Ticks: The First Hour, and How to Stop Getting Bitten

TL;DR: If a tick is on you right now, take it off. Use pointed tweezers, take hold of it as close to your skin as you can, and pull straight out with steady pressure. Do not twist it, and do not put jelly, alcohol, or a hot match on it first. Then write down the date. Ticks need to stay attached about a day and a half before they can give you Lyme disease, so one you find and pull off the same day is very unlikely to make you sick. That is why checking yourself every night matters more than anything else you can buy. If the tick was a deer tick and it had been on for more than 36 hours, call your doctor within 3 days, because 1 dose of an antibiotic can stop Lyme before it starts. Do not pay a lab to test the tick; the answer will not tell you whether you got sick. Watch the spot for 30 days. Most Lyme rashes are a plain red patch that keeps growing, and only some of them make the bull's-eye everyone is looking for. To stop this happening again, put picaridin on your skin and permethrin on your shoes and socks.

Pennsylvania reports more Lyme disease than any other state in the country, year after year, and a large share of the national total comes from here. That is the reason this page reads the way it does. Ticks are not an exotic risk you meet on a mountain somewhere; they are in the tall grass along the river trail, in the leaf litter at the edge of a yard, and on a dog that went out in the morning. The Wissahickon and the Schuylkill Banks are where most of us get our outdoor training in this city, and they are tick habitat. What follows is what to do about that, in the order the questions usually arrive.

What should you do in the first hour after finding a tick?

Take it off, and do it now instead of after a trip to the pharmacy. Every hour it stays attached raises the odds it can pass something on, so speed beats technique here, and the technique is simple anyway.

Use fine-tipped tweezers. Grasp the tick as close to the surface of your skin as you can get, then pull away from the skin with steady, even pressure.² The reason to avoid twisting or jerking is mechanical: the mouthparts are barbed and anchored, and a sudden movement snaps them off and leaves them behind. If a fragment does stay in the skin, try to lift it out, and if it will not come, leave it and let the skin heal over it.

Skip everything you have heard about making the tick let go on its own. Petroleum jelly, nail polish, alcohol, and a hot match have all been tested against attached ticks, and none of them worked, whether the tick had been on for 12 hours or several days. Worse, agitating a tick can push infected fluid back into the bite.² Your goal is removal, and waiting for a tick to volunteer costs you the hours that decide this.

Then do 2 unglamorous things that matter more than the removal itself. Write down the date, and photograph the tick next to something for scale before you put it in a sealed bag. Both of those turn into the answer when somebody asks how long it was on and what kind it was, and those 2 facts are what a prophylaxis decision runs on.

How long does a tick have to be attached to give you Lyme?

Long enough that finding it the same day usually saves you. Transmission of Borrelia burgdorferi, the bacterium behind Lyme disease, generally requires the tick to stay attached for 36 hours or more, which is why the guideline builds that number into who should be treated preventively.¹ The bacterium lives in the tick's midgut and has to migrate to the salivary glands before it can reach you, and that migration takes time.

Sit with what that means, because it reframes the whole problem. The single most protective habit available to you costs nothing and involves no product: look yourself over every night in the summer. A nightly check catches almost everything inside the window where transmission has not happened yet, which is more protection than any spray delivers on its own.

Check the places ticks prefer, because they are not random. Behind and inside the ears, along the hairline and through the scalp, under the arms, around the waistband, the backs of the knees, and the groin. Nymphs, the immature stage responsible for most human infections, are roughly the size of a poppy seed, so give this a proper hunt instead of a glance. Run your hands over skin as well as looking, since a small attached tick often reads as a new scab before it reads as a bug.

Season matters less than people assume. Nymphs peak in late spring and early summer, and adult ticks come back out in the fall, so a warm October walk carries risk that a lot of people have already stopped thinking about; our September guide covers the rest of what changes when the weather turns.

Other tickborne infections do not all follow the 36-hour rule. Anaplasmosis and babesiosis can transmit faster, and the Powassan virus faster still. That is a reason to remove a tick immediately in every case, and it does not change the prophylaxis criteria below, which were written for Lyme.

Should you send the tick off to be tested?

No, and this one surprises people, because plenty of labs will happily sell you the test. The 2020 IDSA guideline recommends against testing a removed tick for B. burgdorferi, and it is a strong recommendation.¹ The reason is that the result does not predict what happens to you. A tick can carry the bacterium and never transmit it, and the detection of B. burgdorferi in a removed tick turns out to be a poor predictor of whether the person develops Lyme disease or even seroconverts.

The harm runs in both directions, which is what makes this worth spending a paragraph on. A positive result on the tick sends somebody into weeks of anxiety and sometimes into antibiotics they did not need. A negative result reads as an all-clear that the test cannot give, and somebody who was infected stops watching the spot.

What the same guideline does recommend is having the tick identified by species.¹ Species is a different question from infection, and it is one of the 3 things that decides whether preventive treatment is on the table. So keep the tick, photograph it, and get it named. Do not pay anybody to look inside it.

Guidance from the Clinic

"The thing I want people to take from this is that the timing is on your side, and almost nobody knows it. A tick you find tonight and pull off tonight is very unlikely to give you anything. That turns the whole problem into a habit instead of a fear: check yourself before bed in the summer, the same way you would lock the door. And treat your shoes. Permethrin on footwear is the piece that gets skipped, and it is the piece that does the most, because that is where ticks get on you. It is what I use to stay ahead of the bugs all summer. When somebody does bring me a tick, the 2 questions I need answered are what kind it was and how long it was on, so photograph it and write down the date before anything else. Those 2 answers decide whether we treat."

When is a single dose of doxycycline the right call?

When 3 conditions are all true, and a physician has confirmed them. The 2020 IDSA, AAN, and ACR guideline recommends a single oral dose of doxycycline after a high-risk bite, and it defines high-risk narrowly: the tick was an identified Ixodes species, the bite happened in a highly endemic area, and it was attached for 36 hours or longer.¹ Miss any 1 of the 3 and the bite is equivocal or low risk, and the guideline recommends against treating it.

The timing is the part people lose. The dose has to be given within 72 hours of removing the tick, so this is a call to make in the first day or 2 and not something to raise at a visit next month. For adults the dose is 200 mg once; for children it is 4.4 mg/kg once, up to that same 200 mg maximum.¹

Pennsylvania clears the endemic-area condition without any argument, which means the question here almost always comes down to the other 2: what kind of tick, and how long. A dog tick does not qualify no matter how long it was on. An engorged deer tick from this morning's hike does not qualify either, because engorgement takes time and a tick found within hours has not had it.

None of this is a decision to make from a website, and it is a short conversation with a photograph attached. What it is not is a reason to take a long course of antibiotics after every bite, which has been studied and does not hold up as a general practice.

What does the Lyme rash really look like?

Usually not like the picture in your head. The bull's-eye is the image everybody carries, and in a North American study of culture-proven erythema migrans, the target appearance with central clearing turned up in about 37% of cases.³ The more common presentation in the United States is a patch of uniform red that expands over days, sometimes with a darker center and no ring at all.

The rash shows up in roughly 80% of people with early Lyme disease, and it goes unnoticed or unrecognized in a meaningful share of the rest, particularly when it turns up on the scalp, the back, or a skin fold where nobody is looking.³ So a spreading red patch anywhere on you in the 30 days after outdoor exposure deserves a photograph and a message, and waiting for it to develop a ring is how people lose weeks.

Watch the bite site for 30 days. A small red bump at the bite that appears within a day or 2 and fades is an irritation from the bite itself, and it is common. A patch that starts several days later and keeps getting bigger is the one that matters, and it is often warm without being painful or itchy, which is part of why it gets ignored.

What keeps ticks off you in the first place?

2 products, and the second one is the one almost nobody uses. On skin, use a repellent with 20% picaridin. It performs on par with DEET, and a 2018 review in the Journal of Travel Medicine comparing the 2 across 11 studies found little difference between them at the same dose, with some evidence that picaridin persists longer.⁴ It also spares plastics and synthetic fabric, which DEET does not. The EPA's repellent search tool will confirm any product you are looking at is registered, and repellent belongs in the travel kit as much as in the hall cupboard.

On clothing, use permethrin, and treat your shoes and socks above everything else. Permethrin goes on fabric, it survives about 6 weeks or 6 washings, and it carries the biggest effect in this whole article. Skin is the one place it does not belong. In a controlled study published in the Journal of Medical Entomology, volunteers wearing permethrin-treated sneakers and socks were 73.6 times less likely to receive a tick bite than volunteers in untreated footwear.⁵ Grade that number before you bank on it: it comes from a controlled exposure, with nymphal Ixodes scapularis placed on participants, so it measures a very large effect on contact and does not promise you a season without bites. Footwear earns the priority because ticks quest low, climbing grass and leaf litter and boarding at the ankle.

Sawyer sells both and the colors keep them apart, which is the practical detail worth having: the blue and white bottle is picaridin and goes on skin, the yellow bottle is permethrin and never touches skin. Any product with the same 2 chemicals works the same way. This practice takes nothing from any manufacturer and has no arrangement with Sawyer.

Coming in from grass or woods, 3 habits close the loop. Shower within a couple of hours, which washes off anything not yet attached and puts you in front of a mirror. Do the full check described above. And put your clothes through a hot dryer cycle, which kills ticks riding in the fabric. Skip anything built on essential oils, since those are not EPA-registered and the protection is measured in minutes.

When should you see a doctor after a tick bite?

When the bite meets the prophylaxis criteria, or when anything develops in the month afterward. Specifically:

• A deer tick that was attached 36 hours or longer, which needs a decision within 72 hours of removal
• Any expanding red patch at the bite or elsewhere, whether or not it has a ring
• Fever, chills, headache, neck stiffness, or aching joints and muscles in the 30 days after a bite
• A tick bite in pregnancy, since the treatment options differ
• A bite that becomes hot, swollen, and increasingly painful, which points to a skin infection instead of Lyme
• Facial droop, a new irregular heartbeat, fainting, or shortness of breath after a known or suspected bite, which need urgent care the same day

How does Fishtown Medicine approach tick bites?

By answering the 2 questions that decide everything, and answering them fast. Dr. Ash will look at a photograph of the tick and the bite, work out whether the species and the attachment time meet the criteria, and tell you whether a preventive dose applies while the 72-hour window is still open. Getting an answer the same day is most of the value here, because a decision that arrives on day 4 is a decision that arrived too late to make.

From there it is watching the right things for the right length of time, treating early Lyme promptly when it appears, and resisting the 2 opposite errors that both do harm: antibiotics for every bite, and dismissal of a rash that does not look like the textbook. If your illness turns out to be the longer story, our guide to Lyme symptoms that will not leave covers what is known about that and what a workup should look like.

If you're in the Philadelphia area and want somebody who will look at the photo today, tell Dr. Ash what's going on at Fishtown Medicine.

Related at Fishtown Medicine

• When Lyme symptoms will not leave
• Alpha-gal syndrome, the tick-borne meat allergy
• Bedbugs: how to know, and what to do first
• Staying healthy at the Jersey Shore

Scientific References

1. Lantos PM, Rumbaugh J, Bockenstedt LK, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. Clinical Infectious Diseases. 2021;72(1):e1-e48. academic.oup.com
2. Centers for Disease Control and Prevention. What to Do After a Tick Bite. cdc.gov
3. Aucott JN, Crowder LA, Yedlin V, Kortte KB. Bull's-Eye and Nontarget Skin Lesions of Lyme Disease: An Internet Survey of Identification of Erythema Migrans. Dermatology Research and Practice. 2012. ncbi.nlm.nih.gov
4. Comparative efficacy of DEET and picaridin. Journal of Travel Medicine. 2018;25(suppl_1):S10. academic.oup.com
5. Miller NJ, Rainone EE, Dyer MC, González L, Mather TN. Tick Bite Protection With Permethrin-Treated Summer-Weight Clothing. Journal of Medical Entomology. 2011;48(2):327-333. pubmed.ncbi.nlm.nih.gov
6. Rosenberg R, Lindsey NP, Fischer M, et al. Vital Signs: Trends in Reported Vectorborne Disease Cases, United States and Territories, 2004-2016. MMWR. 2018;67(17):496-501. cdc.gov
7. US Environmental Protection Agency. Find the Repellent that is Right for You. epa.gov