that has led to atypical presentations of some classic tick-borne diseases. In the United States, ticks account for around 95% of all vector-borne diseases, with the majority being Lyme disease (see the images below).[1]  Also see the Medscape article tick-borne diseases.

In North America, the following diseases are caused by tick bites:

• Lyme disease

• Human granulocytic and monocytic ehrlichiosis

• Babesiosis

• Relapsing fever

• Rocky Mountain spotted fever

• Colorado tick fever

• Tularemia

• Q fever

• Tick paralysis

• Powassan virus infection

• Heartland virus infection

• Borrelia miyamotoi infection

• Borrelia mayonii infection

• Anaplasmosis

• Bourbon virus infection

• Rickettsia parkeri rickettsiosis

• Southern tick-associated rash illness (STARI)

• 346D rickettsiosis

In Europe, the list is similar, but other diseases should be considered as well, including boutonneuse fever (caused by a less virulent spotted fever rickettsial organism, Rickettsia conorii) and tick-borne encephalitis.[2] No postexposure treatment is available for tick-borne encephalitis, but vaccines are in use for prevention.[3, 4, 5]

Animal and human studies have shown that the risk of Lyme disease transmission increases significantly after 24 hours of attachment and is even higher after more than 48 hours of attachment.[6] Testing of ticks for tick-borne infectious organisms is generally not recommended, except for research purposes.

Healthcare practitioners, particularly those in areas where Lyme disease is endemic, should become familiar with the clinical manifestations of, and recommended testing and therapy for, Lyme disease; they should be equally knowledgeable regarding human granulocytic ehrlichiosis (HGE) and babesiosis. If necessary for identification and testing, ticks can be placed in a sealed container containing alcohol.

For patient education resources, see Tick removal and testing available from the Centers for Disease Control and Prevention (CDC).

Removal is indicated when a tick is attached to the skin (see the image below). There are no contraindications for removal.

A study of 93 patients with attached ticks by Şahin et al found that technical errors in tick removal were more common during self-removal versus removal by a healthcare practitioner.[7]

There is also evidence put forth by Taylor et al to support killing ticks in situ before removal to reduce rates of allergic reactions and anaphylaxis.[8]

Equipment required for tick removal includes the following:

• Gloves

• Isopropyl alcohol or other skin disinfectant

• Fine-toothed forceps

As an option, one of the following over-the-counter tick removal devices may be employed:

• TRIX Tick Removal System - A tick lasso that grasps the mouth parts with a fiber loop

• The Tick Key - A key-sized device with a tapered slot that allows gentle traction to be applied for removal of the tick

• Sawyer Tick Pliers - Cradlehead pliers with an attached magnifier

• Pro-Tick Remedy – A small metal device with a tapered end that is used to grasp the tick and gently pull it away

• Ticked Off – A spoon-shaped device with a notched end that is used to grasp the tick and slide it off with gentle pressure

• Tick Twister – A hook-shaped device with a pronged end that is used to grasp the tick and gently pull it while twisting

For simple, uncomplicated tick removal, anesthesia is generally unnecessary. The use of lidocaine (subcutaneously or topically) may actually irritate the tick, causing it to regurgitate its stomach contents.

The patient should be in a comfortable position that allows the clinician easy access to the tick. The room should be well lit.

Persons who have undergone tick removal should up to 30 days of monitoring for signs and symptoms of tick-borne diseases,[9] such as the occurrence of a skin lesion at the site of the tick bite (which may suggest Lyme disease; see the images below) or a temperature higher than 38°C (which may suggest human granulocytic ehrlichiosis [HGE] or babesiosis).

Although routine use of either antimicrobial prophylaxis or serologic testing after a tick bite is not recommended, some experts recommend antibiotic therapy for patients bitten by Ixodes scapularis(Ixodes dammini) ticks that are estimated to have been attached for longer than 48 hours (on the basis of the degree of engorgement of the tick with blood), in conjunction with epidemiologic information regarding the prevalence of tick-transmitted infection.

However, accurate determination of the species of tick and assessment of the degree of engorgement are not possible on a routine basis, and the data are insufficient to demonstrate the efficacy of antimicrobial therapy in this setting.[9, 10, 11]

It is important to use fine-tipped forceps and wear gloves because handling ticks with bare fingers may result in infection through breaks in the skin. This precaution is directed particularly to individuals who remove ticks from domestic animals with unprotected fingers. Children, elderly persons, and immunocompromised persons may be at greater risk of infection and should be especially careful to avoid removing ticks with unprotected fingers.[12]

Grasp the tick as close to the skin surface as possible (eg, grasp the mouth parts), and pull upward with steady, even traction (see the image below). Do not twist or jerk the tick, because this may cause the mouth parts to break off and remain in the skin. However, do not be unduly alarmed if the mouth parts remain in the skin; they are not infectious. Do not squeeze, crush, or puncture the body of the tick, because its fluids (ie, saliva, hemolymph, and gut contents) may contain infectious organisms.[13, 14]

In a comparison of three commercial tick removal tools with medium-tipped nontissue forceps, Stewart et al found that nymphal ticks were removed consistently and more successfully with commercial tools than with forceps but that adult ticks were more difficult to remove.[15] They concluded that the commercial tick removal tools tested were functional for removal of nymphs and adults and should be considered viable alternatives to medium-tipped forceps.

Akin Belli et al retrospectively evaluated 160 patients after dividing them into four groups according to the tick-detachment technique used—card detachment, lassoing, freezing, and tweezers.[16] They found the following efficacy rates: 33 (82.5%) of 40 for tweezers, 19 (47.5%) of 40 for lassoing, 3 (7.5%) of 40 for card detachment, and 0 (0%) of 40 for freezing. The efficacy rate of the technique using tweezers was significantly higher than that of the other three techniques (P< .05).

Do not apply a hot match to the tick or try to smother it with petroleum jelly, gasoline, nail polish, or other noxious substances. Doing so only prolongs exposure time and may cause the tick to eject infectious organisms into the body.[17] The use of lidocaine (subcutaneously or topically) may actually irritate the tick, leading it to regurgitate its stomach contents.

Once the tick is removed, wash the bite area with soap and water or with an antiseptic to destroy any contaminating microorganisms. The person who removed the tick should wash his or her hands as well.

Tick bites can become infected secondarily by organisms such as Staphylococcus aureus and group A Streptococcus. Such infection may be manifested by the following:

• Impetigo

• Ecthyma

• Cellulitis

• Erysipelas

• Shallow, painful, purulent ulcers

Retained tick material may lead to secondary infection. Host scratching may also lead to increased tissue damage with subsequent lichenification or infection.

Lesions may persist chronically to become papules, nodules, or plaques. These represent the formation of a tick-bite granuloma, which is typically a 0.5- to 2-cm nodule that develops days to months after a bite and may persist for months or years, gradually decreasing in size.

The etiology of tick-bite granulomas is not entirely clear. In some cases, retention of tick mouth parts or cuticular fragments may lead to granuloma formation. In other cases, granulomas form in the absence of any evidence of retained mouth parts, which suggests that salivary secretions alone may be responsible. Granulomas may also represent a neurodermatitic response caused by scratching.

In rare cases, alopecia caused by tick bites has been recorded. Alopecia can begin within a week of tick removal and typically occurs in a 3- to 4-cm circle around a tick bite on the scalp; it has the clinical appearance of alopecia areata (see the image below). A moth-eaten alopecia of the scalp caused by bites of Dermacentor variabilis (the American dog tick) has also been described. No particular tick species appears more likely to cause alopecia. Hair regrowth typically occurs within 1-3 months, though permanent alopecia has been observed.[2]