What is the treatment approach for a patient, particularly an elderly individual, young child, or someone with a pre-existing medical condition, who has been bitten by a brown recluse spider?

Brown Recluse Spider Bite Management

Immediate First Aid and Initial Treatment

For brown recluse spider bites, the primary treatment consists of thorough wound irrigation, rest, ice application, and supportive care with over-the-counter analgesics—antibiotics are NOT routinely indicated unless secondary bacterial infection develops. 1

Essential First Steps

• Thoroughly irrigate the bite wound with copious amounts of warm or room temperature potable water until no foreign matter remains 2, 1
• Apply ice with a clean barrier (such as a thin towel) between the ice pack and skin for local pain relief 3, 1
• Remove rings and constricting objects immediately from the affected extremity, as significant swelling may develop 3, 1
• Apply antibiotic ointment and cover with a clean occlusive dressing to improve healing and reduce infection risk 2, 3
• Elevate the affected extremity to reduce swelling and accelerate healing 1

Pain Management

• Use over-the-counter acetaminophen or NSAIDs for pain control 1
• Topical lidocaine 5% can be applied if the skin remains intact for additional pain relief 1
• Continue pain management with over-the-counter medications as needed for several days 3, 1

Critical Pitfalls to Avoid

What NOT to Do

• Do NOT apply suction to the bite site—this is ineffective and potentially harmful 2, 3, 1
• Do NOT apply tourniquets or pressure immobilization bandages—these may worsen tissue injury 3, 1
• Do NOT assume antibiotics are needed for initial swelling—swelling in the first 24-48 hours is caused by venom-mediated inflammation, not infection 4, 1
• Do NOT perform early surgical excision—delayed surgical debridement is preferable once the wound has stabilized and is no longer enlarging 1, 5, 6

When Antibiotics ARE Indicated

Antibiotics should only be prescribed when there are clear signs of secondary bacterial infection, not for prophylaxis. 1

Signs Requiring Antibiotics

• Progressive erythema extending beyond the initial bite site 4, 1
• Purulent discharge from the wound 4, 1
• Systemic signs of infection such as fever or elevated white blood cell count 4, 1

Antibiotic Selection for Confirmed Infection

• First-line therapy: Trimethoprim-sulfamethoxazole or doxycycline to cover MRSA 1
• Alternative: Clindamycin if local resistance patterns permit 1

Advanced Treatment Considerations

Corticosteroids

Systemic corticosteroids should be considered for severe necrotic lesions, systemic loxoscelism, or in pediatric patients. 5

• Corticosteroids are most effective when administered within the first 72 hours after the bite 7, 5
• Consider for necrotic centers greater than 2 cm in diameter 7
• A short course of oral corticosteroids may be used for severe large local reactions 1

Dapsone

Dapsone should only be used in adult patients with necrotic arachnidism who have been screened for G6PD deficiency. 5

• Dapsone reduces polymorphonuclear leukocyte activity and may prevent necrotic ulceration 7, 8
• Must screen for glucose-6-phosphate dehydrogenase deficiency before administration 5
• Not recommended for routine use—reserve for severe necrotic wounds 5

Surgical Management

Delay surgical excision until the wound has stabilized and is no longer actively enlarging. 1, 5, 6

• Early surgical excision is associated with painful recurrent wound breakdown and increased functional complications (20% incidence) 6
• Curettage of subcutaneous tissue in the necrotic area may be performed in early stages to prevent local destructive actions of the toxin 9
• Skin grafting may be required for large, stabilized ulcers 5

When to Seek Urgent Medical Care

Immediate medical attention is required if any of the following develop: 3, 1

• Systemic symptoms: difficulty breathing, muscle rigidity, dizziness, confusion 4, 1
• Severe pain extending beyond the bite site or uncontrolled by over-the-counter medications 3, 1
• Rapidly progressive swelling involving face, lips, tongue, or throat 1
• Signs of systemic loxoscelism: hemolysis, rhabdomyolysis 1
• Development of an open wound or ulcer 3

Expected Clinical Course

• Brown recluse bites can cause painful ulcerated wounds that progress over days to weeks 1
• Most patients with local symptoms only recover completely within 24-48 hours 3, 1
• Necrotic ulcers may be difficult to heal and can require months of treatment 7
• Follow-up within 24 hours by phone or office visit is advised 1

Special Populations

Elderly, Young Children, and Immunocompromised Patients

• Pediatric patients are at higher risk for severe systemic symptoms and should be monitored closely 5
• Consider hospitalization for patients who develop systemic symptoms 5
• Lower threshold for corticosteroid use in small children with severe skin lesions 5