Tick Removal


Article Author:
Thomas Benzoni
Abdul Waheed


Article Editor:
Jeffrey Cooper


Editors In Chief:
David Tauber


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
7/17/2019 12:20:32 PM

Introduction

Finding a tick on oneself or family can be anxiety provoking. Ticks are known to carry many diseases, and the list is growing. Additionally, the range of ticks is expanding, likely caused by climate changes.

Tick removal requires awareness of several factors, in addition, to knowing how to remove the tick. A clinician should consider the following questions:

  • What type of tick is it? (See references, including pictures, from the Centers for Disease Control and Prevention (CDC))
  • What is the geography of the specific, attached tick? (See distribution maps via links to CDC)
  • What should one medically do for a person who has had a tick removed? (See the Infectious Disease Society of position paper attached)

The following sections summarize information about tick identification and tick removal technique.

Anatomy

The removed tick should be identified.

Seven common ticks include:

  1. American dog tick (Dermacentor variabilis[1]
  2. Blacklegged tick (Ixodes scapularis)[2]
  3. Brown dog tick (Rhipicephalus sanguineus)
  4. Gulf Coast tick (Amblyomma maculatum)
  5. Lone star tick (Amblyomma americanum)[3]
  6. Rocky Mountain wood tick (Dermacentor andersoni
  7. Western black-legged tick (Ixodes pacificus)

Indications

Indication for treatment is based partially on geography. A basic understanding of tick distribution will help an individual know when to be concerned.

The American dog tick (Dermacentor variabilis) is widely distributed east of the Rocky Mountains and in limited areas along the Pacific Coast. This tick transmits Tularemia and Rocky Mountain Spotted Fever. The highest risk of tick bites occurs during spring and summer. Dog ticks are sometimes called wood ticks. Adult females are most likely to bite humans.[1]

The Blacklegged tick (Ixodes scapularis) is widely distributed in the northeastern and upper midwestern United States. These transmit Lyme disease, anaplasmosis, babesiosis, and Powassan disease. The greatest risk for bites exists in the spring, summer, and fall. However, adults may be out searching for a host any time winter temperatures are above freezing. Nymphs and adult females are most likely to bite humans.

The Brown dog tick (Rhipicephalus sanguineus) is found worldwide. Brown dog ticks transmit Rocky Mountain spotted fever (in the southwestern United States and along the U.S./Mexico border). Dogs are the primary host for the brown dog tick in each of its life stages, but the tick may also bite humans or other mammals.

The Gulf Coast tick (Amblyomma maculatum) is found in coastal areas of the United States, specifically the Atlantic coast and the Gulf of Mexico. It transmits Rickettsia parkeri rickettsiosis, a form of spotted fever. Larvae and nymphs feed on birds and small rodents, while adult ticks feed on deer and other wildlife. Adult ticks have been associated with transmission of R. parkeri in humans.

The Lone Star tick (Amblyomma americanum) is widely distributed in the southeastern and eastern United States. It transmits Ehrlichia chaffeensis and Ehrlichia ewingii (which cause human ehrlichiosis), tularemia, and STARI (Southern Tick-Associated Rash Illness.) It is a very aggressive tick that bites humans. The adult female is distinguished by a white dot or “lone star” on her back. Lone Star tick saliva can be irritating. Redness and discomfort at the bite site do not necessarily indicate an infection. The nymph and adult females most frequently bite humans and transmit disease.[3]

Rocky Mountain wood tick (Dermacentor andersoni) is found in the Rocky Mountain states and southwestern Canada from elevations of 4000 ft to 10,500 ft. This tick transmits Rocky Mountain spotted fever, Colorado tick fever, and tularemia. These adult ticks feed primarily on large mammals. Larvae and nymphs feed on small rodents. Adult ticks are primarily associated with the pathogens transmission to humans.

Western black-legged tick (Ixodes pacificus) is found along the Pacific coast of the United States, particularly Northern California. It transmits Anaplasmosis and Lyme disease. Nymphs often feed on lizards, as well as other small animals. As a result, rates of infection are usually low (approximately 1%) in adults. Nymphs and adult females are most likely to bite humans.

Contraindications

After being in an area of possible tick infestation, individuals should perform a full-body inspection. Pay particular attention to children. Take meticulous care of crevices and hair.

If one finds a tick, identify it first. It may be best to do this before removal because the tick might not be intact after removal. Estimate the time of attachment. If the tick has taken blood, a time-dependent process, prophylaxis against tick-born disease may be indicated in areas of high prevalence. [4]

Equipment

Have a pair of tweezers or hemostat; they need to be in good working order, with tips that mate/align. Whichever instrument you choose to remove the tick, it must be physically clean; no dirt, visible contamination, etc. It is adequate to clean the instrument with rubbing alcohol. If you use alcohol, do not flame-sterilize! This will cause a fire![5]

Grasp the tick at the head, right where it has attached to the skin. Be sure grasp the head, not the body, as pulling off the body will leave the head attached. If the head is not removed, this becomes a location for infection to set in. This becomes a much more difficult process.[6]

Pull suddenly and directly away from the skin. Expect a tiny patch of the skin to come away with the tick.

If you should leave part of the head behind, seek medical attention for removal of the retained foreign body as this can become a source of infection.[7]

Personnel

Post removal care includes routine cleaning of the skin. Clean with soap and water, not alcohol or other chemicals.

Apply a topical antibiotic. Bacitracin is gentlest. These agents have not been shown to reduce infection but usually, don't harm unless the individual is sensitive. Apply a dressing such as a band-aid.

Tetanus prophylaxis is usually not indicated.[7]

Preparation

Dispose of the tick securely. If the tick is one of concern (after review of the referenced maps and pictures), save the tick to present to your local healthcare provider. Seal it in a jar or similar container. Do not be certain it is dead; ticks are hardy creatures! Wash your hands with soap and water. Clean the instrument used. [7]

Technique

Lyme disease, post tick removal prophylaxis

Post tick removal, prophylaxis against Lyme disease raises concerns. In general, if the tick is in an area with a high likelihood of Borrelia burgdorferi, but the tick has not eaten a blood meal, infection is unlikely.

"For prevention of Lyme disease after a recognized tick bite, routine use of antimicrobial prophylaxis or serologic testing is not recommended (E-III). A single dose of doxycycline may be offered to adult patients (200 mg dose) and to children less than 8 years of age (4 mg/kg, up to a maximum dose of 200 mg) (B-I) when all of the following circumstances exist: (1) the attached tick can be reliably identified as an adult or nymphal I. scapularis tick that is estimated to have been attached more than 36 hours on the basis of the degree of engorgement of the tick with blood or on certainty about the time of exposure to the tick, (2) prophylaxis can be started within 72 hours of the time that the tick was removed, (3) ecologic information indicates that the local rate of infection of these ticks with B. burgdorferi is greater than 20%, and (4) doxycycline is not contraindicated. The time limit of 72 hours is suggested because of the absence of data on the efficacy of chemoprophylaxis for tick bites following tick removal after longer time intervals. Infection of more than 20% of ticks with B. burgdorferi occurs in parts of New England, in parts of the mid-Atlantic States, and in parts of Minnesota and Wisconsin, but not in most other locations in the United States. Whether the use of antibiotic prophylaxis after a tick bite will reduce the incidence of HGA or babesiosis is unknown.[8]

The panel does not believe that amoxicillin should be substituted for doxycycline in persons for whom doxycycline is contraindicated because of the absence of data on an effective short-course regimen for prophylaxis, the likely need for a multi-day regimen (and its associated adverse effects), the excellent efficacy of antibiotic treatment of Lyme disease if infection were to develop, and the extremely low risk that a person with a recognized bite will develop a serious complication of Lyme disease (D-III)." [4]

Complications

Prevention, to avoid complication, should include:[9]

  • Avoiding tick-infested areas
  • Using DEET on skin according to label directions.
  • Applying permethrin to clothing.
  • Wearing clothing in a downward cascade. Pants go over tops of boots and tuck pants into boots to ensure that ticks that fall off in your boots. For overlapping clothes, ensure the bands have no gaps.

If part of the tick remains embedded after attempted removal, seek medical attention as the foreign body (head/mouth parts) may require local anesthesia and removal.

Clinical Significance

When outdoors, tick awareness is critical. Full body inspection upon rerun to shelter must be done, with attention to crevices. Attached ticks must be quickly plucked off the skin. Medical attention is indicated when a tick, meeting high-risk criteria, has attached.

Expert opinion guides medical interventions.

Enhancing Healthcare Team Outcomes

During spring and summer, patients may present to the primary care provider, nurse practitioner, physician assistant, or the emergency department physician with ticks on their body. These professionals should know how to manage ticks. After the tick is identified it should be removed, preferably with tweezers. The patient must be followed up to ensure that he or she has not developed any signs of infection. In some regions, prophylactic antibiotics may be considered due to the high incidence of systemic infections.

The interprofessional team should consider consulting with an infectious disease expert to determine the type of treatment is needed after tick removal. The nurse must educate the patient on possible complications such as local or systemic infections. If the patient and family is unclear, the nurse should request further consultation with the physician, nurse practitioner, or physician assistant. The best results are achieved when the interprofessional team thoroughly educates the patient on the risks of tick-related infection and measures are taken to control the risk. The pharmacist should ensure medication compliance if a systemic infection is being treated. If non-compliance is a concern, the clinical team should be contacted. [10]


  • Image 5668 Not availableImage 5668 Not available
    Contributed by the Centers for Disease Control and Prevention (CDC)
Attributed To: Contributed by the Centers for Disease Control and Prevention (CDC)

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Tick Removal - Questions

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Which of the following is the best method of removing a tick attached to the skin?



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A 17-year-old male presents with a complaint of a tick bite. He went hiking earlier today which is when he noticed the tick. He feels fine otherwise and there is no rash on physical exam. What is the next most appropriate step?



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A group has been out for a stroll in the woods. On return home, a tick was found in the hair of one of the people. What should be done?



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A 17-year-old patient was found to have a tick. It was removed in less than 24 hours and showed no sign of feeding. What are current recommendations for Lyme disease prevention?



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What is the preferred way to remove an attached tick?



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Tick Removal - References

References

Raghavan RK,Peterson AT,Cobos ME,Ganta R,Foley D, Current and Future Distribution of the Lone Star Tick, Amblyomma americanum (L.) (Acari: Ixodidae) in North America. PloS one. 2019;     [PubMed]
Lantos PM,Charini WA,Medoff G,Moro MH,Mushatt DM,Parsonnet J,Sanders JW,Baker CJ, Final report of the Lyme disease review panel of the Infectious Diseases Society of America. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2010 Jul 1;     [PubMed]
Huygelen V,Borra V,De Buck E,Vandekerckhove P, Effective methods for tick removal: A systematic review. Journal of evidence-based medicine. 2017 Aug;     [PubMed]
Kulkarni MA,Narula I,Slatculescu AM,Russell C, Lyme Disease Emergence after Invasion of the Blacklegged Tick, Ixodes scapularis, Ontario, Canada, 2010-2016. Emerging infectious diseases. 2019 Feb;     [PubMed]
James AM,Burdett C,McCool MJ,Fox A,Riggs P, The geographic distribution and ecological preferences of the American dog tick, Dermacentor variabilis (Say), in the U.S.A. Medical and veterinary entomology. 2015 Jun;     [PubMed]
Akin Belli A,Dervis E,Kar S,Ergonul O,Gargili A, Revisiting detachment techniques in human-biting ticks. Journal of the American Academy of Dermatology. 2016 Aug     [PubMed]
Roupakias S,Mitsakou P,Nimer AA, Tick removal. Journal of preventive medicine and hygiene. 2011 Mar     [PubMed]
Richardson M,Khouja C,Sutcliffe K, Interventions to prevent Lyme disease in humans: A systematic review. Preventive medicine reports. 2019 Mar     [PubMed]
Szczepańska A,Kiewra D,Lonc E, Influence of the fabric colour for the ticks, Ixodes ricinus and Dermacentor reticulatus attachment. Infectious diseases (London, England). 2017 Jul     [PubMed]
Wilson KD,Elston DM, What's eating you? Ixodes tick and related diseases, part 3: coinfection and tick-bite prevention. Cutis. 2018 May;     [PubMed]

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