What is the treatment for a bee sting?

Bee Sting Treatment

Remove the stinger immediately within 60 seconds using any method (scraping or plucking—speed matters, not technique), then treat based on reaction severity: local reactions get cold compresses, oral antihistamines, and topical corticosteroids; large local reactions require oral corticosteroids within 24-48 hours; and anaphylaxis demands immediate intramuscular epinephrine 0.3-0.5 mg in the anterolateral thigh as the ONLY first-line treatment. 1, 2, 3

Immediate Stinger Management (First 60 Seconds)

• Remove the stinger within 60 seconds by any means available—scrape with a fingernail or pluck it out with tweezers, as venom delivery continues for the full minute and speed of removal is the only factor that reduces envenomation 1, 4
• The removal method (scraping versus plucking) makes no difference in outcomes—what matters is removing it fast 1, 4
• Wash the area with soap and water after stinger removal 1

Treatment Algorithm by Reaction Severity

Local Reactions (Most Common Presentation)

• Apply cold compresses or ice packs directly to the sting site to reduce pain and swelling 1, 2
• Give oral antihistamines (such as diphenhydramine or cetirizine) to reduce itching 1, 2
• Apply topical corticosteroids directly to the sting site for local inflammation and itching—this is the preferred steroid formulation for uncomplicated local reactions 1, 2
• Administer oral acetaminophen or ibuprofen for pain relief 1, 2
• Do NOT prescribe antibiotics—the swelling represents allergic inflammation, not bacterial infection, and antibiotics are inappropriate 1, 2, 5

Large Local Reactions (Extensive Swelling Beyond Sting Site)

• Initiate a short course of oral corticosteroids promptly within the first 24-48 hours to limit progression of swelling—this is when they are most effective 1, 2
• Oral corticosteroids are supported by the American Academy of Allergy, Asthma, and Immunology for severe cases, though controlled trial data remains limited 1, 2
• Continue cold compresses, oral antihistamines, and topical corticosteroids as adjunctive therapy 2

Anaphylaxis (Life-Threatening Emergency)

Epinephrine is the ONLY first-line treatment for anaphylaxis—antihistamines and corticosteroids are NOT substitutes and play NO role in acute management. 1, 2, 3, 6

Recognition of Anaphylaxis

• Anaphylaxis presents with sudden onset (within minutes to 2 hours) of multi-system symptoms including: 3
  • Skin: hives, itching, redness, or swelling extending beyond the sting site 3
  • Respiratory: hoarseness, throat tightness, stridor, cough, difficulty breathing, chest tightness, wheeze, or cyanosis 3
  • Cardiovascular: hypotension, tachycardia, syncope, or lightheadedness 3, 6
  • Gastrointestinal: vomiting, diarrhea, or abdominal cramps 6
  • Facial swelling extending beyond the sting site indicates systemic involvement 3
• Laryngeal edema is the most common cause of death from bee sting anaphylaxis 3

Immediate Management Steps

1. 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 immediately—this single intervention is the most critical life-saving action 1, 3, 6
2. Activate emergency medical services immediately without delay 1, 3
3. Position the patient supine with legs elevated if hypotension develops to prevent sudden death from empty-ventricle syndrome 3
4. Be prepared to repeat epinephrine every 5-15 minutes if symptoms persist or worsen 1, 3
5. Administer 1-2 liters of IV normal saline bolus for persistent hypotension, as massive fluid shifts occur during anaphylaxis 3

Why Intramuscular Thigh Injection

• Intramuscular injection in the anterolateral thigh (vastus lateralis muscle) achieves faster and higher plasma concentrations than subcutaneous or arm injections 3
• The mid-outer thigh is the optimal site for rapid absorption 3

Adjunctive Treatments (NOT First-Line)

• Supplemental oxygen for all patients with prolonged reactions, hypoxemia, or requiring multiple epinephrine doses 3
• Inhaled albuterol (2.5 mg nebulized) for bronchospasm persisting despite epinephrine 3
• H1 antihistamines (diphenhydramine 25-50 mg IV/IM) and H2 blockers (ranitidine 50 mg IV or famotidine 20 mg IV) as adjuncts only—these do NOT treat life-threatening symptoms 3
• Corticosteroids (methylprednisolone 125 mg IV or prednisone 0.5 mg/kg PO) to potentially prevent biphasic reactions, though they have no immediate effect on acute anaphylaxis 3

Critical Pitfalls to Avoid

• Never delay epinephrine in anaphylaxis to give antihistamines or corticosteroids first—delayed epinephrine administration is strongly associated with fatal outcomes 1, 3
• Do not prescribe antibiotics for swelling—this represents allergic inflammation, not infection 1, 2, 5
• Do not waste time trying to identify whether it was a bee versus wasp—treat based on clinical presentation 1
• Any sting to the eye itself (not just the eyelid) requires immediate medical evaluation due to risk of permanent vision loss from corneal injury, cataracts, optic neuropathy, or changes in ocular pressure 1, 7, 8

High-Risk Populations

• Coexisting asthma (especially if severe or poorly controlled) significantly increases the risk of severe or fatal reactions 3
• Adolescents have higher fatality rates from anaphylaxis 3
• Patients with mastocytosis (found in 3-5% of sting anaphylaxis patients) are prone to very severe reactions 5
• 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, 9

Post-Treatment and Prevention

• All patients with systemic reactions must receive an epinephrine autoinjector prescription (EpiPen or equivalent) and training on self-administration before discharge 1, 3
• Refer all patients with anaphylaxis to an allergist-immunologist for venom-specific IgE testing and consideration of venom immunotherapy 1, 3
• Venom immunotherapy can reduce the risk of future systemic reactions from 25-70% to nearly zero 3
• Educate patients on trigger avoidance: avoid walking barefoot outdoors, wear protective clothing, avoid bright colors and floral patterns, eliminate scented products, and have nests professionally removed 3