Am Fam Physician. 2023;107(2):116-117
Author disclosure: No relevant financial relationships.
To the Editor: We want to correct the information presented in Table 6 about how to remove a bee stinger in the “Arthropod Bites and Stings” article.1 The authors repeat the legend that a person should never squeeze the autotomized stinger embedded in the flesh because it can result in injection of additional venom into the sting site. However, no data supporting this common sense recommendation have been reported in the literature. In contrast, many reports have demonstrated that it is incorrect. In 1935, Snodgrass revealed the morphology of the honeybee sting apparatus. A stinger's valvular lobe on the first valvulae drives the venom through the sting shaft into the stung target.2 When the venom reservoir is pinched, these lobes prevent the venom from passing through them into the sting shaft embedded in the skin. More than 20 years ago, our research groups independently published in medical journals that the primary consideration in removing honeybee stingers is time—the faster, the better.3,4 Venom delivery by the embedded stinger occurs rapidly after implantation, emptying the venom reservoir within 30 seconds. Scraping out the stinger with fingernails or pulling it out with fingers is faster than fumbling around to find a dull (knife) blade or credit card. By the time a person finds a credit card or blade, more venom will have been pumped into the wound than if the stinger had been immediately pulled or rubbed out.
The rapid removal of a bee stinger provides two advantages. It decreases the amount of venom pumped into the wound, thereby reducing the pain of the sting and, more importantly, decreasing the risk of a severe anaphylactic reaction. Anaphylaxis is dose dependent. The more a person can minimize the amount of venom injected, the greater probability of preventing a severe allergic reaction.5
In Reply: We thank Dr. Schmidt and colleagues for their careful reading and interest in our article. We agree that evidence on the proper technique for removing Hymenoptera stingers is limited. The cited articles suggest that rapid removal (within five to 10 seconds) is an important consideration in minimizing envenomation1,2; however, only the Lancet article directly investigated different removal techniques. In the Lancet study, two volunteers were stung multiple times on the forearm, with the stinger removal time and method (grasping vs. scraping) varied by researchers and the weal size measured. The authors concluded that there was not a statistically significant difference in weal size between removal techniques; however, based on the limited study size and the high risk of bias, we believe the results of this study are more hypothesis generating than practice changing.1
Until consistent, high-quality evidence to the contrary is available, we agree with recommendations from the American Academy of Dermatology and the National Institute for Occupational Safety and Health that patients should be advised to try and remove the stinger as rapidly as possible, with the preferred removal method being scraping or flicking (instead of squeezing with tweezers or fingers).3,4
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Air Force or the U.S. Department of Defense.