Ticks, the Tick Center | The tick center would like more pictures of skin rashes after tick bites

In August last year, the Tick Center launched Tick Check, where the aim is to assess suspected tick bites with quick advice on further measures against the tick-borne disease Lyme disease. In case of infection by the bacteria, it is important to start treatment at an early stage to reduce the risk of developing a serious illness. One of the first things to notice is a rash, called erythema migrans (EM).

– The tick check service has become popular, we have received around 500 photos from a total of 300 people who have had a rash. Nevertheless, we have experienced a startling lack of pictures of rashes in people with darker skin. It is a pervasive problem that also applies to other types of skin infections, says advisor Harald Reiso at the Flea Center to NTB.

– We don’t think it’s a matter of the tick going after lighter skin tones to a greater extent. It is more likely that rashes look better on paler skin, and that it is then easier to detect and get assessed, says Reiso.

Consequently, many people may have undiagnosed Lyme disease in the skin.

Global phenomenon

A quick search online reveals a general lack of pictorial documentation of rashes on darker skin tones. Dermatologist Jenna Lester searched medical literature for pictures of rashes on dark skin, to better help her dark-skinned patients. She couldn’t find a single picture anywhere.

– We do not teach (and perhaps do not learn) skin colour, writes Lester in his analysis in the British Journal of Dermatology (BJD) about the phenomenon in general.

In December last year, the Johns Hopkins Medicine Lyme Disease Research Center published research showing large disparities in the diagnosis and treatment of Lyme disease between black and white patients.

While 52.1 per cent of the white patients were diagnosed due to just a rash, this only applied to 18.6 per cent of the dark-skinned patients.

Lead author behind the study, John Aucott, believes this is about a lack of knowledge and awareness both in the healthcare system and society, and not least that there is no teaching on how to identify Lyme disease in patients with darker skin.

Aucott warned that the problem will grow globally as infected ticks spread.

Artificial intelligence

Every year, approximately 7,000 Norwegians get a Lyme disease rash. Those cases that develop systemic disease and late manifestations must be reported. Last year, 570 cases of Lyme borreliosis were registered in Norway. The hope is to reduce the number of cases through early diagnosis and treatment.

One of the moves in Norway is to further develop Flåttjekk.no and use artificial intelligence (AI) for automatic image recognition of the Lyme disease rash. But then many and varied images are needed to get a reliable AI service. The tick center therefore encourages everyone who gets a rash after a tick bite, both young and old, women and men, people with light skin and dark skin, to register a photo.

– In order for our future image recognition app to function optimally, we are dependent on obtaining a varied selection of images, says Reiso.

The American researchers at Johns Hopkins started with the same plan in 2021, but determined that there were major challenges.

– The biggest of them is to compensate for the general lack of available images of rashes on dark skin tones. The computer cannot learn to recognize a Lyme disease rash on dark skin if it does not have the necessary basis, wrote Aucott, who among thousands of rash photos had only found a dozen photos of dark skin.

Structural discrimination

Professor of migration and health services at Oslomet, Jonas Debesay, says there is a lack of global knowledge and understanding that illness can progress differently in people with different skin colours. He explains that it entails a form of discrimination and racism that is often difficult to spot: Structural racism.

– This type of racism proceeds through routines, guidelines and decisions in organisations, but also through social and political perceptions in society, he says.

– So it is not reluctance or willingness to discriminate that creates health inequalities among minority patients. Most likely it happens as a result of a lack of mapping of needs and provision for a more heterogeneous user group, says Debesay.

Some of the lack of a rash picture can perhaps be explained by the fact that ethnic minorities are not infected to the same extent, because they do not have the same culture for traveling in forests and fields, or that they make up a smaller part of the population in the particularly tick-prone coastal areas.

– But as the years go by, more people will get “Norwegian habits” and the tick will spread. And if more people are bitten, it is important that we have a system in place that captures all cases at an early stage, says Debesay.