What does a subcutaneous tick look on a human face, with photos and description?

Understanding the Demodex Mite

What is Demodex?

Two Main Species

Subcutaneous ticks on the face appear as localized swellings where the parasite’s mouthparts remain embedded beneath the epidermis. The skin over the lesion is often pink to reddish, sometimes forming a small raised nodule that may be mistaken for a cyst or insect bite. The tick’s body is not visible externally; instead, a tiny puncture hole or dark spot marks the attachment site. Photographs that document this condition should capture the facial area at a 1‑2 cm distance, using diffuse lighting to avoid glare, and include a scale reference such as a ruler or coin to illustrate size.

Ixodes scapularis (deer tick)
Typical size: unengorged 2–3 mm; engorged up to 5 mm.
Appearance: smooth, dark brown to black dorsal surface; legs short and visible only under magnification.
Facial presentation: a firm, erythematous papule about 3–5 mm in diameter, often on cheek or forehead. The puncture may show a tiny dark speck at its center. In photographs, the lesion appears as a well‑defined, slightly raised spot against surrounding skin, sometimes with a faint halo of inflammation.
Dermacentor variabilis (American dog tick)
Typical size: unengorged 4–5 mm; engorged up to 10 mm.
Appearance: reddish‑brown scutum with white markings; legs longer than those of Ixodes, visible as tiny hairs when magnified.
Facial presentation: a larger, softer swelling ranging from 5–10 mm, commonly located on the jawline or near the nose. The central punctum may be surrounded by a pale ring, giving a target‑like look. Photographs should show the broader base of the nodule and the contrasting color gradient from center to periphery.

Both species produce a characteristic “tick bite nodule” that can be identified by its size, color, and the presence of a central puncture. High‑resolution images taken from multiple angles improve diagnostic confidence, especially when the lesion’s borders are subtle. Early recognition allows prompt removal and reduces the risk of pathogen transmission.

Lifecycle and Habitat

A subcutaneous tick on the face appears as a small, firm, often reddish‑brown nodule. The skin over the lesion may be slightly raised, with a visible central punctum where the mouthparts remain embedded. When engorged, the tick can swell to the size of a pea, giving the impression of a cyst or insect bite. Photographic documentation typically shows a smooth, dome‑shaped bump with a dark spot at its center, sometimes surrounded by mild erythema.

The tick’s development proceeds through four distinct stages, each requiring a blood meal:

Egg: Laid in clusters on the ground, protected by a moist environment.
Larva: Six‑legged, seeks a small host such as a rodent or bird; feeds for several days before dropping off.
Nymph: Eight‑legged, capable of attaching to larger mammals, including humans; remains attached for 3–5 days.
Adult: Males and females feed on larger hosts; females engorge heavily before detaching to lay eggs.

Habitat preferences reflect the need for humid microclimates and access to host animals:

Leaf litter, tall grasses, and low shrubs provide shelter and moisture.
Forest edges, park lawns, and garden borders host abundant wildlife that serve as intermediate hosts.
Areas with dense vegetation near human dwellings increase the likelihood of accidental contact with the face, especially when individuals bend or reach into foliage.

Ticks locate hosts by detecting carbon dioxide, heat, and movement. Facial exposure can occur when a person brushes against vegetation while gardening, hiking, or handling pets that have recently traversed tick‑infested areas. Once attached, the tick may migrate deeper into the dermis, resulting in the subcutaneous presentation described above.

How Demodex Affects Human Skin

Normal Presence on the Face

A subcutaneous tick embedded in facial tissue appears as a small, dome‑shaped nodule beneath the skin. The lesion measures roughly 3–8 mm in diameter, often matching the size of the engorged arthropod. The overlying epidermis may show a faint pink or reddish hue, while the tick’s body can be visible as a darker, slightly raised core within the nodule. In many cases, the surrounding skin exhibits minimal inflammation; occasional mild swelling or a peripheral erythematous ring may be present.

Photographic documentation typically uses macro lenses to capture the lesion at 2–5 cm distance, with diffuse lighting to reduce shadows. Images focus on the central nodule, showing the contrast between the superficial skin tone and the deeper, darker mass. Close‑up shots may reveal the tick’s legs or mouthparts protruding from a tiny puncture site, especially when the skin is gently stretched.

Key visual criteria for identification:

Size: 3–8 mm, consistent with a partially engorged tick.
Shape: Rounded, dome‑like elevation with a central depression.
Color: Light pink to red epidermis; underlying dark brown or black core.
Margin: Smooth, well‑defined border; occasional slight erythema around the periphery.
Surface detail: Possible visibility of legs or mouthparts in high‑resolution images.

These characteristics enable clinicians to differentiate a subcutaneous facial tick from other nodular lesions such as cysts, lipomas, or inflammatory papules. Accurate visual assessment combined with photographic evidence supports timely removal and appropriate medical management.

Factors Leading to Overpopulation

The growing frequency of ticks embedded beneath facial skin reflects a measurable increase in tick populations. Photographic documentation shows small, dark, oval bodies partially visible through erythematous lesions, often accompanied by a central punctum where the mouthparts have entered. This visual pattern correlates with ecological pressures that drive tick overpopulation.

Warmer temperatures extend the active season of ticks, allowing multiple reproductive cycles per year.
Diminished numbers of natural predators, such as certain bird species and parasitic insects, reduce mortality rates.
High densities of deer, rodents, and other wildlife hosts provide abundant blood meals, supporting larger cohorts.
Urban expansion into wooded areas creates edge habitats where ticks encounter both wildlife and humans.
Land‑use changes, including deforestation and the creation of fragmented green spaces, concentrate host species and facilitate tick dispersal.
Limited application of acaricides and inadequate public‑health interventions fail to curb population growth.

Each factor amplifies the likelihood of a tick penetrating facial tissue, producing the characteristic subdermal appearance captured in clinical photographs. The convergence of climate, predator loss, host abundance, habitat alteration, and control gaps forms a comprehensive framework for understanding the surge in facial tick infestations.

Visual Identification of Subcutaneous Mites on the Face

Common Symptoms and Signs

Redness and Inflammation

A subcutaneous tick embedded in facial tissue typically produces a sharply demarcated area of erythema that may appear pink to deep crimson. The redness often surrounds the bite point in a circular or oval halo, extending 1–2 cm from the attachment site. Inflammation is manifested by localized swelling; the affected skin feels firm and slightly raised compared to surrounding tissue.

The inflammatory response includes:

Warmth over the bite area, indicating increased blood flow.
Tenderness when palpated, reflecting nociceptor activation.
Possible development of a small, palpable nodule at the tick’s mouthparts, which may be visible through the skin as a raised bump.

If the tick remains attached for several days, the erythema can become more diffuse, and the skin may exhibit a dusky or purplish tint as hemorrhagic components accumulate. Secondary infection can produce additional signs such as pus formation, ulceration, or spreading cellulitis, which require prompt medical evaluation.

Photographic documentation of facial tick bites commonly shows a central punctum surrounded by a vivid red ring, with varying degrees of edema. The intensity of coloration correlates with the host’s immune reaction and the duration of tick attachment. Early identification of these visual cues enables timely removal and reduces the risk of complications.

Itching and Burning Sensation

A subcutaneous tick embedded in facial tissue creates a localized itching that intensifies after several hours and may persist for days. The itch often feels like a relentless tickle that intensifies when the skin is touched or rubbed. Simultaneously, a burning sensation develops, described as a mild to moderate heat that radiates from the attachment point toward surrounding skin.

The sensations arise from mechanical irritation of cutaneous nerves and the release of tick saliva, which contains anesthetic and anticoagulant compounds. Saliva compounds provoke an inflammatory response, leading to vasodilation and heat perception. If the tick remains attached, the inflammatory reaction can become chronic, producing a constant, low‑grade burning pain.

Typical indicators accompanying itch and burn include:

Small, raised, reddish‑purple nodule at the attachment site
Central punctum or tiny opening where the mouthparts penetrate the skin
Slight swelling that may enlarge over 24‑48 hours
Absence of visible tick body when the parasite is fully embedded

When these signs appear on the face, immediate removal by a qualified professional is advisable to prevent secondary infection and potential transmission of pathogens. If the itching or burning intensifies, or if fever, rash, or lymph node enlargement develop, medical evaluation should be sought without delay.

Rough or Scaly Skin Patches

Rough or scaly skin patches on the face may indicate a buried tick that has penetrated the dermis. The lesion typically appears as a raised, irregularly shaped area with a gritty or sandpaper texture. Surface scaling varies from fine flakes to thicker, parchment‑like sheets. Color ranges from pink‑red to brownish‑gray, often darker at the center where the tick’s mouthparts remain embedded.

Key visual features include:

Elevated border that feels firm to the touch.
Central punctum or tiny ulceration, sometimes exuding serous fluid.
Asymmetrical shape, lacking the smooth outline of common dermatitis.
Absence of surrounding erythema beyond the immediate margin.

Common facial sites are the forehead, cheek, and periorbital region, where hair follicles and skin folds provide easier access for the arthropod. The patch may persist for days to weeks, gradually enlarging as the tick feeds and its saliva induces localized inflammation.

Photographic assessment should focus on:

Close‑up view of the central opening, revealing the tick’s mouthparts or a darkened core.
Comparison of texture between the lesion and adjacent normal skin.
Sequential images showing gradual change in size or scaling pattern.

Differential considerations encompass seborrheic dermatitis, psoriasis, and fungal infection; each presents with smoother scaling, more uniform distribution, or distinct border characteristics. Confirmation relies on visual identification of the tick or removal and laboratory analysis.

Prompt removal by a trained professional, followed by topical antiseptic treatment, reduces the risk of secondary infection and tick‑borne disease transmission. Monitoring for systemic symptoms such as fever, rash, or joint pain remains essential after extraction.

Photo Gallery of Demodex-Related Conditions

Rosacea-like Symptoms

A subcutaneous tick embedded in facial tissue often appears as a solitary, firm nodule measuring 3‑10 mm in diameter. The overlying skin is usually red or pink, mimicking the flushing seen in rosacea. A central punctum or dark dot, representing the tick’s mouthparts, may be visible, especially when the lesion is examined under magnification. The nodule can be slightly raised, with a smooth or slightly rough surface, and may be tender to pressure.

Differentiating this presentation from true rosacea requires attention to specific characteristics:

Presence of a discrete, well‑defined central point, sometimes resembling a tiny black seed.
Lack of the typical distribution pattern of rosacea (central face, cheeks, nose, forehead) and confinement to a single spot.
Absence of the characteristic papulopustular lesions that often accompany rosacea flare‑ups.
History of recent outdoor exposure, especially in tick‑infested areas, or contact with animals.

Photographic documentation commonly shows a reddish plaque with a pinpoint dark core. In close‑up images, the tick’s body may be partially visible through the skin, creating a “halo” of inflammation around it. Contrast with rosacea images reveals that rosacea lesions lack a central punctum and are usually part of a broader pattern of facial erythema.

When a facial nodule exhibits these features, prompt removal of the tick and assessment for potential infection are advised. Failure to recognize the tick can lead to prolonged inflammation, secondary bacterial infection, or transmission of tick‑borne pathogens.

Folliculitis Manifestations

A subcutaneous tick embedded in facial skin often produces a localized inflammatory nodule that resembles folliculitis. The lesion appears as a firm, erythematous papule, typically 3‑7 mm in diameter, with a central punctum that may be dark or slightly raised. Occasionally a tiny, gray‑white halo surrounds the core, reflecting edema of the surrounding follicular unit.

Photographic records show a solitary, raised bump on the cheek or forehead, the surface slightly glossy, and the central point sometimes visible as a tiny black dot. In close‑up images the tick’s mouthparts can be discerned protruding from the skin, creating a subtle indentation that differentiates it from simple pustular lesions.

Typical folliculitis manifestations that may accompany or be confused with a tick bite include:

Red papules centered on hair follicles
Pustules containing purulent material
Perifollicular erythema extending a few millimeters beyond the lesion
Mild swelling of the surrounding dermis
Occasional crust formation after rupture

Key clinical clues separating a tick‑induced nodule from primary folliculitis are the presence of a visible punctum, the persistence of the lesion beyond the usual 48‑hour course of bacterial folliculitis, and the occasional sensation of movement under the skin. Absence of rapid improvement after topical antibiotics also supports a parasitic etiology.

Prompt removal of the tick, followed by antiseptic cleaning and, if needed, a short course of oral antibiotics, reduces the risk of secondary infection and limits progression to deeper skin involvement. Monitoring for localized lymphadenopathy or systemic signs ensures early detection of complications.

Eyelid Involvement («Blepharitis»)

A subcutaneous tick on the facial region may present as a firm, dome‑shaped nodule measuring 2‑8 mm. The overlying skin often appears slightly erythematous, with a central punctum that can be dark brown or black. The tick’s body may be partially visible through the skin, giving a mottled appearance that contrasts with the surrounding tissue.

When the parasite attaches to the eyelid margin, blepharitis‑type signs emerge. The eyelid edge becomes swollen, red, and may develop scaling or crusting along the lash line. Patients frequently report itching, gritty sensation, and occasional tearing. Inflammation can extend to the conjunctival surface, producing a mild conjunctival injection.

Diagnostic clues include:

Central punctum with a visible tick body or silhouette.
Localized erythema confined to the eyelid margin.
Presence of crusted debris at the lash base.
Absence of purulent discharge typical of bacterial hordeolum.

Photographic documentation usually shows a macro view of the eyelid where the tick’s dorsal shield is visible beneath a thin epidermal layer. The surrounding tissue displays a halo of mild redness, while the tick’s legs may be faintly discernible radiating from the body.

Differential considerations are chalazion, meibomian cyst, and stye. Unlike those entities, a tick produces a discrete punctum and a non‑fluctuant nodule without pus formation. Prompt removal under sterile conditions prevents secondary infection and reduces the risk of systemic transmission of tick‑borne pathogens.

Differentiating Demodex from Other Skin Conditions

Pimple vs. Mite-Related Lesion

Key Distinguishing Features

A subcutaneous tick on the facial skin presents as a small, dome‑shaped nodule that often resembles a puncture wound or a raised papule. The lesion is typically 2–5 mm in diameter, smooth to slightly rough, and may display a faint brown or gray coloration that matches the surrounding epidermis. The central area can appear slightly depressed where the mouthparts have anchored, while the peripheral rim may be slightly erythematous. Over time the nodule may enlarge, develop a hard consistency, or become ulcerated if the tick releases saliva or secondary infection occurs.

Key distinguishing features include:

Location of attachment: positioned on the cheek, eyelid, or periorbital region, often near hair follicles or skin folds where ticks can hide.
Shape: rounded, with a subtle central indentation indicating the feeding apparatus.
Color: muted brown‑gray tone that blends with skin, sometimes with a faint halo of redness.
Surface texture: smooth to slightly rough; unlike a typical insect bite, the surface does not exhibit raised papules or vesicles.
Absence of movement: the nodule remains static, unlike a crawling arthropod; the tick is anchored beneath the epidermis.
Presence of a tiny opening: a minute puncture or “mouthpart scar” may be visible at the center, often only discernible under magnification.
Consistency: firm to the touch, not compressible like a fluid‑filled blister.

Photographic identification relies on close‑up macro images that capture the nodule’s dome shape, central puncture, and color contrast. High‑resolution photos taken at 10–15 × magnification reveal the tick’s ventral mouthparts as a tiny, dark line extending from the center. Comparative images of common facial lesions (e.g., acne, cysts, insect bites) demonstrate that subcutaneous ticks lack the inflammatory pustules, central necrosis, or fluctuance typical of those conditions. Accurate visual assessment, combined with a history of outdoor exposure, enables reliable differentiation of a subcutaneous tick from other facial skin anomalies.

When to Suspect Demodex

A subcutaneous tick embedded in facial skin presents as a firm, rounded nodule, often brown or dark‑red, with a visible punctum where the mouthparts penetrate. The surrounding area may show slight erythema, but the lesion typically lacks the fine, hair‑like filaments that characterize microscopic mites. The tick’s body is usually palpable and may be partially visible through the epidermis, especially on the cheek or forehead.

Suspecting a Demodex infestation becomes necessary when the following clinical features appear without an obvious tick:

Persistent itching or burning localized to eyelashes, eyebrows, or facial skin.
Fine, white to translucent cylindrical particles lining the base of hair follicles, visible after gentle extraction.
Diffuse papular or pustular eruptions that fluctuate with stress, hormonal changes, or oily skin.
Redness and swelling confined to the periorbital region, often accompanied by a gritty sensation on the lashes.
Recurrent rosacea‑like flushing that does not respond to standard anti‑inflammatory therapy.

These signs indicate that microscopic mites, rather than a visible arthropod, are implicated. Confirmation requires microscopic examination of skin scrapings or epilated hairs, revealing the characteristic elongated, spindle‑shaped organisms. If Demodex is identified, targeted therapy such as topical metronidazole, ivermectin, or tea‑tree oil formulations should be initiated.

Other Facial Skin Issues

Acne Vulgaris

Acne vulgaris presents as comedones, papules, pustules, nodules and occasional cysts on the facial skin. Open comedones (blackheads) appear as dark, oxidized plugs within enlarged pores, while closed comedones (whiteheads) are flesh‑colored elevations capped by skin. Papules are firm, raised lesions 2–5 mm in diameter, often erythematous. Pustules contain a purulent core, giving a yellow‑white center surrounded by red inflammation. Nodules and cysts are deeper, tender masses that may reach several centimeters and can leave permanent scarring.

When a tick embeds subcutaneously in the facial region, the lesion typically manifests as a small, firm, rounded nodule with a central punctum that may be invisible through the epidermis. The overlying skin often shows a localized erythema but lacks the purulent center characteristic of pustular acne. In many cases, the tick’s mouthparts remain hidden, producing a smooth bulge rather than the rough texture of comedonal lesions. Photo documentation usually shows a solitary, well‑defined swelling without the comedone clusters seen in acne.

Key visual distinctions:

Surface texture: acne lesions exhibit a rough, keratin‑filled plug; tick nodule feels smooth and solid.
Central feature: acne may have a visible blackhead or pus; tick may show a tiny, sometimes invisible, punctum.
Distribution: acne commonly involves the forehead, nose, cheeks and chin in clusters; a tick appears as an isolated focus.
Evolution: acne lesions can fluctuate in size and may rupture; a tick nodule enlarges steadily until the parasite is removed.
Associated symptoms: itching or a sensation of movement is more typical for a tick; acne is usually painless unless inflamed.

Accurate identification relies on close visual inspection and, when necessary, dermoscopic imaging. Dermoscopy of a tick reveals a dark, elongated body with leg structures beneath the skin surface, whereas acne lesions display follicular openings filled with sebum and inflammatory cells. Proper differentiation prevents misdiagnosis and guides appropriate treatment—topical or systemic acne therapy versus mechanical extraction of the arthropod.

Allergic Reactions

A subcutaneous tick on the facial skin appears as a small, dome‑shaped nodule, often brown to reddish‑black, with a central punctum where the mouthparts are anchored. The surrounding area may be slightly raised, firm, and may show a faint halo of erythema. In photographs, the lesion is typically seen as a raised bump with a visible entry point that can be difficult to distinguish from a cyst or acne nodule without close inspection.

Allergic reactions to a buried tick are common and can develop rapidly after attachment. Typical manifestations include:

Localized itching or burning sensation at the bite site.
Swelling that expands beyond the immediate nodule, sometimes forming a larger plaque.
Redness that intensifies, turning into a wheal or urticarial rash.
Secondary skin changes such as hives, vesicles, or crusting if scratching occurs.
Systemic symptoms in severe cases: fever, malaise, joint pain, or lymphadenopathy.

The immune response is triggered by tick saliva proteins and, in some individuals, by antigens released from the tick’s body. Histamine release from mast cells produces the characteristic pruritus and edema. Re‑exposure to the same tick species can amplify the reaction, leading to larger lesions and prolonged healing times.

Management of allergic reactions to a facial subcutaneous tick involves:

Prompt removal of the tick using fine‑point tweezers, grasping the mouthparts as close to the skin as possible, and pulling upward with steady pressure to avoid leaving fragments.
Cleaning the area with antiseptic solution to reduce secondary bacterial infection.
Applying a topical corticosteroid (e.g., 1% hydrocortisone) to diminish inflammation and itching.
Administering an oral antihistamine (e.g., cetirizine 10 mg) for systemic itch control.
Monitoring for signs of infection or escalating allergic response; seeking medical evaluation if fever, expanding cellulitis, or severe swelling develops.

Early identification of the tick’s subdermal presentation and immediate treatment of the allergic response minimize tissue damage and reduce the risk of complications such as secondary infection or prolonged dermatitis.

Diagnosis and Treatment Approaches

Medical Consultation

When to See a Dermatologist

A subcutaneous tick embedded in facial tissue can be difficult to detect without magnification. The lesion may appear as a small, raised bump, a discoloration, or a localized area of swelling that does not resolve after a few days. When such a presentation occurs, prompt evaluation by a skin specialist is advisable.

Indicators for dermatologic consultation

Persistent nodule or papule lasting longer than 48 hours despite removal attempts.
Increasing redness, warmth, or tenderness around the site, suggesting secondary infection.
Development of a central punctum or ulceration that widens over time.
Appearance of a rash, fever, or flu‑like symptoms in conjunction with the facial lesion.
History of recent outdoor exposure in tick‑infested regions, especially if the bite was not fully removed.
Uncertainty about the completeness of tick extraction or presence of residual mouthparts.

A dermatologist can confirm the diagnosis through dermoscopic examination, order appropriate laboratory tests for tick‑borne pathogens, and prescribe targeted treatment such as topical antibiotics, systemic antimicrobials, or anti‑inflammatory agents. Early specialist involvement reduces the risk of complications, including localized infection, allergic reactions, or transmission of diseases such as Lyme borreliosis.

Diagnostic Procedures

A tick lodged beneath the facial skin presents as a firm, slightly elevated nodule, often surrounded by mild erythema. The lesion may display a central punctum or a tiny, dark spot corresponding to the tick’s mouthparts. In many cases the overlying skin retains a normal color, making the infestation difficult to distinguish from benign cysts or inflammatory papules. High‑resolution photographs typically reveal a well‑defined, rounded elevation with a subtle central depression; color contrast between the tick’s body and surrounding tissue aids visual identification.

Accurate diagnosis relies on a sequence of procedural steps:

Visual inspection – magnified examination with a handheld dermatoscope highlights the tick’s dorsal shield, leg arrangement, and mouthparts.
Ultrasound imaging – a 10‑15 MHz linear probe detects a hypoechoic structure within the dermis, confirming depth and size.
Fine‑needle aspiration (FNA) or punch biopsy – tissue sampling provides histopathological confirmation, revealing arthropod fragments and surrounding inflammatory infiltrate.
Molecular testing – PCR analysis of extracted material identifies tick‑borne pathogens such as Borrelia or Rickettsia species.
Photographic documentation – standardized digital images, taken with scale bars, support longitudinal monitoring and specialist consultation.

During physical examination, clinicians should palpate the lesion to assess mobility; a firmly attached tick will resist movement, whereas a cyst may be more pliable. Dermoscopic evaluation should focus on the presence of a central dark pit and peripheral striations characteristic of the tick’s exoskeleton. Ultrasound confirmation of a discrete, hyperechoic body within the subcutaneous layer distinguishes the infestation from fluid‑filled cysts, which appear anechoic.

If imaging and dermoscopy suggest a subdermal tick, tissue sampling is indicated. Histology typically shows chitinous fragments surrounded by neutrophilic and lymphocytic infiltrates. Positive PCR results guide antimicrobial therapy targeting specific vector‑borne infections.

Prompt identification through these diagnostic procedures minimizes tissue damage, reduces the risk of systemic infection, and informs appropriate removal techniques.

Management Strategies

Topical Treatments

A subcutaneous tick embedded in facial skin appears as a firm, slightly raised nodule, often matching the surrounding skin tone but sometimes showing a darker central punctum where the mouthparts attach. The surrounding area may be erythematous or edematous, and a small, translucent halo can be visible if the tick’s body is partially exposed. Clinical photographs typically show a smooth, dome‑shaped lesion with a central pinpoint opening.

Topical agents are employed to alleviate local irritation, prevent secondary infection, and facilitate safe removal. Effective options include:

Lidocaine 2‑5 % cream – numbs the area, reducing pain during extraction.
Antiseptic ointments (povidone‑iodine, chlorhexidine) – diminish bacterial colonization on the skin surface.
Topical ivermectin 1 % – targets embedded arthropod tissue, decreasing inflammatory response.
Permethrin 5 % cream – kills residual tick fragments and prevents local infestation.
Hydrocortisone 1 % ointment – mitigates mild inflammation and itching after removal.

Application guidelines: clean the lesion with mild soap and water, apply a thin layer of the chosen topical agent, and cover with a sterile gauze for 10‑15 minutes before attempting removal with fine‑pointed forceps. After extraction, re‑apply an antiseptic ointment and monitor for signs of infection or expanding erythema. If systemic symptoms develop, oral therapy may be required.

Oral Medications

A tick embedded beneath the facial skin presents as a small, dome‑shaped nodule, often 2–5 mm in diameter, with a dark, smooth surface that may be partially visible through the epidermis. The surrounding tissue can appear erythematous or edematous, and the lesion may feel firm to the touch. In some cases, the tick’s mouthparts remain attached, creating a central punctum that can be seen as a tiny opening or a faint line.

Oral pharmacotherapy addresses two primary concerns: prevention of tick‑borne infections and management of secondary bacterial inflammation. Systemic agents are prescribed when the tick has been attached for more than 24 hours, when the patient exhibits fever, rash, or joint pain, or when the bite occurs in a region endemic for specific pathogens.

Doxycycline 100 mg twice daily for 10–14 days – first‑line for suspected Lyme disease, Rocky Mountain spotted fever, and other rickettsial infections; effective against a broad spectrum of tick‑borne bacteria.
Azithromycin 500 mg once daily for 3 days – alternative for patients unable to tolerate doxycycline; covers certain rickettsial agents and atypical bacteria.
Amoxicillin‑clavulanate 875/125 mg twice daily for 7–10 days – indicated for secondary cellulitis or localized bacterial superinfection of the bite site.
Cefuroxime axetil 500 mg twice daily for 7 days – option for patients with penicillin allergy when bacterial infection is suspected.

The choice of medication depends on the patient’s age, allergy profile, disease prevalence in the geographic area, and the duration of tick attachment. Prompt initiation of the appropriate oral regimen reduces the risk of systemic complications while the local lesion resolves with or without additional topical care.