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Paul K. Carlton, Jr, MD, Brown recluse bite? FACS The A&M University Consider this uniquely Health Science Center College Station, Tex conservative treatment [email protected] An and observation work as well— and often better—than more intensive therapies.

Practice recommendations oped it in 4 phases, which I describe in • Be concerned about brown recluse this article. Not only does this conser- when a patient vative approach consistently heal con- reports intensifying localized firmed brown recluse bite , but pain disproportionate to physical should a bite be mistakenly attributed findings after a “bite” (C). to the brown recluse (or one of its rela- tives in the Loxosceles of spider), • Prescribe an oral antihistamine there is no harm to the patient, nor any alone to control symptoms, even big expense. with a necrotic , and mark the In this Article patient’s progress over 24 hours (C). z z Is a brown  bite • If the patient improves dramatically, to blame? or MRSA? continue the antihistamine; with little Due to limited experience among the Page E6 or no improvement, consider giving an wider medical community in identifying with the antihistamine (C). spider envenomation,1-4 bite recognition and selection of appropriate therapy can Strength of recommendation (SOR) be difficult. A Good-quality patient-oriented evidence Early findings can be confusing. B Inconsistent or limited-quality patient-oriented evidence C Consensus, usual practice, opinion, disease-oriented Brown recluse bites typically feel like a evidence, case series pin prick. A vasoconstrictive halo may surround the bite, but this sign is in- consistent. Usually there is nothing to hat is the best way to treat the see immediately and pain from the bite bite of a ? goes away, so most patients dismiss the WHaving treated more than 185 incident.5 Soon, however, pain from the bite wounds on 150 patients over the envenomation begins and, importantly, past 30 years, I have found that an oral becomes disproportionate to physical antihistamine works best and makes sur- findings—the patient shows you where gery unnecessary. it hurts, but there is nothing visible to I did not arrive at this treatment support a diagnosis or suggest a course protocol immediately but, rather, devel- of action.

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www.jfponline.com vol 58, No 2 / February 2009 e the journal of Family Practice figure 1 z How my treatment The distinctive “fiddle” mark protocol evolved My protocol for treating necrotic bite wounds of the brown recluse, and similar wounds from other insects, progressed over 30 years through 4 phases of treat- ment concepts.

Phase 1: Surgical excision From 1979 to 1980, I treated necrotic wounds with surgical excision and sec- 1 The brown recluse spider has a distinctive “fiddle” mark ondary closure or grafting. Many on the back of its thorax. Unfortunately, though, intact patients complained of severe itching specimens are seldom available for examination after a bite. Rely instead on the natural history of the wound in around these wounds, which I treated attributing a bite to the brown recluse. empirically with the antihistamine Bena- dryl. All patients experienced symptom Progression of the wound usually tells relief and had a reasonable cosmetic re- more than a captured specimen. If you are sult (FIGURE 2). fortunate enough to examine an intact In writing up the case results for a spider caught by the patient, a “fiddle” presentation to the Society of Air Force mark on the spider’s back confirms it is a Clinical Surgeons, I conducted back- brown recluse (FIGURE 1). However, most ground research and found a postulate specimens brought in for examination are suggesting that antigen recognition was so misshapen from the patient’s retribu- an important factor in wound progres- tion as to make identification futile. I fo- sion and that it took approximately cus instead on the resultant wound. 7 days to achieve. That postulate drove Spider’s causes the wound. Spi- the second phase of discovery.1 fast track ders lack a mechanical digestive system; A wound with a their so-called venom actually is a set of Phase 2: enzymes that liquefy a prey’s tissues.6 In Observation before debridement large underlying the 48 hours after a bite, these digestive From 1980 to 1981, I focused on the cavity and small enzymes cause a progressive of postulate, which also suggested that the area of skin fat under the skin. Eventually the overly- antigen–antibody reaction following en- necrosis is a ing skin also turns necrotic. The venom venomation could make reactions to sub- does not penetrate underlying fascia sequent (“second set”) bites less severe.1 likely insect bite. planes, as many infectious processes do. This made sense, though good clinical Necrosis can, rarely, cause dissemi- data were lacking. nated intravascular coagulation and I decided to simply observe patients’ s

death. A more likely scenario, though still wounds for 7 to 10 days before perform- c a f ,

relatively uncommon, is that the necrotic ing debridement, advising patients to use d m

sequence leads to an indolent wound that an antihistamine to control symptoms jr,

, n

heals only with difficulty. Most patients during the waiting period. I took photo- o t

recover without medical care and do not graphs to document clinical progression arl 7-9 c k. even seek it. of wounds. In reviewing these photo-

Wounds can be categorized, as graphs, I noted that the necrotic wounds aul f p f

10 o outlined by Auer et al, into groups 1 stabilized immediately on starting an esy through 4, from least severe to most se- antihistamine—specifically, Benadryl, t

vere. However, this classification scheme 5 mg/kg or 50 mg qid. After 7 to 10 days, our c os

has made no difference in my manage- I debrided the wounds, using fluorescein t ho

ment decisions. and a Woods lamp to guide the proce- p

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figure 2 Bite wound treatment: Debridement and closure or skin grafting a b c

One day following the bite, this 17-year-old boy’s Fully debrided, the wound was ready for skin This skin graft, taken from the groin, healed sat- wound was clearly necrotic. grafting. isfactorily in 4 weeks. Patients often complained of severe itching around the wound, which was relieved with Benadryl.

dure. I found that tissue of doubtful vi- other insects. None have required oper- ability survived if debridement was con- ative debridement, and all have achieved servative and the patient had used an much more acceptable cosmetic results antihistamine (FIGURE 3). using Benadryl therapy than with surgi- cal therapy. Phase 3: My encounter with a brown recluse. Focus shifts from The bite I received was rather typical. I to antihistamine felt a sharp sting when outside working In reviewing phase 2 results in prepara- on the lawn. I looked down, saw noth- tion for a presentation to the Southwest- ing, and assumed I had run into a pin ern Surgical Congress, I realized that or small stick that was now not visible. debridement was rarely indicated. So, For 3 days I noticed nothing unusual. from 1981 to 1982, I relied less on sur- On day 4, after showering I noticed a fast track gery and more on conservative therapy. large amount of purulent material on I noted that Patients got better simply with antihis- the towel after drying my anterior left tamine therapy. Redness diminished very leg. On inspecting the area, I saw an necrotic bite quickly once patients took the antihista- area of necrosis approximately 6 x 6 wounds stabilized mine, and pockets of purulent material cm with a central area oozing a puru- immediately drained on their own. lent material. This appeared just like after giving an This approach also allowed antigen the necrotic insect bites I had treated recognition to occur and seemed to prove with , so I started myself antihistamine the postulate of a less severe second bite. on that regimen. The redness cleared up and improved I saw 4 patients with proven “second in 2 days and the wound healed com- dramatically in set” spider bites (intact specimens were pletely in 10 days without . available) and all had an immediate in- A 3 x 3 mm circular remained; I 24 hours. flammatory response and no subsequent lost none of the surrounding marginal necrosis. An 18-month-old patient with skin. a bite below her right eye healed with Further evidence of less severe second Benadryl therapy alone (FIGURE 4). bites. Another physician—my coauthor on the presentation to the Southwestern Phase 4: Surgical Congress—was bitten at age 12 Exclusive antihistamine therapy by an unidentified insect, resulting in a Since 1982, I have treated more than large necrotic wound on his thigh. The 100 patients (myself included) with lesion, reportedly 10 to 12 cm in diam- necrotic bite wounds from and eter, healed with topical treatment only.

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www.jfponline.com vol 58, No 2 / February 2009 e the journal of Family Practice

figure 3 Bite wound treatment: Observation for 7 to 10 days

a b c

The bite wound on this 52-year-old woman was At day 5, the wound had grown, but there was On day 7, I performed a sharp excision of only the 3 days old when this photo was taken. I observed minimal necrosis. nonfluorescing area, as shown. the wound’s progression without debridement to allow time for adequate antibody response. The patient used Benadryl to control symptoms.

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Also at day 7, the peritendon was intact. The re- At day 21, the patient’s wound had nearly healed mainder of the area within the circle that did light up without further surgical intervention. under the Woods lamp was left alone, and survived. I decided against debridement in this case. fast track After our joint report in 1982, a brown physician hospitalized her for intrave- Allowing 7 to recluse spider bit him on the abdomen nous (IV) antibiotic therapy. while he was working in the yard. He When the patient worsened after 10 days for an captured the spider and verified its genus 2 days of IV antibiotics and incision and antigen–antibody and species. Guessing that the bite he drainage, I was called to examine her for response to occur received as a 12 year old was also from possible surgical debridement. I thought ensures that a brown recluse, he decided to wait and the lesions were necrotic insect bites and see if he had a “second set” reaction to recommended starting Benadryl, 50 mg patients bitten the bite. He had an immediate inflamma- qid. She improved remarkably over the again will have tory reaction, no skin necrosis, and the next 24 hours, her wounds decreasing in a milder reaction. entire area returned to normal in 3 days. size by 50%. She was discharged from His experience became the fifth “second the hospital and, against my advice, the set” spider bite reaction in our series. Benadryl was stopped. Within 48 hours Another dramatic experience. One the area of around the 22-year-old woman’s experience is wounds had doubled in size. She was re- worth a longer discussion. She visited admitted and given Benadryl. Again she her physician because 4 small areas of improved remarkably in 24 hours. The necrosis on her lower abdomen and purulent discharge was sent for culture, chest had lasted several days and were which grew an organism resistant to all getting worse. He assumed these were of her previous antibiotics. She healed small and treated her with an- uneventfully in 10 days on antihista- tibiotics. The lesions slowly enlarged to mines, and without antibiotics. This is become 6 to 8 cm in diameter, and the typical in my experience. Antibiotics

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figure 4 Bite wound treatment: Antihistamine alone

a b c

This 18-month-old girl came to my attention after Twenty-four hours after Benadryl was started, the At 48 hours, the surrounding erythema had having been scheduled for wound excision with a surrounding redness had decreased remarkably. resolved entirely and the area of questionable vi- plastic surgeon. The girl’s mother decided to cancel the major skin ability had gotten smaller. debridement.

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At 72 hours, the wound had clearly stabilized. Seven days after starting Benadryl, the child had The erythema was gone, and the area of potential almost fully recovered without surgery and with no necrotic skin was much smaller. deformity. have seldom proved useful, and culture subcutaneous necrotic process precedes fast track results are generally confusing. surface changes. If patients improve His treatment of choice was . He pointed out that other clinicians, too, dramatically in 24 z Broader support had reported success with dapsone, and hours, continue for my observations with steroids, antibiotics, hyperbaric the antihistamines On January 27, 2006, on eMedicine oxygen, electric shock therapy, and surgi- alone for 7 to 10 (link is no longer active), dermatolo- cal therapy.3,4,11,12 Stibich commented ex- gist Adam S. Stibich, MD, published a tensively on these treatment modalities, days; surgery is physiology review of the brown recluse except electrical shock. However, while unnecessary. bite. He acknowledged that neutrophils the laboratory results achieved were accumulate in the wound at 24 to 72 good, clinical outcomes were mixed. Of hours, consistent with the antigen– these treatments, I have experience only antibody response postulated in my with surgery, and I have found that it clinical review. Neutrophils are prod- does not improve the healing process. ucts of the histamine cascade that most likely brings about tissue necrosis. Stibich’s plea for conservative man- z Antihistamine and agement was well founded. He noted observation: The ideal Tx that only 10% of envenomation epi- The ideal treatment for necrotic wounds sodes result in large open wounds. The from envenomation would account for physical findings he described were in an underlying antigen–antibody process, keeping with my observation that a shorten the natural history of the illness,

www.jfponline.com vol 58, No 2 / February 2009 e the journal of Family Practice

If the wound improves dramatically The brown recluse gets around in 24 hours, which is the norm, I contin- ue the antihistamines for 7 to 10 days. If he brown recluse spider is found primarily in the Mississippi the wound does not improve, I suspect a TRiver Valley and its tributaries. Its genus members can be bacterial component and add an antibi- found in Arizona, Texas, and South America. They are nocturnal otic. Not once in the last 26 years have I creatures, typically living in woodpiles and secluded dark areas. had to resort to surgery. n Usually they are 8 to 9 mm in diameter, but they can reach several centimeters. Correspondence Unfortunately, the spider travels well hidden in clothing, so even Paul K. Carlton, Jr, MD, FACS, The Texas A&M Univer- if you don’t practice medicine in Arizona, Texas, or South America, sity Health Science Center, Office of Homeland Security, 301 Tarrow, 7th Floor, John Connally Building, College you could still find yourself treating a patient with a brown recluse Station, TX 77840; [email protected] spider bite. I saw these wounds in Germany and Spain, on patients who had just arrived from the United States or whose family Disclosure members had been there. Hite and others have also described this The author reported no potential conflict of interest rel- evant to this article. experience.5,12-14 References 1. Hershey FB, Aulenbacher CE. Surgical treatment of brown spider bites. Ann Surg. 1969;170:300-308. 2. Arnold RE. Brown recluse spider bites: five cases Spider bite or MRSA? with a review of the literature. JACEP. 1976;5:262- 264. any people seek care in emergency departments for nasty 3. DeLozier jb, reaves l, king le jr, et al. brown Mlooking spontaneous abscesses, some of which are in fact recluse spider bites of the upper extremity. South Med J. 1988;81:181-184. spider bites. Increasingly, though, lesions in this setting are colonized 4. Wright SW, Wrenn KD, Murray L, et al. Clinical pre- with methicillin-resistant aureus (MRSA). One recent sentation and outcome of brown recluse spider study showed that among patients who visited EDs because of skin bite. Ann Emerg Med. 1997;30:28-32. 15 5. Forks TP. Brown recluse spider bites. J Am Board , more than 58% were infected with MRSA. The difficulty Fam Pract. 2000;13:415-423. is in determining whether MRSA has caused the nasty wound, is a 6. Spiders: Digestive system. Available at: http://www. secondary colonization of a spider bite, or if the wound is actually an greensmiths.com/spiders.htm. accessed Novem- ber 20, 2007. uninfected spider bite. 7. Nance WE. Hemolytic anemia of necrotic - Given the simplicity and low cost of antihistamine treatment, ism. Am J Med. 1981;31:801-807. I recommend it for wound care in these instances. If the clinical 8. Russell FE, Waldron WG, Madon MB. Bites by the brown spiders Loxosceles unicolor and Loxosce- response is good within 24 hours, you are probably dealing with an les arizonica in California and arizona. Toxicon. uninfected spider bite. If the response is slow or the wound worsens 1969;17:109-117. after 24 hours, consider adding an antibiotic or performing surgical 9. Atkins JA, Wingo CW, Sodeman WA, et al. Necrotic arachnidism. Am J Trop Med Hyg. 1958;7:165-184. debridement. 10. Auer a, hershey FB. Proceedings: surgery for necrotic bites of the brown spider. Arch Surg. 1974;108:612-618. 11. Rees rs, shack rb, Withers eh, et al. manage- result in the least deformity, minimize ment of the brown recluse spider bite. Plast Recon- cost, and allow for errors in diagnosis str Surg. 1981;68:768-773. without harming patients. 12. Swanson DL, Vetter RS. Bites of brown recluse spi- ders and suspected necrotic arachnidism. N Engl J Based on my observations since 1982, Med. 2005;352:700-707. I am convinced these necrotic wounds in- 13. Barnes jk. brown recluse and mediterranean re- volve an antigen–antibody reaction, are cluse spiders. University of Mu- seum Notes. Revised May 2003; #11. Available at: histamine driven, and are adequately treat- http://entomology.uark.edu/museum/browrec. ed with oral antihistamines. I now treat html. Accessed January 16, 2009. presumed necrotic spider bite with antihis- 14. Hite JL, Gladney WJ, Lancaster JL, et al. Biology of the brown recluse spider. Arkansas Experiment tamines only. Laboratory or serum testing Station Bulletin. 1966; #711. to confirm a diagnosis has not been useful. 15. Klevens RM, Morrison MA, Nadle J, et al. Invasive methicillin-resistant infec- It takes too long, costs too much, and does tions in the united states. JAMA. 2007;298:1763- not contribute to management decisions. 1771.

e vol 58, No 2 / February 2009 The Journal of Family Practice