[00:00:00] Kara: Sick of the fatigue and fog? Fed up with the unpredictable flares? Hangry from the super restrictive diets?
Hello, and welcome to the Crunchy Allergist Podcast, a podcast empowering those who like me, appreciate both a naturally minded and scientifically grounded approach to health and healing.
Hi, I'm your host, Dr. Kara Wada, quadruple board certified pediatric and adult allergy immunology and lifestyle medicine, physician Sjogren's patient and life coach. My recipe for success combines, the anti-inflammatory lifestyle, trusting therapeutic relationships, modern medicine, and mindset to harness our body's ability to heal.
Now although I might be a physician I'm not your physician and this podcast is for educational purposes only.
Welcome back everyone. This is Dr. Kara Wada aka the Crunchy Allergist. And it was so excited to talk with you this week about a really common problem that I talk with patients about in the office all the time. And even more often, I get asked this question from clients, from friends, family, and even a lot of those questions are in my inbox and in my DMS.
So what's the deal with insect stings and insect sting allergy? Did you know that I have a million emergency room visits every year are the direct result of insect stings? And this is a huge source of fear and anxiety because when one in 100 children and three out of every 100 adults, is severely allergic to a stinging insect, that means that each of us know someone who carries an EpiPen or injectable epinephrin around with them and lives in fear of these critters that are an integral part of our ecosystem. They help with pollination. They create honey. They provide a ton of benefit to our environment, but this comes in direct odds when it is life-threatening to us.
And when we are out at the park or we're at picnics all summer long, and we see them buzzing around the trash bins, or they are trying to make a beeline for our beverages. It can be really unnerving.
*So we are going to talk all through this episode about:* How we can recognize which ones are more aggressive? How we can treat simple reactions? When we need to seek care for more severe reactions? What types of treatments are out there? How can we prevent these stings?
We're going to really dig in.
Now, before we get started, if you're a returning listener and you are loving what you're hearing, I would love. If you would hit that subscribe button and you would think about sharing this podcast with at least five of your friends or family that you think would benefit from learning about things related to allergies, auto-immunity, and anti-inflammatory living. We are trying to spread the word and really help educate and empower our community and provide some clarity on topics that are really confusing sometimes.
All right, now let's get back to the show and talk all about stinging insects and really, figure out what the buzz is all about.
So I want to first start by talking about *the different types of stinging insects that we can encounter*. Most of them will have a black and yellow stripes and they will have a stinger. So they look very similar, but there are *five main types of insects* in the group is broadly known as hymenoptera. At that are more likely to cause allergic reactions. So these are the ones that as allergists we become very familiar with.
*So the first one that you may be aware of are yellow jackets.* They're black with yellow markings. They're found. All across the us and actually all across the globe, their nests are typically underground and they will sometimes be found in like walls of buildings cracks in masonry bricks and/or woodpiles. These are commonly going to be the stings that you might get if you're out mowing the lawn. And the vibrations from the lawnmower disrupt their nests. This is exactly what happened to my dad a few years ago and he ended up with about 10 stings when he was using the push mower in our at our home back in Illinois. These critters tend to be pretty aggressive and they get more aggressive as the summer season winds down because food is becoming more scarce for them and they are trying to get ready and prepare for the upcoming fall and winter time. So yellow jackets are jerks and they live in the ground. They look very similar to bees. And the other thing that's really interesting or notable about them is they can stink multiple times. So their stinger is straight. It does not have, what's called a barb, and we'll talk about which ones have barbs later, but they can sting you multiple times. So that is another characteristic of them. You also will not see the stinger necessarily be stuck in your skin. So many times you will not have to remove a stinger. If you have had a yellow jacket sting.
All right. *Number two, we have the wasps.* Wasps are slender. They tend to have a very small waste. Wasps and wastes are something you can think about. They are often will be black or brown. Sometimes they'll be red with yellow markings. And they live in a circular shaped comb. And this tends to be found under like eaves along your roof line, they may be found under a porch. And sometimes they will be found in shutters or shrubs, wood piles. And they also can be aggressive, especially later in the year, but since these are found in more typical areas you may have a little bit more of an ability to see where they are. Whereas the yellow jackets are hiding under the ground sometimes.
*Number three are hornets.* This is the other, the third group of very aggressive insects. They will be black or brown with white and orange or yellow markings. So these may look a little bit more like a typical bee. The yellow jackets, hornets, and wasps all have non-barbed stinger. So all of these insects can sting multiple times. And the hornets are usually nesting in trees. And these nests typically are gray or brown in coloration.
*Now my favorite of the stinging insects are the honeybees. *On the whole honeybees tend to be quite docile. Although there are a variety that can be a little more aggressive. They have round and fuzzy bodies, so you can look for their fuzzy bottoms. And they tend to have dark brown and yellow markings. Naturally, they're going to form honeycombs and trees, old tires or other partially protected sites. Or if you have neighbors who are beekeepers, they may have their hives in in these special containers that the beekeepers have. Honeybees on the whole will only sting if they are provoked and in part, this is because honeybees have a barbed stinger. They have a little hook on the end of the stinger. So they are only able to stay once, once they sting you and they try to fly away that stinger stays put, but their body keeps moving. And so that unfortunately results in the bee dying. So they have a survival advantage to not sting.
*The fifth and final category of stinging insects that we are concerned about, especially in the US are fire ants.* Fire ants are found in the Southern US, and then a little further north up each of the coasts, they do not do well in surviving a freeze. So they will follow a pretty traditional latitude that they won't go North of. But as we see the climate warming up and climate change, their distribution across the states certainly has increased. Fire ants will attack with little warning, especially if you walk or stumble upon one of their nests. And they are extremely irritating, painful bites. We'll talk more about these. But these little buggers can be pretty vicious. They can swarm. Especially if you're stepping into a nest that you have not seen in your path.
Unfortunately, my sister has encountered some fire and she lives down in Texas. And they are very prevalent down there. And so she has personally experienced them, but also has seen patients as she's an ER physician. So she sees patients, who've had these reactions quite commonly.
Now that we've talked about the different types of these stinging insects. I'd like to talk about *the different types of reactions we can have to their stings.* In particular, I'm going to be focusing a little bit more on bees, wasps, hornets, and yellow jackets since these are the majority of the reactions that I see in my area and that you all may see where you live as well.
*There are three categories of reactions* that we talk about as allergists and as physicians.
*The first type of reaction is your run of the mill sting.* Now run of the mill sting is not necessarily running the mill in how we experience it. It can be extremely painful, itchy, ouchy, swollen area. But it is not too big. So it's typically less than five centimeters or less than about two inches in diameter. And it doesn't progress to any other types of symptoms across the body. So it's a localized reaction. It's relatively small. It's certainly painful and very annoying. But this is considered a typical reaction to the toxins that the stinging insect has injected with their sting.
Now, one of the things that's really important if you have had, for instance, a honeybee staying in that stinger is still in the sting site, so you need to remove that ASAP. So one of the ways you can do that is using the back of your finger nail to scrape away from, or in the opposite direction of where the stinger is. So you slide it back out or you could use a credit card or similar card add a about a 45 degree angle and use that to slide it out.
You want to try to wash the site as soon as possible with soap and water and you can apply ice to help reduce the swelling. You want to do your best to avoid scratching the sting because this could increase the activation of the allergy cells that are in that area.
Allergy cells are not only triggered by the toxins or allergy protein related to the toxin, but they also can be triggered, especially if they're already on edge, due to some of the physical destruction or the scratching that we can do with our fingernails. Now I realize telling you not to scratch something that itches is not terribly helpful, but when you do have some conscious ability to minimize that it can be really helpful. Sometimes our lizard brains will scratch in our sleep and unfortunately we can't do too much to help mitigate that. Aside from keeping our nails trims and some folks may even wear some light cotton gloves over their hands if they tend to be scratchers in their sleep.
The other thing we can do with these run of the mill reactions are these typical sting reactions is we can apply some topical hydrocortisone cream, something that you would pick up over the counter. Sometimes if you are prone to these reactions or you have a prescription strength topical steroid at home that may be indicated, but you would want to talk with your healthcare professional about this first. And you could take some over the counter, long acting anti-histamines something like a generic Zyrtec or Allegra, but be mindful that these can, in some cases, cause a little bit of sedation or sleepiness and they also can dry out your mouth. So that's important for our Sjogren's listeners. That made me tuning in.
I do not recommend using topical Benadryl cream or diphenhydramine cream, although this can feel very soothing initially. It is a common source of allergic rashes that can develop over time. So unfortunately, Benadryl cream is not a very good product. You're actually much better off using something like a mild topical steroid, which is going to have very minimal absorption into kind of the rest of the body. And in general, as we think about the pros and cons of using like a Benadryl cream versus a topical steroid. In this case I would definitely and in most cases I would definitely use a mild topical steroid as opposed to something like that topical anti-histamine, which is going to be more often related to really bothersome, itchy, allergic rashes that can develop over time.
All right. *So the second category of reactions is something we called large local reactions. *These reactions are pretty miserable sometimes. So these reactions. We'll start as a typical run of the mill reaction may start. But over the next 48 to 72 hours, that swelling that started off is pretty mild is going to gradually, or maybe not so gradually increase.
To the point where it's anywhere from 10 centimeters or five inches to even like the whole arm or leg hand, wherever that staying was maybe quite swollen, quite painful and really bothersome. Certainly, depending on where this thing is, this can be a more or less challenging. If you're trying to walk on a foot, that's incredibly slow, swollen, that's quite problematic. Or if you get a sting by your eye, you can't see out of that eye, maybe because the swelling is so profound.
These can be really physically disfiguring for somewhere in the order of a week to 10 days in some cases. About 10% of adults will develop these large local reactions. And large local reactions, although bothersome they, I should say they do increase our risk of a potential more severe reaction in the future. But not to an extraordinary degree.
If you are someone, for instance, who maybe works in a career that exposes you to singing insects quite frequently. So maybe you're a gardener or landscaper. You are an engineer or a surveyor who's working outside. Maybe you are, you love gardening or especially tending to flower beds.
If you are experiencing large local reactions quite frequently, this would be a good reason to seek care from an allergist immunologist, because as we'll talk later there may be some instances where immunotherapy or something like allergy shots in some instances may be helpful in helping prevent or decrease how severe this swelling may be.
Many times what we do is treat patients symptomatically. So similar to the treatments we would think about with those run of the mill reactions. We may add in some other types of anti-inflammatory medications though, as well. So we may recommend certainly some non-steroidal medications such as ibuprofen and/or sometimes we will do a short course of an oral steroid to help decrease that swelling, especially if it is painful and/or interfering with those activities you need to do to get through your day.
So if you're having trouble walking trouble seeing because of the swelling, then that would be a great reason to think about using those medications. But that is something that should be discussed and decided with your healthcare professional.
Because certainly there are in every instance, pros and cons and side effects. You need to think about that may be more problematic given certain underlying health conditions you may deal with.
All right. *Now, the third type of reaction is the one we all fear and that is a systemic or an Anaphylactic type reaction to a sting.* So anaphylaxis is a whole body allergic reaction and as I mentioned at the beginning of the podcast with stinging insects, this can occur in anywhere from one and 100 children, up to about three in 100 adults.
And Anaphylactic reaction is defined by a reaction that occurs in two or more of our organ systems. And so that's a little easier for me to understand because I'm an I'm a physician, I'm an allergist. But what does that mean for you? What does that look like?
So in the instance of a sting, you may see rash, that's all over the body. Typically it would be something like a hives rash. So these rashes are raised, they are red, they are itchy. They look like welts. In most people though, they can look different in in different individuals. And maybe this also has trouble breathing, wheezing, throat swelling. Maybe someone passes out and or starts throwing up. These could all be symptoms of an Anaphylactic reaction.
Some less common symptoms that could be related to an anaphylactic reaction are perfused runny nose. And of course this would happen in the context of some of these other symptoms as well.
And another symptom that will come up from time to time is severe uterine cramping. So it feels like bad cramps, like period cramps. All of these can be related or a sign of an Anaphylactic reaction.
These symptoms typically will start within minutes of the sting. And they are best treated with injectable epinephrin. So something like an EpiPen, generic or otherwise.
And the sooner you're able to use injectable epinephrin to treat that reaction. The sooner it helps turn off the immune system from keeping that reaction going.
The longer delay in giving the epinephrin, then it increases the likelihood of something called a biphasic reaction. So about four to six hours after an Anaphylactic reaction, whether it's due to a sting or a food allergy or a medication allergy, about one in five reactions will result in what's called a biphasic reactions. So four to six hours later, it's like you had that reaction again. It comes back and what's happening is the cells that the allergy cells that are triggered initially by the anaphylaxis, the machinery in them gets turned on and it takes a little while to get going. And it's around that four to six hour mark that you will start seeing a second wave of those allergy light chemicals being released by those cells. And so we try to use certain medications to decrease the risk of that happening. And many times this is why the emergency room may, if you're being treated there, they may keep you and watch you for about four to six hours after the reaction, to monitor for that biphasic or that second part of the reaction.
*So first and foremost, we want to make sure folks that have an Anaphylactic reaction have epinephrin. *So anyone who has a history of these reactions needs to have injectable epinephrin. You should always carry two epinephrin pens together in case one pen misfires. Or in case you may need a second dose of the medication before you can get additional medical care.
And ideally these epinephrin pens are kept at room temperature. You don't want to leave them in the car glove box. You'd want to keep them in your bag. Or in a cooler, if you're able to and you want to make sure that they are not expired. So check the expiration dates. And then many of the different formulations will have a little window where you can look to see if the medication inside the pen remains clear. So you want to make sure that if there is any sediment or discoloration to that liquid inside that you get a new set of epinephrin pens.
Typically with epinephrin pens each design is going to have a little different instructions on how to use them. I would strongly recommend that you talk with your pharmacist or your prescribing physician or the physician's office, to help you learn and understand how to use your specific device, because what happens is if you were under, under the situation of just having had a sting, your body already is releasing fight or flight hormones. It is a time where you are totally in lizard brain mode. It can be really hard confusing anxiety provoking to then have to inject yourself with this medication. And so going through a trial run using the practice pens that may come with your prescription that do not have needles, can be really helpful.
*The other tip that I think is critical is if you have someone that you tend to hike with or garden with, or a spouse, a partner, a good friend, whomever, this is another person that it would be great to have know and understand how to use injectable epinephrin. *That way, if heaven forbid you are in fight or flight mode and you've instead of fighting or flying you've frozen, which is the other response that can happen when we're in lizard brain mode.
They can help out and they can take over. This is exactly what happened to me. I had an, we'll talk about this more in a future episode, but I had an episode of anaphylaxis that was not one that I was anticipating and I needed to use epinephrin. This happened while I was in fellowship. So I was in my training to be an allergist. I was nearly done actually with my training.
And I needed to inject epinephrin in my thigh. And I froze. I had to have my husband use the EpiPen. So no one is immune from this freeze response. And so it can be really helpful to try, have someone you trust that you spend time with understand and know how to use these medications as well.
Another tip I love to share with anyone who has struggled with a condition that can result in anaphylaxis. So food allergy, stinging insects. Medication allergy. *Getting a patient who is experiencing a systemic or Anaphylactic reaction flat on the ground, ideally with even their legs higher than the level of their heart can be very beneficial.*
First of all, it helps prevent anyone from passing out or falling and hitting their head or having additional injuries from that fall, but it also helps the body with blood flow. What happens in anaphylaxis is the body's immune response triggers our blood vessels to become very lax. It decreases the muscle tension around those blood vessels and causes blood to pool in areas of the body where it doesn't necessarily need to be.
We need blood to flow to our heart. We need blood to flow to our brain when we pass out many times, it's because our blood flow is not getting adequately pumped up to our head or to our brain. And first and foremost, we need to keep blood flow heading to our heart. That's the first organ that our blood vessels are when our heart pumps, the first place that blood goes is to our coronary arteries. And what happens if the blood doesn't get to the heart is the heart stops pumping. So that's how we prevent cardiac arrest. So if we are trying to keep someone healthy and help keep them doing well. One of the ways we can do that is treat with epi ASAP and get someone to the ground with their feet above their head.
These are really important maneuvers to help someone survive a life-threatening type allergic reaction.
There are two situations that we haven't addressed yet, and both are the result of getting multiple stings at once. So sometimes if we are caught in a swarm or maybe that lawn mower disrupted a hive. We may end up with dozens or sometimes hundreds of stings at a time. And these situations can result in a different type of reaction.
When we are exposed to this much venom or toxin at once. This can cause what's called a toxic reaction. Or in some cases, a serum sickness like reaction. And in both of these cases, it's going to likely require attention from healthcare professionals, whether this is in an ER situation, or if it's more of a delayed reaction, which a serum sickness like reaction may occur in the days following a reaction, then that may be through your primary care physician or nurse practitioner.
If you are noticing any types of reactions or symptoms in the days following multiple stings you feel like you have the flu, muscle aches, joint aches, anything along those lines it's worth getting in touch with your healthcare team to see what may be able to be done to help you feel better faster.
Now, one of the things I get asked all the time is where do allergy shots come into play for stinging insects? Most people may or may not actually realize that we actually have really great treatment for these systemic or these Anaphylactic type reactions to stings. And those are allergy shots or immunotherapy.
Before we start allergy shots. We do allergy testing. And allergy testing, unfortunately, for stinging insects is not a hundred percent.
So we have two types of allergy testing in general, we have blood testing and we have skin testing.
In venom immunotherapy, we tend to prefer skin testing though the disadvantage to this is it is like getting multiple stings.
So we reserve allergy testing for venom immunotherapy, for those folks who have had a systemic reaction or who have had an Anaphylactic reaction. In part, this is because the allergy testing for venoms has a relatively high, false positive rate. So that means not everyone who has a positive test will actually have a severe life-threatening reaction. So we screen patients ahead of time by getting the story of what happened when they had their reaction.
The other type of testing that we have is blood testing and blood testing is sometimes helpful as well in determining if someone is truly allergic or not. But again, this is always done in context of the history. What happened to the person when they had a sting?
Now we know maybe that someone has had positive testing, they have a story that is suggestive, that they would benefit from immunotherapy or allergy shots.
The purpose of immunotherapy, whether it is for pollens or for stinging insects, is that it takes those things were allergic to and it gradually exposes our immune system to increased doses of that allergen up to a point. And when we get to that target dose, it starts changing that immune response from fighting or finding that allergen dangerous, to then ignoring it. And so we have really great effective immunotherapy for stinging insects, and that's available for honeybees, for wasps, for hornets, yellow jackets, and for fire ants as well.
Typically these shots are given in an allergist office, but sometimes they are administered in like a family practice doctor or internal medicine or pediatrician's office to make things more convenient. And usually they are initially started at a, an every week type interval though there are some ways to get up to that target dose a little bit faster.
And then they're administered typically once a month for three to five years of time. And it's somewhere in that three to five year mark that we will see ongoing benefit once we stop those shots. There are some situations where folks will stay on venom immunotherapy longer term, and that's determined on a case by case basis between the patient, their risk factors and their allergists.
Now last but not least let's go through* five different tips that I like to share with my patients to protect yourself from getting that sting* in the first place. Because as we know, an ounce of prevention is worth a pound of cure.
*So number one is to make yourself look the least amount like a flower as you can. *So you want to wear light colored, smooth, finished clothing, things that don't necessarily have a floral print. And I would avoid wearing things that look or smell florally. Avoid perfume, soaps, shampoos, deodorants. Make yourself the least like what these stinging insects are going to be attracted to just by their nature.
*Number two, we're clothing to cover as much of your body as possible. *This is not only going to help with preventing stings. This is also going to help prevent mosquito bites and other insect bites as well.
*Number three, keep your area that you are in tidy.* And this is also the case like with picnics. So if you think about your beverages, I would recommend keeping a cover over cans. If you can keep the lid on your bottles and keep covers over, especially sweet treats or fruit based dishes, if you're having a picnic or a cookout. You also may want to set up your picnic or cookout away from some of the trash receptacles. Which can be another area where especially yellow jackets are going to congregate. And be more aggressive as they are trying to find food.
*Number four, remain calm.* Especially if it's just a single insect one or two insects that's flying around you, or if you're in the car and you notice that you have had a bee or a wasp end up in your car. So remain calm don't SWAT, take a few deep breaths and then get away from that singing insect. Maybe if you're in the car, you're in a roll down all the windows so that it is able to escape.
*Now number five, if you're being attacked by several insects or you're in a swarm, get the heck out of there.* This is when fight or flight. You want a flight you want to get out of there, get away, go indoors and get the heck out of there.
So today we've covered the gamut. We have talked about the different types of insect stings. We've talked about the different types of insects that can sting you. And the different ways we can prevent and treat insect stings.
If you have found this information helpful and empowering, I would strongly encourage you to hop over to www.crunchyallergists.com and subscribe to our weekly newsletter where we dive in to all things allergy auto-immunity and anti-inflammatory living.
Thanks so much for tuning in and I look forward to talking again next week.
