What is the treatment for a bee sting?

Treatment for Bee Stings

Remove the stinger immediately within 60 seconds by any method—scraping or plucking—because speed of removal is what matters, not technique. 1, 2

Immediate Stinger Management

• Remove the stinger within the first 60 seconds using any method available (scraping with fingernail or plucking), as venom delivery continues for up to 60 seconds and delayed removal increases envenomation even by seconds. 1, 2
• The method of removal (scraping versus plucking) makes no difference in the amount of venom delivered—only speed matters. 1, 2
• Wash the area with soap and water immediately after stinger removal. 1

Treatment Algorithm Based on Reaction Severity

For Local Reactions (Most Common Presentation)

Local reactions require only symptomatic treatment with cold compresses, oral antihistamines, and topical corticosteroids. 3, 1

• Apply cold compresses or ice packs directly to the sting site to reduce pain and swelling. 3, 1
• Administer oral antihistamines (such as diphenhydramine or cetirizine) to reduce itching. 3, 1
• Apply topical corticosteroids directly to the sting site for local inflammation and itching. 1, 4
• Give oral acetaminophen or ibuprofen for pain relief. 1, 4
• Do NOT prescribe antibiotics—the swelling is allergic inflammation, not infection, and antibiotics are unnecessary and inappropriate. 3, 1, 4

For Large Local Reactions (Extensive Swelling Persisting Days)

Initiate a short course of oral corticosteroids promptly within the first 24-48 hours to limit progression of swelling. 1, 4

• Start oral corticosteroids (such as prednisone 40-60 mg daily for 3-5 days) within the first 24-48 hours for maximum effectiveness at limiting swelling progression. 1, 4
• Continue cold compresses and oral antihistamines as adjunctive therapy. 3, 1
• Topical corticosteroids alone are insufficient for large local reactions—oral corticosteroids are required. 4

For Anaphylaxis (Life-Threatening Emergency)

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—this is the ONLY first-line treatment for anaphylaxis. 3, 1, 5, 6

• Inject epinephrine intramuscularly in the anterolateral thigh, as this achieves faster and higher plasma concentrations than subcutaneous or arm injections. 1, 5
• Activate emergency medical services immediately—all patients with anaphylaxis require emergency transport. 1, 5
• Be prepared to repeat the epinephrine dose in 10-20 minutes if symptoms persist, worsen, or recur. 1, 5
• Place the patient in a recumbent position with legs elevated if hypotension develops. 5
• Antihistamines and corticosteroids are NOT substitutes for epinephrine and play NO role in acute anaphylaxis management—delayed epinephrine administration is associated with fatal outcomes. 3, 1, 5, 4

Signs of anaphylaxis include difficulty breathing, tongue/throat swelling, lightheadedness, vomiting, widespread hives, hypotension, or facial swelling extending beyond the sting site. 1, 5, 6

Critical Pitfalls to Avoid

• Never delay epinephrine in anaphylaxis to give antihistamines or corticosteroids first—this delay can be fatal. 1, 4
• Do not prescribe antibiotics for swelling—this is allergic inflammation, not infection. 3, 1, 4
• Do not waste time trying to identify whether the insect was a bee, wasp, or hornet—treat based on clinical presentation. 1
• Any sting to the eye itself (not just the eyelid) requires immediate ophthalmologic evaluation due to risk of permanent vision loss. 1, 5

Special Circumstances

• Multiple stings (typically >100) can cause toxic reactions from massive envenomation even in non-allergic individuals, with an estimated lethal dose of approximately 20 stings/kg in mammals. 1, 5, 7, 8
• Patients with more than 50 stings are at higher risk of toxicity and require close monitoring for hypotension, confusion, seizures, and renal failure. 7
• Oropharyngeal stings may produce life-threatening airway obstruction and require immediate endotracheal intubation and mechanical ventilation for at least 24 hours, even in patients with minimal initial symptoms. 9

Post-Treatment Management

• All patients with systemic reactions must receive an epinephrine autoinjector prescription with training on self-administration before discharge. 1, 5
• Refer all patients with anaphylaxis to an allergist for venom-specific IgE testing and consideration of venom immunotherapy, which can reduce the risk of future systemic reactions from 25-70% to nearly zero. 3, 1, 5
• Educate patients about avoidance strategies: having known nests removed by professionals, avoiding bright clothing and scented products, wearing protective clothing outdoors, and being cautious near bushes, garbage containers, and picnic areas. 5