Tick removal: Forceps or protected fingers are the preferred methods for removing ticks while ensuring successful removal of the mouthparts.

  • Use tweezers/forceps to grab the tick as close to the skin as possible.  Use fingers protected by a cloth or clothing if forceps or tweezers are not available
  • Pull straight up gently but firmly.  Do not use a twisting or jerking motion
  • Do not squeeze, puncture or crush the body of the tick
  • Wash the affected area thoroughly with soap and water
  • If sections of the mouthparts remain, do not forcibly remove them.  They will be expelled normally from the skin
  • Observe the area for the development of erythema migrans for 30 day.

Antimicrobial Prophylaxis

Two randomized trials of antibiotic prophylaxis showed no seroconversion of 869 treated patients with recent tick bites.,  Another study versus placebo showed an absolute risk reduction of 22 fewer cases per 1000 (reduction of developing disease from 2.2% to 0.2%. Prophylaxis is recommended for high-risk bites only. Bites not classified as high risk should follow a watch-and-wait approach. IDSA guidelines for prophylaxis are as follows31

  • The attached tick is an adult or nymph I. scapularis
  • The tick has been attached for > 36 hours
  • Prophylaxis is begun within 72 hours of tick removal
  • Tick bite occurred in an endemic area ((CT, DE, DC, MA, MD, ME, MN, NH, NJ, NY, PA, RI, VA, VT, WI, WV) with a local rate of infection > 20%
  • Contraindications to doxycycline are not present.

If criteria are met, adult patients should receive doxycycline 200 mg x1 and pediatric patients 4 mg/kg (max 200) x1.  There is no data in children; the recommendation was extrapolated from adult data.  Alternatively, patients can monitor the bite site for the development of EM and begin treatment for active disease.  The IDSA does not recommend the use of any other prophylactic agent due to the paucity of data. 






Side Effects


  • 200 mg x 1
  • Pediatric: 4.4 mg/kg x1 (max 200 mg)
  • Administer with meals to decrease GI upset.
  • Capsules and tablets should be taken with a full glass of water. The patient should remain upright for 30 min after ingesting to reduce the risk of esophageal irritation and ulceration.
  • Hypersensitivity to doxycycline, other tetracyclines, or any component of the formulation. 
  • Children <8, during breastfeeding, and during 2nd and 3rd trimester except for Lyme prophylaxis.
  • Pregnancy: D Only use in rocky mountain spotted fever (RMSF)
  • Breastfeeding: Use for RMSF. Relative contraindication for Lyme disease, use if the benefit outweighs the risk.16  For other indications, use another agent if available.
  • Abdominal pain
  • Diarrhea
  • Vomiting
  • Esophageal irritation or ulcer
  • Skin hyperpigmentation,
  • Hepatotoxicity
  • Allergic reactions
  • Rash
  • Photosensitivity
  • Pigmentation of teeth in children.

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