What is the first line treatment for a wasp sting?

First-Line Treatment for Wasp Sting

For uncomplicated wasp stings, immediately remove any visible stinger by scraping or plucking, then apply cold compresses and administer oral antihistamines for symptom relief. 1, 2

Immediate Stinger Management

• Remove the stinger within the first 60 seconds if visible by scraping with a fingernail or plucking it out—unlike honeybees, wasps typically don't leave stingers, but if present, venom delivery continues for up to 60 seconds. 1, 2
• The method of removal (scraping vs. plucking) doesn't matter—speed is what counts. 1
• Wash the area with soap and water after stinger removal. 3

Treatment Algorithm by Reaction Severity

For Local Reactions (Most Common)

Local reactions present with pain, swelling, redness, and itching confined to the sting site. 1

• Apply cold compresses or ice packs to reduce pain and swelling. 1
• Administer oral antihistamines to reduce itching. 1
• Apply topical corticosteroids directly to the sting site for local inflammation and itching. 1, 2
• Give oral acetaminophen or ibuprofen for pain relief. 1, 2
• No antibiotics are needed—the swelling is allergic inflammation, not infection. 1, 2

For Large Local Reactions

Large local reactions involve extensive erythema and swelling extending beyond the sting site, persisting for several days. 1

• Continue cold compresses and oral antihistamines. 1
• Initiate a short course of oral corticosteroids promptly (within the first 24-48 hours) to limit progression of swelling—this is most effective when started early. 1, 2
• The American Academy of Allergy, Asthma, and Immunology supports oral corticosteroids for severe cases, though controlled trial data is limited. 2

For Anaphylaxis (Life-Threatening Emergency)

Anaphylaxis presents with difficulty breathing, throat/tongue swelling, widespread hives, lightheadedness, vomiting, or shock. 3, 4

• Immediately administer intramuscular epinephrine 0.01 mg/kg (up to 0.3 mg) in children or 0.3-0.5 mg in adults into the anterolateral thigh—this achieves faster and higher plasma concentrations than subcutaneous or arm injections. 1, 5, 3
• Epinephrine is the ONLY first-line treatment for anaphylaxis—antihistamines and corticosteroids are NOT substitutes and play no role in acute management. 1, 2
• Activate emergency medical services immediately. 3
• Be prepared to repeat epinephrine dosing if symptoms persist or recur. 1
• Delayed epinephrine administration is associated with fatal outcomes—prompt use is critical. 1, 3

Critical Pitfalls to Avoid

• Never delay epinephrine in anaphylaxis to give antihistamines or corticosteroids first—this can be fatal. 1, 3
• Don't prescribe antibiotics for swelling—this is allergic inflammation, not infection. 1, 2
• Don't waste time trying to identify the insect—treat based on clinical presentation. 1
• Any sting to the eye itself (not eyelid) requires immediate medical evaluation due to risk of permanent vision loss. 1, 3

Post-Treatment Considerations

• All patients with systemic reactions should receive an epinephrine autoinjector prescription and training on self-administration. 1, 5
• Refer patients with anaphylaxis to an allergist for venom-specific IgE testing and consideration of venom immunotherapy. 5
• Multiple stings (typically >100) can cause toxic reactions from massive envenomation, even in non-allergic individuals. 1, 3