Lyme disease pathology

Author: Assoc Prof Patrick Emanuel, Dermatopathologist, Auckland, New Zealand, 2013.

Lyme disease is a systemic infection caused by the spirochete Borrelia burgdorferi. Acrodermatitis chronica atrophicans is a late cutaneous form of the disease.

Histology of Lyme disease

Biopsy of erythema chronicum migrans reveals a sparse superficial and deep infiltrate under an uninvolved epidermis (figure 1). Sometimes there is epidermal and/or dermal necrosis. High power examination reveals the infiltrate is mainly lymphocytic (figure 2). There are often sparse eosinophils, admixed plasma cells and mast cells.

Lesions of acrodermatitis chronica atrophicans can show a similar histopathology but the infiltrate is denser (figure 3). The infiltrate consists of lymphocytes and often there are numerous plasma cells (figure 4) admixed with mast cells. There may be impressive superficial sclerosis and fibroplasia.

Special studies for Lyme disease

The borrelia spirochaetes may be identified with silver stains and immunohistochemical methods in some cases. Many cases will be negative with these methods. Polymerase chain reaction (PCR) may also be used.

Differential diagnosis of Lyme disease pathology

Insect bite reaction – Lesions of erythema chronicum migrans may be non-specific and exactly mimic an insect bite reaction. This is particularly problematic when silver stains and immunohistochemical studies are negative. Clinical correlation, PCR studies and serologic correlation may be needed.

Sclerosing disorders – Acrodermatitis chronica atrophicans may elicit a sclerosing reaction to closely mimic lichen sclerosus or eosinophilic fasciitis.

Related information

Email Newsletter

Would you like to receive our dermatology updates by email?


Submit your images

We're seeking high-quality photos of skin diseases.  


Machine diagnosis

Watch DermNet's proposal to create a 'Skin Disease Image Recognition Tool' - winner of the 2017 'Clinicians' Challenge Active Award' by the NZ Ministry of Health and HiNZ.

Subscribe to our mailing list

* indicates required
DermNet NZ Newsletter