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Repellants and Sunscreens

TICKS

Ticks continue to be widespread at this time. Deer ticks are active in April through July. It is these ticks that transmit Lyme Disease. We recommend that you check your child daily if they are outside. Most ticks can be found at the edge of properties in wooded areas. The overall risk of Lyme Disease from a TICK is less than 1-2%. For a full description of Lyme Disease, see the section of our website entitled “Read Past Newsletters” at the bottom of the homepage. Prevention is the best approach for Ticks (use a repellant like Repel – plant based lemon eucalyptus or 3M Ultrathon Insect Repellant 8 – both provide protection for more than 8 hours according to Consumer Reports). We recommend one application rather than multiple applications. In addition, check you child daily for TICKS and remove them carefully. We recommend using a TICK remover or tweezers. Gently pull up enough to tent the skin and wait for the TICK to detach. (Please have a seat and be patient, the Tick will usually release on its own in 1-4 minutes – do not attempt to pry the Tick off as it will likely break). If you break the Tick, the embedded piece does not need to be removed, it will come out on its own and does not increase the risk for lyme disease. Other preventive measures include: 1) wear light colored clothing and tuck pants into socks and shirts into pants 2) after removing a tick, disinfect the bite with soap, rubbing alcohol or hydrogen peroxide. See below for more information about ticks and lyme disease.

SUNBURN PREVENTION

SUNSCREEN DO’S AND DONT’S:

DO SLATHER ON ENOUGH. People typically use about 25 to 75 percent less sunscreen than they should, according to studies. Be sure to apply 2 to 3 tablespoons of sunscreen for maximum full-body protection of an adult.

DON’T USE EXPIRED SUNSCREEN. Sunscreens aren’t required to post expiration dates as long as manufacturers can prove that they’ll last for at least three years. So if your sunscreen doesn’t have an expiration date, be sure to write the date on it in permanent marker when you buy it. And remember to discard it after three years.

DON”T MISS THESE SPOTS. Lips, ears, feet, hands, bald spots, and the back of your neck are all areas that are easy to forget.

DO REAPPLY REGULARLY. The maximum protection time of a sunscreen is based on the number of minutes it takes for you to burn multipled by the SPF number. So say you have fair skin and burn within 20 minutes and you’re using enough of an SPF 15 sunscreen. That will give you about five hours of protection. Nevertheless, reapply sunscreen every two hours. If you’re swimming or doing lots of sweating on the beach or the tennis court, you may want to reapply it more often than that. Also, keep in mind that reapplying sunscreen after you’ve exceeded your maximum protection time doesn’t mean that you can safely stay in the sun longer. Instead, be sure to cover up or get out of the sun!

Products to consider:

We tend to get more calls this time of year for rashes after being in the sun with sunscreen. As many products have increased their SPF, they have added more chemicals to create the higher SPF. This has meant more rashes for children. Neutrogena and Aveeno both have excellent UVA/UVB coverage at SPF’s of 15 to 30 or higher. Higher is not better since some products (like Neutrogena) get 100% protection (if you reapply) and you only may increase the chance of a rash with a higher SPF. There are also more options for SPF clothing than ever before. Coverage with this clothing will give protection to areas that will not need to be re-coated with sunscreen. Just google “SPF clothing for children” or “babies” to see options. SPF clothing for a baby is ideal. For babies under 6 months the only sunscreen made for this age is Blue Lizard. We recommend SPF clothing as described above, a brim hat and avoidance during the peak high UV rays (10 am to 3 pm). If you must use a sunscreen, for this age, limit to the areas you cannot cover.

Patient information: What to do after a tick bite

Authors: Anna R Thorner, MD – Deputy Editor — Infectious Diseases – Instructor in Medicine, Harvard Medical School. Allen C Steere, MD – Editor — Lyme Disease – Professor of Medicine, Harvard Medical School. Leah K Moynihan, RNC, MSN – Associate Editor — Patient Information. ©2010 UpToDate, Inc.

TICK BITE OVERVIEW

There are many different types of ticks in the United States, some of which are capable of transmitting infections. The risk of developing these infections depends upon the geographic location, season of the year, type of tick, and for Lyme disease only, how long the tick was attached to the skin.

While many people are concerned after being bitten by a tick, the risk of acquiring a tick-borne infection is quite low, even if the tick has been attached, fed, and is actually carrying an infectious agent. Ticks transmit infection only after they have attached and then taken a blood meal from their new host []. A tick that has not attached (and therefore has not yet become engorged from its blood meal) has not passed any infection. The risk of acquiring Lyme disease from an observed tick bite, for example, is only 1.2 to 1.4 percent, even in an area where the disease is common.

If a person is bitten by a deer tick (the type of tick that carries Lyme disease), a healthcare provider will likely advise one of two approaches:

Observe and treat if signs or symptoms of infection develop

Treat with a preventive antibiotic immediately – only under certain circumstances

There is no benefit of blood testing for Lyme disease at the time of the tick bite; even people who become infected will not have a positive blood test until approximately two to six weeks after the infection develops (post-tick bite).

The history of the tick bite will largely determine which of these options is chosen. Before seeking medical attention, the affected person or household member should carefully remove the tick and make note of its appearance. Only the Ixodes species of deer tick causes Lyme disease.

HOW TO REMOVE A TICK

The proper way to remove a tick is to use a set of fine tweezers and grip the tick as close to the skin as is possible. Do not use a smoldering match or cigarette, nail polish, petroleum jelly (eg, Vaseline), liquid soap, or kerosene because they may irritate the tick and cause it to behave like a syringe, injecting bodily fluids into the wound.

The proper technique for tick removal includes the following:

Use fine tweezers to grasp the tick as close to the skin surface as possible.

Pull backwards gently but firmly, using an even, steady pressure. Do not jerk or twist.

Do not squeeze, crush, or puncture the body of the tick, since its bodily fluids may contain infection-causing organisms.

After removing the tick, wash the skin and hands thoroughly with soap and water.

If any mouth parts of the tick remain in the skin, these should be left alone; they will be expelled on their own. Attempts to remove these parts may result in significant skin trauma.

AFTER THE TICK IS REMOVED

Tick characteristics — It is helpful if the person can provide information about the size of the tick, whether it was actually attached to the skin, if it was engorged (that is, full of blood), and how long it was attached.

The size and color of the tick help to determine what kind of tick it was;

– Ticks that are brown and approximately the size of a poppy seed or pencil point are deer ticks. These can transmit Borrelia burgdorferi (the bacterium that causes Lyme disease) and a number of other tick-borne infections. Deer ticks live primarily in the northeast and mid-Atlantic region (Maine to Virginia) and in the midwest (Minnesota and Wisconsin) region of the United States, and less commonly in the western US (northern California).

– Ticks that are brown with a white collar and about the size of a pencil eraser are more likely to be dog ticks (Dermacentor species). These ticks do not carry Lyme disease, but can rarely carry another tick-borne infection that can be serious or even fatal (Rocky Mountain spotted fever).

– A brown to black tick with a white splotch on its back is likely an Amblyomma americanum (Lone Star tick; named after the white splotch). This species of tick has been reported to spread an illness called STARI (southern tick-associated rash illness). STARI causes a rash that is similar to the erythema migrans rash, but without the other features of Lyme disease. Although this rash is thought to be caused by an infection, a cause for the infection has not yet been identified. This type of tick can also carry and transmit another infection called human monocytic ehrlichiosis.

A tick that was not attached, is still flat and tiny and is not full of blood, and was easy to remove or just walking on the skin, could not have transmitted Lyme disease or any other infection since it had not yet taken a blood meal.

Only ticks that are attached and have finished feeding or are near the end of their meal can transmit Lyme disease. After arriving on the skin, the tick that spreads Lyme disease usually takes 24 hours before feeding begins. Even if a tick is attached, it must have taken a blood meal to transmit Lyme disease. At least 36 to 48 hours of feeding is required for a tick to have fed and then transmit the bacterium that causes Lyme disease. After this amount of time, the tick will be engorged (full of blood). An engorged tick has a globular shape and is larger than an unengorged one.

The organism that causes Lyme disease, B. burgdorferi, lies dormant in the inner aspect of the tick’s midgut. The organism becomes active only after exposure to the warm blood meal entering the tick’s gut. Once active, the organism enters the tick’s salivary glands. As the tick feeds, it must get rid of excess water through the salivary glands. Thus, the tick will literally salivate organisms into the wound, thereby passing the infection to the host.

Need for treatment — The clinician will review the description of the tick, along with any physical symptoms, to decide upon a course of action. The Infectious Diseases Society of America (IDSA) recommends preventive treatment with antibiotics only in people who meet ALL of the following criteria:

Attached tick identified as an adult or nymphal I. scapularis (deer) tick

Tick is estimated to have been attached for =36 hours (based upon how engorged the tick appears or the amount of time since outdoor exposure)

Antibiotic treatment can begin within 72 hours of tick removal

The local rate of tick infection with B. burgdorferi is =20 percent (known to occur in parts of New England, parts of the mid-Atlantic states, and parts of Minnesota and Wisconsin)

The person can take doxycycline (eg, the person is not pregnant or breastfeeding or a child <8 years of age)

If the person meets ALL of the above criteria, the recommended dose of doxycycline is a single dose of 200 mg for adults and 4 mg/kg, up to a maximum dose of 200 mg, in children = 8 years. If the person cannot take doxycycline, the IDSA does not recommend preventive treatment with an alternate antibiotic for several reasons: there are no data to support a short course of another antibiotic, a longer course of antibiotics may have side effects, antibiotic treatment is highly effective if Lyme disease were to develop, and the risk of developing a serious complication of Lyme disease after a recognized bite is extremely low.

MONITORING FOR LYME DISEASE

Many people have incorrect information about Lyme disease. For example, some people are concerned that Lyme disease is untreatable if antibiotics are not given early (this is untrue; even later features of Lyme disease can be effectively treated with appropriate antibiotics). Many local Lyme disease networks and national organizations disseminate unproven information and should not be the sole source of education about Lyme disease. Reputable sources are listed below see below.

Signs of Lyme disease — Whether or not a clinician is consulted after a tick bite, the person who was bitten (or the parents, if a child was bitten) should observe the area of the bite for expanding redness, which would suggest erythema migrans (EM), the characteristic rash of Lyme disease

The EM rash is usually a salmon color although, rarely, it can be an intense red, sometimes resembling a skin infection. The color may be almost uniform. The lesion typically expands over a few days or weeks and can reach over 20 cm (8 inches) in diameter. As the rash expands, it can become clear (skin-colored) in the center. The center of the rash can then appear a lighter color than its edges or the rash can develop into a series of concentric rings giving it a “bull’s eye” appearance. The rash usually causes no symptoms, although burning or itching has been reported.

In people with early localized Lyme disease, EM occurs within one month of the tick bite, typically within a week of the tick bite, although only one-third of people recall the tick bite that gave them Lyme disease. Components of tick saliva can cause a short-lived (24 to 48 hours) rash that should not be confused with EM. This reaction usually does not expand to a size larger than a dime.

Approximately 80 percent of people with Lyme disease will develop EM; 10 to 20 percent of people have multiple lesions. If EM or other signs or symptoms suggestive of Lyme disease develop, the person should see us for proper diagnosis and treatment.

Web Sites that are reputable:

National Library of Medicine: http://www.nlm.nih.gov/medlineplus/lymedisease.html

National Institute of Allergy and Infectious Diseases: http://www3.niaid.nih.gov/topics/lymeDisease

National Center for Infectious Diseases: http://www.cdc.gov/ncidod/dvbid/lyme/

American Lyme Disease Foundation, Inc: http://www.aldf.com/faq.shtml