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Three Part Question

In [patients with ticks attached to their skin] is [any of the popular methods better than the others] for [removal of an intact tick]?

Clinical Scenario

A 27-year-old hiker attends with what appears to be a tick in the skin of his right leg. You seek the advice of your colleagues on the best method of removal, the registrar advises you to pull it straight out, another registrar suggests to pull out anticlockwise, the consultant denounces them as fools and says to pull clockwise. Sister suggests suffocating the tick with vaseline and a staff nurse thinks that nail varnish is better for this, a passing porter suggests burning it off with a lighted fag and the patient himself claims that his mother always recommended 70% isopropyl alcohol (for the removal of ticks). Confused you wonder whether there is any evidence for any of the suggested methods.

Search Strategy

Medline 1966-04/02 using the OVID interface.
[exp ticks OR ticks.mp OR arachni$.mp OR tick.mp OR acarines.mp OR ixodes.mp OR parasit$ OR bloodsucker.mp OR dermacentor.mp OR amblyomma.mp OR ceratopogidae.mp] AND [exp"bites and stings" OR bite$.mp] AND [exp foreign bodies OR removal.mp OR excis.mp]

Search Outcome

40 papers found of which 38 were irrelevant or of insufficient quality for inclusion. The remaining 2 are shown below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Needham GR, 1985, USA	29 American dog ticks and 22 lone star ticks attached to a female Dorset sheep.	Experimental	Ease of removal and retained mouthparts. Testing with petroleum jelly, nail polish, 70% isopropyl alcohol and hot match (passive removal) and clockwise pull or straight pull with quick or steady even pressure (mechanical)	Failure of removal with passive methods. Removal with mechanical method steady even pressure most likely to give intact removal	Statistical significance not assessed
De Boer R and van den Bogaard AE, 1993, The Netherlands	Ixodes Ricinus attached to the skin of pigs and sheep.	Experimental	Ease of removal, retained mouthparts. Testing with gasoline, nail polish and methylated spirit or by straight pull or rotation around axis	Failure of removal by chemical methods within 30 minutes. Straight pull less likely to leave mouthparts than rotation (0.01

Comment(s)

Given that ticks have a respiratory rate of 3-15 breaths per hour suffocation would appear unlikely to work as the above studies showed, however anecdotal evidence suggests lignocaine gel may be efficacious in aiding removal (3).

Clinical Bottom Line

Current evidence suggests that a straight slow method is best for removal without leaving the mouthparts.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Needham GR. Evaluation of five popular methods of tick removal. Pediatrics 1985:75(6)997-1002.
2. De Boer R, van den Bogaard AE. Removal of attached nymphs and adults of Ixodes ricinus (Acari: Ixodidae). J Med Entomol 1993;30(4):748-52.
3. Karras DJ. Tick Removal. Ann Emerg Med 1998;32(4):519.