Insect bites
BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m2856 (Published 07 August 2020) Cite this as: BMJ 2020;370:m2856
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Dear Editor,
Dr Paul A J Heaton has a response to our Practice Pointer article on insect bites and correctly points out an error in the decision aid pertaining to Lyme disease.
He is correct, a visible tick or tick bite alone, does not require antibiotics for Lyme disease. This is an unintentional error which myself and coauthors have overlooked. It is not the guidance we intended to give and we are very grateful for Dr Heaton in spotting it. The decision aid figure will be corrected online, unfortunately the error is in the print version. As members and myself as chair of the RCGP overdiagnosis group, we are keen to avoid overuse of antibiotics and so are disappointed to have created the error! Many thanks indeed for the correction,
Jane (Dr Jane Wilcock)
Competing interests: No competing interests
Dear Editor,
The Practice Pointer on Insect Bites [ BMJ 2020;370:m2856 ] addresses the risks of infection and allergic reaction but confirms that little treatment is available for swelling or itchiness. However it may be helpful to share a personal journey.
Stung by a Weaver fish on my heel, I accepted a lifeguard’s advice to put my foot in water as hot as I could bear and was surprised to get relief of the severe pain within a very few minutes. Subsequent reading explained that the venom was denatured above 40 °C. When next suffering from troublesome itchiness from mosquito bites, wondering whether the responsible substance might also be thermolabile, I tried applying a teaspoon taken out of a near-boiling cup of tea to the swelling: it quelled the itch within a minute or two and it did not return.
The Web revealed that nothing is new as battery-powered gadgets have been developed to replace the dripping teaspoon and raise overlying skin temperatures to 50° C. A treatment series in 2011 suggested effectiveness against bee and wasp sting pain as well as itch and swelling from other insects’ attentions [ref].
The omission of heat application from your article suggests the remedy has not been recognized widely as yet. A GP vocational trainee summer attachment in the Scottish Highlands could provide an ideal opportunity to collect outcomes and publish the first really successful outcomes trial treating the miseries of midge bites. Perhaps worth a prize of Lagavulin, awarded by VisitScotland, for the first to publish.
Ref : Müller C,, Großjohann B,, Fischer L (2011). The use of concentrated heat after insect bites/stings as an alternative to reduce swelling, pain, and pruritus: an open cohort-study at German beaches and bathing-lakes. Clin Cosmet Investig Dermatol. 4: 191–196. Published online 2011 Dec 15. doi: 10.2147/CCID.S27825
Competing interests: No competing interests
Dear Editor,
The decision aid for primary care of suspected insect bites states "Erythema migrans or visible tick. Treat as Lyme disease".
Either there was some editing error or the authors are joking? There is no justification for "treating" the presence of a tick alone as a case of Lyme Disease. The finding of a tick, even if it is in the process of feeding, does not equate to Lyme disease being present, and it is very poor advice to suggest this is the case. Unnecessary antibiotic administration will be of no benefit to the patient, and potentially leads to harm through side effect and increasing likelihood of antibiotic resistance.
If erythema migrans, or other suggestive symptoms are present that it quite a different story, and antibiotics are definitely indicated.
Competing interests: No competing interests
The majority of insect bites are inflammatory reactions lasting many days, but progressing before diminishing. Because they mimic infection, inevitably because of patient and doctor anxiety, antibiotics are prescribed as bites appear to be worsening. A brave watch and wait policy monitoring with digital photos available to all, might avert unnecessary and over zealous prescribing.
Competing interests: No competing interests
Pervasive and invasive, parasites are Mother Nature’s army of mini-monsters that plague us with morbidity and mortality. Parasitology is vast and includes viruses, bacteria, fungi, protozoa, worms, insects, and arachnids. Despite media hype, the best antiparasitics are fresh air, sunshine, hygiene, and nutrition, since vaccines are vexed and antibiotics create lethal superbugs and superinfections. To quote GB Shaw, "Science never solves one problem without creating ten more."
Competing interests: No competing interests
Re: Insect bites
Dear Editor
Thank you for publishing this helpful guide on managing insect bites, a common presentation in primary care. I am concerned by the statement in Fig 1, 'Suspected insect bites: decision aid for primary care,' which states: "Erythema migrans or visible tick - treat as Lyme disease."
Only a small proportion of tick bites result in Lyme disease transmission and NICE guidelines(1) reflect this:
"Do not: Diagnose Lyme disease in people without symptoms, even if they have had a tick bite."
I am concerned that this advice will lead to needless courses of antibiotics, resulting in harm in the form of side effects, increased antibiotic resistance and excessive alarm among the asymptomatic tick-bitten general public. It may have been more helpful to provide a picture of the erythema migrans rash or redirect to appropriate guidelines on testing in suspected Lyme disease.
1.Lyme disease. NICE guideline [NG95] https://www.nice.org.uk/guidance/ng95/chapter/recommendations
Competing interests: No competing interests