Steroid Cream for Insect Bites
For typical insect bites, over-the-counter topical hydrocortisone cream is NOT recommended as it has not been proven effective for symptom relief. Instead, use cold compresses and oral antihistamines as first-line treatment 1.
Treatment Algorithm for Simple Insect Bites
First-Line Management (All Patients)
- Apply cold compresses to the bite site to reduce local pain and swelling 1, 2
- Administer oral antihistamines to reduce itching and pain associated with the bite 1, 2
- Use oral analgesics (acetaminophen or NSAIDs) if needed for pain control 2, 3
When to Consider Oral Corticosteroids (NOT Topical)
Reserve oral corticosteroids for severe large local reactions only - defined as extensive erythema and swelling that persists for several days 1. These should be:
- Given as a short course of oral steroids 1
- Started promptly (within first 24-48 hours when swelling develops) 1
- Used to limit the allergic inflammation that causes the large swelling 1
Why Topical Hydrocortisone Doesn't Work
The 2024 American Heart Association guidelines specifically address this issue: over-the-counter topical corticosteroids (0.2% to 2.5% hydrocortisone in various formulations) were NOT found to improve symptoms in a randomized trial of 92 patients 1. Only high-potency topical corticosteroids combined with systemic steroids showed benefit, and these high-potency formulations are not available over-the-counter 1.
Despite FDA approval for hydrocortisone cream for insect bites 4, the clinical evidence does not support its effectiveness for this indication 1, 5.
Important Clinical Pitfalls
Do NOT Use Antibiotics Routinely
- The swelling from insect bites is caused by allergic inflammation, not infection 1, 2
- Antibiotics are unnecessary unless clear signs of secondary infection develop: progressive redness, increasing pain, purulent discharge, or fever 2, 3
- Secondary infection is uncommon following insect bites 2, 3
Recognize When to Escalate Care
Systemic reactions require immediate epinephrine and emergency transport 1:
- Urticaria or angioedema beyond the bite site
- Difficulty breathing or bronchospasm
- Hypotension or shock
- Fatal reactions are associated with delayed epinephrine administration 1
Special Consideration: Fire Ant Stings
- Fire ants create a characteristic sterile pseudopustule within 24 hours 1
- This vesicle is caused by necrotic tissue, not infection 1
- Leave the vesicle intact and keep it clean to prevent secondary infection 1
When to Refer to Allergist
Consider referral if the patient experiences 1, 2:
- Any systemic reaction (beyond local swelling)
- Recurrent severe large local reactions
- Need for education about future risk and venom immunotherapy options
Bottom line: Skip the topical hydrocortisone cream for insect bites - it doesn't work. Use cold compresses and oral antihistamines instead, reserving oral corticosteroids only for severe large local reactions.