Initial Treatment for Bee Sting in Patient Without Known Allergies
For a patient with no known allergies who has been stung by a bee, immediately remove the stinger within 60 seconds by scraping or plucking (speed matters more than method), then apply cold compresses and administer oral antihistamines for symptomatic relief. 1, 2
Immediate Stinger Management
- Remove the stinger within the first 60 seconds by scraping with a fingernail or plucking it out, as venom delivery continues for up to 60 seconds after the sting 1, 3
- The method of removal (scraping versus plucking) does not matter—speed is what counts 1
- Wash the area with soap and water after stinger removal 1
Treatment Based on Clinical Presentation
For Typical Local Reactions (Most Common)
Most insect stings cause transient localized reactions that are of little serious medical consequence, and no treatment is usually required 4
Symptomatic management includes:
- Apply cold compresses or ice packs to reduce pain and swelling 4, 1, 3
- Administer oral antihistamines (such as diphenhydramine or cetirizine) to reduce itching 4, 1, 3
- Apply topical corticosteroids directly to the sting site for local inflammation and itching 1, 2
- Give oral acetaminophen or ibuprofen for pain relief 1, 3
For Large Local Reactions
Large local reactions present with extensive erythema and swelling surrounding the sting site that can persist for several days or more, accompanied by pruritus or pain 4
Treatment approach:
- Initiate a short course of oral corticosteroids promptly (within the first 24-48 hours) to limit progression of swelling 4, 1, 2
- Continue cold compresses and oral antihistamines 4
- Do NOT prescribe antibiotics—the swelling is caused by allergic inflammation, not infection 4, 1, 2
For Systemic Reactions/Anaphylaxis (Emergency)
Even in patients without known allergies, anaphylaxis can occur after the first sting 4
Signs of anaphylaxis include:
- Difficulty breathing, bronchospasm, or upper airway obstruction 4, 5
- Widespread urticaria or angioedema not contiguous with the sting site 4
- Hypotension, shock, or cardiovascular symptoms 4, 5
- Gastrointestinal symptoms (nausea, vomiting, diarrhea, abdominal pain) 4, 5
Immediate treatment:
- 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 4, 1, 3, 5
- Activate emergency medical services without delay 1, 3
- Be prepared to repeat epinephrine every 5-15 minutes if symptoms persist or recur 4, 1, 3
- Provide supportive therapy and transport to an emergency department 4
Critical Pitfalls to Avoid
- Never delay epinephrine administration in anaphylaxis to give antihistamines or corticosteroids first—fatal sting reactions have been associated with delay in administration of epinephrine 4, 1, 2
- Epinephrine is the ONLY first-line treatment for anaphylaxis; antihistamines and corticosteroids are NOT substitutes and play no role in acute anaphylaxis management 1, 2
- Do not prescribe antibiotics for swelling—this is allergic inflammation, not infection 4, 1, 2
- Do not waste time trying to identify the specific insect—treat based on clinical presentation 1
Post-Treatment Considerations
- All patients who develop systemic reactions should receive an epinephrine autoinjector prescription and training on self-administration before discharge 1, 3
- Refer patients with anaphylaxis to an allergist for venom-specific IgE testing and consideration of venom immunotherapy, which can reduce future reaction risk from 25-70% to nearly zero 4, 3
- Patients with large local reactions are at risk for recurrent large local reactions (and up to 10% may eventually have a systemic reaction), so consider prescribing injectable epinephrine for future use 4
- Multiple stings (typically >100 honeybee stings or ≥50 Africanized bee stings) can cause toxic reactions from massive envenomation even in non-allergic individuals and require hospitalization for observation 1, 3, 6