What is the management of an acute Hymenoptera (Hymenoptera) sting?

From the Guidelines

To manage a bee sting, removal of the stinger as soon as possible by plucking or scraping is recommended, followed by washing the area with soap and water, and applying a cold compress to alleviate local pain and itching, as per the 2024 American Heart Association and American Red Cross guidelines for first aid 1. The priority in managing a bee sting is to minimize the amount of venom released into the skin and to alleviate symptoms.

• Removal of the stinger is crucial and should be done by scraping it off with a flat edge, not by squeezing or using tweezers, which can inject more venom.
• Cleaning the area with soap and water helps prevent infection.
• Applying a cold compress can reduce swelling and pain.
• For discomfort, over-the-counter pain relievers such as ibuprofen or acetaminophen can be used, and antihistamines like diphenhydramine can help with itching and swelling 1.
• Topical corticosteroids can also be used to alleviate local itching, and it is reasonable to consider administration of over-the-counter acetaminophen and nonsteroidal anti-inflammatory agents for local pain relief 1. However, it is essential to recognize the signs of a severe allergic reaction (anaphylaxis), such as difficulty breathing, swelling of the face or throat, dizziness, or rapid heartbeat, and to seek immediate medical attention if these symptoms occur 1. People with known bee allergies should carry an epinephrine auto-injector (EpiPen) and use it immediately if stung, then call emergency services, as fatal sting reactions have been associated with delay in administration of epinephrine 1.

From the FDA Drug Label

1 INDICATIONS & USAGE Adrenalin® is available as a single-use 1 mL vial and a multiple-use 30 mL vial for intramuscular and subcutaneous use. Emergency treatment of allergic reactions (Type I), including anaphylaxis, which may result from allergic reactions to insect stings, biting insects, foods, drugs, sera, diagnostic testing substances and other allergens, as well as idiopathic anaphylaxis or exercise-induced anaphylaxis.

The signs and symptoms associated with anaphylaxis include flushing, apprehension, syncope, tachycardia, thready or unobtainable pulse associated with hypotension, convulsions, vomiting, diarrhea and abdominal cramps, involuntary voiding, airway swelling, laryngospasm, bronchospasm, pruritus, urticaria or angioedema, swelling of the eyelids, lips, and tongue.

Bee Sting Management involves the emergency treatment of allergic reactions, including anaphylaxis, which may result from allergic reactions to insect stings.

• The treatment for anaphylaxis includes the administration of epinephrine (IM).
• Patients should be advised to seek proper medical attention if symptoms return after initial treatment.
• Patients should also be warned about the possibility of rare but serious skin and soft tissue infections at the injection site, and advised to seek medical care if they develop signs or symptoms of infection 2, 2.

From the Research

Bee Sting Management

• Bee stings can cause large local reactions, defined as a skin reaction around the sting site with edema, erythema, itching, and an injury diameter >10 cm, affecting 5% to 15% of those afflicted 3
• Standard treatments for large local reactions include ice, nonsteroidal anti-inflammatory medications, antihistamine medications, and topical or systemic corticosteroids, but these do not immediately treat the pain associated with the symptoms nor initiate immediate treatment of the allergic and inflammatory response 3
• Injection of lidocaine with epinephrine can provide rapid reversal of large local reactions, with the lidocaine reversing symptoms of pain and pressure, and the epinephrine reversing allergic edema 3

Anaphylaxis Management

• Adrenaline (epinephrine) is used to treat anaphylaxis, but there is confusion among medical practitioners regarding its indications, dosage, and route of administration 4
• Corticosteroid agents are often used or recommended too frequently, sometimes as the sole therapeutic agent, and there is a lack of awareness of the need for volume replacement in hypotensive shocked patients 4
• Patients with systemic reactions to bee stings often receive antihistamines, systemic corticosteroids, and epinephrine, but only a small percentage receive more than one dose of epinephrine 5

Anxiety and Depression

• Patients with bee sting allergy often experience anxiety and depression, which can be exacerbated by the need to carry self-injectable epinephrine and the fear of being stung again 6
• Venom immunotherapy (VIT) can improve quality of life by reducing anxiety and depression in patients with bee sting allergy, especially in female subjects 6
• Patients receiving VIT have lower anxiety and depression scores compared to those receiving epinephrine only or no treatment 6

Treatment and Referral

• Many patients with systemic reactions to bee stings do not receive adequate treatment or referral to an allergist, with only a small percentage receiving a prescription for self-injectable epinephrine or being referred to an allergist 7
• The Joint Task Force on Practice Parameters for Allergy and Immunology recommends that patients with a history of a systemic reaction to an insect sting be educated on ways to avoid insect stings, carry injectable epinephrine for emergency self-treatment, undergo specific IgE testing for stinging insect sensitivity, and be considered for immunotherapy 7