What are the red flags for insect bites, stings & tick bites in urgent care?

Wheeze, lip/tongue swelling, hypotension, collapse → Anaphylaxis — IM adrenaline now; Pain out of proportion, rapidly spreading, systemically unwell → Necrotising soft-tissue infection; Expanding target-like rash after a tick bite (erythema migrans) → Lyme disease — treat clinically; Bite in the mouth or throat → Airway risk — observe / ED

Which decision rule is used for insect bites, stings & tick bites?

Reaction or infection?: Itch, swelling within 24–48 h, little tenderness → allergic/local reaction (no antibiotics); Increasing pain, heat, spreading after 48 h, fever → infection (treat as cellulitis). NICE NG182: don’t give antibiotics for bites or stings without signs of infection.

What should I prescribe for insect bites, stings & tick bites?

Cetirizine: 10 mg once a day (As needed for itch); Hydrocortisone 1% cream: Apply thinly once or twice a day (not on face without advice) (Up to 7 days); Erythema migrans: doxycycline: 100 mg twice a day (or 200 mg once a day) (21 days (NICE NG95); alternatives per NICE if pregnant/allergic); Infected bite: as for cellulitis: e.g. flucloxacillin 500 mg–1 g four times a day (5–7 days — see the cellulitis page)

Insect Bites, Stings & Tick Bites | Urgent Care Clinic

Q: What safety-netting advice should I give for insect bites, stings & tick bites?

Advise the patient to return or seek help if: Swelling of the face, lips or tongue, wheeze or difficulty breathing — call 999; Redness spreading, more painful, pus, fever; A spreading circular rash in the weeks after a tick bite.

1Rule out first — red flags

If you find…	…then
Wheeze, lip/tongue swelling, hypotension, collapse	Anaphylaxis — IM adrenaline now
Pain out of proportion, rapidly spreading, systemically unwell	Necrotising soft-tissue infection
Expanding target-like rash after a tick bite (erythema migrans)	Lyme disease — treat clinically
Bite in the mouth or throat	Airway risk — observe / ED

2Focused history

What bit/stung, when, where (UK or abroad)
Swelling, itch, pain; timing of redness (reactions peak 24–48 h)
Systemic symptoms: breathing, swelling of face, dizziness, fever
Tick: duration attached, removed?
Previous severe reactions

3Focused examination

Size and character of the reaction; warmth, tenderness, lymphangitis
Obs
Erythema migrans: expanding, often > 5 cm, may be target-like

4Decide — investigate only if it changes the plan

Reaction or infection?

Itch, swelling within 24–48 h, little tenderness → allergic/local reaction (no antibiotics)
Increasing pain, heat, spreading after 48 h, fever → infection (treat as cellulitis)

NICE NG182: don’t give antibiotics for bites or stings without signs of infection.

Investigation	Only if…
None	Lyme serology is not needed to treat erythema migrans

5Treat & send home

Management & advice

Cold compress, elevate, avoid scratching
Oral antihistamine for itch
Tick: remove with fine tweezers close to skin; most bites don’t transmit Lyme

Refer / follow-up

Anaphylaxis → ED, then allergy clinic and adrenaline auto-injectors

℞

Discharge prescription (TTO)Typical adult doses — check the BNF/BNFc, allergies, renal function, pregnancy and interactions.

Drug	Dose	Duration / notes
Cetirizine	10 mg once a day	As needed for itch
Hydrocortisone 1% cream	Apply thinly once or twice a day (not on face without advice)	Up to 7 days
Erythema migrans: doxycycline	100 mg twice a day (or 200 mg once a day)	21 days (NICE NG95); alternatives per NICE if pregnant/allergic
Infected bite: as for cellulitis	e.g. flucloxacillin 500 mg–1 g four times a day	5–7 days — see the cellulitis page

6Safety-net

Say it like this

This is a strong reaction to the bite, not an infection, so antibiotics won’t help. The antihistamine and a cold compress will ease the itch and swelling over the next few days. If your lips or tongue swell or you struggle to breathe, call 999. Come back if it becomes hotter, more painful or you feel feverish.

Come back / call 111 — or 999 if severe — if:

Swelling of the face, lips or tongue, wheeze or difficulty breathing — call 999
Redness spreading, more painful, pus, fever
A spreading circular rash in the weeks after a tick bite

7Patient leaflets — scan & go

Official NHS pages. Ask the patient to scan the code with their phone camera, or tap “Show to patient” to make it full screen.

Insect bites and stingsnhs.uk/conditions/insect-bites-and-stings

8Document

Insect bites, stings & tick bites — clinic note

A structure to document efficiently. It is not a completeness check — use your trust’s system and your clinical judgement.

URGENT CARE — INSECT BITES, STINGS & TICK BITES PRESENTING COMPLAINT: HISTORY What bit/stung, when, where (UK or abroad): Swelling, itch, pain; timing of redness (reactions peak 24–48 h): Systemic symptoms: breathing, swelling of face, dizziness, fever: Tick: duration attached, removed?: Previous severe reactions: RED FLAGS (record present / absent) [ ] Wheeze, lip/tongue swelling, hypotension, collapse [ ] Pain out of proportion, rapidly spreading, systemically unwell [ ] Expanding target-like rash after a tick bite (erythema migrans) [ ] Bite in the mouth or throat PMH: DRUG HISTORY: ALLERGIES: SOCIAL (job / who is at home / driving): OBSERVATIONS: RR SpO2 HR BP Temp (NEWS2 ) EXAMINATION Size and character of the reaction; warmth, tenderness, lymphangitis: Obs: Erythema migrans: expanding, often > 5 cm, may be target-like: DECISION RULE — Reaction or infection?: result ______ INVESTIGATIONS: none required / None — result: IMPRESSION: PLAN Treatment / TTO (drug, dose, duration): Advice given: Leaflet given (QR / printed): Insect bites and stings Follow-up / referral: SAFETY-NETTING (told to return / call 111 / 999 if): - Swelling of the face, lips or tongue, wheeze or difficulty breathing — call 999 - Redness spreading, more painful, pus, fever - A spreading circular rash in the weeks after a tick bite Patient understands and agrees with the plan: Y / N Seen by: Grade: Date/Time:

✓Guidelines

Doses are typical adult doses drawn from the guidance above. Always check the current BNF/BNFc and your local antimicrobial policy.

More wounds, burns & skin

Lacerations & wound careClose it right, check tetanus, and know which wounds aren’t yours.Minor burns & scaldsCool, cover, size it — and know when it goes to the burns unit.Human & animal bitesWho gets prophylaxis, rabies risk and the fight bite.CellulitisOral antibiotics at home or IV? Mark the edges and safety-net.