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Bees are generally known for two things: their industriousness and their venom. A worker honeybee will typically hit between 50 and 100 flowers in single trip while collecting pollen and nectar for her hive. And if you inadvertently trap this bee, she will plunge her stinger into your skin, releasing venom that for most people will cause skin irritation, but can, in rare cases, be life threatening. In North America, bees and fire ants, another stinging insect, are highly active in the summer. Below, Kathleen Sheerin, MD, an allergist with the Atlanta Allergy and Asthma Clinic, and vice chair of the public education committee at the American College of Allergy, Asthma and Immunology, discusses normal and allergic reactions to bees and fire ants, and what treatment is available to people who are allergic to insect stings.
What North American insects usually sting people?
Insects have been around for a long time, and some of them can cause life-threatening problems for people who are allergic to them. The class of insects that usually sting are called Hymenoptera, and it includes bees and ants.
There are five members of that class that cause problems: the honeybee, the yellow jacket, the wasp, the hornet, and then in the South, we have problems with fire ants, which don't fly.
How common are allergic reactions to insect stings?
The problem with stinging insects is they hurt when they sting, but for a small number of people in the country, about 1 percent of children and 3 percent of adults, you can actually have anaphylaxis, which is the most severe allergic reaction, and the worst case of anaphylaxis can lead to death. There are over 50 deaths a year from insect stings in this country, and the number's probably higher, but it's not reported as an insect death. For example, someone might be stung and have anaphylaxis, but it will be considered a heart attack.
How are the various stinging styles of insects different?
The honeybee is more of a problem out on the West Coast. Honeybees usually won't bother you if you don't bother them, and the way people get stung is walking barefoot in the grass, or the bees get trapped in clothing. Honeybees like colorful clothing and perfume, so they'll just land on your blouse, and then if you bother them they'll sting you.
Most people recognize the honeybee. It's yellow and fuzzy, with black and white stripes. They're fatter than the other bees. The honeybees only sting once; when they sting, their stinger comes out and they die.
The yellow jacket, on the other hand, is a vicious little creature that is more common on the East Coast. They live in the ground, so a lot of times people will be cutting their grass or raking leaves, and they'll step on a yellow jacket hole, and the bees will swarm out and sting them. They'll go after you, and they can sting multiple times. They'll be in trash cans, so if you're in the park and you're not paying attention and you throw something in the trash or you touch the side of the trash can, they may come after you.
They also like to land on food or will even go inside a Coke can, so parents have to be very careful, especially about drinking and picnicking. It's bad enough to be stung on the finger or the arm, but facial stings cause a lot swelling and discomfort, even if you're not allergic to it. The yellow jackets are yellow and black, and they're smaller and skinnier than the honeybees, with smaller stripes.
The wasps and the hornets are also aggressive insects. The wasps usually are located under eaves, so if people look up on their roof, on their gutter line and they see a nest, it's probably a wasp nest. The wasp is one of the larger insects, and they're dark colored. Wasps are more of a problem in the South, and they will sting multiple times, like the yellow jackets.
Hornets make nests that look like papier-mâché. They'll often be in the trees, and they're very aggressive if they get disturbed. So you don't want to cut the nest down yourself, because they may come after you.
The fire ants are a little bit different. They actually bite and then sting. They build big mounds, so if you are walking through a yard there may be nothing there one day, and the next day you see what looks like a pile of sand. And if you step on it, all of a sudden hundreds of thousands of ants will swarm. They're little tiny things, but they are very aggressive and hurt like the dickens when they bite.
Any of these insects can sting. The ones that cause more problems in terms of allergic reactions are the honeybees and the yellow jackets.
What kinds of reactions can people have to insect stings?
There are basically four reactions. You can have a small, local reaction, a large local reaction, a systemic reaction that isn't life threatening, and a life-threatening reaction.
The small, local reactions are what happen to anybody who's been stung by a bee or a fire ant. It hurts, it itches, and you get what looks like a mosquito bite. There are a lot of wives' tales about how to treat the local reactions, and what actually works the best is Adolph's meat tenderizer. But you've got to put it on the minute it happens, so you can't go to the store and buy it two hours later. It's a proteolytic enzyme, so it actually helps to break up the enzymes and the toxins that cause the local reaction. Ice or a topical steroid such as hydrocortisone can also sometimes help.
The second kind of reaction is a large local reaction, and what happens here is you get an extreme amount of swelling around the site that you got the sting. For example, you could be stung on the tip of your finger and have swelling all the way up to your armpit, and it's still considered a local reaction. If you're stung on your finger on the left hand and your whole right leg swells, that's not a large local reaction. It's got to be adjacent to the site.
Once you start getting these big swellings, then a call to your doctor would be appropriate. The way you treat the large local reaction is with ice or an antihistamine. Sometimes it's so bad that a health professional will have to prescribe steroids taken by mouth.
Then we have the systemic reactions, or anaphylaxis. In these instances, you may have two stings on your hand, for example, and within minutes your lips start to swell. You break out in hives all over. In the worst systemic reactions, people break out in hives, their blood pressure drops, they get dizzy, they throw up and some people will have trouble breathing. Sometimes they will wheeze as well. These reactions are life threatening, and if they occur, you should go to the emergency room.
What are some common myths about bee stings?
One is that an allergic reaction is just a fluke. We know from studying people over the course of years that if you're stung and you have a severe reaction, there is a 60 percent chance that you'll have the same reaction again.
Another myth is that the reaction will get worse with each sting. It's usually the same or milder. So you don't start with a local reaction and then go to hives and then go to, "I can't breathe." Another common myth is that kids outgrow the allergy, which is not true.
How can people avoid insect stings?
First of all, don't bug the bugs. I tell all my patients to wear shoes when they're outside. I tell the kids to wear shoes and socks. Don't exterminate bees yourself: Hire somebody to do it. Look before you eat or drink, and watch out when wearing colorful clothing outside or wearing loose clothing that can trap honeybees.
How can people with insect sting allergy protect themselves?
People with insect allergy need to have an EpiPen. An EpiPen contains epinephrine, which is the life-saving medication for people who have had an anaphylactic reaction. The EpiPen is a device that looks like a pen, and it's easy to carry in your book bag or purse. If you are stung, you just uncap it and push it into your thigh. It will deliver the medication within seconds to minutes after the sting, and it buys you 20 minutes to get to the emergency room to make sure that you don't have any more problems. Some people will have delayed reactions, which is why you still have to go to the ER.
If people are going on vacation to the Grand Canyon, or somewhere else where they're going to be far from medical treatment, they might want to take a couple of EpiPens with them. And when kids go back to school, you want to be sure that their EpiPens are up to date, because they expire about every 18 months.
Who should see an allergist for insect stings?
Anyone who has had a life-threatening reaction should be evaluated by an allergist. That includes anyone who has had loss of consciousness, hives, if they're an adult, wheezing, a drop in blood pressure, or breathing problems in response to an insect sting.
Hives are complicated because kids who are younger than 16 who have just hives don't need to go through the allergy testing, because the studies have shown that getting hives doesn't meant they are at risk for a true life-threatening problem. So that's something they need to discuss with their doctor. But anyone over 16 who has had hives needs to be evaluated.
How are people with this allergy treated?
If we're able to prove that someone is allergic, we can decrease their chance of having a subsequent reaction if they're stung again from 60 percent down to less then 3 percent with allergy shots.
We put venom into the allergy shot in order to desensitize people to it. People come to the office once a week over a period of about 12 weeks, and at the end of the 12 weeks they have been desensitized to the bee stings. We have tricked the immune system, so that the patient doesn't react allergically anymore.
At the end of the 12 weeks, when they're on their top dose of shots, they come once a month, usually for a minimum of five years. When they're at the top dose, they're receiving in the office the equivalent of two bee stings, so they should be able to tolerate several bee stings without having a problem. Some people need shots for life, depending on the severity of their reaction, but that would be determined on an individual basis.
Allergy shots can be a major, life-changing experience, because parents, for example, no longer have to be fearful when their kids go out and play soccer, or go hiking in the woods. Even having a picnic outside can be life threatening for people who have insect allergy.
