The cause of a bite can often be readily diagnosed where an insect remains attached, as in ticks and with bloodsuckers that are highly visible - eg, mosquitoes, midges and black flies. Others may not be so easy to diagnose because they bite at night or when the patient is asleep - eg, some mosquitoes, sandflies, bedbugs and triatomine bugs, or when it is inconspicuous and does not cause an immediately painful bite - eg, harvest mites, some fleas and biting flies. Bites typically result in single or grouped pruritic erythematous papules. Some may have a central punctum and others may be bullous.
There is often a skin reaction to an insect bite and this may lead to pruritus and urticarial papules and sometimes to secondary bacterial infection. As well as a local reaction, the bite may cause an anaphylactic reaction and may act as a vector of disease.
General management measures include cooling the skin, use of calamine and antihistamines to reduce itching, antibiotics for secondary bacterial infection if one develops and any specific treatment for disease transmitted as a result of the bite.
- Insects of the order Hymenoptera include bees, wasps and ants.
- Stings from these insects can cause fatal anaphylaxis.
- The insects of Hymenoptera most relevant in the UK are wasp (Vespula vulgaris) and honey bee (Apis mellifera). Hornets (Vespa crabro) are also found in Britain, more commonly in the South of England.
- Wasp venom allergy is more common in the UK. Bee venom allergy usually occurs in beekeepers, their household members or where there is occupational risk.
- The risk for systemic reactions is increased by 58% if preceded by a sting within two months, even if the first sting was well tolerated.
- Venom allergy is not more common in atopic individuals.
- Some local reactions can be large and troublesome and are characterised by oedema, erythema or pruritus.
- An area of induration with a diameter of 10 cm and which peaks between 24 and 48 hours and then subsides is referred to as a large local reaction (LLR).
- LLRs occur in up to 26% of people and systemic reactions can occur in up to 7.5% of people who are stung.
- The likelihood of anaphylaxis from a future sting following an LLR is around 5%.
- However, when there is a history of anaphylaxis from a previous Hymenoptera sting and the patient has positive skin tests to venom, at least 60% of adults and 20-32% of children will develop anaphylaxis from a future sting.
Systemic reaction to wasp or bee stings
- Venom allergy is a common cause of anaphylaxis and may be fatal.
- Food, medications and insect stings are the three most common triggers of anaphylaxis.
However, anaphylaxis due to insect stings is still under-appreciated and undertreated.
The main features of systemic reactions are:
- Rapid-onset generalised urticaria.
- Bronchospasm and/or laryngeal oedema.
- Hypotension with collapse and loss of consciousness.
Investigation of patients with bee or wasp sting allergy
- All patients who experience a systemic reaction to wasp or bee stings should be referred to an allergy specialist for investigation and management.
- Minor local reactions to insect stings are normal and do not warrant allergy testing.
- Skin testing (skin prick and intradermal) is the first line of investigation.
- This is with standardised venom extracts with both bee and wasp venoms and positive (histamine) and negative controls.
- Skin testing provides greater discrimination between bee and wasp sensitisation than serum-specific IgE to whole venom.
- Skin tests are also more often positive than serum-specific IgE and correlate better with history.
- Baseline tryptase should be measured. Those with raised levels have a higher risk of severe systemic reactions.
Treatment of patients with bee or wasp sting allergy
- All patients with a history of systemic reaction should be immediately provided with a written emergency management plan, an adrenaline (epinephrine) auto-injector and education in its use.
- With children, appropriate liaison with the school is recommended.
- Venom immunotherapy (VIT) is recommended for all patients with a severe systemic reaction after a sting. It reduces the chances of a serious allergic reaction to an insect sting and improves quality of life.
- VIT is the only specific treatment that is currently available for patients with a history of systemic reaction to a Hymenoptera insect sting.
- VIT is effective in 95% of patients allergic to wasp venom and about 80% of those allergic to bee venom.
- VIT is not often recommended for children.
- A Cochrane review found that approximately 1 in 10 people treated had an allergic reaction during their treatment.
- The usual duration of VIT is three years in the UK.
- All patients should be advised of measures to reduce their risk of future stings. These include:
- Wear light-coloured clothing.
- Avoid strong fragrances, perfumes and highly scented shampoos.
- Wear shoes while outdoors and cover the body with clothing and a hat; use gloves while gardening.
- Avoid picking fruit from the ground or trees.
- Avoid drinking out of opened drink bottles or cans to prevent being stung inside the mouth.
- Wash hands after eating or handling sticky or sweet foods outdoors (especially children).
- Keep uneaten foods covered, especially when eating outdoors.
- Always contact professionals to remove bee or wasp nests.
- Wear full protective clothing while handling bees.
Management of bee or wasp stings
- The majority of people will have a localised reaction to a sting.
- Patients should be given antihistamines. Those with large local reactions may need oral prednisolone.
- Those with infected bites or stings will need oral antibiotics, usually in addition to oral antihistamines.
- Worldwide, these are held responsible for the spread of a large number of diseases, including malaria, filariasis, yellow fever, dengue fever, onchocerciasis, trypanosomiasis, leishmaniasis and loiasis.
- In the UK, these are usually only a nuisance. Discomfort of a bite is followed in sensitive individuals by pruritus with scratching and possible secondary infection.
- Where possible, the problem can be minimised by wearing clothing that covers the skin, and with use of insect repellents.
True bugs (Hemiptera)
- In the UK, the only medically significant species is bedbugs (Cimex lectularius).
- There is no evidence that they transmit disease. They may cause sleeplessness and bites may be painful and swollen. Bedbugs hide during the day and feed at night. They are found by searching the bedding at night or their hiding places during the day.
- They superficially resemble lentils and can live for six months without feeding, becoming paper thin. Control is by removal or steam cleaning of infected mattresses and treatment of the room with insecticide.
- In South America, triatomine (reduviid) bugs transmit trypanosomiasis.
- Worldwide, tick bites are responsible for the transmission of both rickettsial and viral infections and Lyme disease.
- In America, Rocky Mountain spotted fever, Colorado tick fever and Lyme borreliosis.
- In Australia, Q fever, tick paralysis, Queensland tick typhus and worldwide tick typhus.
- Soft ticks are widely distributed and can cause endemic relapsing fever.
- Ticks attach to the skin and feed with a barbed hypostome and then detach when engorged.
- The bites are usually painless but can cause local sensitisation and secondary infection.
- In the UK, most common ticks on humans are sheep tick (Ixodes ricinus), a vector of Lyme disease, and hedgehog tick (Ixodes hexagonus).
- Where there is tick infestation, bites can be avoided by tucking trousers into boots and the body should be searched after leaving the area to allow prompt removal of ticks, which can reduce risk of disease transmission.
- There are many suggested ways for removing ticks, including, but not limited to, heat, alcohol, and Vaseline®. None of these methods is recommended and they may, in fact, agitate the tick - in the case of the paralysis tick, this can cause more toxin to be expressed into the victim.
- A method that works well and minimises further expression of tick fluids is to lay small forceps along the skin with the ends either side of the tick's head, press down into the skin and firmly grip the head of the tick. Then steady traction can be applied perpendicular to the skin, without twisting, until the tick is finally released. The aim is not to break the tick so that mouth parts are left in the wound. If remnants do get left behind use local anaesthetic and scrape them away carefully with a scalpel blade.
- In an area of significant Lyme disease incidence, doxycycline for ten days is the antibacterial of choice for early Lyme disease. Amoxicillin, cefuroxime or azithromycin are alternatives if doxycycline is contra-indicated.
- If there is significant paralysis then tick antivenom can be administered in addition to supportive care.
Harvest mites (Trombiculidae)
- In Britain during late summer, larvae of the harvest mite (Neotrombicula autumnalis), which are tiny and often not noticed, may attach under tight-fitting clothes, feed and then detach causing itchy lesions that are sometimes bullous.
Further reading and references
Insect Bite Reaction; DermIS (Dermatology Information System)
Venom anaphylaxis - immunotherapy pharmalgen; NICE Technology Appraisal Guidance, February 2012
Severino M, Bonadonna P, Passalacqua G; Large local reactions from stinging insects: from epidemiology to management. Curr Opin Allergy Clin Immunol. 2009 Aug9(4):334-7.
Koterba AP, Greenberger PA; Chapter 4: Stinging insect allergy and venom immunotherapy. Allergy Asthma Proc. 2012 May-Jun33 Suppl 1:12-4.
Tracy JM, Lewis EJ, Demain JG; Insect anaphylaxis: addressing clinical challenges. Curr Opin Allergy Clin Immunol. 2011 Aug11(4):332-6.
Demain JG, Minaei AA, Tracy JM; Anaphylaxis and insect allergy. Curr Opin Allergy Clin Immunol. 2010 Aug10(4):318-22.
Diagnosis and management of hymenoptera venom allergy - guidelines; British Society for Allergy and Clinical Immunology (2011)
Boyle RJ, Elremeli M, Hockenhull J, et al; Venom immunotherapy for preventing allergic reactions to insect stings. Cochrane Database Syst Rev. 2012 Oct 1710:CD008838. doi: 10.1002/14651858.CD008838.pub2.
Radolf JD, Caimano MJ, Stevenson B, et al; Of ticks, mice and men: understanding the dual-host lifestyle of Lyme disease spirochaetes. Nat Rev Microbiol. 2012 Jan 910(2):87-99. doi: 10.1038/nrmicro2714.
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