SKIN 
 

July 2023     Volume 7 Issue 4 
 

(c) 2023 THE AUTHORS. Published by the National Society for Cutaneous Medicine. 945 

SKINmages 
 

 

Vesiculobullous Erythema Migrans with Central Necrosis 
 

Julian Stashower, BA1, Abigail Wills, MD2, Barrett Zlotoff, MD2,3 
 
1University of Virginia School of Medicine, Charlottesville, VA 
2Department of Dermatology, University of Virginia School of Medicine, Charlottesville, VA 
3Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA 
 

 
 

 
 

A 35-year-old male with no prior medical 
history presented with a three-day history of 
an expanding annular rash on his upper 
back. He reported that the rash had become 
increasingly painful, as well as new onset of 
systemic symptoms including fevers, chills, 
fatigue, and arthralgias. He lived in a wooded 
area but denied any known tick exposure. 
Physical exam revealed a large, 
erythematous targetoid patch with central 
necrotic bullae on his mid-upper back. The 

patient’s presentation was consistent with 
bullous Lyme disease and he was started on 
a four-week course of doxycycline. Several 
hours following his initial dose of doxycycline, 
he noted worsening of fevers and chills, 
rigors, and myalgias consistent with Jarisch 
Herxheimer reaction. At four-day follow-up he 
described near resolution of systemic 
symptoms, with sloughing and increased 
necrosis of his rash. 
 



SKIN 
 

July 2023     Volume 7 Issue 4 
 

(c) 2023 THE AUTHORS. Published by the National Society for Cutaneous Medicine. 946 

Lyme disease is most commonly reported in 
the summer months and is caused by the 
spirochete Borrelia burgdorferi. It is primarily 
transmitted through the Ixodes tick and is the 
most prevalent tick-borne disease in North 
America, Europe, and parts of eastern Asia. 
Lyme disease typically presents with 
erythema migrans at the site of inoculation 
and a flu-like illness. The most common 
appearance of erythema migrans is annular, 
expanding erythema, however the clinical 
presentation may vary. Ulceration, central 
hemorrhage, or necrosis may be exhibited, 
the rash may not have stereotypical central 
clearing, and a vesiculobullous component 
may be found in up to 8% of cases.1,2 

Findings of vesicles or bullae may represent 
a strong immune response to the tick bite 
itself. When presenting atypically, the 
differential diagnosis may expand to include 
varicella zoster, herpes simplex, arthropod 
bite, Sweet syndrome, and necrotizing 
fasciitis.  
 
Diagnosis of Lyme disease is primarily 
clinical, as histopathologic findings are non-
specific and serologic tests, culture, and 
polymerase chain reaction have poor 
sensitivities, especially in the acute phase of 
the disease. Patient history may not be 
helpful towards this end, as many patients do 
not recall tick exposure and ticks may attach 
to bodily regions that are not visible to the 
patient. Thus, clinical recognition of erythema 
migrans is essential to prevent delayed 
diagnosis and potentially severe cardiac, 
neurologic, and rheumatologic sequelae. 
Notably, a Jarisch-Herxheimer reaction may 
occur early in the treatment course and may 
cause an increase in systemic symptoms and 
worsening of cutaneous disease.3,4  
 
This case highlights a seldom-seen form of 
cutaneous Lyme disease. Familiarity with the 
numerous morphologic variants of erythema 
migrans is vital to accurate identification and 

timely initiation of treatment. Lyme disease 
itself is common and clinicians should 
maintain a high index of suspicion in patients 
with the appropriate clinical context. 
Additionally, dermatologists should have a 
low threshold for starting empiric treatment in 
patients with suspected Lyme disease in 
order to avoid long-term complications. 
 
Conflict of Interest Disclosures: None 
 
Funding: None 
 
Corresponding Author: 
Julian Stashower, B.A. 
University of Virginia School of Medicine 
1215 Lee Street,  
Charlottesville, Virginia 22908 
Email: jas2wf@virginia.edu

 
 
References: 
1.  Bhate C, Schwartz RA. Lyme disease: Part I. 

Advances and perspectives. J Am Acad 
Dermatol. 2011;64(4):619-636; quiz 637-638. 
doi:10.1016/j.jaad.2010.03.046 

2.  Goldberg NS, Forseter G, Nadelman RB, et 
al. Vesicular erythema migrans. Arch 
Dermatol. 1992;128(11):1495-1498. 

3.  Doughty H, O’Hern K, Barton DT, Carter JB. 
Vesiculobullous Lyme disease: A case 
series. JAAD Case Rep. 2022;24:56-58. 
doi:10.1016/j.jdcr.2022.04.001 

4.  Paul S, Song PI, Ogbechie OA, et al. 
Vesiculobullous and hemorrhagic erythema 
migrans: uncommon variants of a common 
disease. Int J Dermatol. 2016;55(2):e79-82. 
doi:10.1111/ijd.12927