What is the recommended wound management for a brown recluse spider bite?

Brown Recluse Spider Bite Wound Management

The recommended wound management for brown recluse spider bites includes thorough wound irrigation with warm water, application of antibiotic ointment, covering with a clean occlusive dressing, and monitoring for signs of infection or necrosis. 1

Initial Assessment and Management

• Thoroughly irrigate the bite wound with a large volume of warm or room temperature potable water until there is no foreign matter in the wound 1
• Apply antibiotic ointment and cover with a clean occlusive dressing to improve healing and reduce infection risk 1
• Apply ice with a clean barrier between ice and skin for local pain relief 1
• Elevate the affected body part, especially if swollen, to accelerate healing 2
• Remove rings and other constricting objects from the bitten extremity as swelling may occur 1

Pain Management

• Use over-the-counter acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control 1
• Consider topical lidocaine (5%) if the skin is intact for additional pain relief 1

Monitoring and Follow-up

• Most brown recluse bites vary from mild erythema to severe necrosis, with severity of cutaneous injury differing between patients 3
• Monitor for signs of infection requiring medical attention, including:
  • Progressive erythema extending beyond the initial bite site 4
  • Purulent discharge 4
  • Systemic signs of infection such as fever or elevated white blood cell count 4
• Follow up within 24 hours either by phone or during an office visit 2
• Patients should seek immediate medical attention if:
  • Pain extends beyond the bite site or becomes severe 1
  • Pain is not controlled by over-the-counter medications 1
  • An open wound develops 1
  • Systemic symptoms develop (difficulty breathing, muscle rigidity, dizziness, or confusion) 1

Management of Necrotic Wounds

• Infected wounds should not be closed 2
• Surgical excision of necrotic skin lesions is indicated only after lesions have stabilized and are no longer enlarging 5
• Delay surgical debridement for several weeks to allow clear demarcation of necrotic tissue 6
• Deeper debridement should be done cautiously to avoid enlarging the wound and impairing skin closure 2

Medication Considerations

• Update tetanus prophylaxis status if outdated or unknown 2
• Systemic antibiotics may be used to prevent secondary infection 7
• Dapsone should be considered only in adult patients who develop necrotic arachnidism and who have been screened for glucose-6-phosphate dehydrogenase deficiency 5
• Steroids may be indicated in bites associated with severe skin lesions, systemic loxoscelism, or in small children 5
• Topical nitroglycerin can be valuable in decreasing the enlargement of necrotic skin ulcers 5

Common Pitfalls to Avoid

• Do not apply suction to the bite site as this is ineffective and potentially harmful 1
• Avoid tourniquets or pressure immobilization bandages as these may worsen tissue injury 1
• Do not assume antibiotics are needed for swelling around the bite site, as swelling is typically caused by mediator release, not infection 4
• Avoid early suturing of wounds (within 8 hours after injury) as this may increase infection risk 2
• Do not delay medical care when systemic symptoms are present 8

Special Considerations

• Hand wounds are often more serious than wounds to fleshy parts of the body and may require more aggressive management 2
• Very young, very old, and those with underlying health conditions may be at higher risk for severe reactions 8
• Diagnosis is often difficult as the victim may not feel the bite or see the spider 3
• Systemic loxoscelism is rare but can produce massive hemolysis requiring hospitalization 5, 6