What is the recommended treatment for bug bites?

Bug Bite Treatment

For most common bug bites, treatment should include cold compresses, oral antihistamines for itching, and topical hydrocortisone for inflammation, with epinephrine auto-injectors reserved for those with history of systemic allergic reactions. 1

Treatment Based on Reaction Type

Localized Reactions (Most Common)

1. First-line treatments:

   • Apply cold compresses to reduce local pain and swelling 1
   • Elevate affected area if possible 1
   • Use topical hydrocortisone (apply to affected area not more than 3-4 times daily) 2
   • Take oral antihistamines for itching and discomfort 1

2. For more severe local reactions:

   • Consider short course of oral corticosteroids 1
   • Topical lidocaine may help relieve local pain if skin is intact 1

Large Local Reactions

These occur in 5-15% of stings, peak at 24-48 hours, and may last over a week 1:

• Continue with antihistamines, elevation, and cold compresses
• Monitor for signs of infection (increasing redness, warmth, swelling, pain)

Systemic Allergic Reactions

These occur in 0.4-0.8% of children and up to 3% of adults, usually within 10 minutes of the sting 1:

• Emergency treatment with injectable epinephrine is essential
• Adult dosage: 0.3-0.5 mg intramuscularly into anterolateral thigh
• Children ≥30 kg: 0.3-0.5 mL intramuscularly into anterolateral thigh
• Children <30 kg: 0.01 mg/kg, up to 0.3 mg intramuscularly
• Transport to emergency department for further monitoring and care

Management of Potential Infection

• Antibiotics are not routinely needed for early, uninfected insect bites 1

• Consider antibiotics if signs of infection develop (increasing redness, warmth, pain, purulent discharge)

• First-line antibiotic options include:

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

• Infected wounds should not be closed to prevent further complications 1

• Consider hospitalization if infection progresses despite appropriate antimicrobial therapy 1

Special Considerations

For Mosquito Bites

• Second-generation antihistamines are most effective for itching 4
• Severe mosquito reactions (skeeter syndrome) may require prednisone 5

For Bed Bug Bites

• Various treatments including antihistamines, topical and oral corticosteroids have been used with varying results 6
• No evidence-based interventions to prevent bites were identified in clinical trials 6

Prevention Strategies

1. Avoid attracting insects:

   • Avoid wearing brightly colored clothing or flowery prints 3
   • Avoid using strongly scented materials that might attract insects 3

2. Physical protection:

   • Wear long pants, long-sleeved shirts, socks, shoes when outdoors 3, 1
   • Avoid walking barefoot or with open shoes 3

3. Chemical protection:

   • Apply DEET-containing repellents (10-30% concentration) to skin and clothing 1
   • Consider permethrin-treated clothing for high-risk activities 1

4. Environmental measures:

   • Remove known nests in the vicinity of home by trained professionals 3
   • Avoid areas with high uncut grass, weeds, and low brush 1
   • Be cautious near bushes, eaves, and attics 3

Follow-up Recommendations

• Monitor bite site for 48-72 hours for signs of infection or progression 1
• Patients with history of systemic reactions should be referred to an allergist for evaluation for venom immunotherapy 1
• Patients with systemic reactions should carry injectable epinephrine 3, 1

Common Pitfalls to Avoid

1. Overuse of antibiotics: Many practitioners prescribe antibiotics unnecessarily for insect bites. One study found antibiotics were prescribed to nearly 75% of patients with insect bites, likely representing overuse 7.

2. Underutilization of antihistamines: Only 22% of patients were taking antihistamines before consulting despite 45% complaining of itch 7.

3. Confusing cellulitis with inflammation: Insect bite inflammation may mimic cellulitis and promote unnecessary antibiotic usage 7.

4. Delayed epinephrine administration: For those with anaphylaxis, delay in epinephrine administration has been associated with fatal reactions 1.