Large local reactions to insect envenomation

Purpose of review Insect stings often induce large local reactions (LLRs) that result in morbidity. These reactions do have an immunologic basis; however, patients presenting with LLRs should be managed differently than those with systemic allergic reactions, as described in this review. Recent findings Morbidity results from the inflammation itself along with the iatrogenic consequences of treatment. The prescription of antihistamine medications and the use of antibiotics are generally not indicated for patients with LLRs because of the risks/side-effects of these medications and the low probability of benefit. Some patients are also concerned over the possibility that a future sting will evolve into a life-threatening reaction. Although these reactions do involve IgE, patients are not at sufficient risk to warrant prescription of autoinjectable epinephrine. Venom-specific immunotherapy can be considered when LLRs are frequent and associated with significant impairment. Summary Clinicians can reduce morbidity from LLRs by reassuring the patients, avoiding medications that result in side-effects when they are not indicated, and referring to an allergist when there are additional concerns, such as frequent impairment.