Overview of Bee Sting Reactions and Allergies

If you've ever been stung by a flying insect—a honeybee, hornet, wasp, yellow jacket, or fire ant—you already know how your body responds: Some people have relatively mild reactions to insect bites or stings, while others are highly allergic and have potentially life-threatening symptoms of anaphylaxis such as wheezing and swelling of the tongue and throat that make it hard to breathe. 

But if you've never been bitten or stung, how it might affect you may be a mystery—and not one you necessarily want to solve. Even so, it's a good idea to understand the risk factors for having an encounter with an insect, to know how to recognize the symptoms that should receive immediate medical attention, and to become familiar with the types of stinging insects so that you can avoid them as much as possible and also be able to tell your doctor if you have a run-in with one. 

Overview

Most people who are stung by a flying insect such as a honeybee, hornet, or wasp will at the very least develop a reaction at the site of the sting—typically pain, swelling, redness, and itching.

But although most people are not allergic to insect stings, thousands of people go to the emergency department or seek medical care for potentially life-threatening reactions to encounters with flying insects each year. What's more, according to a 2013 report by the American College of Allergy, Asthma & Immunology (ACAAI), the number of people who have allergies to insect stings is on the rise.

The ACAAI estimates that between 4 percent and 8 percent of children and 3 percent of adults have such reactions each year. What's more, the ACAAI reports that about between 90 and 100 people die from insect sting anaphylaxis each year. 

Risk Factors

Anyone can have a severe allergic reaction to an insect sting, but people who have a history of other allergic diseases such as allergic rhinitis (hayfever) and asthma are at greater risk of being allergic to bees and other flying insects. 

Signs and Symptoms

An anaphylactic reaction to an insect sting—meaning one that affects the whole body—can happen within minutes or take several hours to develop and can cause any or all of the following symptoms, usually within a matter of minutes to a few hours:

  • Itching over the entire body
  • Hives or swelling that spread from the site of the sting
  • Flushing (reddening of the skin)
  • A runny nose, sneezing, or postnasal drip
  • Itchy, watery eyes
  • Swelling of the lips, tongue, and/or throat
  • Shortness of breath, wheezing, and/or coughing
  • Stomach cramping, nausea, vomiting, and/or diarrhea
  • Lightheadedness, increase in heart rate, low blood pressure, or passing out
  • A sense of panic or sense of impending doom
  • A metallic taste in the mouth

Insects That Cause Venom Allergies

Besides bees (including honeybees, Africanized honeybees, and bumblebees), there are other flying insects that can sting or bite and, in people who are predisposed to them, cause an allergic reaction. These creatures all belong to the order Hymenoptera: yellow jackets, hornets, wasps, and fire ants. 

It's more important in the moment to seek medical attention for a severe allergic reaction to an insect sting than to identify which bug was responsible. But it can be helpful in general to recognize insects that can cause an anaphylactic reaction and know a bit about their habits (where they nest, for instance) so you can avoid them.

Honeybees

Honeybees commonly nest in tree hollows, logs or inside buildings. Away from their hive, honeybees tend to be non-aggressive but can be more aggressive when their hive is threatened or disturbed. Stings from honeybees are common when a person walks barefoot on a clover-filled lawn.

They are the only stinging insect to routinely leave a stinger in the victim’s skin, although other stinging insects occasionally do so as well. While there has been much written about removing stingers, the best method is whatever is quickest. The longer the stinger is in the skin (up to 20 seconds anyway) the more venom which may be injected.

Africanized (Killer) Honeybees

Africanized (killer) honeybees are far more aggressive than domestic honeybees, which were created by cross-breeding African honeybees with domestic honeybees in South America for the purpose of greater honey production.

Their venom is essentially the same as domestic honeybees—meaning that a person allergic to a typical honeybee will also be allergic to Africanized honeybees. They tend to sting in large groups, sometimes by the hundreds.

Bumblebees

Bumblebees rarely sting people because they are non-aggressive and typically mild-mannered. They will sting if provoked or if their nest is disturbed, but they are so loud and slow, a person usually has plenty of time and warning to escape. They nest on the ground or in piles of grass clippings or wood and feed on insects and flower nectar.

Yellow Jackets

Yellow jackets are wasp-like insects that live in mounds built into the ground, They tend to be aggressive insects, and are a common nuisance at picnics and around trash cans where food and sugary drinks are abundant.

Stings on the lip or inside the mouth or throat can occur when a drink is taken from an open can of soda that a yellow jacket had crawled into. Occasionally, stings from yellow jackets can result in a skin infection because these insects can carry bacteria.

Hornets

Hornets, including yellow and white-faced hornets, build paper-mâché type nests in trees and shrubs. These insects may be very aggressive, and sting people because of a mild disruption, such as someone nearby mowing a lawn or trimming a tree.

Wasps

Wasps build honeycomb nests under the eaves of a house, or in a tree, shrub or under patio furniture. They tend to be less aggressive than yellow jackets and hornets, and mostly feed on insects and flower nectar.

Prevention

Put simply, the best way to prevent an allergic reaction is to avoid being stung. Here are a few tips:

  • Hire a trained exterminator to treat any known nests in the immediate area; periodic surveillance for further infestation should be performed.
  • Avoid looking or smelling like a flower. Do not wear brightly colored clothing or flowery prints, or perfumes or other scents that will attract insects.
  • Always wear shoes when walking outside, particularly on grass.
  • Wear pants, long-sleeved shirts, gloves, close-toed shoes, and socks when working outdoors.
  • Use caution when working around bushes, shrubs, trees and trash cans.
  • Always check food and drinks (especially open cans of soda or drinks with straws) before consuming, especially at pools and picnics, where yellow jackets are known to be present.
  • Keep an insecticide, approved for the use on stinging insects, available should treatment of a nest be necessary.

Testing

Testing is performed using allergy skin testing or by performing a RAST. Skin testing is still the preferred method and the procedure is similar to testing for pollen or pet allergies. However, it may be necessary to use increasing concentrations of venom extracts to make a diagnosis. Allergists usually test for all stinging insects (bees, wasps, etc.) since studies have shown that people usually can't identify which type of insect stung them.

A person stung by only one insect may show positive allergy tests to more than one type of insect. In this situation, treatment using venom from all of the species is usually given.

Who Should be Tested

It's not always a clear-cut case who should be tested for a bee allergy, but in general: Testing is not needed If a person has never been stung by an insect, or never had any symptoms (other than pain at the site of the sting) as a result of a sting, there is no need to perform any venom allergy testing.

Or, if a child under 16 years of age has only skin symptoms (such as hives and swelling) after a sting. This is because anaphylaxis will only occur in up to 10 percent of future insect stings. Or, if a child or adult has a large local reaction, where swelling occurs at the site of the sting only, is not usually a reason to perform venom testing or to administer venom allergy shots.

This is because the chance of developing anaphylaxis with future stings is only about 5 to 10 percent for both children and adults. (A few studies show that these reactions can be decreased with the use of venom immunotherapy, and this may be required in situations where stings are frequent and the swelling disrupts a person’s quality of life or ability to work.)

Testing is needed if a person of any age has symptoms of anaphylaxis (see page 1) after being stung. That's because the person has about a 60 to 70 percent chance that future insect stings will cause a similar reaction. The chance of a reaction to a future sting will decrease over time but still remains at about 20 percent many years after the last sting.

Also, if there is a particular parental concern or the child is at high risk for frequent stings, venom testing and treatment is a reasonable option. People older than 16 with these same concerns should have venom testing and treatment, given a higher risk of anaphylaxis with future stings.

If a person is found to have a positive allergy test to venom, yet has had no symptoms with stings, the chance of developing anaphylaxis with future stings is approximately 17 percent.

Immediate Treatment of Acute Reactions

The treatment of venom allergy involves the management of an acute reaction, as well as the prevention of future reactions. Epinephrine is the treatment of choice for anaphylaxis.

People with venom allergy are encouraged to carry a self-injectable form of epinephrine, such as an Epi-Pen or Twin-Jet device. If this medication is required, immediate medical attention is also needed, and the person should call 911 or go to the emergency room.

If itching or hives are the only symptoms, an oral antihistamine may be all that is required although seeking emergency medical attention is still advised. If symptoms worsen or swelling of the skin affects the ability to breathe, then epinephrine will be required.

If a stinger remains in the skin, such as with a honeybee sting, it should be removed quickly so that more venom is not injected into the sting. Do not squeeze the stinger or the site of the skin—instead, pull the stinger out with tweezers or scrape the stinger out with the edge of a credit card. Put ice or a cold compress at the sting site to reduce local swelling.

Treatment of Future Reactions

To prevent reactions to future insect stings, avoid being around stinging insects. If a person has experienced anaphylaxis, or whole-body skin symptoms (hives, itching, flushing, swelling away from the sting site) in those 16 years and older, then venom and testing are required.

Immunotherapy, or allergy shots, using purified venom from the type of insect to which a person is allergic, can cure venom allergy. Allergy shots using pure venom is given in much the same way as allergy shots for pollen allergy.

After a person is receiving appropriate doses of venom allergy shots, the chance of a reaction with future stings is reduced to less than 5 percent. After a series of venom allergy shots for at least 3 to 5 years, most people can stop the shots without a significant increase in the chance of allergic reactions.

However, some people with severe, life-threatening reactions from insect stings, or those who have had anaphylaxis from the venom allergy shots themselves, may require life-long venom allergy shots.

This is because a person’s chances of a reaction to future stings may slowly increase to as high as 20 percent many years after venom allergy shots are stopped. This topic is an evolving area of venom allergy research and requires careful discussion between a person and their allergist.

For those with severe allergies who must—due to occupation or hobby—be in a situation in which stings could easily occur, the option of rush immunotherapy should be considered. Accelerated immunotherapy such as rush, though it carries an increased risk of reactions, can result in control of venom allergies much more rapidly that "regular" allergy shots.

After Allergy Shots for Bee Allergy

Some allergists perform venom allergy testing, either with skin testing or RAST, after venom immunotherapy has been given for a period of time. Venom immunotherapy can be stopped in the majority of people whose allergy test turns negative, although the test does not always turn negative, even in people who have received venom allergy shots for years.

Recent studies suggest that many children who begin allergy shots for bee stings do not complete their therapy. Keep in mind that allergy shots can cure a bee sting allergy and reduce the likelihood of a life-threatening allergic reaction in the future, but the full course of treatment needs to be completed.

The Bottom Line

All people with a history of allergic reactions to insect stings, including children with skin-only reactions and even those with large local reactions, should consider having some form of medical alert, whether a bracelet, wallet card, or scroll I.D. identifying their medical condition, as well as having an injectable form of epinephrine available for immediate use.

This EpiPen should be carried with you wherever you go. The TSA generally allows you to carry your EpiPen with you in your carry-on if you fly, but check ahead to make sure.

Bee stings are common, and allergic reactions can result in severe reactions or even death. That said, recognizing the symptoms of anaphylaxis and calling for immediate attention can decrease the risk of these life-threatening complications.

Most people with mild reactions will not need shots, yet allergy shots offer the option of a cure for those with serious allergies.

It's important to note one last time that most fatalities due to bee sting allergy occur in those who do not have a known allergy. Everyone should be familiar with the signs and symptoms of anaphylaxis and how to contact emergency help if needed.

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