Quality statement 1: Erythema migrans

Quality statement

People presenting with erythema migrans are diagnosed and treated for Lyme disease based on clinical assessment, without laboratory testing.

Rationale

Erythema migrans is a skin rash that is associated specifically with Lyme disease. It can be identified by clinical assessment and so serological tests are not needed for diagnosis, as shown in NICE's visual summary of the recommendations for testing for Lyme disease. In some cases, serological tests may be misleading because they may be negative when the rash occurs. Prompt diagnosis and treatment of Lyme disease based on the presence of erythema migrans will help to reduce the risk of further symptoms developing.

Quality measures

Structure

Evidence that healthcare professionals are trained to recognise symptoms of Lyme disease.

Data source: Local data collection, for example, audits of annual performance reviews and records of continuing professional development, such as completion of the Royal College of General Practitioners (RCGP) e-learning course, participating in events or using resources for education, training and quality improvement (such the RCGP Lyme disease toolkit: resources for education, training and quality improvement).

Process

Proportion of people diagnosed with Lyme disease based on erythema migrans without laboratory testing.

Numerator – the number in the denominator who did not have laboratory testing.

Denominator – the number of people diagnosed with Lyme disease who had erythema migrans.

Data source: Local data source, for example, an audit of patient records.

What the quality statement means for different audiences

Service providers (such as general practice, community pharmacies, out-of-hours services and emergency departments) have systems in place to ensure that people presenting with erythema migrans are diagnosed and treated for Lyme disease, without having laboratory tests. They also ensure that GPs and other healthcare professionals are trained to recognise symptoms of Lyme disease, for example, through completion of the RCGP e-learning course, participating in events or using resources for education, training and quality improvement (such the RCGP Lyme disease toolkit: resources for education, training and quality improvement).

Healthcare professionals (such as GPs, practice nurses, pharmacists, and doctors in out-of-hours services and emergency departments) diagnose and treat people presenting with erythema migrans for Lyme disease, without ordering laboratory tests. They are trained to recognise symptoms of Lyme disease, which include erythema migrans, for example, through completion of the RCGP e-learning course, participating in events or using resources for education, training and quality improvement (such the RCGP Lyme disease toolkit: resources for education, training and quality improvement).

Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which people presenting with erythema migrans are diagnosed and treated for Lyme disease based on clinical assessment, without laboratory tests.

People who go to their healthcare professional with a spreading red rash that is identified as 'erythema migrans' are diagnosed with Lyme disease from the rash alone and do not need to have blood tests. They are treated for Lyme disease based on this diagnosis.

Source guidance

Lyme disease (2018) NICE guideline NG95, recommendation 1.2.11

Definition of terms used in this quality statement

Erythema migrans

Erythema migrans is a red rash, specific to Lyme disease, that increases in size and may sometimes have a central clearing. It is not usually itchy, hot or painful. It usually becomes visible from 1 to 4 weeks after a tick bite (but can appear from 3 days to 3 months) and lasts for several weeks. It is usually at the site of a tick bite, and appears in around two-thirds of cases.

NICE has also produced a resource with images showing different presentations of erythema migrans.

[NICE's guideline on Lyme disease, recommendation 1.2.1]

Equality and diversity considerations

Healthcare professionals should be aware that it may be more difficult to identify erythema migrans in people with darker skin tones; this may be of particular relevance to people in black, Asian and minority ethnic groups.