Bee Sting Guide  Written By Jamie Ellis

The article content on this page is an excerpt from an article written by Jamie Ellis in The American Bee​ Journal , Volume 156, No.1.  We felt that this well written article needed to be republished as a community service. Thankfully, so did the publisher and they have granted us permission to reprint this excerpt. Please contact The American Bee Journal if you wish to use or reprint this information.
  The human body’s reaction to bee stings One of the things I like to do when giving lectures on bees is to ask the audience how many people are allergic to bees. Invariably, many hands fly into the air when I ask this question. In fact, it is common to see 10-20% of the audience claim that they are allergic to bees. Of course, they are wrong. The vast majority of people are not allergic to bee stings. ​​
 However, many have been stung and experienced a reaction that they incorrectly determined to be an allergic one. Undeniably, some people are allergic to bee stings. In all the research that I did to write this article, I found that about 0.5 – 4% of people have a true allergy to bee stings. The data also suggest that the number is lower in Europe and North America where about 0.5 – 2% of the population is allergic to bees. Thus, in a crowd of 100 people, only a maximum of two likely exhibit a true allergy to stings.
 In this section, I will review what the possible reactions to bee stings are and the appropriate response to the sting by the victim. Justin Schmidt, world expert on honey bee stings, wrote a good chapter on the topic for the 1992 edition of The Hive and the Honey Bee (Schmidt, 1992). He has a number of notable quotes on the topic of bee venom allergies that I include in this article.​ 
 The first quote follows:. “Allergy is a general term that describes a variety of human symptoms and reactions to a diversity of materials including pollen, animal dander, foods, drugs, dust mites (house dust), stinging insects and others. Stinging insect allergy refers to sting-induced systemic reactions of the body that occur at body locations distant from the sting site. Allergic reactions do not include the immediate pain caused by the sting itself or to the burning, redness, itching and swelling that might occur at the sting site. Such reactions include very large local swelling are referred to as “local reactions.”” (I added the emphasis on “distant” and “do not include”.)
 He also notes that people’s normal and allergic reactions to stings can vary enormously from person to person and even from sting to sting. Interestingly, allergic reactions to bee stings do not usually occur after the first sting. Instead, a second sting separated by space and time usually is required to trigger an allergic reaction. Schmidt (1992) notes: “An allergic reaction typically occurs after the second or subsequent stinging event by the same or closely related species. The first sting, (or stings), induces the production of the allergy causing antibody, immunoglobulin E (IgE), by the body resulting in the sensitization of the individual to the venom. Later when the now hypersensitive individual is stung again, the venom causes an IgE-mediated allergic reaction.” Schmidt (1992) recognizes six categories of the body’s response to stings. I list the categories in Table 2, a modified version of a table Schmidt included in his 1992 chapter. I think this table summarizes well what one can expect when stung and when to seek emergency medical attention. I modified the table to include recommendations from medically-supported websites maintained by eMedicinehealth, WebMD, the Mayo Clinic, and the American Academy of Allergy Asthma & Immunology (see the references section). It is important to note that I am not a medical doctor. Thus, I stop short of personally making medical recommendations. Rather, I note the medical recommendations made by medical doctors who developed the literature I used when writing this article.  

it does not matter which way the stinger is removed...

it only matters how quickly it is removed...

get the stinger out of the body as quickly as possible,
regardless of whether you scrape or pinch it...

Categories of reactions to honey bee stings:

1) Normal, non-allergic reactions at the time of the sting (Table 2)
 These symptoms can vary tremendously from individual to individual. That said, these are the symptoms that most people stung by a honey bee experience. These include the sharp pain/burning at the sting site that intensifies for minutes after the sting and then slowly decreases over time. There usually is some redness or swelling associated with this response. The sting site can be tender to the touch.
Medical intervention usually is not needed for these reactions.

2) Normal, non-allergic reactions hours or days after the sting (Table 2)
 As for category 1, these symptoms can vary from individual to individual. In this category, the victim may itch, experience redness, swell, etc. for a number of hours or days after the sting. It is common for the sting site to contain a small brown or red damage spot at the puncture site. This happens to me a lot, especially on my fingertips – they look almost like small freckles.
Medical intervention usually is not needed for these reactions.

3) Large local reactions (Table 2)
 These reactions usually are not to be feared as they rarely progress to systemic reactions. However, many sting victims consider these symptoms to be significant and end up seeking medical attention, though the medical attention usually is not necessary. The primary symptom associated with this category is the rapid or massive swelling around the sting site, with the swelling extending considerably farther than the sting site. For example, it is relatively common (the literature suggests nearly 20% of all cases) for people to be stung somewhere such as on the hand and the swelling to progress up the arm to the shoulder, or be stung on the leg, causing the entire leg to swell.
 Admittedly, this reaction is visually disturbing. The swellings can be enormous, occuring anywhere on the body, including the face. The swelling can be painful and otherwise be a nuisance since it can restrict the movement of a given body part, worry the friends/family/coworkers of the victim (after all, this can be quite a temporarily disfiguring body response), etc.
 However, these symptoms are rarely cause for alarm. Despite this, many sting victims experiencing this response end up going to the doctor, who, then, prescribes medicine to help control the symptoms.
It is, however, recommended that people experiencing a large local reaction go to the doctor if the reaction is occurring in the mouth or neck area, especially if the swollen area is beginning to restrict airflow. Many people try to relieve the symptoms of a large local reaction with an over-the-counter pain killer (Tylenol/Aspirin) and antihistamines (such as Benadryl).

4) Cutaneous allergic reactions (Table 2) 
 These reactions are not believed to be life threatening, though they often are quite worrisome to the victim. Schmidt (1992) calls these reactions a “gray area” given that the medical community tends to debate the seriousness of this reaction. It is important to note that this only affects the skin. Admittedly, the skin is the visible part of the body, hence the alarm it causes the victim who has to see it. People experiencing this reaction have hives, swelling, itching, or redness remote from the sting site. Usually this reaction does not imply that the victim will progress into one of the final two reaction categories. However, a good general recommendation is that when in doubt, seek medical advice.

5) Non life-treatening systemic allergic reactions (Table 2)
 As the name implies, this reaction to bee stings is a systemic, allergic reaction meaning that it causes problems away from the sting site. It is the “catch-all” category for systemic responses that are rarely life-threatening,but not occurring on the skin. Even though typically not lifethreatening (Schmidt 1992), every medical site I visited recommended seeking medical attention immediately if experiencing any of the symptoms in this category. Without question, the symptoms are unpleasant and frightening, hence providing a good reason to see a medical doctor the moment they occur. The symptoms include allergic inflammation inside the nose or around the eyes, some minor respiratory symptoms, abdominal cramps and associated gastrointestinal problems (nausea, vomiting, and diarrhea), general weakness, etc.

6) Life-threatening systemic allergic reactions (Table 2)

 This is a comparatively less common response to bee stings. This reaction affects the body’s life support systems, the circulatory and respiratory systems, and can lead to death. People experiencing these symptoms following a sting must seek medical attention immediately. Otherwise, the response can led to shock, cardiac arrest, and unconsciousness in ten or fewer minutes. This can be a fatal response unless addressed by medical doctors quickly. Essentially, the body is eliciting a life-threatening response called anaphylaxis or is entering anaphylactic shock. The symptoms associated with this category include shock, unconsciousness, abnormally low blood pressure, respiratory distress, laryngeal blockage, rapid pulse, and dizziness. People who are allergic to bees often know that they are and carry an epinephrine shot with them. Epinephrine (usually sold in an EpiPen) is the only treatment capable of arresting the systemic reactions. If you notice these symptoms in yourself or anyone stung by a bee, call 911 immediately.

 How does this allergic response happen? As noted, a bee’s venom contains substances that destroy cells. The peptides and enzymes (Table 1) break through cell walls, including the walls of the skin’s mast cells. Mast cells contain histamine. Their destruction releases histamine into the blood stream, causing blood vessels to dilate. For people with allergies, too much histamine is released. The blood vessel dilation is too extreme and the person loses the ability to regulate blood pressure, which then drops significantly. This leads to the starvation of cells for oxygen, swelling, spasms, and eventually death. This is why it is so important the people experiencing the symptoms in categories 5 and especially 6 seek medical attention immediately. As bad as the symptoms in the final category sound, there is hope for people who are very allergic to honey bee stings. Such individuals can try venom immunotherapy, where a medical doctor specializing in allergies gives the individual a series of venom injections over time, with the amount of venom in the injection increasing each time. This is done until the person is no longer hyper-responsive to bee stings. It is worthwhile to discuss this with your allergist if you develop a life-threatening allergy to bees. The body also can suffer from mass envenomation if too many stings are received, leading to a second way that bee stings can kill.
 Generally speaking, humans can take about 5 – 10 stings per lb of body weight before they die from venom toxicity. This means that a 100 lb adult can receive 500 – 1,000 stings before they die. A 200 lb adult can withstand 1,000 – 2,000 stings. The following symptoms begin to appear when a person has been stung too many times: nausea, fever, swelling at the site of the sting, fainting, seizures, shock and even death. Generally speaking, non-beekeepers are recommended to seek medical advice anytime they receive 100+ stings in a single stinging event or if any of the symptoms listed above are expressed. Incidentally, this is why African-derived honey bees are so dangerous. It usually takes a significant stimulus to cause European-derived honey bees (those we keep) to elicit a defense response. Even when they do, they respond with a few to a couple dozen bees. African bees, on the other hand, are hyper-sensitive to even small stimuli. They respond in significantly greater numbers, leading the victim to be stung more than their body can withstand. The venom of African bees is no more toxic than that of European bees. They are problematic simply because more of them attack, causing the victim to receive too many stings.
 Appropriate response to bee stings The first thing that a non-beekeeper sting victim should do is get away from the area as quickly as possible. Being stung, especially if stung multiple times, is an indication that you are too close to the bees’ nest and that they want you gone. The best thing non-beekeepers can do is accommodate the bees’ clear request. The general recommendation for non-beekeepers who find themselves being attacked by bees is to pull their shirt over their head/neck to minimize stings to this area and run away from the site as quickly as possible. Do not jump into the water. If possible, get indoors, inside an enclosed area such as a vehicle, shed, or house. Beekeepers, of course, take a different response if they are getting stung at a level under what they perceive to be the “danger threshold.” They usually just stay and stick it out unless dangerous symptoms are exhibited. Once safely away from the area where you are stung, remove the sting(s) from your skin. The longer the sting remains in the body, the more venom the victim receives. The more venom the victim receives, the bigger the potential reaction. As noted, honey bees leave their stinger behind in tough-skinned threats. If you look closely at the sting (if you are willing to leave it in your body long enough to notice☺), you will notice that the muscles of the bulb are contracting, causing it to beat like a heart, pumping venom into the sting site.
 Conventional wisdom, then, suggests that you should scrape the stinger out of your skin rather than grabbing it and pulling it out. After all, it seems intuitive that grabbing the bulb simply pushes more venom into the sting site. Look up “how to remove a honey bee stinger” online and you will see all types of advice on how to scrape out the stinger, from using your fingernail to using a credit card or even a knife. Interesting enough though, three investigators conducted a research project on how best to remove a sting from the body, i.e. they attempted to settle the “scrape vs. pinch” debate (Visscher et al. 1996). They found that it does not matter which way the sting is removed. It only matters how quickly it is removed. The resulting recommendation, then, is to get the stinger out of the body as quickly as possible, regardless of whether you scrape or pinch it. Once stung, you can note the body’s response (Table 2) and develop an appropriate treatment plan. Most medical doctors recommend washing the sting site with soap and water to lessen the chance of bacterial infection. This they usually suggest following with wound icing, taking an antihistamine such as Benadryl, and applying a topical sting aid to alleviate pain. You can apply soothing ointment on the sting site and take pain relief medicine to help with the pain associated with a sting. Of course, beekeepers would never get any work done if they took the time to do this every time they were stung. Most of us just live with the results. As an aside, medical doctors also recommend seeking medical attention if stung on the eyeball. Finally, as I have stated already, it is always best to consult with a physician if you are worried about your body’s reaction to a given sting.
How to protect yourself from stings To borrow a line from football, the best offense against a sting is a good defense. By this I mean, you should take defensive precautions to avoid getting stung and know what to do in the event you are stung. Some people, perhaps you, reading this article are not yet beekeepers and have never been stung. Consequently, these readers will not know if they are going to develop an allergy to bee stings. The good news is that local medical allergists/immunologists can help. There are sting sensitivity tests that allergists can perform to determine if someone is going to have a problem with stings. I recommend scheduling a consultation with an allergist/immunologist if you want to keep bees, but are worried about developing an allergy or if you keep bees and fear that you suddenly are developing an allergy. Many new and seasoned beekeepers elect to carry an EpiPen with them into the apiary. EpiPens are injectors (shots) that contain epinephrine. They are a prescription controlled product. Thus, every individual wanting to carry an EpiPen has to consult with his/her own doctor and convince him/ her to prescribe the product. EpiPens are not for everyone. There are certain risks associated with using EpiPens given certain existing preconditions. It is important to consult your medical specialist before electing to carry one.

The article content on this page is an excerpt from an article written by Jamie Ellis in The American Bee Journal , Volume 156, No.1. Used by Permission