Podcast
Questions and Answers
What is the recommended duration for reapplying DEET for effective protection?
What is the recommended duration for reapplying DEET for effective protection?
Which of the following populations should avoid high concentrations of DEET?
Which of the following populations should avoid high concentrations of DEET?
What is a critical counseling point regarding the use of DEET with other products?
What is a critical counseling point regarding the use of DEET with other products?
Which insect repellent ingredient is considered similar in efficacy to DEET for malaria prevention, but does not last as long?
Which insect repellent ingredient is considered similar in efficacy to DEET for malaria prevention, but does not last as long?
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What concentration of DEET is believed to provide the best protection against tick bites?
What concentration of DEET is believed to provide the best protection against tick bites?
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What is the primary ingredient in the OFF! Deep Woods Sportsmen Insect Repellent?
What is the primary ingredient in the OFF! Deep Woods Sportsmen Insect Repellent?
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Which of the following insect repellent options is designed for application on clothing and camping equipment?
Which of the following insect repellent options is designed for application on clothing and camping equipment?
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Which essential oil is NOT mentioned as an alternative insect repellent?
Which essential oil is NOT mentioned as an alternative insect repellent?
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Which method is recommended for effective tick removal to minimize complications?
Which method is recommended for effective tick removal to minimize complications?
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What is the primary concern when treating insect bites, particularly in individuals with compromised immune systems?
What is the primary concern when treating insect bites, particularly in individuals with compromised immune systems?
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What important factor should be considered when counseling patients about bites from bed bugs?
What important factor should be considered when counseling patients about bites from bed bugs?
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Which statement best describes the nature of chigger bites?
Which statement best describes the nature of chigger bites?
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When educating patients on flea bites, what should be emphasized as a serious potential outcome?
When educating patients on flea bites, what should be emphasized as a serious potential outcome?
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What is a key counseling point related to the bites of black widow spiders?
What is a key counseling point related to the bites of black widow spiders?
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What precaution should be taken when dealing with scabies, particularly in community settings?
What precaution should be taken when dealing with scabies, particularly in community settings?
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What is a misleading assumption about mosquito bites?
What is a misleading assumption about mosquito bites?
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Which of the following statements is NOT true regarding the application of local anesthetics for treating external conditions?
Which of the following statements is NOT true regarding the application of local anesthetics for treating external conditions?
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What is the first step in the treatment protocol for managing honeybee stings?
What is the first step in the treatment protocol for managing honeybee stings?
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Which group should avoid using topical antihistamines and local anesthetics?
Which group should avoid using topical antihistamines and local anesthetics?
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Which condition requires immediate medical referral according to the exclusion criteria for insect stings?
Which condition requires immediate medical referral according to the exclusion criteria for insect stings?
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What is the recommended frequency for the application of a skin protectant like calamine or zinc oxide?
What is the recommended frequency for the application of a skin protectant like calamine or zinc oxide?
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Which of the following is a recommended nonpharmacologic method to prevent insect stings?
Which of the following is a recommended nonpharmacologic method to prevent insect stings?
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What should be done after removing a honeybee stinger and sac?
What should be done after removing a honeybee stinger and sac?
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For which of the following symptoms is it necessary to seek medical attention during treatment for insect stings?
For which of the following symptoms is it necessary to seek medical attention during treatment for insect stings?
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Which external treatment is not appropriate for scabies or infections?
Which external treatment is not appropriate for scabies or infections?
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What is the indication for using counterirritants such as camphor and menthol?
What is the indication for using counterirritants such as camphor and menthol?
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Study Notes
Sting, Bites, and Pediculosis
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Insect Bites:
- Mosquitoes: Anticoagulant saliva causes swelling and itching. Vectors for Eastern equine encephalitis, West Nile virus, Chikungunya, and Zika viruses.
- Fleas: Multiple bites, usually on legs and ankles. Red swelling around puncture, intense itching. Can transmit bubonic plague and endemic typhus.
- Scabies: Tiny arachnid mite burrows into stratum corneum. Females deposit eggs in tunnels. Presents in interdigital spaces of fingers, flexor surfaces of wrists, genitalia, buttocks, and underarms. Intense itching, highly contagious.
- Bed Bugs: Hide and lay eggs in crevices (bedding, suitcases). Increased global travel and resistance to pesticides has increased incidence. Bites appear as clusters of 2-3 in a straight line on head, neck, and arms.
- Ticks: Can transmit Lyme disease, Rocky Mountain Spotted Fever, and Ehrlichiosis. If tick is removed but mouth parts remain, it can cause itching and nodules. Remove intact ticks within 36 hours using fine tweezers.
- Chiggers: Live in shrubs, trees, and grass. Larvae secrete digestive enzyme causing intense itching. Their skin hardens and makes a tube to feed, engorge, and fall off.
- Spiders: Most are venomous, but most cannot penetrate skin with fangs. The exceptions are black widow, brown recluse, and hobo spiders. Black widow bite has delayed initial pain and can produce symptoms like stiffness, joint pain, fever, chills, and abdominal discomfort. Brown recluse causes spreading ulcerated wounds; hobo spider bites cause moderate-severe slow healing wounds.
Treatment Goals and General Approach for Insect Bites
- Goals are to relieve symptoms and prevent secondary bacterial infections. Monitor bites and prevent future bites.
- Apply ice pack (wrapped in washcloth) to affected area up to 10 minutes with at least 10 minutes between applications. This method is appropriate for fleas, mosquitoes, chiggers, or bedbugs (not scabies).
- If insufficient relief, apply external analgesic. Avoid scratching the bite or wearing rough/irritating clothing over the bite area.
Exclusion Criteria for Insect Bites
- Hypersensitivity to insect bites resulting in systemic symptoms or symptoms away from the insect bite.
- Patients under 2 years old (external analgesics cannot be used).
- History of tick bite with systemic effects indicating infection.
- Suspected spider bite requiring medical attention.
- Suspected scabies infection (no OTCs to treat).
- Secondary infection signs present.
Nonpharmacological Prevention: Avoidance of Insects
- Cover skin as much as possible with clothing and socks. Avoid swamps, dense woods, dense brush. Keep pets free of pests. Remove standing water. Limit time outside at dawn and dusk. Use barriers such as window screens and netting. For bed bugs, do not put clothes on carpets/upholstered chairs, and use a metal suitcase rack. Check bed bug registry.
Prevention: Insect Repellents
- N,N-diethyl-m-toluamide (DEET): Most effective all-purpose repellent. Does not kill insects, it repels them, thus preventing bites. Safe in pregnancy and lactation. Various concentrations, children benefit from below 30% concentrations. Applied every 4-8 hours; not more frequently. Combining with sunscreen is discouraged due to frequent application.
- Other Insect Repellents: Alternative products include essential oils (citronella, lemon eucalyptus, soybean oil, lavender oil, tea tree oil, garlic), or scented moisturizers in mineral oil. Less effective than DEET. Picaridin is promoted as less odorous and irritating than DEET. Permethrin is for clothing and camping equipment.
Selected Insect Repellents (Table 1)
- Provides a table listing various trade names and their primary ingredients.
EPA Guidelines for Safe Use DEET (Table 2)
- Provides EPA guidelines for using DEET, emphasizing the importance of following all directions, avoiding application over wounds or irritated skin, and caution with young children.
Pharmacological Therapy: External Analgesics
- Local Anesthetics: benzocaine, pramoxine, lidocaine, dibucaine, phenol, and benzyl alcohol. Relieve itching and irritation. Apply up to 3-4 times daily. Be aware of allergic reactions.
- Topical Antihistamines: diphenhydramine HCl. Apply up to 3-4 times daily; depresses cutaneous receptors, relieving pain and itching.
- Counterirritants: camphor and menthol. Apply up to 3-4 times daily. Relieve itching and provide a “cooling” sensation.
- Hydrocortisone 1%: Apply up to 3-4 times daily. Not for scabies or infections.
Pharmacological Therapy: Continued
- Skin protectants: Calamine or zinc oxide. May be used to reduce irritation or inflammation, and can absorb weeping fluids. As needed, up to 4 times per day.
- Seek medical attention for worsening symptoms, persisted symptoms for 7 days, or worsening of condition during treatment
Insect Stings
- Honeybees, wasps, hornets, and yellow jackets: Honeybee stinger is barbed, continues to inject venom. Honeybees may cause a more significant histamine release compared to other stinging insects. Wasps, hornets, and yellow jackets do not have barbed stingers.
- Fire Ants: Some fire ants just bite, while others bite and sting. Pain/swelling/tissue necrosis may occur.
Treatment Goals and General Approach for Insect Stings
- Goal: Relieve itching and pain, prevent future stings, and address allergic reactions (medical referral if necessary).
- Remove the stinger: remove quickly (2–3 minutes) to remove venom.
- Apply ice: Apply ice in 10-minute intervals to slow venom absorption and help with pain/swelling.
- Do not squeeze or scrape stinger: avoid damage.
- Apply antiseptic: after removal, apply alcohol or hydrogen peroxide.
Exclusion Criteria for Insect stings
- Presence of hives, excessive swelling, dizziness, weakness, nausea, vomiting, and difficulty breathing are warning signs.
- Significant allergic response away from the sting site.
- History of previous stings by honeybees, wasps, or hornets, or of previous severe reactions to insect bites.
- Personal or family history of significant allergic reactions.
- Under 2 years old (external analgesics discouraged).
Nonpharmacological Prevention: Avoidance of Insects
- Avoid attracting insects by avoiding strongly colored clothing, perfume, or scented lotions in picnic or garbage areas if near stinging insect nests. Change clothes if contaminated by summer foods. Wear shoes outdoors, destroy nests of stinging insects. Hypersensitive individuals should wear a medical alert bracelet or carry a card indicating nature of the allergy.
Pediculosis
- Three common types: Pediculus humanus capitis (head lice), Pediculus humanus corporis (body lice), and Phthirus pubis (crabs).
- Life cycle of head lice: Commonly spread by head-to-head contact, impacts socioeconomic groups, usually peaks in August-November in schools. Louse requires a blood meal within 24 hours of hatching. Bite creates a wheal and papule, itching subsequently occurs. Female lives one month, lays 7-10 nits/day which hatch in 8–10 days and becomes a mature adult in 8-9 days. Nits are cemented to the hair shaft.
- Assessment: Complete physical examination using gloves, light, and hand magnifier. Few adult lice are generally found. Look for nits on hair shaft at the nape of the neck or behind the ears. Adult body lice and nits are found in seams of clothing.
Treatment Goals and General Approach for Pediculosis
- Goal: Rid the infestation by killing lice and nits and removing nits.
- Apply Pediculicide to infected area, remove nits and dead lice with hair comb. Use FDA-approved nit comb, for treatment prevention.
- Avoid future infestations by using nonprescription pediculicide.
Exclusion Criteria for Pediculosis
- Hypersensitivity to Chrysanthemums, ragweed, or pediculicide ingredients.
- Cannot use OTC FDA-approved products.
- Presence of secondary skin infection.
- Under 2 years of age (discouraged from using pyrethrins).
- Under 2 months of age (discouraged from using permethrins).
- Lice infestation of eyelids or eyebrows.
- Pregnancy or breast-feeding.
- Strong caution on self-treatment.
- Regional resistance to pediculicides, presence of active tumors.
Nonpharmacological Therapy for Pediculosis
- Heat treatment for lice.
- Avoid contact of clothing, bedding, combs, towels, hats.
- Wash clothing in hot water and dry thoroughly. Seal hair brushes and combs in very hot water, or plastic bag for 2 weeks.
- Regularly vacuum carpets, rugs, and furniture for possible lice/nits.
Synergized Pyrethrins
- Approved for head and pubic lice.
- Synergized with piperonyl butoxide, limiting the ability of lice to break down pyrethrin resulting in higher/more toxic concentrations.
- Blocks nerve impulse transition killing lice (not eggs).
- Low toxicity but may cause irritation, redness, swelling. Caution with allergies to pyrethrins, chrysanthemums, ragweed.
Permethrin
- Treatment for head lice only.
- Disrupts nerve cell membrane of lice, killing the louse.
- 10% of patients experience itching, burning, stinging, and irritation.
- Contraindicated for people with sensitivity to pyrethrins or chrysanthemums
- More effective than pyrethrin in a single application.
OTC Product Directions
- Specific directions given for the use of synergized pyrethrins and permethrin. Details include timing, product application as a shampoo, foam, or gel, and method of combing for treatment.
Ivermectin 0.5% (Sklice®)
- FDA approved lotion.
- Effective in killing lice.
- Does not require nit combing.
- Does not require a second application.
Homeopathic: Natrum Muriaticum
- Sodium chloride solution.
- Shows greater efficacy than permethrin in treating head lice.
Alternative Therapies
- Not FDA-approved therapies may include lice enzyme shampoos, including tea tree oil (10%), and lavender oil (1%).
- Treatments like Petroleum Jelly, mayonnaise, or olive oil are not effective.
- Battery-operated combs and other remedies lack supporting evidence. Avoid in patients with pacemakers or seizure history.
Emerging Therapies
- Dry-on, suffocation pediculicide lotions.
- Nuvo method or Cetaphil Gentle Skin Cleanser can be applied to hair and dried with hair dryer. The DSP loitons cause suffocation of the head lice, and some examples provided.
- Dimethicone 100% gel immobilizes lice within minutes.
Selected Products (Table 3)
- A table listing various products (by trade name) with their primary ingredients.
Key Points for Assessment and Treatment
- Assess presence of lice and nits, consider regional resistance, and refer if necessary.
- Select and counsel treatment, re-assess in 10 days following treatment.
- Important to use non-pharmacological prevention.
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Description
Test your knowledge on the safe use of DEET and other insect repellents. This quiz covers critical counseling points and efficacy comparisons with other ingredients. Perfect for healthcare professionals or anyone interested in insect bite prevention.
