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Patient Education
General: If attacked or stung by flying bees or wasps, do not flail arms, etc. Crushing one insect may
incite others to attack even more vigorously. Although the insects may defend an area up to 150 meters
from their nests, they can only fly about four miles per hour. Therefore, healthy individuals can easily outrun
the swarm and escape.
Medication: Any individual with a generalized reaction should be referred for allergy testing and desensitiza-
tion, and should thereafter wear a medic-alert tag and carry an emergency medical kit containing at least
an antihistamine and aqueous epinephrine in a pre-filled syringe for immediate self treatment. Continue
immunotherapy indefinitely as long as risk of exposure is substantial.
Prevention: Avoid nests, hives, bee trees, locations around flowers, fruit, etc. Avoid bright colored clothing,
perfume/cologne, etc. Wear shoes (ground nests are common). Do not use noisy equipment (mowers, etc.)
in vicinity of “killer-bee” colonies.
Follow-Up Actions
Return Evaluation: Be alert for rebound anaphylaxis as medication levels diminish. Observe stings for
secondary infection. Be alert for serum sickness up to 14 days post-sting.
Evacuation/Consultation Criteria: Immediately evacuate cases with anaphylactic or generalized reactions.
Other cases do not require evacuation, even with multiple stings. Consult primary care physician and allergist
as needed.
Skin: Mites
MAJ Daniel Schissel, MC, USAIntroduction: Mites are tiny parasites that burrow under or attach themselves to the skin where they inflict
small bites that cause much larger rashes. The best known, the mite Sarcoptes scabiei or scabies, is covered
in another section of this of this chapter. Other common mites are dust mites, which cause respiratory allergic
symptoms, and chiggers. Chiggers hide in tall grass or undergrowth waiting to attach to a passing victim.
When they meet an obstacle in the clothing, like a belt or boot top, they inject an irritating secretion that
causes the itching sensation, and then drop off or are scratched off. The pruritus peaks on the second day
and gradually subsides in a week.
Subjective: Symptoms
Local pruritic, burning or stinging sensation accompanying erythematous lesions.
Objective: Signs
Using Basic Tools: Chiggers: Discrete, 1-2mm, erythematous papules (often with a hemorrhagic center)
commonly seen along the belt line or boot top. The primary lesion of other mites follows a spectrum from
erythematous papules, pustules, vesicles, to general urticaria. Secondary linear excoriations are common
with all mite infestations. In children these eruptions are often widespread, with urticaria, and even bullae
formation. The pruritus may persist for weeks and may progress to impetigo in children.
Assessment: Diagnosis based on clinical morphologic criteria and history of exposure.
Differential Diagnosis - irritant or allergic contact dermatitis, drug or viral reaction.
Plan:
Treatment
Primary: Relief of pruritus with oral antihistamines (i.e., diphenhydramine), cool baths or compresses,
topical steroids or topical antipruritics (calamine lotion, aloe or Chig-a-rid).
Primitive: Clear nail polish.