What is the appropriate management for a bee sting in an adult without a known allergy?

Bee Sting Treatment in Adults Without Known Allergy

Remove the stinger immediately by any method—scraping or pinching—because speed of removal matters far more than technique, then apply cold compresses and give oral antihistamines for symptomatic relief. 1

Immediate Stinger Removal

The single most important action is rapid stinger removal within seconds, using whatever method is fastest. 1, 2

• Remove the stinger by scraping, flicking, or pinching—the method does not matter 1
• Research demonstrates that envenomation increases with every second of delay, even within the first few seconds 2
• The long-standing advice to "scrape, never pinch" has no scientific basis and only delays removal 2, 3
• Honeybees leave a barbed stinger with an attached venom sac that continues injecting venom for up to 60 seconds 1

Local Symptom Management

For uncomplicated local reactions (pain, swelling, redness, itching at the sting site), symptomatic care is sufficient. 1, 4

• Wash the area with soap and water 1
• Apply ice or cold packs to reduce local pain and swelling 1, 4
• Administer oral antihistamines (such as cetirizine or diphenhydramine) to alleviate itching 1, 4
• Consider over-the-counter acetaminophen or NSAIDs for pain relief 1
• Topical corticosteroids can be applied to reduce local itching 1

Large Local Reactions

Large local reactions (swelling >10 cm that peaks at 24-48 hours and persists 5-10 days) represent IgE-mediated allergic inflammation, not infection. 4

• Continue cold compresses and oral antihistamines throughout the reaction 4
• For severe swelling, initiate a short course of oral corticosteroids within the first 24-48 hours 4
• Do not prescribe antibiotics unless clear signs of secondary bacterial infection develop (progressive redness, purulent discharge, fever, increasing warmth and tenderness) 4
• Elevate the affected limb if swelling is significant 4

Critical Pitfall to Avoid

The most common error is misinterpreting large local swelling as infection and inappropriately prescribing antibiotics. 4 The extensive swelling is caused by allergic mediator release, not bacterial infection. 4

When to Activate Emergency Services

Immediately call emergency services and administer epinephrine if any systemic symptoms develop: 1

• Urticaria (hives) beyond the sting site 1
• Angioedema (swelling of face, lips, tongue, or throat) 1
• Respiratory symptoms (wheezing, stridor, dyspnea, chest tightness) 1
• Cardiovascular symptoms (hypotension, lightheadedness, syncope, tachycardia) 1
• Gastrointestinal symptoms (nausea, vomiting, abdominal cramping) 1

If the patient has an epinephrine autoinjector available, assist them in self-administering it immediately into the anterolateral thigh. 1 Antihistamines and corticosteroids are not substitutes for epinephrine in anaphylaxis, and delayed epinephrine administration has been linked to fatal outcomes. 4, 5

Special Circumstances

• Eye stings require immediate evaluation by a trained medical professional due to risk of permanent vision loss 1, 5
• Massive envenomation (typically >100 stings from honeybees or >20 stings from large hornets) can cause toxic multi-organ reactions even without allergic sensitization 1

Post-Acute Considerations

Any patient who develops systemic symptoms (even isolated widespread urticaria) should be referred to an allergist-immunologist for venom-specific IgE testing and consideration of venom immunotherapy (VIT). 4, 5

• VIT reduces the risk of future systemic reactions from 30-60% down to <5% 1, 5
• Adults who experience any systemic reaction beyond isolated skin manifestations are generally candidates for VIT 1, 5
• Patients with large local reactions and frequent unavoidable exposure may also benefit from allergist referral 4
• Up to 10% of patients with large local reactions may later develop systemic reactions 5