Bee Sting Treatment in Adults Without Known Allergy
For an uncomplicated bee sting in an adult without known allergy, remove the stinger immediately by any method (scraping or pinching), apply cold compresses, and give oral antihistamines for symptom relief.
Immediate Stinger Removal
- Remove the stinger within 10-20 seconds using any method available—scraping with a fingernail or pinching and pulling—as speed of removal is far more important than technique 1, 2, 3.
- The traditional advice to only scrape (never pinch) has been disproven; research shows no difference in venom injection between methods when removal occurs within 2 seconds, and delaying removal to find a scraping tool increases envenomation 2, 3.
- Venom continues to be delivered for up to 60 seconds after the sting, so any delay worsens the reaction 4.
Common pitfall: Do not waste time searching for a credit card or other scraping tool—use your fingers immediately 2, 3.
Treatment of Simple Local Reactions
For typical local reactions (redness, swelling, itching, pain at the sting site):
- Apply cold compresses or ice packs to reduce pain and swelling 1, 5.
- Give oral antihistamines (such as cetirizine) to reduce itching and discomfort 1, 5.
- Provide oral analgesics (acetaminophen or ibuprofen) for pain relief 1, 5.
- Simple local reactions typically resolve within 24 hours and require no further intervention 5.
Common pitfall: Do not prescribe antibiotics for simple local reactions unless clear signs of secondary bacterial infection are present (not just swelling) 5.
Treatment of Large Local Reactions
For reactions with swelling >10 cm that persist 5-10 days:
- Initiate a short course of oral corticosteroids within the first 24-48 hours to limit progression of swelling 1, 5.
- Continue cold compresses and oral antihistamines 1, 5.
- Consider prescribing an epinephrine autoinjector, as up to 10% of patients with large local reactions may later develop systemic reactions 5.
When to Recognize and Treat Anaphylaxis
If systemic symptoms develop (hives beyond the sting site, difficulty breathing, throat tightness, dizziness, hypotension):
- Administer intramuscular epinephrine 0.3-0.5 mg immediately into the anterolateral thigh—this is the ONLY first-line treatment for anaphylaxis 1, 5, 4.
- Epinephrine has no absolute contraindications in anaphylaxis, even in patients with hypertension, cardiac disease, or those taking β-blockers 5.
- Repeat dosing may be required for persistent or recurrent symptoms 5.
- Anaphylactic symptoms typically appear within 10 minutes of the sting 6.
Post-Treatment Counseling
For patients who experienced only a simple local reaction:
- No epinephrine autoinjector prescription is needed 5.
- No allergy testing or referral to allergist is required 7.
- Reassure that future stings will likely produce similar mild reactions.
For patients who experienced a large local reaction:
- Consider epinephrine autoinjector prescription if frequent unavoidable exposure is anticipated 5.
- Allergy testing and venom immunotherapy are generally not indicated unless there is demonstrable venom-specific IgE and frequent exposure 5.
For patients who experienced any systemic reaction:
- Prescribe an epinephrine autoinjector for lifelong carry and provide training on proper use 5, 4.
- Refer to an allergist-immunologist for venom-specific IgE testing and evaluation for venom immunotherapy (VIT) 5, 4.
- VIT reduces the risk of subsequent systemic reactions to less than 5% 7, 5.
Special Circumstances
- Multiple stings (typically >100) can cause toxic reactions from massive envenomation even in non-allergic individuals, potentially causing multi-organ dysfunction and death 1, 8.
- The estimated lethal dose is approximately 20 stings/kg in mammals 6.
- Stings to the eye require immediate ophthalmologic evaluation due to risk of permanent vision loss 5.
- Stings to the throat or mouth require emergency department evaluation due to risk of life-threatening laryngeal edema 4.