What is the appropriate treatment for an adult or child who has been stung by a bee, with or without a known history of bee sting allergies?

Treatment of Bee Stings

For simple local reactions, remove the stinger immediately (speed matters more than method), apply cold compresses, and give oral antihistamines; for anaphylaxis, inject intramuscular epinephrine 0.3-0.5 mg in adults (0.01 mg/kg up to 0.3 mg in children) into the anterolateral thigh without delay—this is the only first-line treatment and delayed administration is associated with fatal outcomes. 1, 2, 3

Immediate Stinger Management

Remove the stinger within 60 seconds by any method—scraping or plucking—as venom delivery continues during this time. 2, 4, 5

• The method of removal (scraping vs. pinching) does not affect envenomation; speed is the critical factor. 2, 5
• Research demonstrates that weal size increases with each second of delay, even within the first few seconds after stinging. 5
• After removal, wash the area with soap and water. 2

Treatment Algorithm by Reaction Type

Simple Local Reactions (Most Common)

Apply cold compresses or ice packs to reduce pain and swelling. 1, 2, 6, 4

Administer oral antihistamines to reduce itching. 1, 2, 6, 4

Give oral acetaminophen or ibuprofen for pain relief. 2, 6, 4

Apply topical corticosteroids directly to the sting site for local inflammation. 2

• Most insect stings cause transient localized reactions requiring no treatment. 1
• No antibiotics are needed—the swelling represents allergic inflammation, not infection. 1, 2, 6

Large Local Reactions

Initiate a short course of oral corticosteroids promptly within the first 24-48 hours to limit progression of swelling. 1, 2, 6

Continue cold compresses and oral antihistamines as adjunctive therapy. 1, 6

• Large local reactions present with extensive erythema and swelling that persists for several days with pruritus or pain. 1
• Although controlled trial data is limited, prompt oral corticosteroids are effective in limiting swelling based on clinical experience. 1
• Antibiotics are not indicated—this is allergic inflammation, not bacterial infection. 1

Anaphylaxis (Life-Threatening Emergency)

Immediately inject intramuscular epinephrine 0.3-0.5 mg in adults (0.01 mg/kg up to 0.3 mg in children) into the anterolateral thigh. 1, 2, 6, 3

Activate emergency medical services without delay. 1, 2, 4

Be prepared to repeat epinephrine every 5-15 minutes if symptoms persist or recur. 2, 4, 3

Provide supportive therapy and transport to an emergency department. 1

• Epinephrine is the ONLY first-line treatment for anaphylaxis—antihistamines and corticosteroids are NOT substitutes and play no role in acute management. 1, 2, 6
• Fatal sting reactions have been associated with delay in epinephrine administration. 1, 2
• Anaphylaxis can manifest as flushing, syncope, tachycardia, hypotension, bronchospasm, laryngospasm, urticaria, angioedema, or airway swelling. 3
• Reactions can be biphasic or protracted, requiring extended observation. 1

Special Considerations for Cutaneous Systemic Reactions

In patients with a history of only cutaneous systemic reactions (urticaria/angioedema without respiratory or cardiovascular symptoms), initial treatment may include antihistamines and close observation rather than immediate epinephrine. 1

• However, maintain a low threshold for epinephrine administration if symptoms progress. 1
• Venom immunotherapy (VIT) is generally not necessary in children ≤16 years with isolated cutaneous systemic reactions. 1
• VIT in adults with only cutaneous manifestations is controversial but usually recommended. 1

Post-Treatment Management

All patients with systemic anaphylactic reactions must receive an epinephrine autoinjector prescription and training on self-administration before discharge. 2, 6, 4

Refer patients with anaphylaxis to an allergist-immunologist for venom-specific IgE testing and consideration of venom immunotherapy. 1, 2, 6, 4

• Patients with a history of systemic reactions have a 25-70% risk of anaphylaxis with future stings. 1
• VIT reduces this risk to less than 5% and is extremely effective. 1, 4, 7
• Skin testing or in vitro IgE testing may be temporarily non-reactive within the first few weeks after a systemic reaction and may require retesting in 6 weeks. 1

Critical Pitfalls to Avoid

Never delay epinephrine in anaphylaxis to give antihistamines or corticosteroids first—this can be fatal. 1, 2

Do not prescribe antibiotics for swelling—this is allergic inflammation, not infection. 1, 2, 6

Do not inject epinephrine into buttocks, digits, hands, or feet—use the anterolateral thigh only. 3

• Rare cases of serious skin and soft tissue infections have been reported following epinephrine injection; advise patients to seek medical care if signs of infection develop. 3

Massive Envenomation (Multiple Stings)

Multiple stings (typically >30 in children, >100 in adults) can cause toxic reactions from massive envenomation even in non-allergic individuals. 2, 6, 8

Patients with ≥50 stings from Africanized bees require 24-hour hospitalization for observation due to risk of delayed multi-organ toxicity. 4

• Direct venom toxicity can cause hypotension, tachycardia, and multi-organ dysfunction without features of anaphylaxis. 8
• Death from massive envenomation requires at least 20 stings by large hornets or hundreds of stings from honeybees. 4

Age-Specific Considerations

Children ≤16 years with isolated cutaneous systemic reactions do not generally require venom immunotherapy. 1

Adults with cutaneous systemic reactions should usually receive venom immunotherapy. 1

• The same treatment principles apply to both children and adults for local reactions and anaphylaxis. 6
• Dosing of epinephrine is weight-based in children: 0.01 mg/kg up to 0.3 mg maximum. 6, 3