Bites and Stings; Land and Water by Mark B. Levin, M.D. The Pediatric Group, P.A., Princeton

This is the eighth article in a series written for Princeton Online on summer hazards. Click here for an archive of other articles.

Humans are hosts to numerous smaller organisms that may or may not welcome our participation in their environment. Insects, the most successful organism on earth, are often helpful to humans. They help us in agriculture and they keep each other in check. Unfortunately, they also like to check us out. For most of us, the sight of an insect “makes our skin crawl”. Most invasions of our skin are for purposes of feeding. These are often annoying and sometimes dangerous. Some insects sting to protect themselves. Knowing how to protect ourselves from bites and stings, how to treat them once they occur and how to distinguish dangerous from innocuous ones is important to our health.

The annoying variety of insects--gnats, flies, mosquitoes, fleas--is far more common than the potentially dangerous variety--bees, some spiders, ticks. Routine bites of the annoying bugs cause local reactions at the site of the bite. Even a large reaction at the site of the bite is considered a local reaction, not an allergic reaction. This distinction is important because, as a rule, local reactions are not dangerous.

A local reaction--redness, swelling and itching-- begins within 1-3 days of a bite. It reach its pinnacle at about 48 hours later and subsides 2 to 3 days after the peak. Treatment is directed at alleviating discomfort, since the lesion resolves on its own with time. Cool compresses, topical 1% hydrocortisone cream, and topical agents such as Rhulli Gel®, Itch-X®, Caladryl®, calamine lotion and Aveeno Anti-itch Cream® may help. For multiple bites or excessive itching, an oral antihistamine, such as diphenhydramine (Benadryl®), hydroxyzine (Atarax®), cetirizine (Zyrtec®), cyproheptadine (Periactin®) or loratidine (Claritin®) may also help. Oral steroids are not used for minor bite reactions. Try to keep your child’s fingernails short and clean to avoid a secondary infection caused by scratching.

It is usually difficult to determine what insect caused the bite because the skin reactions are similar. Spider bites, however, are different. They usually cause more firm swelling of the skin and last longer. The only potentially dangerous spider in New Jersey is the Brown Recluse, identifiable by the violin shaped mark on its brown back. It is so termed because it likes to hide under rocks and in other dark places. The bite of this spider may cause destruction of the skin at the site of the bite. If a bite looks black or gray to you at its center, you should have it examined by a physician. Systemic toxicity from a Brown Recluse spider bite is rare.

Tick bites are on everyone’s mind in the northeastern United States. The actual bite of a deer tick causes little immediate local reaction. It is the later onset of the rash of Lyme Disease that will be noticed. For a description of this rash, how to remove a tick and how to deal with Lyme Disease, please refer to our article in this series entitled Coping With Lyme Disease. The larger dog or wood ticks may cause a red bump where the tick was removed. It is common for regional lymph glands to swell, sometimes to the size of a small grape, near the bite. The glandular swelling gradually recedes in 2 to 4 weeks.

Hornets, wasps, honeybees, yellow jackets and fire ants cause only local reactions in individuals who are not allergic to the venom of these stinging insects. Although the reaction is often larger and more painful than that of the insects mentioned in the preceding paragraphs, the treatment is similar. If a stinger is left at the site by the insect, whether and how to remove a it is controversial. The stinger, which looks like a small splinter, has an attached venom sac. Squeezing the sac during removal may inject more venom, making the reaction worse. To avoid a foreign body reaction, pluck out a stinger with a sterilized needle, as you would a splinter. Expect the swelling at the sting site to peak at 48 to 72 hours after the sting and to resolve in 3 to seven days, with stings on the face, hands or feet taking more time than stings elsewhere.

Allergic reactions (generalized hives or perspiration, facial swelling, nausea, vomiting, light-headedness, pallor, wheezing, swelling of the airway, dropping blood pressure) occur away from the site of the sting. Swelling to the forearm from a sting on the hand is a local reaction. Hives on the trunk or other arm from a sting on the hand is an allergic reaction. The medical management of an allergic reaction is more complex than that of simple local reactions. Options include automatic adrenaline injectors, antihistamines, oral steroids, inhalant medications and desensitization immunizations (allergy shots). Be especially prepared with appropriate medications if you plan to be in an area where you will not have access to medical facilities. If you suspect your child is allergic to stings, you should contact your pediatrician for advice on how to confirm the diagnosis and prepare for reactions.

Aggressive preventative measures are appropriate for those who are allergic to stings. But life would be more pleasant for all of us if did not have to encounter stings or bites. Exposure can be minimized by modifying our patterns of activity or behavior. Avoid outdoor activity during times when mosquitoes are most active (dawn and dusk). Avoid perfumes and brightly colored clothing as these may attract insects. Wear long sleeved shirts, long pants and a hat to reduce skin surface available for bites. Shirts should be tucked in and repellent applied to clothing, tents, mosquito netting and other gear. Try to remove habitats, such as standing water where mosquitoes can breed, from your environment. Even small pools in old discarded automobile tires can be the source of thousands of mosquitoes.

Stinging insects also have preferred living quarters. Honeybees like to hover above clover and near flowers. Do not walk barefoot outdoors. Yellow jackets nest in the ground and like to visit areas where fresh food or waste is available. Stay away from garbage collection areas. Keep your food and drink covered when on a picnic. Avoid stepping where yellow jackets are circulating over an area of ground. Wasps and hornets tend to build nests hanging from some structure that will offer protection to the nest, e.g., under the eaves of houses, in the nooks and crannies of wood fences, amidst the branches of shrubbery, hanging from tree branches. Search these areas around you home and remove (or have removed) any nests you find. Warn children to avoid bee habitats when you go to a park.

Repellents can be helpful in certain situations. Travel to malaria-stricken areas demands proper clothing, altering daily habits and application of DEET products to the skin (maximum 10% concentration for a child). The repellent should be washed off when returning indoors. Clothing and mosquito netting should be sprayed with permethrin (Permanone® and others). We do not recommend the routine use of DEET products on children’s skin in the U.S., as frequent on children use can cause neurologic complications.

Among other more pleasant things, the coastal waters of the Eastern Seaboard are known for jellyfish. These marine animals can sting unsuspecting ocean swimmers. If you see a group of jellyfish in the water, it makes sense to return to the beach. Jellyfish stings are treated much the same way as spider bites, and may take as long to resolve.

“Bathers’ eruption” is caused by jelly fish larvae burrowing into the skin. Although the larvae die, they cause a self-resolving itchy rash most heavily distributed in the area where the bathing suit traps them against the skin. Topical preparations and oral antihistamines, as for annoying insect bites outlined above, are the mainstays of treatment.

The excessive warmth of the water in the increasingly popular hot tubs pose a risk of skin infection with a germ called pseudomonas. This itchy rash, which eventually goes away without specific treatment, can be avoided by assuring that the hot tub is adequately chlorinated. The eruption generally appears 1-2 weeks after bathing most intensely on uncovered skin. The affected bather can be kept comfortable with oral antihistamines.

Any break in the skin can become secondarily infected. The most common opportunistic invaders in this regard are staphylococcus and streptococcus. The best way to avoid infection is to avoid picking at bites. Cleanse bites with soap and water and cover them with an antibiotic ointment (e.g., bacitracin, Neosporin®, Polysporin®, Mycitracin®, etc.) and perhaps a bandage. If the bite enlarges, spawns new lesions, develops red streaks, becomes crusty, develops pus, becomes swollen or redder after the 48 hour mark or if you develop fever, achiness or increasing pain, call your doctor for advice.

The expression “There is no such thing as a free lunch” applies here. With proper precautions and treatment, bites and stings will remain a minor annoyance and we will be able to enjoy nature more than it enjoys us.

All Rights Reserved 8/98 The Pediatric Group, P.A.

Dr. Levin has been a member of the staff at The Pediatric Group since 1977. Currently an attending Pediatrician at the Medical Center at Princeton, he has been Chairman, Department of Pediatrics, Medical Center at Princeton, 1984 to 1986, 1989 to 1992, and past President, Medical and Dental Staff, Medical Center at Princeton, 1987 to 1988. Dr. Levin has served on numerous Departmental and hospital committees. He has published original articles both while at Upstate Medical Center in Syracuse and at The Pediatric Group. He has a wife and three children. Dr. Levin enjoys alpine skiing, jogging, hiking and camping, travel, computers and racquetball.