This progressive skin process is due to the effect of continuing active infection with the spirocheteBorrelia afzelii, which is the predominant pathophysiology.[3]B. afzelii may not be the exclusive etiologic agent of ACA; Borrelia garinii has also been detected.[citation needed]
Presentation
The rash caused by ACA is most evident on the extremities. It begins with an inflammatory stage with bluish red discoloration and cutaneous swelling, and concludes several months or years later with an atrophic phase. Sclerotic skin plaques may also develop.[citation needed] As ACA progresses the skin begins to wrinkle (atrophy).
Cause
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Diagnosis
Generally a two-step approach is followed. First, a screening test involving IgM and IgG ELISA. If the ELISA screening has a positive or equivocal result, then the second step is to perform a Western Blot as a confirmatory test.
Other methods include microscopy and culture (in modified Kelly's medium) of skin biopsy or blood samples.
Stanek G & Strle F (2008) Lyme Disease—European Perspective| Infectious Disease Clinics of North America | Volume 22 | Issue 2 | June 2008, Pages 327-339|Abstract