DocSmo here with another edition of Portable Practical Pediatrics. From the onesie all the way to the three-piece if it involves kids, we talk about it here. Thanks for joining me today. I’ve got another biking story for you today. You know I’m part of the “Biking friends”, a group of adults and sometimes kids, who go biking weekly to a bakery or a coffee shop. We bike about 25 miles and have lots of interesting conversations along the way. Well, in one of my most recent outings with the group I got to ride along side a teen with a rash. His mom was also riding and she asked me to take a look at his rash that was around his upper arm. Mom’s question for me was should she take him to urgent care or even the emergency department since his spots looked bigger and angrier than they had the day before. His rash was getting worse and she was worried. I knew the likely outcome of one of those ED or urgent care visits- lots of medications and therapies that are often unnecessary. So let’s break down this young man’s rash a little more in today’s pedcast and give you my thoughts about a how to identify and manage his rash that turned out to be from insect bites. I’ll also tell you what I told this young man to do to care for his rash that turned out to be easy and very inexpensive.
How does a parent recognize that the skin spot is a bite?
What I saw on this young man when I took a look at his skin was a crop of red spots on his upper arm. The marks looked like typical insect bite reactions. More on that in a minute. He couldn’t recall having been bitten by anything so I deduced that they were likely large mosquito bites for the following reasons: he hadn’t noticed being bitten-typical of mosquitos (check), the red spots were on exposed skin where insects have easy access to bite (check), the rash was on the upper body, an area not usually accessible to crawling insects but rather flying ones (check), the center of the red spot was elevated compared to the rest of the spot which is typical of an insect bite (check), the spots were itchy but not painful (check), and the spots were grouped into multiple wheals in the same area (typical for bites-check). These were bites! Turns out, there are thousands of insects all around your children that potential can bite them, but in this young man’s case, I thought mosquitos were the most likely insect causing the rash for the reasons I just stated. The spots were large and a little angry looking when I saw them but I still thought they were uncomplicated mosquito bites. Let’s take the mosquito as our prototype insect bite and analyze what happens in the skin of a child who gets bitten. I think once you begin to recognize the signs of an insect bite, you will be able to identify bite marks on your children since most insect bites look very similar.
What happens in a child’s skin when they are bitten?
When a mosquito bite occurs, skin bacteria and venom from the mosquito and possibly even viruses that are carried by the mosquito are injected into the skin of your child. Within minutes to hours of an insect bite, your child’s immune system leaps into action, recognizing that something foreign has entered the child’s skin. The skin barrier has been breached. Alarms go off and your child’s immune system goes into action with swelling that dilutes the toxins, blood vessels dilating that bring in cells to detoxify and neutralize the venoms as well as killing bacteria that have entered the skin and repairing the damage to the broken skin. All these processes cause your child’s skin to develop the cardinal signs and symptoms of inflammation: swelling, heat, redness, and itch/pain. Other conditions can cause your child’s skin to become inflamed but bites from insects is one of the more common conditions that lead to skin inflammation and this inflammation is most intense at the center of the bite. That’s why if you feel these swellings, the center is thicker than the edges. Dermatologists call this reaction a wheal, their term for a bump bigger than a pimple.
What are the signs of the skin spot is more serious?
What are the signs that a insect bite has gone serious, what I call a complicated bite? Here are some of the features of a child’s skin rash that get me worried. My radar goes up that something is very wrong if the following things start happening:
-Swelling that is increasing after the third day of onset. As I said before, insect bite reactions that are uncomplicated start getting better by the fourth day in my experience.
-A red streak radiating from the wheal. Doctors call this lymphangitis and it can mean real trouble.
-Pain instead of itch in the area of the rash. Itch is mild pain. If the lesions go beyond itch into the pain level, there is often trouble.
-Blistering of the skin, involvement of the tissue under the skin, pustules or abscess, or the dreaded skin ulceration. All these things involve the skin breaking down and that’s never good.
-If there’s a concerned that there’s a foreign body in the skin. Most foreign bodies will eventually get infected and the splinter or whatever will need to be removed.
-If there are swollen lymph nodes anywhere near the rash. Next to fever or the skin breaking down, this is the second most serious sign that your child’s body is fighting hard and that the skin process has moved beyond the skin.
– If the child with the rash is sick with a fever, doesn’t feel well, or just doesn’t look or act well.
Any of these factors make me worry that this is more than just a simple insect bite. It may have started as a bite but it’s likely if any of these factors are present, that there are some secondary infection on top of the bite. Any of these signs warrant a visit to your child’s pediatrician, urgent care, or ED.
What is advice did I give my teenage biking friend?
What is advice did I give my teenage biking friend? Well I told him to seek care immediately if any of the previously mentioned signs occur but at the time that I saw him, even though his spots were getting redder and bigger, I didn’t feel that he needed medical attention since he was still within the magic three day window when bites look their worst. I also told my young friend that if none of these serious signs or symptoms occurred, that he should simply keep the spots clean with some soapy water, put a think smear of Vaseline on them, and just simply observe them for another 36 hours. Another 36 hours would put him past the magic three days when his bites should start to look better. You see, insect bites increase in size until about the third day and then they usually begin to resolve. I’m pretty sure that if his mother had taken him to the ED or UC as she was contemplating at the beginning of our bike ride, he would have likely left these facilities with a prescription for oral and topical antibiotics because of their concern the bite was infected, topical and possibly oral steroids to reduce swelling, and instructions to take an antihistamine for five days. In my experience, most of the time, these medications are not necessary during the first three days of a bite. I know some doctors recommend oral or topical antihistamines, topical antibiotic’s, covering the bites with the bandage, topical and or oral steroids for all bites but I just haven’t found these medications necessary unless a child has one of the warning signs I mentioned earlier or is very allergic to mosquito venom. For very allergic children, aggressive treatment can be very helpful but is not necessary for most. And while we are talking about treatment, I do not recommend you use any product that contains topical Benadryl (diphenhydramine) or topical neomycin (the Neo in Neosporin). They can make things worse. I recommend a thin layer of plain Vaseline to cover the bite. No bandages and nothing fancy.
Which children need to see an allergist?
Here is a good question that I am often asked, which children need to see an allergist? This question seems to come up frequently. In my opinion, if your child has a large local reaction and by local I mean a reaction that’s only at the site of the bite, they don’t need to see an allergist. But if they get a reaction at sites beyond the site of the bite itself such as hives, throat tightness, hoarseness, wheezing, vomiting, look pale and ill shortly after any kind of bite, they certainly need a trip to the emergency department immediately as well as a trip to a pediatric allergist after they recover from the bite.
Well I hope that helps you both identify insect bites in your children and know how to handle them should they occur. I also hope that you now know some of the signs that your child’s insect bites are getting more complicated I need medical attention. Certainly if you ever have concerns about your children’s health please contact those wonderful people you call your children’s pediatricians. I’m sure they can help. Oh, and by the way, in future pedcasts, I plan to address other types of insect bites, those that present other health problems such as spider bites, fire ant bites, and tick bites. If you enjoy learning about child health pedcast, by all means share them with your friends and family, and go ahead subscribe on my website at www.DocSmo.com to hear about the latest content via email. I would appreciate it you would also consider writing a review on iTunes or on my Facebook Page at DocSmo. Doing so helps others find my podcast. This is your host, Doc Smo, broadcasting from studio 1E in beautiful Charlotte North Carolina, hoping you won’t find it trite to pay attention to those bites. Until next time.
Many thanks to Dr. Monica For her editing of this pedcast. Thanks Monica