Acute and recurrent skin ulceration after spider bite
Acute and recurrent skin ulceration after spider bite
We reviewed the records of the Australian Venom Research Unit and The Alfred Hospital Department of Hyperbaric Medicine from January 1992 to July 1998 and found 15 cases of skin ulceration after spider bite that could be followed up with the patient and the treating physician. Fourteen patients had skin ulceration attributed to white-tailed spider bites but in only three was this confirmed. One patient had skin necrosis after a confirmed black house spider bite. Recurrent skin ulceration occurred in nine of the 15 patients.
Steven J Pincus, Kenneth D Winkel,
Gabrielle M Hawdon and Struan K Sutherland
MJA 1999; 171: 99-102
See also White
Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details
- - More articles on Insects, bites and stings
|Introduction|| Spider bite is the single commonest reason for inquiries to the Victorian Poisons Information Centre, with over 1300 calls recorded in 1997.1 Most people with spider bite require no specific treatment and suffer only minor symptoms, but a small number develop necrotic skin lesions associated with significant morbidity.2-4 One series reported no significant illnesses in 36 bites,5 and only seven definite cases of skin necrosis after spider bite have been published in Australia.3,4,6,7 This paucity of reports has led to debate as to the ability of Australian spiders to cause skin necrosis (necrotising arachnidism). |
We performed a retrospective analysis of case records of suspected necrotising arachnidism in Australia to better define its clinical features and to compare it with loxoscelism, a well-recognised cause of skin ulceration in the Americas.
|Methods|| Patients were identified from records of inquiries from clinicians between January 1992 and July 1998 held by the Australian Venom Research Unit and cases referred to the Hyperbaric Unit of the Alfred Hospital, Melbourne. Initial case-finding criteria were a history of spider bite with subsequent ulceration or necrosis at the bite site. Only cases in which both the patient and primary treating doctor were contactable by telephone were included (with the informed consent of both patient and doctor). |
In the patient interview we asked for demographic details, the method of identification of the spider, details of ulcerative or necrotic lesions and any other related problems, treatment, outcome details and relevant past medical history. This information was confirmed with the patient's doctor, who was also asked about details of investigations, treatments and outcomes.
|Results||Fifteen cases were identified from more than 600 patients with skin lesions but without confirmed spider bite. In 14 cases (Box 1) the spider was said to be a white-tailed spider (Lampona species) but in only three cases was this identification confirmed. One case involved two black house or black window spiders (Badumna species; see Box 2). |
All of the spider bites were to the limbs, and involved blistering, ulceration or necrosis of the skin. Thirteen were described as painful. Five patients experienced ongoing disability, and one required amputation of the hand and distal forearm. Four of the 15 patients experienced systemic symptoms (fever), and three had ulcers that were culture-positive for Staphylococcus species (one positive for Streptococcus species also). Nine patients had recurrent lesions, involving recurrent breakdown or blistering of the skin after healing, or breakdown of skin grafts used to treat non-healing ulcers.
Oral or intravenous antibiotics (including doxycycline, penicillin or flucloxacillin) were given to 14 patients. Other treatments included dressings, antihistamines, topical and oral corticosteroids, hyperbaric oxygen therapy and skin grafting.
|Discussion|| A major difficulty in the clinical study of spider bite is accurately identifying the spiders involved. Our series included 11 cases in which a spider was witnessed to bite the patient but was not captured for identification, one case where the spider was captured and identified by a clinician, and three cases where the spider was captured and identified by an expert arachnologist. White-tailed spiders are distinctive, but in most of these cases absolute attribution to Lampona is not possible. Window spiders are relatively nondescript, and therefore less likely to be correctly identified unless captured and formally identified by an arachnologist. |
Four cases of skin loss attributed to bites from Lampona have been previously reported.3,4,7 Two of these (Cases 54 and 137) are included in this study, as both patients were reported to the AustralianVenom Research Unit independently.
Several cases of bites from Badumna species have been published. These patients mostly experienced significant sickness, without skin loss.2,8 Some skin loss was reported in the case of a male black house spider bite.6 The case presented here (Box 2) is the first to link the female spider to skin necrosis.
It has been suggested that many cases of suspected necrotising arachnidism in Australia may be the result of bites from spiders of the genus Loxosceles, a group associated with necrotising arachnidism on several continents.9 While it is probable that some Australian cases of necrotising arachnidism might be attributed to this spider, it would be difficult to implicate Loxosceles in the cases reported here.
The lesions reported in this series show similarities but also significant differences from those caused by Loxosceles. As with Loxosceles, the initial bite appears to be relatively painless, with pain developing over the next 12-24 hours, accompanied by local erythema and oedema, then blister formation and ulceration.10 However, Loxosceles produces a deep ulcer, with a rolled edge and necrotic base, extending into and sometimes through subcutaneous fat to expose underlying muscle.10,11 By contrast, most ulcers reported here were superficial, being confined to the epidermis and dermis. Another important difference appears to be the site of bites that progress to significant ulceration. Significant Loxosceles lesions occur in areas of abundant subcutaneous fat, with involvement extending beyond the margins of the skin necrosis.11 The lesions reported here occurred in areas of little or no subcutaneous fat.
An infectious aetiology has been proposed for necrotising arachnidism in Australia,12 but the concept that Mycobacterium ulcerans might be such an agent13 was subsequently challenged.14Bacillus, Staphylococcus and Penicillium species have been cultured from several spider venoms, including that of a Lampona species.14 Only three of the 15 patients in our series had ulcers which grew any microorganisms, but, as 14 patients had been treated with antibiotics, infective organisms may have been cleared before cultures were prepared. However, the absence of cultured organisms and poor clinical response to antibiotic therapy seen in many patients suggests that this condition is more complex than simple skin infection.
Nine of the 15 patients in our case series had recurrent ulceration. This problem had not been reported in Australia until very recently.7 There are several American reports of lesions attributed to Loxosceles that have resulted in chronic non-healing ulcers and recurrent ulceration. These were felt to be secondary to induction of a pyoderma gangrenosum-like disease process.15 Pyoderma may follow a minor injury and may be aggravated by surgery.16 It is typically associated with systemic immune abnormalities, but up to 50% of cases are described as "idiopathic". Spider bite may act as a trigger to precipitate this condition in susceptible individuals.
Several patients in our case series had histological findings consistent with pyoderma, and surgical intervention may have been associated with a poorer outcome. Although no patient in this series received corticosteroids at the doses recommended for pyoderma, long term topical corticosteroids may have slowed progression of the lesion in case 14. Prospective study of the value of this treatment in cases of necrotising arachnidism should be considered.
Management of necrotising arachnidism remains an area of debate, and there is limited information upon which to make recommendations for the Australian situation.
At least for Loxosceles envenomations, conservative management appears to be the best primary treatment. This should include tetanus prophylaxis and routine wound care. Early ice water application to bites is recommended to counter inflammation. Initial studies proposed early excision and grafting of ulcers,11 but more recent experience suggests that this may worsen the lesion and delay healing.17
Hyperbaric oxygen therapy is gaining popularity in general wound management. Animal models have produced conflicting results on the value of this type of treatment for Loxosceles lesions.18,19 Treating ulcers attributed to Lampona bites with hyperbaric oxygen therapy appears to have a marked clinical benefit.4
|We thank Mr Albert Ong, of the Pathology Department, Gladstone Base Hospital, for permission to reproduce his photograph of a patient, Dr Robert Raven and Mr Phil Lawless of the Arachnology Department of the Queensland Museum, and Ms Catriona McPhee and Dr Ken Walker of the Museum of Victoria for spider identification and photographs, and Dr Ian Miller, Director of the Hyperbaric Unit at the Alfred Hospital in Melbourne, for assistance in collecting patient information. This study would not have been possible without the assistance of the many other clinicians and patients involved. We thank the Victorian Department of Human Services, CSL Limited, BHP Community Trust and Snowy Nominees for financial support, and Dr Anna Young and Dr Tony Pennington for helpful discussion.|
(Received 19 Oct 1998, accepted 1 Jun 1999)
|Authors' details|| Australian Venom Research Unit, Department of Pharmacology, The University of Melbourne, VIC.|
Steven J Pincus, MB BS, BSc(Hons), Research Registrar.
Kenneth D Winkel, MB BS, FACTM, Director.
Gabrielle M Hawdon, MB BS, MPH, Deputy Director.
Struan K Sutherland, MD DSc, Honorary Principal Fellow.
Reprints: Dr K D Winkel, Australian Venom Research Unit, Department of Pharmacology, The University of Melbourne, Parkville, VIC 3052.
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Everything You Should Know About Papular Urticaria
Papular urticaria is an allergic reaction to insect bites or stings. The condition causes itchy red bumps on the skin. Some bumps can become fluid-filled blisters, called vesicles or bullae, depending on size.
Papular urticaria is more common in children between the ages of 2 and 10. It can affect adults and children at any age, however.
Keep reading to learn more about this condition.
Papular urticaria usually appears as itchy, red bumps or blisters on top of the skin. Some blisters can appear in clusters on the body. The bumps are usually symmetrically distributed, and each bump is usually between 0.2 and 2 centimeters in size.
Papular urticaria can appear on any part of the body. The bumps and blisters can disappear and reappear on the skin. After a blister disappears, it sometimes leaves behind a dark mark on the skin.
Symptoms usually appear in the late spring and summer. The lesions of papular urticaria can last for days to weeks before clearing up. Since the rash can disappear and reappear, symptoms can recur for weeks or months. The bumps can reappear because of new insect bites and stings, or continued environmental insect exposure.
Sometimes secondary infections appear because of scratching. Scratching the itchy bumps and blisters can break open the skin. That increases your risk for infection.
The condition is more common among children between the ages of 2 and 10. Papular urticaria is not as common among adults, but it can occur in anyone.
See a doctor
You may want to see a doctor so that they can rule out other medical conditions. Your doctor may do a skin examination or skin biopsy to determine the cause of the bumps and blisters.
If a secondary infection is present because of scratching, then it may be necessary to see a doctor immediately.
Several treatment options are available for papular urticaria. Most of them address the symptoms of the condition.
Medications your doctor may prescribe or recommend include:
- topical steroids
- oral anti-inflammatory corticosteroids
- systemic antihistamines
- topical or oral antibiotics
Over-the-counter options include:
- calamine or menthol lotions and creams
- oral antihistamines
These treatment options may be appropriate for children. Talk to your doctor about treatments that are safe for your child. Your doctor can also help you determine the correct dosage.
You can take several measures to prevent papular urticaria from occurring. The first is to eliminate the source of the problem. The second is to regularly check for insect infestations and treat them.
- Use pesticide and insecticide treatments to reduce populations of mosquitoes and other insects around your house.
- Use flea control medications and treatments on pets and livestock.
- Use bug sprays on children and adults that are safe and recommended by a doctor.
- Wear protective clothing when outside or in areas with large insect populations.
- Limit the amount of time you spend in areas with a lot of insects.
- Consider using insecticide-treated bed nets and clothing in areas with many mosquitoes.
- Eliminate bed bug infestations in the home.
- Regularly inspect pets and livestock for fleas and mites. Take immediate action to treat them.
- Give pets frequent baths.
- Wash all bedding and cloth items that pets sleep on to reduce risk for infestations.
- Vacuum the entire indoor area of your home to pick up fleas, flea eggs, and other insects. Carefully dispose of the vacuum bags to avoid reintroducing the insects into the environment.
- Avoid keeping chickens or pet birds in the home because of the risk of mites.
Learn more: How to get rid of fleas »
Papular urticaria is likely to recur. The condition can return because of continued exposure to the allergen. Children can sometimes outgrow it by building a tolerance.
After repeated exposure, the reactions may stop. This varies from person to person, and it can take weeks, months, or years to stop.
Papular urticaria is not a contagious disease. It usually appears as itchy, red bumps and blisters on the skin after an insect exposure. There are several treatment options for the symptoms, but the condition can resolve on its own over time.
How to identify papular urticaria
Papular urticaria is the medical term for an allergic skin reaction or hypersensitivity to insect bites. The word papule refers to a solid bump on the skin. Urticaria is another word for hives, which are round, red welts on the skin that itch severely.
One unique characteristic of this skin disorder is that scratching an area affected by a bug bite can trigger the inflammation of old bites. As a result, it can appear as though there are more new bites than there really are.
Symptoms and appearance
The symptoms of papular urticaria include numerous reddened skin bumps, which usually appear in clusters. The bumps tend to be around 1/12 to 3/4 of an inch in diameter.
At times, the bumps may form scabs or fluid-filled blisters.
The bumps may appear in a curve shape, or in a line, particularly when caused by bed bugs or fleas.
These bumps erupt every few days. They appear most often on the legs, forearms, and face, but have been known to occur in small clusters all over the body.
Some people may notice a central and very small round spot differing in color and appearance from the surrounding tissues. This kind of spot is known as a punctum.
As the result of continuous bug bites, an increase or decrease in the color of the skin may occur.
This type of skin breakout is long-term and comes back repeatedly
The skin bumps are usually accompanied by intense itching, which can lead to severe infections and scarring from constant scratching. When the bumps are scratched, they may become infected, painful, and can become full of pus.
Each bump usually remains on the skin for a few days and up to several weeks.
Causes and risk factors
The most prevalent types of insect bites involved in the disorder come from fleas and mosquitoes.
Other insects that have been known to cause papular urticaria include:
- carpet beetles
- bed bugs
- bird mites
- insects that live in masonry
- other insects
A recent study of 2,437 children, published in the , revealed that 20 percent of the children in the study had papular urticaria.
In 50 percent of the children, fleabites caused the condition. Other major risk factors identified in the study included:
- presence of fleas in the home
- having household pets
- using a mattress without springs
- daily use of public transportation
- living in a warm, tropical climate
- living in a geographic area heavily infested with insects
- having siblings with a history of atopic dermatitis
- being aged under 7 years
- being raised in poverty
Sometimes, symptoms of papular urticaria improve when a family takes a vacation or moves to a new home. When this happens, it suggests that the cause of the problem is most likely an infestation in the living environment.
Papular urticaria in children
Although adults can be affected, papular urticaria is more common in children than in adults. It most commonly occurs in children aged from 2 to 7 years.
Children often outgrow the disease because they become desensitized, which is a process of becoming immune to an allergen after repeated exposure.
When to see the doctor
As soon as a person detects signs and symptoms, it is time to see a healthcare professional. They might carry out some testing to rule out other causes of the itchy bumps and prescribe medication to treat the symptoms.
More serious diseases might be the underlying cause of skin bumps. These include:
It is essential to visit the doctor who can rule out other, more serious disorders.
Treatment and prevention
There are several ways of treating papular urticaria. A person who has the condition can take the following steps:
- Apply moderately strong steroid cream to the effected itchy spots right away.
- Take oral antihistamine medication at night to reduce itching and promote sleep.
- Apply antibiotic cream or give oral systemic antibiotics to treat or prevent secondary infection caused by scratching.
- Cover exposed skin and use an insect repellent when outside.
It is also important to get rid of the source of the infestation that has caused the problem. People who want to remove an infestation can take the following steps:
- Treat all household pets with flea medication.
- Treat pet bedding with flea spray.
- Spray the home, classroom, or bus with insecticide, being sure to follow instructions carefully.
- Treat carpets and upholstery with a pyrethroid spray, being sure to vacuum afterward.
- Check mattresses for signs of bed bugs.
- Contact certified pest control agency to treat bed bug infestations.
To recap, the three most common appearances of papular urticaria are:
- small, raised red patches on the skin that may or may not be fluid-filled
- bumps appearing mostly in clusters, that erupt at old insect bite sites
- itchy bumps that may last from several days to several weeks
Papular urticaria is a preventable condition. The best way to prevent popular urticaria is to implement a plan to control the presence of fleas and other insects in the home, classroom, and on public transport.
Over time, most children and adults will eventually become desensitized to papular urticaria.
White-tailed Spider. © Australian Museum
The white tailed spider (Lampona cylindrata) is commonly found in homes throughout Australia. It tends to hide in bedding, or within clothes left on the floor.
Occasionally, weals, blistering or local ulceration have been reported – symptoms together known medically as necrotising arachnidism, although recent research suggests that the white tailed spider bite is probably not linked to this condition.
In most cases, the bite from a white tailed spider only causes a mild reaction, including itching and skin discolouration, which usually resolves after a few weeks. There are no specific first aid treatments for a white tailed spider bite, except the use of icepacks to help relieve the swelling. You should not use antibiotics. Always see your doctor if any spider bite does not clear up.
Seek advice from your local council or a professional pest control operator on how to eliminate the white tailed spider from your home.
Characteristics of the white tailed spider
The characteristics of the white tailed spider include:
- Having a cylindrical body.
- Being from 1 cm to 2 cm in length.
- Being dirty grey to brown colour.
- Having glossy legs.
- A characteristic light coloured grey or white spot at the ‘tail’.
- That two similar spots near the front of the body may also be present.
Hiding spots for white tailed spiders
The white tailed spider is found in homes throughout Australia. It tends to be more active during summer. Favourite hiding spots include:
- Towels or clothes left on the floor.
- Nooks and crannies.
- Beneath mulch, leaves and rocks.
- Beneath tree bark.
Symptoms of a white tailed spider bite
Bites can occur anywhere on the body, but most often on arms and legs. The symptoms of a white tailed spider bite can include:
- Localised irritation, such as a stinging or burning sensation.
- A small lump.
- Localised itchiness.
- Discolouration of the skin.
- Ulceration of the bite (in some cases).
- Nausea and vomiting (in some cases).
First aid for a white tailed spider bite
Always try to keep the spider for identification purposes if you have been bitten. First aid suggestions to treat a white tailed spider bite include:
- Apply an icepack to help relieve swelling.
- See your doctor if the skin starts to blister or ulcerate.
Necrotising arachnidism is a type of skin inflammation and ulceration that is caused by the bite of some spiders. Occasionally, the reaction is so severe that the person loses large amounts of skin and needs extensive skin grafts.
The white tailed spider and the black house spider, also found in Australia, have both been linked to necrotising arachnidism. However, a study published in the Medical Journal of Australia in 2003 examined 130 confirmed cases of white tailed spider bites and found that none had caused necrotising arachnidism. The study found most bites happened indoors, in warmer months and at night. In two thirds of cases, the spider was caught in bedclothes, towels or clothing. Most bites were painful, with some redness and itching. Nearly half the cases had a persistent, painful red lesion, but none of the lesions were found to be necrotic.
There is no confirmed cause of necrotising arachnidism. It is unclear why most people who are bitten have only mild reactions, while a very tiny minority suffers from skin ulceration. Researchers are divided, but current theories on the causes of necrotising arachnidism include:
- Mistaken identity – some researchers believe that white tailed spider bites aren't capable of causing skin ulceration and suggest that other spiders or other factors are to blame.
- Misdiagnosis – in rare cases, a diagnosis of necrotising arachnidism has later been found to be another condition.
- Pre-existing medical conditions – various immune system disorders or problems with the circulatory system may predispose a person to necrotising arachnidism.
Localised skin breakdown, loss and death (necrotic lesions) can be caused by a range of other factors, including:
- Poor blood circulation (one of the most common causes of leg ulcers).
- Unmanaged diabetes.
- Some fungal infections.
- Some bacterial infections.
- Burns, such as chemical burns.
Treatment for necrotising arachnidism
There is no cure for necrotising arachnidism. Treatment includes:
- Medications – including antibiotics and cortisone medication (corticosteroids).
- Hyperbaric oxygen therapy – oxygen delivered at higher than usual intensity and pressure.
- Surgery – the dead skin is removed and a skin graft applied.
Pest control treatment for white tailed spiders
Most white tailed spider bites occur inside the home where the spiders are found in bedding, towels or clothing. White tailed spiders prey on other spiders, and may help to control the population of other venomous spiders. You can control white tailed spiders in the house by clearing rooms of the webs of other spiders that attract the white tailed spider.
If you are concerned about spiders in the home, contact a qualified pest control operator.
Where to get help
Things to remember
- The white tailed spider is commonly found in homes throughout Australia.
- Most bites occur indoors, at night and in warmer months.
- The bite of a white tailed spider can be painful, but is unlikely to cause necrotising arachnidism, a rare condition characterised by ulceration and skin loss.
Same spot recurring spider bite
Infected Sores That Are Not From Spider Bites
Bites on Both Feet? Probably Not.
Ivonne H. shared this picture of her mother's tissue damage following what the family believes were brown recluse spider bites. According to Ivonne, her mother was bitten twice; on one foot while in Alaska and on the other while in Utah.
With the first bite, Ivonne says her mom felt a sharp pain and ignored it, thinking it was a lost needle in the carpet. She began feeling pain in her leg and went to a healthcare provider who diagnosed it as "weather-related."
After a while, the pain got worse and the damage became visible. Ivonne say the wound looked like a "colander." Eventually, part of her mother's right foot had to be amputated.
But Were They Spider Bites?
Reading Ivonne's account of her mother's struggle, it's not clear whether a spider had anything to do with the wound.
Ivonne says her mom had diabetes, which often leads to circulation problems that are especially bad in the feet and legs. Many people with diabetes suffer from cellulitis (inflamed skin cells) that can get bad enough to need amputation.
Another cause for skepticism is the claim of two separate spider bites, one on each foot. Spider bites are rare; brown recluse bites are even rarer yet.
The odds of getting a brown recluse bite on one foot in Alaska followed by a brown recluse bite on the other foot in Utah—when neither state is in the brown recluse's known habitat—are extremely small.
Staphylococcus aureas and group A streptococcus both cause skin infections that are regularly mistaken for spider bites. Combined with the increased risk of foot infections in diabetes, it's a perfect storm for bilateral (both right and left) tissue damage of the type in the picture.
Whether caused by spider bites or skin infections, wounds like these are painful and dangerous. It's important to seek medical attention when a wound starts to form. Your healthcare provider may be able to identify the cause and treat it.
I tried it, at first it hurt, but after a couple of minutes it goes away and the buzz remains to heaven. I don't suffer from this. If she suffered, she would have lured the men to her room for a long time. And you, Len.
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Well, as usual, I met my school friends. We ordered a sauna, collected snacks, alcohol. It was decided to abandon the girls so that no one and nothing would distract from cultural communication. At the appointed hour, four school friends arrived at the scene. Ahead loomed four hours of unrestrained drunkenness and relaxation in the bath.