How to Recognize and What to Do About Allergic Reactions to Bee and Wasp Stings

Posted on 23 Sep 2011 20:31

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If you or someone you know just got stung and you are having any of the following symtpoms:

  • choking
  • trouble breathing
  • feeling faint or dizzy
  • experiencing generalized (other than the sting site) hives, itching, or swelling
  • dilated pupils
  • blueness around lips and mouth (or other blueness of skin other than the sting site)
  • any other generalized reactions other than on the area of the sting itself:


ACTIVATE EMERGENCY MEDICAL SERVICES by calling 911 or the appropriate telephone number for your country. Tell the operator that someone is having a severe reaction to a sting and may be suffering from anaphylaxis (an-a-fi-lak-sis). You are having a systemic reaction to a bee or wasp sting, which should be considered a medical emergency. Otherwise, read on to learn more about systemic allergic reactions to bee or wasp stings.

This explanation is intended as a general guide to caring for someone with a bee or wasp allergy, or for anyone who is having an unusual reaction to a sting. Please consult a medical professional before implementing any of these guidelines.

Both bees and wasps belong to the order hymenoptera, which comprises about 250,000 insect species. Wasps, which include hornets, paper wasps, and yellow jackets (aggressive stingers) are of the family vespidae. Bees, including honey bees and bumble bees, belong to the family apidae. Among the stinging hymenopterans, only the females possess an ovipositor, which is a barbed stinging apparatus capable of injecting a venom. These venoms contain complex mixtures of histamine, dopamine, serotonin, meliitin, kinins, phospholipases and other enzymes. The venoms can cause local pain, inflammation, and tissue injury. They can also cause a type I, iimmunoglobulin E-mediated allergic reaction. 1

Despite the sensational nature of most information about bee and wasp stings, most stings from bees or wasps cause only a local reaction, are not dangerous, and can be treated at home. Even without treatment, the effects usually subside within hours. Some people, however, can have a severe allergic reaction to these stings which causes a life-threatening reaction called anaphylaxis.

In the United States, about 40 to 50 deaths occur annually from fatal reactions to bee or wasp stings. In fact, more people die each year from bee stings than from snake bites. In the U.S. and Europe, the majority of death from venom are caused by these insects. Therefore, they are medically the most important venomous animals in the world.6 Despite this danger, however, it should be clearly noted that the potential for death is not a consequence of the toxicity of the venom itself (except in large numbers of stings), but is the body's immunological over-reaction to these stings causing anaphylactic shock in the body, with repeated sings throughout a lifetime increasing the risk of these reactions. These allergic reactions are all out of proportion to the actual toxicity of the venom itself, except for stings occurring on the throat, which may cause direct swelling sufficient to cut off the airway.

It is sometimes reported that severe allergic reactions are more common in children but, according to research, this does not seem to be true. Adult reactions have been reported to be between 1 and 3% of various populations, with more danger of death from cardiovascular complications. There is an increased risk of death from these reactions, however, in children under 10 years old. The frequency of severe reactions increases with exposure to stings. This may account for the increased incidence in adults. Bee keepers, for example, are at high risk of allergy, with systemic reactions reported 20 to 35%. 2

Interestingly, most fatalities occur after the first ever anaphylatic reaction to a sting. Up to 75% of these happen in males over 50 years of age and with some preexisting cardiovascular or pulmonary disease. 7

Those who have a known allergy to bee, wasp stings should carry an allergic reaction emergency kit (bee sting kit) which their doctor will prescribe. These kits contain an antihistamine and an epinephrine auto-injector such as an Epipen or Twinject. It is imperative that you know how to use these devises in advance of having to use them. Waiting to the last moment to read the directions or figure out how to use the injectors could waste valuable time or even result in the incorrect dosage. Go to the Epipen or Twinject website to read the detailed usage directions. Also, be sure to check the expiration date often and replace the device as needed. Adrenaline kits can lose their potency over time. 5

Reactions to Bee and Wasp Stings

Reactions to bee and wasp stings can be normal, severe (local), and/or systemic. Although many people think that a severe reaction to a sting means that more severe systemic reactions are sure to follow, this is not always true. The risk for systemic reaction upon subsequent stinging is only 5 to 10%. Those who experience severe local reactions usually have venom-specific IgE antibodies. They need to by vigilant and observant but further treatment is not always required.

What's in a Sting?

The most common allergic reactions to bee and wasp stings are from Honey bees (Apsi mellifera) also known as the Western honeybee or European honey bee; and Wasps of the species Vespula vulgaris, otherwise known as the Yellow Jacket or Eurasian wasp. Although allergic reactions to other wasp and bee stings, like hornets and bumble bees, are possible, they are less common.

honey bee, Western honeybee, European honeybee, Apsi mellifera

Common Honey Bee
Apsi mellifera

The sting of a bee releases about 50 to 100µg of toxin (µg is a microgram). A wasp sting releases about 10 to 20µg. These toxins contain biogenic amines and proteins that posses enzymatic activity, the most troublesome of which are hyaluronidase and phospholipases, which are destructive to tissues. Phospholipase A2 (PLA2) but some hyaluronidase, acid phosphateses, and mellitin have allergenic potential as well. Wasp stings contain phospholipases, hyaluronidase, and phosphatases.

Yellow Jacket, Eurasian wasp, Vespula vulgaris

Yellow Jacket Wasp
Vespula vulgaris
image by Fir0002/Flagstaffotos

What is a Normal Reaction to a Sting?

Thousands of people are stung by insects every day. Although it is possible for anyone to be killed by stinging insects, for those without allergy, it is the sheer number of stings that is needed to produce a toxic effect that is important. It may take 500 or more bee stings to kill a non-sensitive individual. It is quite possible, however, to survive even more stings, although the toxic reaction may be quite severe and life-threatening. Just one or two stings, however, are usually just a painful annoyance.

A normal reaction to a sting is local. Within 2 to 3 minutes the local area around the sting will become red, itchy, swollen, and a painful welt will form. This should abate in two or three hours. 6, 7

What is a Severe Local (Large Local) Reaction to a Sting?

Severe or large local reactions have been reported in 2 to 19% of various populations. 2 They start at the sting site but spread to at least a 5 to 10cm diameter, causing a painful, itchy swelling. These severe reactions can cover an entire extremity and can last as long as ten days. As stated above, such a large reaction does not automatically mean that anaphylaxis will occur with subsequent stingings, the risk of which is 5 to 10%. 6, 2 However, if you do have a large local reaction to a sting, it is up to your doctor to decide if it is necessary for you to have a prescription for an epinephrine autoinjecter such as Epipen or Twinject.

What is a Systemic Reaction to a Sting?

A systemic reaction to a sting is a reaction that produces symptoms in areas other than the local area of the sting. They have been reported in less than 1% of children and in 1 to 3% of adult studies. The local pain and swelling still occurs but the following generalized reactions may also happen:

  • generalized iching (pruritis)
  • hives (uticaria)
  • swelling beneath the skin (angiodema)
  • respiratory distress
  • syncope (transient loss of consciousness)
  • hypotension (low blood pressure)

The reaction normally starts with the skin manifestations, with which the reaction may end, or they may progress to widespread swelling and breathing problems. If the reaction is severe enough, the victim may go into shock and present with a rapid pulse and low blood pressure. The thoat and chest may feel constricted and breathing may continue to become more difficult. In the event of an extremely severe reaction, anaphylactic shock and death can occur within 20 to 30 minutes, if not sooner. 6 Systemic reactions, based on number and severity of symptoms, can be divided into different grades, which will be covered below.

Two-thirds of bee or wasp sting related deaths occur after only one sting. Sting to the head or neck are more likely to lead to death due to allergic reaction and death is more common in victims over the age of 40. 1 The risk of having a systemic reaction to a sting increases after having one, the frequency reported from 27 to 57%. 2

What is Anaphylcatic Shock and What are the Signs and Symptoms of Anaphylaxis?

Anaphylaxis is a shock-like response caused by a severe allergic reaction. An allergic reaction is the immune system's exaggerated response to a substance that is normally harmless. Although many allergic reactions are a simple runny nose, or itchy eyes, or a rash, some can be potentially fatal reactions to an allergen or a substance to which a person has a hypersensitivity. Anaphylactic shock can result in death from circulatory collapse or respiratory failure. Anaphylaxis does not always occur immediately after exposure to an allergen. It may be delayed 30 minutes or more.

Not all the symptoms that are possible occur in every case of anyphalaxis. However, some symptoms occur with greater prevalence than others. A Cutaneous reaction occurs in over 90% of cases with hives and angiodema being the most common. Flushing of the skin occurs in about half of all cases. A generalized itching without the presence of visible hives occurs in about 2 to 5%.

Respiratory reactions occur in 40 to 60 percent of cases. Shortness of breath (dyspnea), wheezing, and upper airway swelling being the most common. A stuffy nose occurs in about 14 to 20% of patients. Dizziness, fainting, and low blood pressure are common.

Somewhat less common but possible are abdominal symptoms, manifesting in 25 to 30% of cases as nausea, vomiting, diarrhea and cramping pain. Cyanosis (blue or purple skin or mucous membranes), especially of the lips and around the mouth, may occur. Other symptoms may include headache, pain below the sternum, and seizure (uncommon). 7

Below are the general symptoms of anaphylactic shock, not all of which, as stated, occur in every instance 9:

  • general feeling of warmth
  • intense itching (particularly on soles of feet and palms of hands)
  • localized rash and swelling around sting
  • dizziness
  • choking
  • wheezing
  • shortness of breath
  • rapid and weak pulse
  • headache
  • nausea
  • vomiting
  • dilated pupils
  • blueness around lips and mouth (cyanosis)
  • tightness and swelling in throat and chest
  • swelling of mucous membranes - tongue, mouth, nose)
  • seizure

Classifications of Systemic Allergic Reactions to Bee and Wasp Stings

According to the Handbook of Clinical Toxicology of Animal Venoms and Poisons, systemic reactions to sings can be classified into 4 grades with increasing symptoms:

  • Grade I - generalized urticaria, itching, tachycardia, malaise, anxiety
  • Grade II - angio-edema (swelling under the skin) which may be accompanied by any of the above, chest constriction, nausea, vomiting, diarrhea, abdominal pain, dizziness
  • Grade III - any of above plus at least two of the following: breathing difficulty (dyspnea), wheezing, trouble speaking or forming words (dysarthria), weakness, confusion, catastrophic thoughts (feeling of immense danger or impending disaster)
  • Grade IV - any of above plus low blood pressure, collapse, unconsciousness, incontinence, blue skin (cyanois, especially lips and around mouth) 2

Symptoms of myocardial ischemia or even myocardial infarction are possible as well, referred to as Kounis syndrome or allergic angina/myocardial infarction. 7

First Aid for Bee and Wasp Stings

Most likely, a bee or wasp sting will occur during some kind of outdoor physical activity. Whether you are moving the lawn, exercising, playing, etc. the first thing to do after sustaining a bee sting is to cease any and all strenuous activity, after, that is, getting away from the nest (stings usually occur near the nest as the insects are defending their home).

The treatment required for stings depends on the severity of the reaction. For a normal local reaction, very little first aid is actually required. If the stinger is left in the skin, as in a bee sting, it needs to be removed. When the stinger is left in, venom can continue to enter the skin from the stinger for 45 to 60 seconds. It has traditionally been reported that the method of removing the stinger is important. Particularly, the public has been advised to never pinch and squeeze the venom sac, as this could cause more venom to be pumped into the skin. Therefore, according to common wisdom, the stinger sac should be scraped off with a fingernail, credit card, or other such object.

According to Kirk Visshcher and Scott Camazine, however, when it comes to removing bee stings, "speed matters, method doesn't." The researchers found that the response to a bee sting worsened as a direct result of the time taken to remove the stinger sac. The faster the sac was removed, the less the reaction, even to within a few seconds. The method of removal, though, made no difference, whether it was to pinch off the stinger or scrape off the stinger. Therefore they concluded that the proper advise is to remove the stinger as soon as possible, regardless of method. More important than removing the stinger immediately, however, is the need to get away from the nest as quickly as possible. When bees (and wasps) sting, a pheromone is released which raises a defense alarm in the other insects and helps them locate the threat, causing more of them to sting. Each new sting releases more pheromone, making it more likely that a large number of stings will occur. So first get away from the vicinity of the nest and then remove the stinger, if there is one left behind in the skin. 3

The sting site may be washed and disinfected but there is not much danger of an infection from a bee or wasp sting. If needed, local anesthetics can be applied for pain and a systemic antihistamine such as Claratin or Benadryl (loratadine, diphenydramine) can be taken to help with itching and swelling. Topical antihistamines and analgesics, such as Benadryl Itch Stopping Gel, can also be applied. Be sure to keep such products away from children and do not confuse them with liquid oral products, which may come in similar looking containers. Also, if you have already taken an oral antihistamine antihistamine, do not also apply a topical product containing the same active ingredient. If unsure of the ingredients, then only use one product, topical or oral, but not both. There are also some aerosol or cream antihistamines which contain a skin coolant to relieve pain.

Ice may be applied to the sting area to provide some pain relief. Ibuprofen or Acetaminophen can also be taken for the pain but are probably not necessary. How normal reaction to a bee or wasp sting affects you has much to do with how much you dwell on it!

People stung inside the mouth or on the neck should seek medical assistance because the swelling in these areas can block the airway and cause suffocation. Large numbers of stings, 50 plus for children or 100 plus for adults, should be considered a medical emergency.

First Aid for Large Local Reactions

The basic first aid for stings above applies to large local reactions. However, antihistamines such as Benadryl (diphenhydramine) or Claritin (laratadine - nondrowsy) should be taken as long as the itching persists. If the large local reaction is severe enough, corticosteroids (such as prednisone, methylprednisolone) may be beneficial.

First Aid for Systemic Reactions

Much depends on whether the sting victim has a known allergy or not. If there is no known allergy or history of large or systemic reaction to stings, then general monitoring for signs of anaphylaxis should be undertaken (given below), observing the first aid steps given above.

If the victim has a known allergy and has a bee sting kit with antihistamine tablets, gluticosteroid (glucocorticoid) tablets, and epinephrine auto-injector, the tablets should be taken immediately after the sting occurs. However, if the person is showing signs of choking or having trouble breathing, avoid oral medication. Do not give any other oral medications (aspirin, ibuprofen, or other pain medication) to a person with known allergy unless these have been prescribed by a doctor. After the tablets are taken and initial first aid is given watch closely for these general signs for anaphylaxis, repeated here for reference:

  • Apprehension
  • Dizziness
  • Rapid and/or Weak Pulse
  • Fainting
  • Tingling or Pricking Sensation of Skin (Parasthesia)
  • Numbness
  • Choking and/or signs of swelling in the throat (hoarse or whispered voice when talking, coarse sounds when breathing)
  • Swelling of of eyes or face
  • Skin turning blue, especially lips and around mouth
  • Wheezing, coughing
  • General difficulty breathing of any kind
  • Generalized hives or swelling
  • Dilated Pupils
  • Weakness

If these signs of anaphylaxis occur, call for emergency medical services immediately. Place the victim in a lying position with their feet elevated. Cover them with a coat or other covering. Do not place anything under the person's head if they are having trouble breathing, as this can further block the airway. Apply ice to the site if not already done, as this may help retard venom absorption. If an EpiPen or TwinJect is available, inject the proper does of epinephrine into the thigh, according to manufacturer's instructions. If breathing or heartbeat stops, administer CPR. Get the victim to the nearest hospital as soon as possible. 8, 9, 7

It should be noted that the use of a bee sting kit including an epinephrine auto-injector is NOT a substitute for medical attention and, in fact, the use of the medical kit itself may present complications. Medical supervision should always be sought after any severe systemic reaction to a sting.

If an emergency medical kit or epi-injector is not available, follow all the steps above while waiting for EMS. If possible, obtain systemic antihistamine tablets to administer to victim, as long as the victim is not choking and can safely take the tablets.

Emergency Medical Bee Sting Kit

Upon diagnosis of an allergy to bee or wasp stings, a doctor may prescribe an injectable epinephrine kit such as one of the following, according to where you live and what is available 10:

  • Epipen
  • Epipen Jr.
  • TwinJect
  • Adrenaclick
  • Fastjekt
  • Anapen
  • Anapen Jr.
  • Generic Epinephrine Injector

He or she also may prescribe corticosteroid tablets such as a prednisone, prednisolone or methylprednisolone. In addition he or she may also prescribe an oral antihistamine, which may be prescribed or purchased over-the-counter depending on your doctor's preference. If you have a bee or wasp sting allergy, you should keep these items on your person anytime you are engaging in activities where you are likely to encounter these insects. Keep them together in a small kit or plastic bag.

Medical ID Bracelets or Necklaces

People with sting allergies should also where a medical ID bracelet or necklace. These can be custom ordered and will provide an engraved overview of your health condition, alerting medics and doctors, and even strangers, to your condition immediately. They can be bought in a variety of styles and metals, made to look quite stylish.

Preventing Severe Allergic Reactions to Bee and Wasp Stings

The best way to prevent an allergic reaction to a sting is to avoid being stung. Insect repellants used to repel mosquitoes are not effective against bees and wasps. Although a systemic antihistamine, taken prophylactically, may help prevent large local reactions, they cannot protect against more severe ones. Also avoid perfumes, colognes, and scented lotions or soaps.

1. Greenberg, Michael I. Greenberg's Text-atlas of Emergency Medicine. Philadelphia: Lippincott Williams & Wilkins, 2005. 883.
2. Meier, J., White J., eds. Handbook of Clinical Toxicology of Animal Venoms and Poisons, v. 236. 1995.
3. Visscher, Kirk P., Ph.D., and Scott, MD Ph.D. Camazine. "Removing Bee Stings Speed Matters, Method Doesn't." University of California, Riverside. Web. 12 Sept. 2011. <>.
4. Schultz, Nathan D. The Best Guide to Allergy. Totowa, NJ: Humana, 1994. 146.
5. Ehrlich, Paul M., and Elizabeth Shimer. Bowers. Living with Allergies. New York: Facts on File, 2009.
6. goddard : Goddard, Jerome. Physician's Guide to Arthropods of Medical Importance. Boca Raton: CRC, 2007.
7. Castells, Mariana C. Anaphylaxis and Hypersensitivity Reactions. New York: Humana, 2011.
8. "Anaphylaxis: MedlinePlus Medical Encyclopedia." National Library of Medicine - National Institutes of Health. Web. 23 Sept. 2011. <>.
9. Anderson, Marcia K., and Gail P. Parr. Fundamentals of Sports Injury Management. Baltimore, MD: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2011.
10. "EpiPen Auto-Injector Medical Facts from" | Prescription Drug Information, Interactions & Side Effects. Web. 23 Sept. 2011. @

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