Prevention and Management of Tick-Borne Illness

Publication Date: October 9, 2021
Last Updated: March 14, 2022


Long-Sleeved Clothing

Wear long-sleeved clothing when traveling in tick habitat. (U-CBS)

Light-Colored Clothing

Although light-colored clothing may not reduce the risk of tick bites, it does make it easier to identify ticks on clothes during tick checks. (2C)

Clothing Care

Washing clothes at temperatures over 54°C/130°F and drying clothing in high heat for 10 min kills ticks and therefore may reduce the risk of TBIs. (1C)

Tick and Insect Repellents


DEET is an effective tick repellent. DEET should be reapplied based on the concentration of formulation. (1B)
DEET can be used in children over the age of 2 months. (1B)


Picaridin is an effective tick repellent and is comparably efficacious to DEET. (1B)
Picaridin may have a superior safety profile when compared to DEET. (2B)


Permethrin-treated clothing is an effective tick repellent. (1A)
Permethrin-treated clothing, when used in combination with a skin-based tick repellent such as DEET or picaridin, may further reduce the risk of TBI. (1C)

Other Repellents

Essential oils, citriodiol, nootkatone, and IR3535 have either a lower repellent efficacy or significantly shorter duration of action. Given these attributes, wilderness recreationalists should avoid these products as first-line tick repellents. (2B)

Tick Checks

Evidence supporting tick checks is contradictory; however, when combined with bathing within 2 h of being outdoors, these measures may help prevent TBI. (1C)

Shower or bathe within 2 h of returning from tick habitat. (2C)

Other Behavioral Modifications

When feasible, avoid areas with high grass or leaf litter. When in tick habitat, walk in the middle of trails to mitigate the chance of contact with ticks. (U-CBS)

Tick Removal

Mechanical removal by pulling upward, or perpendicular to skin, directly on an embedded tick with forceps is the best currently available method. Mechanical removal using commercial devices may also work, but evidence suggesting superiority does not exist. (1C)

Pulling embedded ticks with straight, steady pressure is preferred over a twisting motion. (1C)

Passive removal techniques, particularly chemical strategies that involve exposing attached ticks to petroleum jelly, fingernail polish, isopropyl alcohol, gasoline, or methylated spirits are ineffective and not recommended. (2C)

Using local or systemic medications such as locally infiltrated anesthetics or systemic ivermectin is not effective in removing or exterminating attached ticks. No evidence exists to suggest any benefit to these strategies. (2C)

Timing of Tick Removal and Risk of Lyme Transmission

Once discovered, ticks should be removed as soon as possible. To meaningfully reduce the risk of Lyme disease, ticks should be removed within 36 h of attachment. (1B)

Prophylactic Antibiotics for Lyme Disease

A single dose of 200 mg doxycycline orally is recommended after a high-risk tick bite if given within 72 h to reduce the risk of Lyme disease. (1B)

If a provider is unable to identify the tick, or if the time of attachment is unknown, then a period of “watchful waiting” is recommended instead of prophylaxis. Should the patient develop fever, EM, or arthralgias within 30 d of the presumed tick bite, treatment with doxycycline can then be initiated. (1B)

Prophylactic Antibiotics for Other TBI

Providers should not employ prophylactic antibiotics for management of anaplasmosis, ehrlichiosis, Rocky Mountain spotted fever, relapsing fever, or any other TBI. Outside of high-risk Lyme disease exposures, prophylactic antibiotics are not indicated. (1C)

Decision to Evacuate

Individuals who develop systemic or high-risk symptoms (fever, generalized rash, arthralgias, cranial nerve palsy, dyspnea, or syncope) related to a suspected TBI should be evacuated to a higher level of medical care. (1C)

Individuals who develop symptoms suggestive of Lyme carditis such as dyspnea, dizziness, or syncope should receive a screening ECG as soon as possible and would benefit from a thorough cardiovascular evaluation in an appropriate clinical setting. (1C)


While no vaccine for tick-borne encephalitis is currently available in the United States, vaccines such as Encepur appear to be efficacious for inducing seroconversion against tick-borne encephalitis. (2A)

Although not currently available in the United States, Lyme vaccination is efficacious at reducing the risk of infection. (2A)

Educational Programs

Educational programs can change behavior and lower rates of TBI and should be encouraged. (1B)

Recommendation Grading




Prevention and Management of Tick-Borne Illness in the United States

Authoring Organization

Publication Month/Year

October 9, 2021

Last Updated Month/Year

July 24, 2023

Document Type


Country of Publication


Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Childcare center, School

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Management, Prevention

Diseases/Conditions (MeSH)

D064927 - Tick Bites, D017282 - Tick-Borne Diseases, D013987 - Ticks


Lyme Disease, ticks, tick-borne rickettsial infections, lyme, wilderness, safety, tick borne illness

Source Citation

Ho BM, Davis HE, Forrester JD, Sheele JM, Haston T, Sanders L, Lee MC, Lareau S, Caudell M, Davis CB. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Management of Tick-Borne Illness in the United States. Wilderness Environ Med. 2021 Dec;32(4):474-494. doi: 10.1016/j.wem.2021.09.001. Epub 2021 Oct 9. PMID: 34642107.

Supplemental Methodology Resources

Data Supplement