Treatment of Bed Bug Bites
For bed bug bites, treatment is primarily symptomatic with topical pramoxine and oral antihistamines for pruritus, topical corticosteroids for significant eruptions, and no antibiotics unless secondary infection develops. 1
Immediate Assessment
When evaluating suspected bed bug bites, look for these characteristic features:
- Pruritic, erythematous maculopapules in clusters or linear/curvilinear distribution on exposed skin 1
- Small red punctum at the center of bite marks 1
- Three lesions in a row ("breakfast, lunch, dinner" pattern) 1
- Papules on upper eyelids with erythema and edema (highly suggestive) 1
Treatment Algorithm Based on Reaction Severity
Simple Local Reactions (Most Common)
For typical pruritic papules without severe inflammation:
- Oral antihistamines to alleviate pruritus 1
- Topical pramoxine for additional itch relief 1
- No treatment is also acceptable as reactions are self-limited 1
Significant Eruptions or Exaggerated Local Reactions
For vesicles, urticarial wheals, diffuse urticaria, bullae, or nodules in previously sensitized individuals:
- Topical corticosteroids (high potency recommended for bullous reactions) to control inflammation, reduce pruritus, and hasten resolution 1, 2
- Continue oral antihistamines 1
- Monitor for progression, as bullous reactions can take weeks to heal 2
Systemic Reactions (Rare but Serious)
If anaphylaxis occurs (extremely rare but reported):
- Intramuscular epinephrine 0.01 mg/kg (maximum 0.3 mg in children, 0.3-0.5 mg in adults) into anterolateral thigh immediately 3
- Transport to emergency department with supportive care 3
- Prescribe epinephrine autoinjector for future use 4
Critical Management Considerations
Antibiotics are NOT routinely indicated because the inflammatory response is allergic, not infectious, and occurs within the first 24-48 hours 3. Secondary bacterial infection is uncommon but can occur if lesions are excoriated 1.
Monitor for bullous reactions, which represent a destructive cutaneous vasculitis histologically similar to Churg-Strauss syndrome 2. These patients warrant:
- High-potency topical corticosteroids 2
- Efforts to prevent further bites 2
- Monitoring for systemic vasculitis (though this remains theoretical) 2
Common Pitfalls to Avoid
- Do not prescribe antibiotics prophylactically - the swelling is allergic inflammation, not infection 3, 1
- Do not underestimate patient anxiety - bed bug infestations cause significant emotional stress, stigmatization, and poor quality of life that requires acknowledgment and management 1
- Do not recommend insecticide application by patients - insecticide misuse has caused 111 reported illnesses including one fatality, with pyrethroids implicated in 89% of cases 5
Eradication Counseling
While symptomatic treatment addresses the bites, professional pest control consultation is essential for complete eradication 1. Advise patients:
- Integrated pest management combining nonchemical (vacuuming, hot water washing of linens, decluttering, bed bug interceptors) and professional chemical interventions 1
- Insecticide resistance is widespread, requiring trained professionals who understand current resistance patterns 1
- Avoid over-the-counter insecticide misuse due to toxicity risks, especially with children present 1, 5