Journal of Cutaneous and Aesthetic Surgery
Print this page
Email this page
Small font size
Default font size
Increase font size
Home About us Current issue Archives Instructions Submission Subscribe Editorial Board Partners Contact e-Alerts Login 

   Table of Contents     
Year : 2015  |  Volume : 8  |  Issue : 3  |  Page : 184-186
Tâche noire: A classic case treated with dual freeze cycles of liquid nitrogen cryotherapy and clasped manoeuvre

1 Department of Dermatology, Skin Diseases Centre, Nashik, Maharashtra, India
2 School of Public Health, The Chinese University of Hong Kong and The Prince of Wales Hospital, Hong Kong

Click here for correspondence address and email

Date of Web Publication14-Oct-2015

How to cite this article:
Zawar V, Karad G, Chuh A. Tâche noire: A classic case treated with dual freeze cycles of liquid nitrogen cryotherapy and clasped manoeuvre. J Cutan Aesthet Surg 2015;8:184-6

How to cite this URL:
Zawar V, Karad G, Chuh A. Tâche noire: A classic case treated with dual freeze cycles of liquid nitrogen cryotherapy and clasped manoeuvre. J Cutan Aesthet Surg [serial online] 2015 [cited 2022 Jan 27];8:184-6. Available from:

Dear Editor,

A tâche noire is a cutaneous hallmark occurring after a hard tick bite. [1] We report an effective and safe method of tick removal using a specific manoeuvre along with liquid nitrogen double-freeze cryotherapy.

A 24-year-old milkman presented with sudden onset of an itchy and painful black-crusted lesion with a red halo on his left upper scapular area [Figure 1]a]. He had a history of handling dogs and cattle. However, he did not recollect any arthropod bite. Close examination showed irregular movement within the lesion, which revealed a tick holding onto the skin [Figure 1]b].
Figure 1: (a) Black, itchy, and slightly painful crusted eruption on the back of the patient (b) The tick was seen holding onto the skin

Click here to view

After informed consent from the patient, we opted for cryotherapy. We applied 15 s of freezing directed from the lateral side of the tick, focusing on its mouthparts by tightly pinching the lesion [Figure 2]. The previously flat and horizontally engorged tick became vertical [Figure 3]. This was due to transient spasmodic movements of its trunk posteriorly with its clasp not released anteriorly. After 3 min of thawing, we executed a second cycle of 15 s of freezing to the top position of the mouthparts [Figure 4]. After another 3 min of thawing, the tick spontaneously released its clasps and was removed in toto. The site became ulcerated [Figure 5]. Under 10× microscopy, we visualized its mouthparts and confirmed that it was a hard tick [Figure 6]. We prescribed systemic azithromycin 500 mg twice daily for 3 days, systemic levocetirizine 5 mg daily for 7 days, and topical sodium fusidate ointment 2%. The site healed after 1 week [Figure 7].
Figure 2: First freeze cycle after firmly clinching the base of skin with liquid nitrogen spray directed to clasped mouthparts of the tick at the site of tick adherence

Click here to view
Figure 3: The previously flat and horizontally engorged tick moved into a vertical position after the first cycle of 15 s of freeze

Click here to view
Figure 4: Freeze cycle repeated from the top

Click here to view
Figure 5: Prompt and complete removal of the tick after 3 min of the second cycle. The site became ulcerated

Click here to view
Figure 6: Tick mounted on light microscope (10×)

Click here to view
Figure 7: Appearance of the lesions 1 week after the procedure. The ulcer healed with transient depigmentation

Click here to view

Ticks belong to two major families, Ixodidae (hard tick) and Argasidae (soft tick). [2] The hard tick bears a chitinous dorsal surface, and its mouthparts project forward with a toothed hypostome. Tâche noire is the cutaneous hallmark after a hard tick bite in 13-68% of patients with Rickettsia conorii infection, the pathogen causing Mediterranean spotted fever (African and Indian tick typhus). [1] It is endemic throughout Africa, the Middle East, southern Europe, India, and southwestern Asia. [3] It is important to remove the ticks as early as possible to reduce the chance of tick-borne infections. Ticks should not be arbitrarily pulled as twisting may break off its mouthparts, thereby leading to secretion of its infective body fluids. [2] Unless promptly and carefully treated, complications such as tick paralysis, transmission of rickettsial infections with serious systemic involvement, subcutaneous hemorrhage, chronic ulceration, and leukocytoclastic vasculitis can arise. [1],[2] Modalities such as liquid paraffin, kerosene, petrol, iodine, ether, chloroform, and lignocaine jelly bear their respective drawbacks. [3]

Pavlovic et al.[4] and Lanschuetzer et al.[5] reported tick removal by the application of liquid nitrogen with 20 s for a single freezing.

Based on our previous experience, the single-freeze method is inadequate in certain patients. A physical maneuver to pinch the chunk of skin on which the tick is attached may increase efficacy, more so than merely a distant cryospray. It may also prevent salivary dispersion of the tick into the deeper tissue, thus minimizing a risk of subsequent dissemination of tick-borne infection. We speculate that administration of cryotherapy may cause acute cryospasm of mouthparts and body parts at the base of the clasped skin, which may help immediate release the clasp of the tick. To the best of our knowledge, our report is the third report on the utilization of cryotherapy in removing an attached tick and the first in the literature describing administration of double-freezing with a clasping maneuver.

We emphasize that cryotherapy is an easy, inexpensive method for prompt, safe, and complete removal of a tick by liquid nitrogen cryotherapy. Cryotherapy might prevent the subsequent risk of transmission of infections. However, close clinical monitoring is still highly recommended.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Hay RF, Asriaans BM. Bacterial infections. In: Burns T, Breathnacth S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. 8 th ed. UK: Blackwell Publishing Ltd; 2010. p. 30.72-30.74.  Back to cited text no. 1
Piesman J, Hojgaard A, Ullmann AJ, Dolan MC. Efficacy of an experimental azithromycin cream for prophylaxis of tick-transmitted lyme disease spirochete infection in a murine model. Antimicrob Agents Chemother 2014;58:348-51.  Back to cited text no. 2
Needham GR. Evaluation of five popular methods for tick removal. Pediatrics 1985;75:997-1002.  Back to cited text no. 3
Pavlovic M, Alakeel A, Frances C. Tick removal with liquid nitrogen. JAMA Dermatol 2013;149:633.  Back to cited text no. 4
Lanschuetzer CM, Wieser M, Laimer M, Emberger M, Hintner H. Improving the removal of intact ticks. Australas J Dermatol 2003;44:301.  Back to cited text no. 5

Correspondence Address:
Vijay Zawar
Department of Dermatology, Skin Diseases Centre, Nashik, Maharashtra
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-2077.167290

Rights and Permissions


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  

    Article Figures

 Article Access Statistics
    PDF Downloaded101    
    Comments [Add]    

Recommend this journal