Stinging Insects: Q and A with Dr. Stephen Lockey

What does the tomb of King Menes of Egypt have to do with stinging insects? It is said there were hieroglyphics on the wall of his tomb describing his death about 2641 B.C. from a wasp or hornet sting. Though this claim is disputed by some, it is true that stinging insects have been around for a long, long time and people who are allergic to these stings can be dealing with a life- threatening situation.

Dr. Stephen Lockey of Allergy and Asthma Center is an allergist, amateur botanist and fly fisherman. He has been in practice for over 30 years.

Q - Dr. Lockey, what stinging insects are we talking about?

Dr. Lockey - In this area, the five most common stinging insects are honeybees, wasps, yellow jackets, white-faced hornets, and yellow hornets.

Q - How do they differ in appearance, starting with the honey bee?

Dr. Lockey - To the uneducated eye they have really very similar appearances. If you are stung by an insect it is very difficult to identify it. Your first reaction is to either brush it off or swat it. If you brush it off it will fly off and perhaps come back and try to get you some place else if it wasn’t a honeybee, which usually leaves its stinger behind and dies.

Q - Does the honeybee tend to be fatter or furrier?

Dr. Lockey - There are some distinctive characteristics of each one of these insects. The honeybee is more of a beige yellow color, than a bright yellow color. It does have a higher degree of fur or hair on its body than the wasps, hornets, or yellow jackets. The yellow jackets are generally of a smaller size than hornets. So, if there are two together, the hornet will be the larger insect, and the wasps have a very thin body and generally speaking are darker in color, although there are some brightly colored yellow striped wasps also.

Q - Is there an order to the power of their stings?

Dr. Lockey - We do not really think so. Most of the stings deliver about the same dosage of venom. Every insect has the potential of delivering about 50 mcg. of the venom when it stings you. They are prepared to sting you if you are threatening their kind, or their hives. When they land on you, they land in a stinging, or horseshoe position.

Q - As opposed to the way they land on a flower?

Dr. Lockey - Right, as opposed to landing on a surface where they are just lying flat . When a wasp or hornet lands on you to sting you, he is really almost landing with his face down and the bottom of his abdomen on your skin. He is prepared to sting you the instant he lands on you.

Q - It makes him sound like a commando.

Dr. Lockey - They are very swift and very stealthy for the most part. Most people do not know that the insect is around when they are stung. They say things like, “I was just walking on my deck” or “I just reached over and was weeding next to this wall and all of a sudden I was stung”.

Q - I have read there are more than 2 million people in the United States that are allergic to insect stings. How does central Pennsylvania fit into that statistic?

Dr. Lockey - Well, I think we have the same rate as the national figures. Some authorities quote a 3 to 5% rate of sensitivity to insect stings. This varies from a large local swelling to the more severe anaphylaxis. For example, if you took 100 people at a mall and they volunteered to be stung, up to 5% of them would have allergic reactions even though they have not had allergic reactions before. This is one of those areas of life where, after the accident, patients have to go to her family doctor and explain what happened. After the patient has gotten some treatment, the physician will review the history and make some determination as to whether or not it qualifies as a true allergic reaction. The physician would then refer to specialists such as ourselves to investigate the issue and come up with a treatment plan.

Q - What is the difference between a non-allergic sting reaction and an allergic sting reaction both in the body and on the skin?

Dr. Lockey - Both involve pain. There is also going to be some swelling and minor itching at the site of the sting. But when one develops the allergic phenomena, there can be anything from extensive large local swelling to symptoms we call systemic. That is, a generalized allergic reaction with additional swelling on other areas of the body, including tongue, throat, or hands.

Suppose you were stung on your elbow and you started to have swelling of both of your hands and both of your feet or you had swelling of your lips and eyes. That would indicate you were having a systemic response to the insect sting. That qualifies you as being a candidate for investigation and for possible desensitization to insect stings. A person who has been stung and had a systemic reaction can also have generalized hives. They can have asthmatic airway difficulty. They can have abdominal pain, cramps, vomiting, or diarrhea. They can have what is called collapse or cardiovascular collapse. All individuals do not have the same type of response.

Q – Is it possible to predict the probable reaction?

Dr. Lockey - You cannot make a prediction about what type of reaction you are going to have. That is one of the reasons these patients are referred to us. We have to sometimes differentiate between whether or not they have had a true allergic reaction. They may become hysterical or upset, or they may hyperventilate. They can put themselves in a great deal of distress by just being anxious over what has happened to them when they are stung.

Q - What is the most severe reaction?

Dr. Lockey - The phenomena of anaphylaxis is classically felt to be the most severe of all allergic responses but all of these responses are somewhat anaphylactic in their nature. That is, the person has an antibody against the venom of the insect and the manifestations of that antibody are what I just described. Obviously, the most severe is cardiovascular collapse where somebody is stung and has passed out .

Q - Can you get an anaphylactic reaction from the very first sting?

Dr. Lockey - Yes, you can. We normally think that in order to become allergic to something you have to be exposed first. So, your chances of having an anaphylactic reaction the first time you are stung are relatively small. But, the history is not always clear in people who think they have had a first time reaction. In other words, if you go back and ask the person if they have ever been stung in their childhood, most usually do not remember. Generally speaking, the first sting should not cause anaphylaxis but it is not unheard of.

Q - Speaking of childhood, do children react as strongly as adults?

Dr. Lockey - Children do have a tendency to get hives more often when they are stung by insects. In those cases we do not feel a child who only manifests generalized hives after being stung and no other symptoms is subject to any greater risk when she is stung again. It is the child who has more advanced symptoms than just hives that we think has the potential of having more serious allergic reactions the next time. That is not the case in the adult. In mature persons we feel a manifestation of hives is a sign that the next time they are stung they may have more serious symptoms and it is a reason to go ahead with what we describe as a desensitization program.

Q - What type of exams or tests do you give?

Dr. Lockey - We test them with the venoms of the insects by skin testing; prick tests and under the skin tests. These are two different types of tests but we do them on all the patients for all the insect venoms. We start with .001 mcg. of the venom and we go on a serial method up to 1 mcg. which we give underneath the skin. If they show a response, that is, they develop what we call wheal and flare, or a hive at the site of where the venom is given into the skin, then that is considered a positive reaction. That is an indication they have antibodies to that particular venom. If they are negative to those venoms, then we do blood tests to make sure that what we are reading on their skin is appropriate in terms of their sensitivities. Then we take the combined two tests and decide at that point which of the venoms they should receive as a means of desensitizing. Not everybody gets all five venoms. Some people are allergic to only one.

Q - Do most people get stung around their homes, or out camping or on a picnic?

Dr. Lockey - We’ve done surveys in our practice and we discovered that about 70% of patients are stung within 50 yards of their back door. They are out working or playing in their yard.

Q - If you are stung by an insect at home and you are not aware of an allergy to it, what should you do?

Dr. Lockey - My recommendation is to seek adult companionship. You should not be alone. I do not think there is any reason to be highly alarmed but if you are stung, it is not something you should just ignore saying, “I just want to finish mowing the grass,” or “I’ll just finish planting these flowers,” or even “It’s so comfortable on this deck. I’ll get to it later.” The thing to do is to get up and go inside if there are family members there. Be with somebody for an hour or two and if everything is all right, if there is nothing more than just a local swelling, then go about your activities. Obviously, if you are doing something that got you stung, you might want to be very suspicious about that location and make sure you look at the area very carefully.

We have people stung in all circumstances of life but there are some places that have a much greater risk potential than other things. For instance, where these insects make their nests is an issue of care. For example, if you are painting, it is really important you look around the area you are painting. If you happen to be painting spouting or things that are close to walls and eaves or behind shutters, you want to inspect those areas. Most wasps’ nests are three or four feet above ground. Very rarely are they underneath seats or benches. If you find obvious nests you are going to want to take care of them.

Q - How?

Dr. Lockey - That depends upon whether or not you are sensitive to the insects. If you know that you are, you should get a professional or a person who is not allergic to take care of them. If you have the experience and understanding of the insect you could take care of them. If you spray the area do it in the evening because the insects are back in their nests at night and you can get the greatest number then.

Q - If you do get stung, should you try to remove the stinger?

Dr. Lockey - Well of the five insects we spoke about, the only insect that will leave a stinger in you almost every time is the honeybee. The honeybee has a serrated stinger and cannot retract its stinger once he or she stings you. Once it has left its stinger in you, it is going to go off and die. The wasp, yellow jacket, white-faced hornet, and yellow hornet can all retract their stingers so they are capable of stinging you more than once and when they leave, they are then capable of stinging somebody else as well.

Q - What’s the best way to try to get a stinger out?

Dr. Lockey - You should scrape it off with your fingernail or even a credit card because it is just like a small syringe. When you try to squeeze it, you are going to be pushing more venom into your skin and therefore exposing yourself to more of what you could be allergic to.

Q - And then do you ice it or elevate it?

Dr. Lockey - I think probably the best thing to do is wash the area off with soap and water and just leave it alone.

Q - What if you have a more serious reaction?

Dr. Lockey - Even a local swelling can be serious. For example, while you are drinking a canned soft drink outside, a bee or a yellow jacket may have gotten in that can and this insect can get in your mouth and sting your tongue. I think that is a reason to get somebody to drive you to an emergency room. You may have no manifestation other than just the pain in your tongue. But it is smart to go to the emergency room and tell people what has happened to you. If you do not want to register and are not having symptoms, sit near the door and then go in if you begin having problems.

If you are stung and if you have any symptoms other than the local swelling, anywhere on your body, you should get that adult companion to take you to the emergency room or call 911 and get an ambulance to take you. These symptoms include hives, itching on the palms of your hands or scalp, shortness of breath, swelling of your tongue or throat, or wheezing.

Q - Should you be carrying special medications like EpiPens with you if you know you are allergic to bees or other stinging insects?

Dr. Lockey - Yes, only under circumstances where you have had a previous reaction that would warrant emergency care, that is hives or any of the other manifestations outside of local swelling.

Q - We talked about the stinging insects as if they are at least a nuisance and at worst life threatening. What’s good about them?

Dr. Lockey - Well, of course, the honeybee is a life-sustaining insect for us. It is very responsible for the fruits and many of the foods that we eat because without the honeybee , we would not have the pollination of the flowers that are responsible for the fruits’ development. The honeybee has been completely domesticated. It is much like the cow and is very dependent upon man for its existence.

The people who raise and take care of bees have a wonderful hobby or occupation depending upon how many hives they have and they are extremely interested and very protective of their insects. Frankly, they get bonded to them much like people get bonded to their dogs and cats.

Q – Stinging insects also prey on other harmful pests.

Dr. Lockey - You are speaking about the vespid family; yellow jackets, white-faced hornets, and yellow hornets. They are very interesting insects also and they have their place in nature.

Q - It seems that most insects, even the ones we don’t like, get rid of others that are as bad or worse.

Dr. Lockey - Correct. They are basically the tigers of the insect world. Some of the hornets, for example, control insects that are very harmful to plants and very harmful to the environment. And so we have a need for them. But, we do not need them living right outside our door or under our favorite bench.

Q - The honeybees also provide us with one of our favorite sweets.

Dr. Lockey - True. There would be no honey without the honeybee.

Q - Is there anything else you would like to add?

Dr. Lockey - I think, from my perspective, protecting yourself from an insect sting is about as much as you can do. If you are interested in protecting yourself or your child, knowing a little bit about the insects’ habits is a very important way of protecting yourself.

As I mentioned earlier, we’ve done surveys in our practice and we discovered that about 70% of patients are stung within 50 yards of their back door. We do not even know stinging insects are there and yet, if you are close enough to them, they are going to sting you.

Q - And if you get a welt or something that looks like a hive, as you said, check with an adult?

Dr. Lockey - Yes. If you get stung, the first thing you should do is stop what you are doing, and then go seek adult companionship. Just be with somebody. If there are any symptoms at least you are with somebody that can call for emergency help, if necessary.

Q - And then after the emergency care that’s the time to see an allergist?

Dr. Lockey – Right. Once you come to see us or your doctor has referred you to us what we will do is determine what you are sensitive to and then we will put you on a program of desensitization to the specific venom. The venom is actually extracted from the insects, freeze dried, and purified. That is what we give you. You will get an injection once a week for about ten weeks and then you are extended to once a month for about six months and after that we go to an every six week program, and we do that for four and a half years in all.

The total therapeutic approach is to do it for five years and then we skin test you to see if you are still sensitive. If you are we continue with your immunotherapy for another two years and then retest you. Once you are on maintenance therapy, receiving your injections on a monthly basis or every six- week basis, you are considered desensitized.

Q - Are you then on an equal basis with someone who has never been stung?

Dr. Lockey - You are at less risk of having an allergic reaction to an insect sting than your peer who has never been stung. You are actually at a risk of less than probably 2%. From what we have seen in our practice it is almost down to 0%. We rarely see anyone who has been on desensitization having allergic reactions. We do ask them to carry emergency medications in case they happen to be one of the very few that will have an allergic reaction while they are on these injections. But, I can tell you right now there is nothing more effective that we do as allergists than desensitize people to insect stings. It is really an extremely effective means of protection.

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