How should I manage a bee sting in an adult without a known bee‑venom allergy, including first‑aid steps, medication, and indications for epinephrine?

Bee Sting Management in Adults Without Known Allergy

For an adult without known bee-venom allergy, immediately remove the stinger by scraping or flicking it away within seconds, apply ice to reduce pain and swelling, and administer oral antihistamines for itching and oral analgesics (acetaminophen or ibuprofen) for pain. 1

Immediate First Aid Steps

Stinger Removal

• Remove the stinger as quickly as possible—within the first 10-20 seconds if feasible—by scraping or flicking it away with a fingernail or any flat edge. 1
• The method of removal (scraping vs. pinching) does not matter; speed is what counts, as venom delivery continues for up to 30-60 seconds after the sting. 1, 2, 3
• Do not waste time trying to avoid grasping the venom sac—just get it out immediately. 2, 3

Symptom Relief for Local Reactions

• Apply ice or cold compresses directly to the sting site to reduce local pain and swelling. 1
• Give oral antihistamines (such as diphenhydramine or cetirizine) to reduce itching. 1
• Administer over-the-counter oral analgesics—acetaminophen or ibuprofen—for pain control. 1

Large Local Reactions

If extensive swelling develops beyond the immediate sting site (extending several inches), peaking at 24-48 hours and lasting up to a week, this represents a large local reaction that is IgE-mediated but not life-threatening. 1

• Continue cold compresses, oral antihistamines, and analgesics. 1
• Consider prompt oral corticosteroids (such as prednisone 0.5 mg/kg) to limit progressive swelling, especially if the patient has a history of large local reactions. 1
• This swelling is caused by allergic inflammation, not infection, and does not require antibiotics. 1

When to Administer Epinephrine

Epinephrine is indicated immediately if any signs of systemic anaphylaxis develop, including:

• Skin reactions beyond the sting site: generalized urticaria, flushing, or angioedema 1, 4
• Respiratory symptoms: throat tightness, hoarseness, stridor, wheezing, shortness of breath, or cough 1, 4
• Cardiovascular symptoms: dizziness, hypotension, syncope, or chest pain 1, 4
• Gastrointestinal symptoms: nausea, vomiting, diarrhea, or abdominal cramping 4

Epinephrine Administration

• Inject epinephrine 0.3-0.5 mg intramuscularly into the anterolateral thigh (vastus lateralis) immediately upon recognizing anaphylaxis. 1, 5
• Intramuscular injection in the thigh achieves faster and higher plasma concentrations than subcutaneous or arm injections. 1, 5
• Call emergency medical services immediately after administering epinephrine—do not delay. 1, 5
• Be prepared to repeat the epinephrine dose every 5-15 minutes if symptoms persist or worsen. 5, 4
• Position the patient supine with legs elevated if hypotension develops. 5

Critical Pitfall

Antihistamines and corticosteroids are NOT substitutes for epinephrine in anaphylaxis and have no role in treating life-threatening symptoms. 1, 5 Delayed epinephrine administration is strongly associated with fatal outcomes. 1, 4

Special Circumstances

Eye Stings

• If the sting occurs directly to the eye itself (not just the eyelid or periorbital area), seek immediate ophthalmology evaluation, as permanent vision loss can occur. 1, 5

Multiple Stings

• Patients with more than 50-100 stings are at risk for toxic reactions from massive envenomation, which can mimic anaphylaxis but result from direct venom effects rather than allergic mechanisms. 1, 5, 6
• These patients require hospitalization for observation and supportive care, with attention to airway, blood pressure, and renal function. 6

Patients with Cardiovascular Disease or on Beta-Blockers

• There are no contraindications to epinephrine in life-threatening anaphylaxis, even in patients with cardiovascular disease or those taking beta-blockers. 1, 5
• Patients on beta-blockers may require higher or repeated doses of epinephrine, as they can be relatively refractory to standard dosing. 5

Post-Sting Follow-Up

For Patients Who Develop Anaphylaxis

• Prescribe an epinephrine autoinjector (EpiPen or equivalent) before discharge and demonstrate proper technique. 1, 5, 4
• Refer all patients with systemic anaphylactic reactions to an allergist-immunologist for venom-specific IgE testing and consideration of venom immunotherapy. 1, 5, 4
• Venom immunotherapy can reduce the risk of future systemic reactions from 25-70% down to nearly zero. 4

For Patients with Large Local Reactions Only

• The need for an epinephrine autoinjector can be discussed between patient and physician, as the risk of future severe anaphylaxis is relatively low (though not zero). 1
• Consider allergist referral if large local reactions are recurrent or significantly impact quality of life. 1

Prevention Education

• Avoid walking barefoot outdoors or wearing open shoes like sandals. 1
• Wear long pants, long-sleeved shirts, socks, closed shoes, and gloves when working outdoors. 1
• Avoid brightly colored clothing, flowery prints, and strongly scented products that attract insects. 1
• Be cautious near bushes, eaves, attics, garbage containers, and outdoor food areas. 1
• Have nests professionally removed by trained experts. 1, 5
• Keep insecticides approved for stinging insects readily available for use from a distance. 1