What topical corticosteroid is recommended for insect bites?

Topical Corticosteroid Recommendations for Insect Bites

For insect bites, use moderate-to-high potency topical corticosteroids such as mometasone furoate 0.1% ointment or betamethasone valerate 0.1% ointment applied twice daily, as over-the-counter hydrocortisone preparations (1-2.5%) have not been shown to improve symptoms in controlled trials. 1, 2

Evidence-Based Treatment Approach

First-Line Topical Therapy

• Moderate-to-high potency corticosteroids (mometasone furoate 0.1% or betamethasone valerate 0.1%) should be applied twice daily to the affected areas for symptomatic relief of inflammation and itching 2

• Over-the-counter hydrocortisone preparations at concentrations of 0.2%, 1.0%, 2.5% (lotion, ointment, or cream) were specifically studied and found not to improve symptoms in randomized controlled trials 1

• While hydrocortisone 1% is FDA-approved for insect bite itching 3, the clinical trial evidence demonstrates it lacks efficacy at these concentrations 1

Critical Evidence Gap

The 2024 American Heart Association guidelines explicitly state that low-potency corticosteroids (including standard OTC hydrocortisone) were not associated with symptom improvement in blinded trials 1. Only the combination of systemic corticosteroids with high-potency topical corticosteroids reduced symptom duration 1

Adjunctive Measures

• Cold compresses should be applied to reduce local pain and swelling as the primary initial intervention 4

• Oral antihistamines (loratadine 10 mg daily for daytime, or diphenhydramine 25-50 mg at night) can reduce itching and pain 4, 2

• Oral analgesics may be considered for pain management 4

For Severe Large Local Reactions

• Continue moderate-to-high potency topical corticosteroids twice daily 2

• Oral corticosteroids (prednisone 0.5-1 mg/kg) may be considered for extensive swelling, though definitive proof of efficacy is lacking 4, 2

• Ensure adequate treatment duration (4-6 weeks taper if systemic steroids used) to prevent rebound flare 2

Important Clinical Pitfalls

• Antibiotics are not indicated for insect bites unless there is evidence of secondary infection (progressive redness, increasing pain, purulent discharge, fever) 4

• The swelling from insect bites is due to mediator release, not infection 4

• Topical corticosteroids and oral antihistamines may relieve persistent itching or burning that continues after the bite, which is not a reason for re-treatment 1

• Application duration for moderate-to-high potency topical corticosteroids should not exceed 3 weeks without reassessment 5

Formulation Selection

• Ointments are preferred for dry, scaly lesions and provide better penetration 5

• Creams are appropriate for moist or weeping areas 5

• Apply using the fingertip unit method: one fingertip unit covers approximately 2% body surface area 5