Bug bites, Insection stings & Pediculosis

Camphor and Menthol dosing for Insect bites/stings

-*3~4x/day for up to 7 days*

OTC concentration of Permethrin (Nix)

-1%

Dosing of Antibiotic ointments for Insect bites/stings

-Apply to affected area 3 times/day

Antibiotic Ointments (2)

-Broad spectrum coverage of gram + & - infections 1. Neomycin/Polymyxin B/Bacitracin (Neosporin) 2. Polymyxin B/Bacitracin (Polysporin) => For patients Allergic to Neomycin

Hydrocortisone 1% MOA for Insect bites/stings

-Decreases inflammation by suppressing the migration of polymorphonuclear leukocytes & reverse capillary permeability

Permethrin MOA

-Disrupts Na+ channel delaying repolarization causing paralysis & death

Treatment resistance lice

-Due to overuse to pharmacological agents, or improper use, or decreased contact time -Non-pharm method -Benzyl alcohol (Ulesfia) -Malathion (Ovide) -Ivermectin (Sklice)

Pediculosis

-Infestation with lice

Lice enzyme shampoos (10% Tea tree, 1% Lavender) dosing

-Once a week for 3 weeks

Pyrethrin/Piperonyl Butoxide is effective in which type of pediculosis?

-Phthirus pubis

Honey bee stings (3)

-Release pheromones -> Attract more bees to attack -Single puncture causing redness & swelling -Anaphylactic reaction in 0.1~0.2% of population

Sting treatments

-Same as insect bites

Lyme disease treatment (Prophylaxis) (2)

-Single dose of *200mg doxycycline* -Only if nymphal deer tick present for *72 hours and/or partially engorged*

Exclusion for Self care: Insect Bites (7)

1. Difficulty breathing, nausea, vomiting, hives, dizziness, weakness, excessive swelling 2. Less than 2 years 3. Significant allergic response at a site away from the sting 4. Previous sting by honeybee, wasp, or hornet 5. Previous severe reaction to insect bite 6. Spider bites 7. Personal or family history of significant allergic reaction (Predesposition)

Lyme disease treatment (w/o Neurological symptoms)

1. Doxycycline 100mg PO 2x/day

Presentation of Lyme disease

1. Erythema migrans -Bulls-eye shaped rash in multiple locations varying in size -Not always at the site of tick bite -Not everyone infected develops rash (May have fever, nausea, chills)

Exclusion to self care: Mosquito bites (4)

1. Fever 2. Severe Headache 3. Body ache 4. Nausea & vomiting

Presentation of Tick bites (9)

1. Flu-like symptoms 2. Fever 3. Numbness 4. Rash 5. Joint pain 6. Nausea & Vomiting 7. Weakness 8. Palpitations 9. SOB

How to use Epipen (4)

1. Form fist around Epipen & pull off safety cap 2. Place end w needle against *outer mid thigh* (w or w/o clothing) 3. Push down hard until a click is heard or felt & hold in place for *10 seconds* 4. Remove Epipen & Massage injection site for 10 seconds

How to use Permethrin (5)

1. Generously apply to towel-dry hair & scalp 2. Leave it on for 10 minutes 3. work into hair completely & rinse throughly 4. Use a nit comb to remove dead lice & eggs -Single treatment is usually curative (10 days) 5. Repeat in 7~10 days only if active lice is present

Pyrethrin/Piperonyl Butoxide shampoo how to use

1. Generously apply to wet hair & scalp 2. Leave in hair for 10 minutes 3. Work shampoo into a lather & rinse throughly 4. Use a nit comb to remove dead lice & eggs 5. Repeat 7~10 days

Pediculosis exclusions for self treatment (7)

1. Hypersensitivity to chrysanthemums, ragweed, or pediculicide ingredients 2. <2 years: Pyrethrins 3. <2 mos: Permethrins 4. 2ndary infection 5. Lice infestation in the eyelids or eyebrows 6. *Pregnancy & Breastfeeding* 7. Active tumor

Pyrethrin/Piperonyl Butoxide adverse effects (4)

1. Irritation 2. Erythema 3. Itching 4. Swelling

Presentation of Chiggers (2)

1. Juvenile form of Trombiculidae mite 2. Formation of *stylostome* -Red papule -Intense itching

Complementary therapy for pediculosis

1. Lice enzyme shampoos (10% Tea tree, 1% Lavender) -More effective than Pyrethrin/Piperonyl Butoxide applied twice (1 week apart)

Symptoms of mosquito bites (3)

1. Mild, red, raised skin bump 2. Itchiness & tenderness 3. Onset of symptoms may take up to 2 days

Fire ants (3)

1. Most common cause of anaphylaxis in S. US 2. SMALL RED BUMP that turns into a blister within hours 3. Occur in CLUSTERS

Black widow spider bites (6)

1. Neurotic venom (Iatrotoxin) 2. Abdominal pain 3. Paralyzed diaphragm 4. Dry mouth 5. Diaphoresis 6. Swollen eyelids

Hobospider bites (3)

1. Northwestern united states 2. Cause TISSUE NECROSIS but not fatal (Moderate to slow healing wound) 3. Often confused with brown recluse bites

Symptoms of Hobospider bites (5)

1. Numbing of bite area & tongue 2. Dizziness 3. Severe headache 4. Visual/auditory disturbances 5. Joint pain

Effect of hymenoptera stings (2)

1. Pain, itching, irritation 2. Hives, itching, swelling, burning, decrease in BP, Lightheaded, Chest tightness, Dyspnea etc.

Pharmacological therapies for pediculosis (5)

1. Permethrin 2. Pyrethrin/Piperonyl Butoxide 3. Complimentary therapy 4. Rx therapy 5. Alternative therapy

Scabies treatment (3)

1. Permethrin 5% cream 2. Apply chin down, leave on for *8~14 hours* & rinse 3. Single application usually curative

Permethrin adverse effects (4)

1. Pruritis 2. Stinging 3. Burning 4. Irritation of the scalp

Pyrethrin/Piperonyl Butoxide MOA

1. Pyrethrin: Block nerve impulse transmission causing paralysis & death 2. Piperonyl butoxide: Inhibit breakdown of pyrethrin, increasing insecticidal levels in louse

How to remove stinger (3)

1. Scrape away by credit card by sliding across skin or with finger 2. Do not rub, grasp or scratch the sac of the stinger 3. Do not tweezers

Presentation of Scabies (3)

1. Severe itching (At night) 2. Rash (between fingers), at belt-like 3. Thin pencil-like marks on skin -Rx only

Adverse effects of DEET (2)

1. Skin irritation, Rash 2. Seizures, Ataxia, Hypotension, Encephalopathy, Angiodema

Presentation of Flea bites (2)

1. Slightly raised, red, swollen itching spot with a single puncture 2. Can remain inflamed for weeks after initial bite

Topical antihistamines for Insect bites/Stings (4)

1. Temporary relief of itching & pain 2. *Diphenhydramine 2%* Apply to affected area 3~4x/day for no longer than 7 days 3. Limited systemic absorption 4. Inc risk for contact dermatitis, especially with prolonged use

Non-pharmacological treatment for pediculosis (4)

1. Use nit comb 2. Vacuum living areas regularly during treatment 3. Wash bedding, clothes, towels, hair brushes, combs & toys in water >130F 4. Items that cannot be washed: Store in a plastic bag for 2 weeks

Treatment outline for insect bites (5)

1. Wash site with *antibacterial* soap 2. Ice may provide sufficient relief from bites of mosquitos, chiggers, bed bugs, and fleas? 3. Disinfect with *rubbing alcohol or hydrogen peroxide* 4. Hydrocortisone, Diphenhydramine, Topical anesthetic for itching 5. Antibiotic ointment (Prevent infection)

Skin protectants for Insect bites/stings (2)

1. Zinc oxide 2. Calamine -Safe & Effective in concentrations 1~25% -May absorb fluid from weeping lesions

Epipen

1.Epinephrine injection 2. Used to treat anaphylactic shock 3. Relaxes muscles in airways while constricting blood vessels -Strong Beta-1 & Alpha adrenergic receptor -Moderate Beta-2 agonist

Dosage for Local anesthetics for Insect bites/Stings (2)

1. Benzocaine, Pramoxine, Lidocaine, Dibucaine: 3~4x/day 2. Phenol: 1 Spray every 2 hours

Signs of an Anaphylactic reaction (10)

1. Difficulty breathing 2. Tightness in throat 3. Trouble speaking 4. Nausea/Vomiting 5. Drop in blood pressure 6. Hives 7. Tachycardia 8. Anxiety 9. Dizziness 10. Loss of consciousness

DSP (Dry-on, Suffocation-based Pediculicides)

1. Cetaphil cleanser -Newer class of medication -Nontoxic lotion applied to hair & then hair dried -Forms "shrink wrap" film over hair, suffocating lice -May be more effective than Malathion & Pyrethrin/Piperonyl Butoxide

Efficacy of DEET by concentration (3)

1. 10%: 2~3 Hours 2. 20%: 3~5 Hours 3. 30%: 5~6 Hours

Presentation of Brown Recluse Spider bites (5)

1. 2 Separate fang marks about 1/16th of an inch apart 2. Initial bit may be painless -Onset varies from *few hours to weeks* 3. ULCERATED wound at bite site 4. Do not apply camphor, phenol, or other disinfectants (Inc rate of ulceration) 5. Never apply heat

Follow up for insect bites/stings (2)

1. 7 days after self care 2. Seek medical assistance: -Analphylaxis -Localized swelling worsen -2ndary infection -Joint pain -Fever -Lymph node enlargment

Concentration of DEET based on age & exposure

1. <30%: Safe for children 2 mos or older 2. 50~100%: Adults with high exposure to insects in heat/humidity

Contraindications of Permethrin

1. Allergy to Pyrethrins or chrysanthemums 2. < 2mos of age

Pyrethrin/Piperonyl Butoxide contraindications

1. Allergy to pyrethrin or chrysanthemums 2. < 2 years of age

Hymenoptera

1. Ants, bees, wasps 2. Inject venom w *allergenic proteins & active molecules*

Procedure after stinger removal (3)

1. Apply Ice for 10 minute intervals 2. Apply ANTISEPTIC: Alcohol, Hydrogen peroxide 3. Apply local anesthetic, skin protectant, or skin irritant

Alternative insect repellants (10)

1. Citronella 2. Lemon eucalyptus oil 3. Soybean oil 4. Lavendar oil 5. Tea tree oil 6. Garlic 7. Thiamin 8. Scented moisturizers 9. Picardin: Less odor & Less irritating & greasy to skin 10. Permethrin 0.5%: Only for clothing & camping equipment (Equipment)

Dimethicone 4% Lotion (2)

1. Coats lice & irreversibly immobilize them within 5 minutes 2. Less irritation than traditional therapy

DEET (N,n-diethyl-m-toluamide) (5)

1. Best all-purpose insect repellent 2. Unknown MOA, but release vapor that deters insects when applied to skin or clothing 3. Does not kill insects 4. Concentrations vary based on age & exposure 5. Combinations of sunscreen & bug spray discouraged (Use sunscreen more frequently)

Presentation of Bed bugs (3)

1. Bites occur in clusters or rows 2. Nocturnal 3. Feed on human blood

Counterirritants for Insect bites/stings

1. Camphor (Stimulate circulation) & Menthol (Analgesic & Antipruritic effects)

Lyme disease treatment (w Neurological symptoms)

1. Ceftriaxone 2g IV daily for 14 days

Prevention of Bug Bites & Stings

1. Avoid wearing perfume, scented lotions & brightly colored clothes 2. Control odors in picnic, garbage & wooded areas 3. Change clothing if it contaminated w foods such as fruit 4. Wear shoes, long sleeve shirts & pants 5. Destroy nests of stinging insects near home 6. Sulfur powder: Best chigger repellent & Foul smell 7. Use DEET insect repellent

Local anesthetics for Insect bites/Stings (5)

1. Benzocaine 2. *Pramoxine/Benzyl alcohol (Best)* 3. Lidocaine 5% 4. Dibucaine 1% (Most adverse effects) 5. Phenol 1.4% (Most adverse effects)

Pyrethrin/Piperonyl Butoxide cream rinse how to use

Same as shampoo except wash hair with normal shampoo & towel dry hair