What is the recommended management for bug bites?

Management of Bug Bites

For most simple insect bites, treatment should focus on symptom relief with antihistamines, topical corticosteroids, and proper wound care, while severe reactions require immediate epinephrine and medical attention. 1

Initial Assessment and Management

Local Reactions

• Clean the area by washing with soap and water to prevent secondary infection 1
• Remove any stinger within 10-20 seconds by flicking or scraping to prevent further envenoming 1
• Apply ice or cold compresses for 10-15 minutes several times daily to reduce pain and swelling 1
• For itching and inflammation:
  • Non-sedating H1 antihistamines are first-line treatment (e.g., Cetirizine 10mg daily, Loratadine 10mg daily, Fexofenadine 180mg daily) 1
  • For inadequate response, dose of non-sedating antihistamine can be increased up to 4 times the standard dose 1
  • Consider adding a sedating antihistamine at night for nighttime symptoms (e.g., diphenhydramine 25-50mg) 1
• For significant inflammation, apply topical hydrocortisone cream to affected area not more than 3-4 times daily 2
• For pain relief, use over-the-counter acetaminophen or NSAIDs 1

Large Local Reactions

• Treatment includes antihistamines, cold compresses, and in severe cases, a short course of oral corticosteroids 3
• Antibiotics are usually not necessary unless there are signs of infection 3

Signs of Infection and Antibiotic Treatment

Consider antibiotic treatment if signs of infection develop (increasing redness, warmth, swelling, purulent drainage):

• First-line options:
  • Cephalexin 250mg four times daily 1
  • Amoxicillin-clavulanate 875/125mg twice daily 3, 1
• For penicillin-allergic patients:
  • Clindamycin 300-400mg three times daily 3, 1

Management of Systemic Reactions

Mild Systemic Reactions (Cutaneous Only)

• Initial treatment may include antihistamines and close observation 3
• Monitor for progression to more severe symptoms 3

Severe Systemic Reactions/Anaphylaxis

• Administer epinephrine immediately as the first-line treatment 3, 1
  • Adults: 0.3-0.5mg intramuscularly in anterolateral thigh
  • Children: 0.01mg/kg (up to 0.3mg)
• Delayed use of epinephrine may be ineffective; fatal outcomes are associated with delay or lack of administration 3
• Supportive therapy and transport to an emergency department 3
• Antihistamines and corticosteroids should not be considered substitutes for epinephrine 3

Special Considerations for Specific Insects

Bee and Wasp Stings

• Remove stinger immediately by scraping (not squeezing) 1
• Patients with history of systemic reactions should:
  • Carry epinephrine for emergency self-treatment 3
  • Be educated on proper use and indications 3
  • Consider obtaining medical identification bracelet or necklace 3

Fire Ant Stings

• Typically cause sterile pseudopustule within 24 hours 3
• Keep vesicle intact and clean to prevent secondary infection 3

Bed Bug Bites

• Typically present as pruritic, erythematous maculopapules in clusters or linear distribution 4
• Treatment is mainly symptomatic with topical pramoxine, oral antihistamines, and topical corticosteroids for significant eruptions 4
• Consultation with professional exterminator recommended for infestation 4

Prevention Strategies

• Avoid wearing brightly colored clothing or flowery prints 3
• Avoid using strongly scented materials that might attract insects 3
• Wear protective clothing (long pants, long-sleeved shirts, socks, shoes) when outdoors 3
• Apply insect repellent containing DEET 10-35% or picaridin 20% 5
• Have known or suspected nests removed by trained professionals 3
• Be cautious near bushes, eaves, attics, garbage containers, and picnic areas 3

When to Refer to an Allergist-Immunologist

Referral is recommended for patients who:

• Have experienced a systemic allergic reaction to an insect sting 3, 1
• Need education about risk of future reactions, emergency treatment options, and insect avoidance 3, 1
• Might be candidates for venom immunotherapy (VIT) 3
• Have coexisting conditions that might complicate treatment of anaphylaxis 3

Common Pitfalls and Caveats

• Antibiotics are usually unnecessary for simple insect bites unless there are signs of infection 3, 1
• Fire ant stings produce sterile pseudopustules that are not infected and don't require antibiotics 3
• Delayed administration of epinephrine in anaphylaxis can lead to fatal outcomes 3
• There is no contraindication to epinephrine use in life-threatening anaphylaxis, even in patients with cardiovascular disease 3
• Most spider bites in the US are benign; medically significant bites primarily come from Black widow and Brown recluse spiders 1

By following these evidence-based recommendations, most bug bites can be effectively managed with minimal complications, while ensuring appropriate escalation of care for more serious reactions.