An Anxious Hiker With Recurring Annular Rash and Sleep Loss

Dirk M. Elston, MD


January 26, 2022

The patient says that she is allergic to peanuts and birch pollen but has no current respiratory symptoms. Peanut allergy is not likely to be relevant if she is careful about diet and exposure. Her family history of lupus erythematosus may be relevant because many patients with urticaria have a family history of autoimmune disease, but her skin lesions are evanescent and migratory, which does not fit with a diagnosis of subacute cutaneous lupus erythematosus. Her eruption also lacks the scales and lilac color characteristic of that condition. Further evaluation for the possibility of connective tissue disease should be based on the presence of suggestive signs or symptoms.

Given her outdoor activities and history of hiking, the patient also expresses concern about the possibility of Lyme disease. She recalls removing a few nonengorged ticks after hiking in the Midwest and New England. Nonengorged ticks are very unlikely to spread disease, although many patients with tick-borne illness do not recall tick attachments. She is not experiencing current symptoms of Lyme disease, and her eruption does not match the slow 1 cm per day outward migration of erythema migrans. To protect herself in the future, she can be advised that wearing permethrin-treated clothing combined with the use of protective clothing and insect repellents are effective when paired with tick checks after hiking.

The results of this patient's evaluation were normal except for peripheral eosinophilia, and tests for parasites, Lyme disease, and antinuclear antibodies, which were requested by the patient, were negative. She responded well to fexofenadine 180 mg twice a day paired with doxepin 50 mg given at bedtime.


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