Management of Insect Stings

Removal of the Insect or Stinger

The American Academy of Allergy, Asthma, and Immunology recommends removing the stinger as quickly as possible by scraping with a straight-edged object or direct extraction with tweezers, as delay increases the amount of venom injected 1
Honeybees typically leave a barbed stinger with a venom sac attached to the skin, while other insects may also leave stingers 1
The American Academy of Allergy, Asthma, and Immunology advises against applying topical substances to "draw out" the insect, as this has no evidence of effectiveness and delays proper mechanical removal 1

The American Academy of Pediatrics recommends applying cold compresses to reduce pain and swelling 2
The American Academy of Allergy, Asthma, and Immunology suggests administering oral antihistamines, such as cetirizine, to reduce itching and pain associated with skin reactions 2
The American Academy of Pediatrics advises using oral analgesics for pain management 3

The American Heart Association recommends administering epinephrine 0.3-0.5 mg intramuscularly in the anterolateral thigh immediately if systemic symptoms develop, such as generalized urticaria, angioedema, respiratory, or cardiovascular symptoms 5
The American Academy of Allergy, Asthma, and Immunology states that epinephrine is the drug of choice for anaphylaxis, and delayed use can be ineffective and is associated with fatal outcomes 6
The American Academy of Allergy, Asthma, and Immunology notes that antihistamines and corticosteroids are not substitutes for epinephrine in systemic/anaphylactic reactions 5

The American Academy of Allergy, Asthma, and Immunology warns against confusing allergic inflammation with cellulitis, as swelling in the first 24-48 hours is caused by allergic inflammation, not infection 2
The American Academy of Pediatrics advises against delaying stinger removal by attempting unproven methods to "extract" the insect 1
The American Academy of Allergy, Asthma, and Immunology recommends against prescribing antibiotics routinely for local swelling without evidence of secondary infection, as this contributes to antibiotic resistance 2

The American Academy of Allergy, Asthma, and Immunology notes that patients with extensive local reactions have up to 10% risk of eventually developing a systemic reaction in subsequent stings 3
The American Academy of Pediatrics suggests considering prescribing an epinephrine auto-injector for patients with extensive local reactions who have frequent unavoidable exposure 3
The American Academy of Allergy, Asthma, and Immunology recommends referring patients who experience systemic reactions to an allergist-immunologist for skin tests and consideration of venom immunotherapy 2