What is the immediate management for a honeybee sting with a local wheal?

Immediate Management of Honeybee Sting with Local Wheal

For a honeybee sting with a local wheal, immediately remove the stinger within 60 seconds by any method (scraping or plucking—speed matters, not technique), then apply cold compresses and administer oral antihistamines for symptomatic relief. 1

Step 1: Immediate Stinger Removal (First 60 Seconds)

• Remove the stinger immediately using any method available—scraping with a fingernail or plucking it out directly—because venom delivery continues for up to 60 seconds after the sting. 1
• The method of removal (scraping vs. plucking) does not affect the amount of venom delivered; speed is the only factor that matters. 1, 2
• Research demonstrates that weal size (envenomation) increases with each second of delay, even within the first few seconds, but there is no difference in response between stings scraped or pinched off after 2 seconds. 2
• After stinger removal, wash the area with soap and water. 1

Step 2: Symptomatic Treatment for Local Wheal

Cold Therapy

• Apply cold compresses or ice packs directly to the sting site to reduce pain and swelling. 3, 1

Antihistamines

• Administer oral antihistamines (such as diphenhydramine or cetirizine) to reduce itching associated with the local wheal. 3, 1, 4

Topical Corticosteroids

• Apply topical corticosteroids directly to the sting site for local inflammation and itching control. 1, 5
• Topical corticosteroids are the preferred steroid formulation for local reactions. 5

Analgesics

• Give oral acetaminophen or ibuprofen for pain relief as needed. 1, 5

Critical Pitfalls to Avoid

• Do NOT prescribe antibiotics—the swelling and erythema from a local wheal represent allergic inflammation, not infection, and antibiotics are not indicated unless there is clear evidence of secondary infection (which is uncommon). 3, 1, 5
• Do not delay stinger removal to gather supplies or prepare for removal—every second counts in the first minute. 1, 2
• Do not waste time trying to identify whether it was specifically a honeybee versus another stinging insect—treat based on clinical presentation. 1

When to Escalate Treatment

Large Local Reactions (>10 cm diameter, lasting 5-10 days)

• If the wheal progresses to a large local reaction with extensive swelling that increases over 24-48 hours, initiate a short course of oral corticosteroids promptly within the first 24-48 hours to limit progression. 3, 1, 5
• Continue cold compresses and oral antihistamines. 3

Systemic Reactions (Anaphylaxis)

• If any systemic symptoms develop (urticaria beyond the sting site, angioedema, difficulty breathing, throat swelling, lightheadedness, vomiting, widespread hives), immediately administer intramuscular epinephrine 0.3-0.5 mg in adults (0.01 mg/kg up to 0.3 mg in children) into the anterolateral thigh. 1, 4, 6
• Epinephrine is the ONLY first-line treatment for anaphylaxis—antihistamines and corticosteroids are NOT substitutes and play no role in acute anaphylaxis management. 1, 4, 5
• Activate emergency medical services immediately, as delayed epinephrine administration is associated with fatal outcomes. 3, 1, 4

Special Considerations

• Most insect stings cause only transient localized reactions that require minimal or no treatment. 3
• The local wheal typically resolves within hours to a few days with symptomatic treatment alone. 3
• If the sting is to the eye itself (not just the eyelid), immediate medical evaluation is required due to risk of permanent vision loss. 1, 4
• Patients with a history of large local reactions have up to a 10% risk of eventually developing systemic reactions to future stings, though most only require symptomatic care. 3