Bed bugs have been making the headlines recently. On vacation in some (and to be sure not most) New York City hotels, bed bugs have been biting tourists and business people alike. Sweet songs about itsy bitsy spiders and other creepy crawlies are anything but cute when it comes to finding oneself covered with itchy, sometimes blistery bug bites. Let's face it, insect bites can really "bug" you.

What's the definition of an insect? According to Merriam-Webster, insects "belong to the class Insecta of arthropods with well-defined head, thorax and abdomen, only 3 pairs of legs, and typically one or two pairs of wings." These 6-legged skin-afflicting pests include no-see-ums, bed bugs, bees (wasps and hornets), and of course the perennial mosquito. For completeness, chiggers will be covered as well, but technically they are the immature 6-legged stage of the 8-legged harvest mite.

Not all bug bites are created equal. Each has its own unique issues, concerns and frequently varies in appearance. A combination of recognition, prevention and some intervention can keep your skin calm and your summer fun uninterrupted.

Bedbugs

To be honest, not until I studied medicine did I realize that bedbugs, the subject of that odd little childhood bedtime rhyme (goodnight, sleep tight, don't let the bedbugs bite), actually existed. As an aside, why would anyone tell this to a child at bedtime? Anyway, bedbugs are actually far more common internationally, particularly in poor, rural countries, than they are in the U.S. The prevalence of bedbugs in Gambian children's beds, alone, is estimated to be 37.5%. However, in warmer climates in the U.S., bedbugs can be found. The bedbug featured in the photo was removed from a patient I treated while training in Virginia.

Bedbugs are 5-7 mm in length, just visible to the naked eye. They live in tiny cracks, hidden between floorboards, in furniture, bed frames and even mattresses. At night, the bedbug steals out of its hiding place to feed upon its human prey. Feeding time is usually just before dawn, taking anywhere from 3 to 12 minutes to complete.

The mouthparts of the adult bedbug are modified for piercing and sucking. The bedbug grabs hold of the skin with its forelegs, pierces the skin with its mouthparts and injects saliva laden with both anticoagulant and anesthetic to allow its feeding to take place uninterrupted by the still-sleeping host.

Bedbugs are unusually capable of surviving hostile environments. They have been known to survive starvation for more than a year.

The initial bite of the bedbug goes unnoticed due to the anesthetic quality of its saliva. However, the bites quickly become very itchy. Scratching can easily be complicated by a secondary bacterial infection, particularly in less than sanitary environments.

Here again, bedbugs can transmit a variety of infections including hepatitis B, and American trypanosomiasis aka Chagas disease.

While unusual, highly allergic response of anaphylaxis can occur, similar to that seen in patients highly allergic to bee stings.

Treatment of highly pruritic bites revolves around itch relief products as detailed above.

Cut children's nails if necessary to reduce potential skin damage caused by scratching. Keep any open excoriations clean to prevent bacterial infection or impetigo.

Eradication of bedbugs consists of thorough cleansing of potential hiding places, treatment of clothing with Permethrin (such as Nix Spray For Bedding and Furniture), topical DEET containing insect repellants such as Off!.

Bed nets can be treated with Permethrin in tropical regions and is credited with eliminating bed bug infestations in many parts of Africa.

Consider placing bedbug-free bed legs into pans of paraffin oil to prevent them from crawling up onto the bed. However, there have been reports of bedbugs dropping onto the bed from the ceiling, so be wary of this possibility.

No-See-Ums

A bug by any other name can still inflict a lot of pain, and aggravation. No-see-ums, a member of Ceratopogonids, carry a variety of regional names including, biting midges, punkies, sand fleas, jejenes, gnats and moose flies. Over 700 species exist worldwide. A bare 1/25 to 1/10 inch in length, these minute insects are easily capable of passing through a screen door. No-see-ums resemble a shorter, stubbier version of a mosquito with 2 hairy wings.

No-see-ums are often at their worst come dawn and dusk, during the middle to late summer. Light attracts them. They may resemble swarms of "dust" and produce a high-pitched noise produced by the incredibly rapid beating of their wings (approximately 133,000 beats per minute). It is not unusual for no-see-ums to fly into open mouths, ears or the eyes.

No-see-ums lay their eggs upon the water or within moist decaying organic matter. Hatching occurs in just 3 days. Their early larval stage is lived out within this aquatic environment. Borne of this aquatic environment, they possess a unique method of breathing through gills similar to fish.

It is only the winged mature adult female with a limited lifespan of just a few short weeks that feeds upon the blood of animals including horses, farm animals, turtles and humans.

For such a tiny pest, they possess exquisitely sharp jaws capable of cutting the skin, inflicting painful bites. Once the feeding process has begun, the saliva of the no-see-um prevents blood clotting to ensure a complete blood-sucking process. This is localized to the bite and has no systemic anti-clotting concerns. Raised red welts and even water-filled blisters can immediately form and last several days.

Since these bugs are so difficult to visualize, many patients may misdiagnose their condition and even the physician may mistakenly contemplate a contact or allergic dermatitis.

The bite of the no-see-um is not limited to simple Dermatologic manifestations. No-see-ums are capable of transmitting viruses such as bluetongue, a disease afflicting cattle. In tropical indigenous regions, African horse sickness, leishmaniasis and monkey malaria (different from monkeypox) are also potential infections.

While unusual, multiple no-see-um bites can cause potentially life-threatening kidney failure from their toxins alone, unassociated with any transmissible virus.

Treatment of painful bites consists of palliative treatments such as the use of topical cortisone creams (such as Cortaid), topical anesthetics including LMX 4% Topical Anesthetic Cream - 30gm and systemic relief such as NSAIDS (like Motrin, Advil) or Tylenol.

Blisters may be dried out with the use of Domeboro Astringent Solution. Open wounds should be cleansed with hydrogen peroxide and Polysporin First Aid Antibiotic Ointment.

Prevention remains the best protection against no-see-ums. Protective clothing (long sleeved shirts and long pants) and the use of DEET containing insect repellants help reduce the likelihood of becoming a no-see-um snack.

Turn house lights out at night when out on your porch or in the yard. This helps avoid attracting them.

Avoid watery areas at dawn and dusk; no-see-ums tend not to stray far from their breeding ground.

Eliminating backyard breeding sites by draining stagnant water out of pots, yard depressions as one would with mosquito prevention.

Chiggers

Chiggers: aka harvest mites, red bugs, jiggers, berry bugs or bracken bugs. They put in an appearance during the late summer and early fall. Orange in color, they are barely visible to the human eye. Chiggers are not true insects; they are mites belonging to the Arachnid group that includes spiders, ticks and scorpions. Chiggers maintain a home deep within tall grassy areas, lawns and underbrush.

For chiggers to become mature mites they must first feed off a warm-blooded animal. They lie in wait while their prey (humans or other animals including pets) work or play blissfully unaware of the torment about to befall them. Chiggers tend to attach themselves within protective body creases or crevices, where they can proceed to feast in safety.

However, chiggers do not feed off of blood. This is a myth. It is likely this misconception arose from the chigger's orange coloration. Chiggers are barely visible to the naked eye, but en masse, they impart an orange color to the skin when attached in large numbers.

Chiggers have mouthparts similar to ticks and affix themselves to the skin with their strong jaws. They inject their saliva into the epidermis initially causing skin to harden around the mouthpart, creating a "straw" through which it feeds. The saliva actually liquefies the skin cells. It is this cellular soup that provides nourishment, not blood. Feeding lasts for 2 to 3 days and then the chigger drops back to the ground to complete its life cycle. Chiggers do not burrow beneath the skin's surface or set up permanent residence upon its hapless victim. These again are common myths.

After a chigger has matured into the adult stage, nourishment is limited to vegetation.

The host animal will ultimately experience a delayed reaction to the proteins in the chigger's saliva which results in intense itching, ranging from 24-48 hours after the chigger has bitten. In fact, the chigger may be long gone by the time the itching has begun. With this in mind, treatment is aimed at helping soothe the discomfort, not trying to smother a non-existent chigger.

Once the discomfort has begun, it's time to rely upon antihistamines to provide general itching relief such as Zyrtec. Topical cortisone creams (OTC version such as Cortaid or Rx options available from your doctor can also help reduce the inflammation and control the itch. For rapid relief, apply a topical anesthetic such as LMX 4% Topical Anesthetic Cream - 30gm, PrameGel or Caladryl Clear Lotion.

Controversy still exists on the benefits of applying clear nail polish to active red bumps. Since the chigger is gone, the nail polish doesn't kill the mite; however, some reports still support the palliative nature of this treatment. If you were prone to sensitive skin, I'd recommend skipping this option.

As with all open skin, bacteria may take advantage of the situation and a secondary bacterial infection may arise. Keep all open wounds clean with hydrogen peroxide and antibacterial ointment (like Polysporin). And don't scratch! Apply your topical relief instead.

From a preventative vantage, apply an insect repellant before going outdoors. Don't miss potential problem areas such as the underarms or ankles. Upon your return, change into fresh clothing (wash the dirty ones) and take a shower. Applying rubbing alcohol to vulnerable areas may be helpful.

Try to keep lawn mowed and grassy areas cleaned up. For known chigger infested areas, Premethrin Pro can often be safely used on the lawn check first with your local lawn and garden center.

Fire Ants

Five species of fire ants are now present in the United States. The most concerning is the aggressive red imported fire ant, Solenopsis invicta. The black or dark species is Solenopsis richteri, which is limited to Alabama and Mississippi. The red imported fire ant is responsible for the fire ant problem in the rest of the Southwestern United States.

Fire ants are aptly named for the painful, fiery sting they are capable of inflicting. Fire ants are extremely aggressive, especially when disturbed or threatened. This insect boldly grabs onto its victim with its jaws and is able to deliver multiple stings in a circular pattern.

The venom that a red imported fire ant injects contains an alkaloid, solenopsin A. This substance is toxic to skin cells, rapidly killing epidermal and dermal cells around the sting site. White blood cells swarm to the area in response to the body's defense mechanism, ultimately forming collections of pus. Clinically this appears in the formation of pustules. Breaking the pustules can result in secondary infection and possible scar formation.

If stung by a fire ant, apply a cold compress or ice to the area to help reduce swelling and discomfort. Gently wash the area, but leave the blister intact.

Applying a topical anesthetic such as benzocaine or LMX 4% Topical Anesthetic Cream - 30gm to the area can help rapidly reduce discomfort. Systemic pain relievers such as Tylenol or Advil can also be beneficial.

Treat the area with Polysporin to prevent bacterial infection.

Similar to bee or wasp venom, imported red fire ant venom also contains a small amount of protein (usually less than 10 percent of the overall formulation). While this is typically responsible for the raised itchy bump at the sting site, it is the source of a potentially dangerous allergic reaction. Rarely, fire ant stings can cause life-threatening anaphylactic shock.

Symptoms of anaphylactic shock include dizziness, sweating, shortness of breath, tongue swelling, chest pain, fainting, slurred speech, nausea, or wheezing. These symptoms warrant emergency medical attention. Anaphylaxis due to fire ant stings occurs in approximately 0.5 percent of cases.

Bees, Wasps and Hornets

Several related stinging insects belong to the class Hymenoptera. These include bumblebees, honeybees, hornets, wasps, yellow jackets and fire ants (see below).

Only the female of each of these species will sting.

Honeybees have barbs at the end of the stinger which catch in the skin and the stinger becomes dislodged from the bee. The bee is unable to sting more than once and will die once its stinger is lost.

Africanized (or killer bees as they are also known), are more aggressive than honeybees. While they too can only sting once, they are more likely to attack in large numbers, increasing the risk of shock.

Wasps, hornets and yellow jackets are able to sting multiple times. Of all these stinging relatives, the yellow jacket is more likely to cause a serious allergic reaction. However, 10 or more stings received at any one time by any of the insects in this category sharply increase the risk of significant side effects.

A bee's weapon is a complex mechanism designed to remain behind in the victim and capable of injecting poison for up to 10 minutes. What's left embedded in the victim's skin is a hypodermic syringe capable of injecting venom for about 10 minutes. Even more concerning, the venom contains an alarm pheromone, alerting other bees to continue the attack.

The cellular membrane is the protective envelope surrounding all living cells. It's composed of proteins and phospholipids. Two factors vital to the venom's successful attack are mellitin and phospholipase A. The mellitin is capable of penetrating the cellular wall while phospholipase A breaks the phospholipids apart, resulting in the destruction of the cell. Blood flow is shut down at the bee sting site due to the presence of norepinephrine in the venom. This results in the characteristic blanching of the site. Until the mellitin and other venom components are diluted, the site will continue to throb for approximately 5 to 10 minutes.

The raised red wheal forms upon the release of histamine from the mast cells, much like the characteristic welt that forms with a mosquito bite.

Proper removal of the stinger can reduce the amount of venom injected into the skin. It is important to not squeeze the stinger. Sideways scraping of the stinger (such as swiping a credit card across the skin) can dislodge the barbs without releasing the venom.

Ice or cold compresses can help reduce the intensity of the pain. Systemic antihistamines (Zyrtec) can help reduce localized swelling and inflammation. Thick pastes made with either baking soda or meat tenderizer and water applied to the wound can be soothing.

Because of the presence of protein in bee venom, a small percentage of individuals may become highly allergic to bees. Anaphylactic reactions typically require at least one previous bee sting incident.

Those with a known history of bee sting allergy should carry an Epi-Pen. These are available in dosing for both children and adults.

Symptoms of severe allergic reaction such as shortness of breath, hives, swelling of lips or tongue, fainting, etc. should receive emergency medical treatment.

Steps to take to help reduce the risk of being stung include:

• Avoid being around gardens, flowering foliage, fruit ripening upon trees or vines and open garbage cans that might also contain sugary treats that might lure them.
• Avoid wearing fragrance, scented sunscreens/lotions or washing with scented cleansers.
• Avoid wearing bright colors (especially red), floral prints or wool.
• Don't swat, shoo or throw anything at the bee and especially the hive.
• Move away slowly if caught in a swarm of bees.

Mosquitoes

Don't hold your breathe that mosquito season is going to go away anytime soon. And did you know it's the carbon dioxide present in every breath we expel that attracts the mosquito in the first place?

Avoiding mosquito bites essentially boils down to masking our scent and the carbon monoxide hanging in the air about us. Studies have shown that DEET (as found in Off!) is by far the most effective mosquito repellant, and protection is concentration dependent. The higher the level, the longer lasting the product.

Don't think that mosquitoes are entirely brainless little creatures. They are perfectly smart enough to nibble a patch of untreated skin lying right next to an area that was treated with repellant. Since it's proven that mosquito repellant only works on areas it is applied to, those DEET and citronella wristbands should have little to no effect upon avoiding undesirable bites.

The American Academy of Pediatrics recently expanded the use of DEET to include children as young as 2 months of age and raised approved levels from 10 to 30%.

For those parents leery of applying DEET (despite long term studies that back its safety), a combination SPF and repellant is a great way to protect children. Apply a product such as California Baby SPF 30+ Citronella liberally in the manner one would a sunscreen to ensure proper UV protection.

Mosquitoes love to breed in standing or stagnant water. Eliminate these sources from around your home to discourage them from moving into your yard.

Scratching mosquito bites can lead to infection, skin discoloration or scar formation. Squelch the urge to scratch with any of the anti-itch treatments mentioned below.

How To Stop The Itch

No matter what the bug bite, itching is itching. Try any of the following to help put a stop to the itch.

• Zyrtec
• PrameGel
• Prax Lotion
• LMX 4% Topical Anesthetic Cream - 30gm
• Caladryl Clear Lotion
• Aveeno Oatmeal Anti-itch Concentrated Lotion
• Sarna Lotion
• Cortaid Maximum Strength Cream
• baking soda baths
• Prescription topical steroids
• Prescription topical Zonalon (antihistamine)
• Prescription oral antihistamines such as Atarax, Zyrtec, etc.
• Prescription systemic steroids should only be used in extreme cases

Quit Buggin' Me

A few last notes about bug bites. Biting (rather than stinging) insects often leave behind a calling card. Dermatologists often refer to it as the "breakfast-lunch-dinner" sign. These pests may initially go unnoticed in their quest for a quick munch and bite in the same area 3 times, hence the b-l-d designation. General dermatologic rashes don't tend to show 3 consecutive red bumps.

Those prone to atopic dermatitis, a form of eczema, may have exquisitely hypersensitive reactions to bug bites, most often due to the flea and mosquito. It is not unusual to see large clear fluid-filled blisters rather than the red bump typically expected. My own child had this tendency early in infancy and it can be very anxiety provoking as well as confusing in a dermatologic work-up. Groups of blisters particularly around the ankle are often due to flea bites (just envision them jumping only as high as this point).

Blisters as always rapidly respond to Domeboro Astringent Solution compresses. If necessary, the blister can be deflated by lightly nicking the edge with a sterile needle. But always keep the area clean and try to squelch the urge to remove the top of the blister early on. Think of it as Nature's Band-Aid. And if your child is prone to developing blisters in this manner, it's always best to make certain your doctor agrees that this is all that's going on rather than missing a more serious concern.

Finally, there is a form of hives which can form in response to bug bites. Known as papular urticaria, (aka lichen urticatus), this is a common concern in childhood. It's basically a hypersensitivity reaction to the bites of mosquitoes, fleas, bedbugs and other biting insects. The average age of children (who again tend to be atopic) is 2-7, but infants have been known to develop this condition. Antihistamine treatment and topicals that control the itch and trying to maintain control of household infestations are the best means of defense.

If you're traveling, these tips should help make your stay more enjoyable. If it's the height of insect season, make your summer a time of carefree, bug-free fun. A little repellant and a lot of knowledge should be just what the entomologist (and the skin doctor) ordered!

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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