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Insect and other arthropod bites

AUTHORS: Jerome Goddard, PhD, Patricia H Stewart, MD
SECTION EDITORS: David BK Golden, MD, Daniel F Danzl, MD, Ted Rosen, MD
DEPUTY EDITORS: Anna M Feldweg, MD, Elinor L Baron, MD, DTMH

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jan 2024.

This topic last updated: Sep 26, 2023.

INTRODUCTION

The bites of insects and other arthropods may be a minor nuisance or may lead to serious
medical problems, including transmission of insect-borne illnesses and severe allergic
reactions. Reactions to the bites of mosquitoes, ticks, black flies, horse and deer flies, sand
flies, stable flies, biting midges, fleas, centipedes, and biting mites are discussed in this topic
review. Infectious diseases transmitted by mosquitoes, ticks, fleas, kissing bugs, and sand
flies are discussed in detail separately.

● Insect bites are different from insect stings. Stings involve the injection of venom into
the victim and may cause reactions ranging from local irritation to life-threatening
anaphylaxis. The medical consequences of the most common insect stings are reviewed
separately. (See "Bee, yellow jacket, wasp, and other Hymenoptera stings: Reaction
types and acute management" and "Stings of imported fire ants: Clinical
manifestations, diagnosis, and treatment" and "Scorpion envenomation causing
neuromuscular toxicity (United States, Mexico, Central America, and Southern Africa)".)

● Spider bites are mentioned briefly here and discussed in greater detail separately. (See
"Diagnostic approach to the patient with a suspected spider bite: An overview" and
"Bites of recluse spiders" and "Widow spider bites: Clinical manifestations and
diagnosis" and "Widow spider bites: Management".)

● Contact with caterpillars and moths can also cause dermatitis and even allergic
reactions in humans in the absence of a bite or sting, as discussed separately. (See
"Lepidopterism: Skin disorders secondary to caterpillars and moths".)

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OVERVIEW OF ARTHROPOD BITES

Most arthropods are insects, but the phylum Arthropoda also includes spiders, centipedes,
and crustaceans.

Host (human) factors — There is some evidence that specific host factors may predispose
individuals to increased arthropod biting. Analyses of the distributions of transmission rates
of insect-borne infections indicate that, typically, 20 percent of the host (human) population
is responsible for approximately 80 percent of disease transmission by blood-sucking insects
[1]. Possible factors that attract mosquitos specifically include blood type, metabolic rate,
amount of CO2 released, body temperature, clothing types and colors, and varying amounts
of volatile organic compounds (VOCs) emanating from human skin [2-5]. In addition, the less
defensive the host, the higher the probability that the insect will be successful in achieving
the desired high quantity of blood needed for its meal. Thus, the presence of ketones or
lactic acid, signaling a malnourished, weakened, or physically exhausted host, serves as an
attractant. Whether specific dietary components alter host attractiveness is largely
unexplored, although one study showed that eating bananas may increase attraction of
certain Anopheles mosquitoes [6].

Mechanisms of injury — Arthropod bites consist of punctures made by the mouthparts of

the offending organism. The word "bite" probably should be restricted in meaning to
purposeful biting by a species for catching prey or blood feeding and not to accidental biting
by plant-feeding (phytophagous) insects. Phytophagous and predaceous insects sometimes
"bite" in self-defense, piercing the skin with their proboscis, but the injury is actually just a
simple stab wound and rarely has noticeable consequences.

Arthropod bites result in minimal mechanical injury to human skin. Lesions instead result
from the host's immune reactions to the arthropod's salivary secretions or venom. In
addition, atopic individuals may develop hypersensitivity to antigens found in arthropod
saliva.

Arthropod saliva is injected while feeding for a variety of reasons:

● Lubrication of mouthparts to aid insertion

● Increased blood flow at the bite site
● Anesthesia at the bite site
● Interference with blood coagulation
● Suppression of host immune and inflammatory responses
● Enhanced digestion

Mouthpart types — There are two methods of obtaining blood by arthropods. Some
groups, such as mosquitoes, bed bugs, kissing bugs, and sucking lice, obtain blood directly
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from capillaries or small veins: a method called "solenophagy." Others, such as ticks, horse
flies and deer flies, black flies, and biting midges, obtain their blood by lacerating blood
vessels and feeding from the resulting pool of blood: a method termed "telmophagy."

There are several types of insect mouthparts that can be generally grouped into three broad
categories: piercing-sucking, chewing, and sponging. Within these categories, there are all
sorts of adaptations and specializations among the various insect orders ( figure 1).
Piercing-sucking mouthparts, especially the bloodsucking types, are most important in
human bites, while chewing (common in beetles and cockroaches) and sponging mouthpart
types are of little significance to human health.

Arthropods that bite humans — Arthropods that commonly bite humans include [7]:

● Mosquitoes (see "Malaria: Epidemiology, prevention, and control", section on 'Mosquito

life cycle')

● Ticks (see "Evaluation of a tick bite for possible Lyme disease")

● Kissing bugs (see "Reactions to bites from kissing bugs (primarily genus Triatoma)")

● Bed bugs (see "Bedbugs")

● Black flies

● Horse and deer flies

● Sand flies

● Stable flies

● Biting midges

● Fleas

● Centipedes

● Biting mites

● Chiggers (see "Chigger bites")

● Lice (see "Pediculosis capitis" and "Pediculosis corporis" and "Pediculosis pubis and
pediculosis ciliaris")

● A small number of types of spiders (see "Diagnostic approach to the patient with a
suspected spider bite: An overview" and "Bites of recluse spiders" and "Widow spider
bites: Management" and "Widow spider bites: Clinical manifestations and diagnosis")

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TYPES OF REACTIONS

Insect bites may result in several types of local reactions, papular urticaria, or systemic
allergic reactions. Rarely, other forms of systemic reactions occur, such as serum sickness [8].

Local reactions — The normal reaction to an insect bite is an inflammatory reaction at the
site of the punctured skin, which appears within minutes and consists of pruritic local
erythema and edema. A single punctum may be visible. Dual puncta can be seen with spider
bites and centipede envenomations. Symptoms usually subside within a few hours. Local
reactions are caused by irritant substances concentrated in insect saliva (eg, anticoagulants
such as factor Xa inhibitors, digestive enzymes such as amylases and esterases, agglutinins,
and mucopolysaccharides) [9]. In some cases, a local reaction is followed by a delayed skin
reaction consisting of local swelling, itching, and redness.

Treatment — Insect bites and local reactions should be washed with soap and water.
Reduction of local edema may be induced with cooling (ice or cold pack). Topical creams,
gels, and lotions, such as those containing calamine or pramoxine, can be helpful in reducing
pruritus, if necessary. However, routine use of topical anesthetic and antihistamine
preparations should be avoided because they can sensitize the skin following sun exposure
and induce allergic contact sensitivity [10].

Minimally sedating oral antihistamines (eg, cetirizine or fexofenadine, once or twice daily)
may be helpful for patients with troublesome itching and are preferred over sedating agents,
particularly in small children. However, the sedating agent hydroxyzine (hydrochloride or
pamoate; 10 to 25 mg every four to six hours, as needed) may be helpful for controlling
persistent pruritus in adults, perhaps largely due to the sedating effects. H1 and H2
antihistamines (eg, famotidine) may be used concurrently.

Concurrent use of oral H1 antihistamines and topical antihistamines applied over large
surface areas should be avoided because this combination can cause systemic
anticholinergic toxicity and topical antihistamines can induce contact hypersensitivity from
application of the medication, precluding future systemic administration of the H1
antihistamine.

Dramatic local swelling and induration can be reduced with a brief course of oral
glucocorticoids, although this should be reserved for severe cases.

Unusual local reactions

● Uncommonly, local reactions evolve to become vesicular ( picture 1), bullous

( picture 2 and picture 3), or necrotic ( picture 4) [11,12]. Patients should
maintain good hygiene and avoid scratching to prevent infection.

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• Bullous reactions have been reported with bed bug and other arthropod bites (see
"Bedbugs"). Bullae should be kept clean as they heal, and, if lesions persist, they
may be treated with topical corticosteroids [12]. They may warrant additional
workup to rule out other bullous disorders. If the arthropod bite has resulted in
longstanding bullous lesions with tissue eosinophilia, the diagnosis of eosinophilic
cellulitis should be considered [13].

• Necrotic lesions most commonly result from the injection of venom, which occurs
with some spider bites and centipede bites. Treatment of spider bites is discussed
elsewhere. (See "Bites of recluse spiders", section on 'Treatment'.)

● Immunocompromised patients and those with certain lymphoproliferative disorders

(eg, acquired immunodeficiency syndrome, Epstein-Barr virus-related NK
lymphocytosis) may develop severe local reactions [11,14-18]. In such patients, lesions
can progress to become necrotic or may be accompanied by systemic symptoms,
including lymphadenopathy and fever. However, bite-like lesions may also arise
spontaneously in patients with these disorders, a condition called eosinophilic
dermatoses of hematologic malignancy (EDHM) [19]. (See 'Differential diagnosis'
below.)

Papular urticaria — Papular urticaria is a hypersensitivity disorder in which insect bites,

most often those of fleas, mosquitoes, or bed bugs, lead to recurrent and sometimes
chronic, itchy papules on exposed areas of skin (eg, arms, lower legs, upper back, scalp)
[20,21]. The 0.5 to 1 cm lesions may be urticarial at the start of the syndrome but become
persistent and papular and/or nodular with time ( picture 5 and picture 6).

Papular urticaria is reported predominantly in young children (typically 2 to 10 years of age).

The diaper/underwear areas, genital, perianal, and axillary areas are spared [22]. The
diagnosis of papular urticaria is made clinically, although there may be a delay between the
inciting bite(s) and the onset of lesions, or insect bites may not have been noticed at all [22].
Usually, only one child in a family is affected, a clue that infestation at home is unlikely. New
lesions may appear sporadically, and renewed itching may reactivate older lesions, leading to
a chronic and cycling disorder that may last from months to years.

Treatment — Management of papular urticaria includes selective and limited use of

nonsedating antihistamines for pruritus, midpotency topical corticosteroids applied to
individual lesions, and reassurance, as the disorder eventually resolves spontaneously [22].

Systemic allergic reactions — Systemic allergic reactions to insect bites are uncommon but
have been described in response to the bite of Triatoma (kissing bugs), mosquitoes, ticks,
black flies, deer flies, horse flies, and centipedes [23-28]. Reactions to Triatoma are reviewed

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in more detail separately. (See "Reactions to bites from kissing bugs (primarily genus
Triatoma)".)

Patients with mast cell disorders may present with severe systemic allergic reactions
following insect bites [29,30]. Reactions can result following insect bites, stings of
Hymenoptera insects, and a variety of other triggers, which cause widespread activation of
mast cells with prominent flushing and hypotension. In patients with hypotension in
response to an insect bite or sting, a serum total tryptase can be obtained to screen for mast
cell disorders. Patients with tryptase levels above 5 to 8 ng/mL are at risk for severe and/or
systemic reactions to Hymenoptera and insects, even in the absence of systemic
mastocytosis [31,32]. (See "Mast cell disorders: An overview" and "Mastocytosis (cutaneous
and systemic) in adults: Epidemiology, pathogenesis, clinical manifestations, and diagnosis".)

Treatment — Anaphylaxis associated with insect bites needs to be treated promptly with
epinephrine. Patients who have experienced systemic reactions should be supplied with an
epinephrine autoinjector and instructed in how and when to use it. (See "Anaphylaxis:
Emergency treatment", section on 'Discharge care' and "Prescribing epinephrine for
anaphylaxis self-treatment".)

Referral to an allergy specialist should be facilitated whenever possible. Allergy specialists

are able to assess the patient's clinical history to assure that the correct trigger for the
allergic reaction has been identified and, in some cases, perform confirmatory testing. For
patients who have suffered anaphylaxis, allergists are able to provide effective training in the
self-injection of epinephrine.

Other systemic reactions — Occasionally, patients develop systemic reactions of uncertain

pathogenesis to insect bites that cause minimal symptoms in most individuals. As an
example, a Japanese report described two patients with local skin reactions, fever, fatigue,
nausea, anorexia, and hepatosplenomegaly in response to mosquito bites [33]. These
sporadic reactions likely result from factors unique to the patient.

DIFFERENTIAL DIAGNOSIS

Several dermatologic disorders can present with flattened lesions or scattered inflammatory
papules that may resemble arthropod bites.

● Folliculitis – Superficial folliculitis is characterized by small, follicularly based

inflammatory papules and pustules ( picture 7A-B). Cultures taken from pustular
lesions are useful for identifying causative organisms. (See "Infectious folliculitis".)

● Herpes zoster – Very limited cases of herpes zoster involving just a few papules or
vesicles can mimic insect bites. When the clinical presentation is uncertain, laboratory
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confirmation of varicella zoster virus is indicated, and polymerase chain reaction (PCR)
testing can be performed on a lesion of any stage. (See "Epidemiology, clinical
manifestations, and diagnosis of herpes zoster", section on 'Approach to diagnosis'.)

● Lymphomatoid papulosis – Lymphomatoid papulosis is an uncommon, chronic,

recurrent skin disorder that presents with red-brown papules or nodules that typically
persist for several weeks ( picture 8). Lesions are often asymptomatic and may be
crusted, necrotic, or hemorrhagic. Progression to mycosis fungoides, anaplastic large
cell lymphoma, or Hodgkin lymphoma occurs in a minority of patients. The diagnosis is
confirmed via skin biopsy. (See "Lymphomatoid papulosis".)

● Eosinophilic dermatoses of hematologic malignancy (EDHM) – Lesions resembling

insect bites may arise spontaneously in patients with a variety of hematologic
malignancies, with most reports in patients with chronic lymphocytic leukemia [14].
Proposed diagnostic criteria involve persistent and pruritic papules, plaques, nodules,
or blisters with eosinophilic infiltration on histopathology and no other identifiable
cause of tissue eosinophilia. (See "Eosinophilic cellulitis (Wells syndrome)", section on
'Differential diagnosis'.)

● Pityriasis lichenoides et varioliformis acuta (PLEVA) – PLEVA is a rare, benign skin

disease that presents with recurrent crops of inflammatory papules ( picture 9).
Lesions may demonstrate ulceration, vesiculation, pustulation, or crusting. Skin
biopsies assist with diagnosis. (See "Pityriasis lichenoides et varioliformis acuta
(PLEVA)".)

● Erythema multiforme – Raised, targeted lesions, often symmetrical, sometimes with a

central blister on the limbs, can be confused with arthropod bites ( picture 10). (See
"Erythema multiforme: Pathogenesis, clinical features, and diagnosis".)

● Drug use – Chronic abusers of amphetamine and cocaine may experience formication
(a feeling that ants are crawling on the skin) and can present with self-inflicted skin
lesions from an imaginary infestation ( picture 11). (See "Methamphetamine: Acute
intoxication".)

● Delusional infestation – Patients with delusional infestation (also called delusions of

parasitosis) believe that they are being bitten by imaginary insects or mites. The skin
may be excoriated and scabbed from efforts to remove the offending insects. (See
"Delusional infestation: Epidemiology, clinical presentation, assessment, and diagnosis"
and "Treatment of delusional infestation".)

SPECIFIC ARTHROPOD BITES

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Mosquitoes — The most commonly occurring insect bites are inflicted by mosquitoes, of the
family Culicidae (order Diptera). The genera Anopheles, Culex, Aedes, and Psorophora are
usually responsible for human bites. Only female mosquitoes feed on blood ( picture 12).
Mosquitoes may be found near their breeding sites, which include a wide variety of stagnant
water sources, since they need an aquatic environment to complete their life cycle. (See
"Malaria: Epidemiology, prevention, and control", section on 'Mosquito life cycle'.)

Local reactions — Local pain, pruritus, and erythema are typical after mosquito bites
( picture 13). Common reactions include an immediate wheal-and-flare response that
peaks at approximately 20 minutes and/or an indurated pruritic papule that peaks at two to
three days and resolves over the ensuing days to weeks [34]. Sometimes, large indurated
lesions may occur ( picture 14).

Some people, particularly young children, can develop very dramatic swelling surrounding
the site of the bite, heat, redness, itching, and pain, which may be accompanied by low-grade
fever [35]. This has been termed "Skeeter syndrome" and can be mistaken for and treated as
cellulitis [36]. However, large local reactions develop within hours after a bite, while cellulitis
develops over days. In many patients, these exaggerated local reactions improve with age,
presumably due to natural desensitization, and can be managed with prophylactic
antihistamines during the summer months [37,38]. (See "Allergic reactions to mosquito
bites", section on 'Differential diagnosis'.)

There are reports of more severe local reactions including ecchymotic, vesiculated, blistering,
bullous, and Arthus reactions, which may linger for weeks [34].

Patients with Epstein-Barr virus-associated lymphoproliferative disorders may develop

necrotic skin lesions at the site of mosquito bites [18,39-42].

Systemic allergic reactions — Rarely, patients can develop classical anaphylaxis in

response to mosquito bites, presenting with some combination of generalized urticaria,
angioedema, wheezing, vomiting, hypotension, loss of consciousness, or other
manifestations of anaphylaxis [34,35,43]. (See "Allergic reactions to mosquito bites".)

One case series of four patients with severe anaphylactic reaction after mosquito bites
reported that all were ultimately found to have a diagnosis of systemic mastocytosis [44].
(See "Mastocytosis (cutaneous and systemic) in adults: Epidemiology, pathogenesis, clinical
manifestations, and diagnosis".)

Disease transmission — Diseases routinely transmitted by mosquitoes in the United States

include West Nile virus, St. Louis encephalitis, Eastern equine encephalitis, and La Crosse
encephalitis. Transmission of chikungunya and Zika may also occur. (See "Chikungunya fever:
Epidemiology, clinical manifestations, and diagnosis" and "Zika virus infection: An overview"
and "St. Louis encephalitis" and "Arthropod-borne encephalitides".)
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Diseases transmitted by mosquitoes worldwide include malaria, yellow fever, dengue and
dengue hemorrhagic fever, lymphatic filariasis, chikungunya, and other arboviruses. (See
"Laboratory tools for diagnosis of malaria" and "Yellow fever: Epidemiology, clinical
manifestations, and diagnosis" and "Chikungunya fever: Epidemiology, clinical
manifestations, and diagnosis" and "Arthropod-borne encephalitides" and "Dengue virus
infection: Clinical manifestations and diagnosis" and "Lymphatic filariasis: Epidemiology,
clinical manifestations, and diagnosis".)

Mosquitoes do not transmit human immunodeficiency virus (HIV) infection, since the virus
neither survives nor replicates well in mosquitoes, and blood from one meal is not flushed
into the next host [45,46].

Prevention — Guidelines on vector control on a global level, issued by the World Health
Organization [47], focus on reducing or eliminating larval habitats. On an individual level,
patients should be instructed to apply insect repellents that contain active ingredients such
as N,N-diethryl-3-methylbenzamide (DEET), picaridin (known as KBR 3023 and icaridin
outside of the United States), IR3535, oil of lemon eucalyptus, para-menthane-diol (PMD), or
2-undecanone [48]. Additional protective measures include the use of protective covers such
as screens on windows and netting over beds [9]. (See "Prevention of arthropod and insect
bites: Repellents and other measures", section on 'Mosquitoes'.)

Specific allergen immunotherapy may play a role in preventing subsequent reactions in

those rare cases where the individual experiences anaphylaxis to mosquito bites. Some
studies have reported the potential role of allergen immunotherapy, using either whole body
mosquito extracts or recombinant salivary antigens, as a means of desensitizing patients
who have experienced anaphylactic or delayed reactions to mosquito bites [34,49]. This
therapy is not widely employed, as the available commercial extracts are whole body
mosquito extracts, which contain few salivary proteins and therefore provide an
unpredictable outcome and response. The salivary antigens that have been identified are all
derived from Aedes aegypti but may have crossreactivity with other mosquito species. The
use of immunotherapy with recombinant salivary allergens is only available in a few centers
[34].

Ticks — Ticks have multiple life stages in which they may bite people ( picture 15). The
primary concern with tick bites is disease transmission, although tick paralysis may occur
from an attached tick, and (rarely) allergic reactions to their bites may happen, and some tick
bites appear to sensitize patients to allergens that can later cause food (specifically red meat)
allergy. (See "Allergy to meats", section on 'The role of ticks in red meat allergy'.)

Tick paralysis — The salivary neurotoxins of various tick species can cause a disease known
as tick paralysis, which is rare but has been reported, most often in Australia and North
America [50-52]. It typically begins after a tick has been attached and feeding for four to
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seven days. Initial symptoms often include paresthesias and a sense of fatigue and weakness
and can progress to unsteady gait, followed by ascending and then respiratory paralysis. The
patient should be examined and any ticks removed immediately. Tick paralysis is important
to recognize because it can be fatal, although, if diagnosed promptly, it can be cured with the
combination of tick removal and supportive care. (See "Tick paralysis".)

Disease transmission — Ticks can transmit several infectious diseases:

● Lyme borreliosis (ie, Lyme disease) is one of the most frequently reported tick-borne
human diseases. It is caused by the spirochete Borrelia burgdorferi, which is transmitted
by the bite of infected Ixodes ticks. I. scapularis, the deer tick, is the primary vector of
Lyme disease in the Eastern and North-Central United States ( picture 16), while I.
pacificus is the vector in the Western United States ( picture 17). Other Ixodes species
are involved in Europe and Asia. (See "Evaluation of a tick bite for possible Lyme
disease" and "Epidemiology of Lyme disease".)

● Rocky Mountain spotted fever (RMSF) in the Eastern and South-Central United States is
primarily transmitted through the bite of Dermacentor variabilis (the American dog tick)
( picture 18). Dermacentor andersoni (the Rocky Mountain wood tick) is the primary
vector in the Mountain states west of the Mississippi River ( picture 19). The brown
dog tick, Rhipicephalus sanguineus has been found to transmit the agent of RMSF [53].
(See "Biology of Rickettsia rickettsii infection".)

● Human ehrlichiosis and tularemia may be transmitted by the lone star tick (Amblyomma
americanum) ( picture 20), as well as I. scapularis. (See "Human ehrlichiosis and
anaplasmosis" and "Tularemia: Clinical manifestations, diagnosis, treatment, and
prevention".)

● Babesiosis is most commonly transmitted by I. scapularis. (See "Babesiosis:

Microbiology, epidemiology, and pathogenesis".)

Allergy — Bites of some ticks can cause rare systemic allergic reactions immediately after
the bite itself, which have been reported with bites from the Ixodes tick, I. holocyclus (the
Australian paralysis tick), and Argas reflexus (the European pigeon tick) [54-57]. Salivary
proteins of ticks are thought to be allergenic [54].

The bites of other ticks have been implicated in sensitizing patients to a carbohydrate
determinant, galactose-alpha-1,3-galactose (also called alpha-gal), which is also found in the
drug cetuximab and some red meats, resulting in allergic reactions upon exposure to these
substances instead of to the tick bites directly [58]. In the United States, A. americanum (lone
star tick) is thought to be the sensitizing tick, while I. ricinius is implicated in Europe and I.
holocyclus in Australia [59,60]. Patients with alpha-gal sensitization can react to cetuximab (an
epidermal growth factor receptor [EGFR] inhibitor) upon the first exposure because
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cetuximab is a human-murine chimerized immunoglobulin monoclonal antibody, produced

in mammalian cell cultures, which contains the alpha-gal moiety in the Fab region of the
molecule [61]. The reactions can be severe, including anaphylaxis [62]. Alpha-gal-related
reactions to the ingestion of red meat is unusual in its delayed onset (up to four to six hours
after ingestion). (See "Allergy to meats", section on 'Meats and monoclonal antibodies
(cetuximab)' and "Infusion-related reactions to therapeutic monoclonal antibodies used for
cancer therapy", section on 'Cetuximab'.)

Prevention — The only known form of prevention of tick bites is avoidance of the tick.
Suggestions for avoidance include: wear protective clothing, use repellents that contain DEET
or permethrin, avoid areas of high vegetation including tall grass and leaf litter, bathe or
shower within two hours of coming indoors to assist in washing off crawling ticks, carefully
examine gear and pets for ticks, and tumble-dry clothes in a dryer for one hour on high heat
[63]. The only known prevention of anaphylaxis to red meat as a result of sensitization
through the tick bite is to avoid ingesting red meat [58]. (See "Allergy to meats".)

Flies — Species of biting flies are capable of inducing allergic reactions and/or transmitting
infectious diseases.

Reactions — Black flies, horse and deer flies, stable flies, sand flies, and biting midges have
been reported to induce systemic allergic and inflammatory reactions.

● Black flies, sometimes called buffalo gnats or turkey gnats, are vicious biters
( picture 21 and picture 22 and picture 23). Black fly bites have been implicated
in allergic reactions of intensely itching papular urticaria, angioedema ( picture 24),
anaphylaxis, and in a late-onset systemic syndrome characterized by fever, leukocytosis,
lymphadenitis, and papular lesions [64-66]. Black flies occur near fast-flowing streams,
creeks, and rivers worldwide. In North America, some of the worst problems occur in
the Northeastern United States and Canada.

● Horse flies and deer flies occur worldwide and inflict painful bites with their
slashing/lapping mouthparts ( picture 25 and figure 1) [67]. Delayed or necrotic
reactions may develop ( picture 26) [9]. In addition, there have been several reports
of systemic anaphylaxis from their bites [24,68].

● Sand flies are small, delicate, mosquito-like flies that inflict painful bites ( picture 27)
[69]. These bites can also be pruritic but usually do not enlarge. Sand flies occur
worldwide (including the United States) but are notorious pests in the Middle East and
tropics.

● Stable flies resemble house flies but have a piercing, bayonet-like proboscis capable of
biting through clothing ( picture 28). They can be significant medical and veterinary
pests in temperate and tropical areas and especially along beaches [67].
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● Biting midges (genus Culicoides) are found worldwide. They are tiny, gray/black, winged
insects less than 3 mm in length ( picture 29). The term "no-see-um" comes from the
fact that people often feel the sharp, burning bite but are unable to see the midge.
Females require blood in order to produce mature eggs and typically feed at dawn and
dusk. Coastal areas and marshlands are preferred breeding habitats [70,71]. Bites may
result in small welts or localized allergic reactions in sensitive individuals [72,73]. In a
Taiwanese series of 220 subjects, local reactions included immediate (ie, within one
hour), immediate followed by delayed, and isolated-delayed reactions consisting of
pruritic papules or vesicles that could persist for weeks to months [72]. A small number
of patients had systemic symptoms of fever and lymphadenopathy. Seasonal exposure
to midges (especially nonbiting midges, family Chironomidae) may cause respiratory
symptoms [74].

Biting midges are widespread but only transmit diseases to humans in certain
geographical areas. Important examples include Oropouche and Simbu viruses in
Africa and South America [75] and filarial worms of the Mansonella species in South and
Central America as well as parts of Africa and the Caribbean. (See "Loiasis (Loa loa
infection)".)

Disease transmission — Flies can serve as vectors of infectious diseases in geographic

regions that support transmission of specific pathogens:

● In Africa and Latin America, black flies in the genus Simulium (particularly S. damnosum)
are vectors of onchocerciasis [76]. (See "Onchocerciasis".)

● In West and Central Africa, the Chrysops fly, also known as the tabanid fly, transmits
Loa loa. (See "Loiasis (Loa loa infection)".)

● Also in Africa, the bite of a tsetse fly (Glossina spp) can transmit human African
trypanosomiasis, or sleeping sickness. (See "Human African trypanosomiasis:
Epidemiology, clinical manifestations, and diagnosis".)

● Sand flies are capable of transmitting sand fly fever, bartonellosis, and leishmaniasis. Of
these, leishmaniasis is by far the most widespread and clinically important [77]. (See
"South American bartonellosis: Oroya fever and verruga peruana" and "Cutaneous
leishmaniasis: Clinical manifestations and diagnosis" and "Visceral leishmaniasis:
Epidemiology and control".)

● Nonbiting fly species such as house flies and other filth flies with sponging mouthparts
( figure 1) are involved in mechanical disease transmission [78]. House flies have
been implicated in transmission of enteric infections in settings where facilities for
clean water and hygienic practices are limited [79]. (See "Pathogenic Escherichia coli

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associated with diarrhea" and "Shigella infection: Epidemiology, clinical manifestations,

and diagnosis".)

● Myiasis is the infestation of human tissues by a variety of bot fly and other fly larvae.
Myiasis may be obligate (such as with screwworm flies) or facultative (opportunistic
infestations due to common blow flies). Obligate myiasis is usually seen in patients or
travelers returning from tropical areas, whereas cases of facultative myiasis can occur
anywhere, especially in hospitals and nursing homes. (See "Skin lesions in the returning
traveler", section on 'Myiasis'.)

Prevention — Biting flies can be deterred by DEET and para-menthane-diol (PMD).

Additionally, the sand fly can be repelled by picaridin (known as KBR 3023 and icaridin
outside of the United States). (See "Prevention of arthropod and insect bites: Repellents and
other measures".)

Ongoing studies examining efficiency of traps for biting midges suggest that ultraviolet (UV)
baited traps outperform CO2-baited traps for most Culicoides species, with UV black light
seeming to be more effective than UV LED light [80,81].

Fleas — Fleas (order Siphonaptera) inflict bites that are often inconsequential and ignored
( picture 30). They can, however, result in local reactions or even eschars, pustules, or
necrotic lesions. (See "Clinical manifestations, diagnosis, and treatment of plague (Yersinia
pestis infection)", section on 'Clinical manifestations'.)

Reactions — Flea bites are usually papules arranged in a nonfollicular pattern but can
induce papular urticaria ( picture 31 and picture 32) [82,83]. (See 'Papular urticaria'
above.)

Prevention — Fleas can be deterred by DEET and para-menthane-diol (PMD). (See

"Prevention of arthropod and insect bites: Repellents and other measures".)

Centipedes — Centipedes are found in moist and usually warm climates worldwide, and,
although they occur in the continental United States, human envenomations are typically
reported from Asia, Indonesia, India, Hawaii, South America, and Australia ( picture 33)
[84-89].

Reactions — Centipedes inject venom, which they use to immobilize prey through a
modified first pair of legs (not the mouth). Centipedes are largely nocturnal, and most
human bites occur during the night. Bites are usually painful, and localized erythema and
edema are common. Many patients are bitten on the extremities, and two small puncture
marks may be visible [85].

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In many cases, symptoms are transient and do not require treatment. However, in a series of
94 patients presenting for emergency care in Sao Paulo, one-third required treatment for
persistent or severe symptoms (usually pain) [89].

Most centipede bites resolve without complications, although various sequelae are reported,
including local infection and necrosis [88], myocardial infarction [86,87], rhabdomyolysis with
kidney failure [90], and allergic reactions, including anaphylaxis [28,91]. In the largest
retrospective series, which included 245 patients presenting to an urban hospital in Bangkok
over 10 years, bites were accompanied by urticarial rash in six percent, anaphylaxis in five
percent, and fever in four percent [92].

Treatment — For patients who do present for post-bite care, reported therapies include
systemic analgesics, antihistamines, application of ice packs, immersion of the affected body
part in hot water, and local injection of anesthetics [88,89,92-94]. In a prospective study of 60
patients, subjects were randomized to one of three interventions: application of ice packs (15
minutes), hot water immersion (43 to 45°C [109.4 to 113°F] water bath for 15 minutes), or
injection of ketorolac 30 mg [93]. Each of the therapies reduced pain, although the authors
concluded that ice packs were the most practical and least invasive and noted that 3 of 22
patients assigned to hot water immersion had worsening of symptoms.

Mites — Mites are tiny arachnids that display incredible diversity in form and habitat
( picture 34). Many species of mites may bite people, including chigger mites (see "Chigger
bites"); rat, chicken, and fowl mites; straw itch mites; scabies mites; cheyletid mites; bird
mites, and others [95]. With the exception of scabies mites and follicle mites (Demodex spp),
all cases of biting mites are self-limiting and will subside after removing the source of
infestation (ie, they do not take up residence and live on humans).

Reactions — Bites from mites are generally small, erythematous papular lesions that are
intensely pruritic. They may have a wheal appearance or appear pustular, vesicular, or, rarely,
bullous. They can become crusted and need to be monitored for progression to secondary
infection. Both chigger bites ( picture 35) and scabies are generally localized or grouped,
though scabies have burrows as a typical finding ( picture 36). Treatment of infestations is
reviewed separately. (See "Scabies: Epidemiology, clinical features, and diagnosis" and
"Infectious folliculitis", section on 'Demodex folliculitis'.)

Prevention — People complaining about mites biting them should be evaluated for
exposure to mite-infested areas and a detailed history obtained to rule out exposure to
infested animals or (certain) grains and food products. In addition, persons claiming to be
infested with mites may be suffering from delusions of parasitosis [96]. Chiggers can be
deterred by DEET or by wearing knee-high rubber boots when outdoors in infested areas.
(See "Prevention of arthropod and insect bites: Repellents and other measures".)

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Spiders — Spider bites are discussed in detail separately. (See "Diagnostic approach to the
patient with a suspected spider bite: An overview" and "Bites of recluse spiders" and "Widow
spider bites: Clinical manifestations and diagnosis" and "Widow spider bites: Management".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on "patient education" and the keyword(s) of interest.)

● Basics topic (see "Patient education: Insect bites and stings (The Basics)")

● Beyond the Basics topic (see "Patient education: Bee and insect stings (Beyond the
Basics)")

SUMMARY

● Spectrum of reactions to insect bites – Most insect bites cause local inflammatory
reactions that subside within a few hours without complications. However, more severe
local symptoms, papular urticaria, systemic allergic reactions, and transmission of a
disease-causing pathogen are also possible. (See 'Introduction' above and 'Types of
reactions' above.)

● Mosquitos – Mosquito bites can cause varying degrees of local swelling, papular
urticaria in children, and rare systemic allergic reactions, including anaphylaxis. Several
pathogens are transmitted by mosquitoes in the United States, including the vectors for
West Nile virus, St. Louis encephalitis, Eastern equine encephalitis, La Crosse
encephalitis, Dengue virus, and Zika virus. (See 'Mosquitoes' above.)

● Ticks – Tick bites are mainly of concern because ticks can cause tick paralysis and
transmit infectious pathogens such as Lyme disease, Rocky Mountain spotted fever,
ehrlichiosis, and anaplasmosis. The lone star tick has been identified as a vector for an

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acquired food allergy that presents as delayed anaphylaxis after red meat
consumption. (See 'Ticks' above.)

● Flies – Various biting fly species are capable of inducing systemic allergic reactions
and/or transmitting infectious diseases. (See 'Flies' above.)

● Fleas – Flea bites are usually only a nuisance, but children can develop papular
urticaria, and bites can transmit infectious diseases such as plague and murine typhus.
(See 'Fleas' above.)

● Centipedes – Centipedes are found in moist and usually warm climates worldwide and
inject venom, which they use to immobilize prey, through their first pair of legs (not the
mouth). Most bites occur at night and, aside from pain and erythema, resolve with only
rare complications. Centipedes do not transmit disease. (See 'Centipedes' above.)

● Mites – Many species of mites may bite people, although only scabies mites and follicle
mites (Demodex spp) take up residence and live on humans. Bites of mites are generally
small, erythematous papular lesions which are intensely pruritic. They can become
crusted and need to be monitored for progression to secondary infection. (See 'Mites'
above.)

ACKNOWLEDGMENT

The UpToDate editorial staff acknowledges Mariana C Castells, MD, PhD, who contributed to
earlier versions of this topic review.

Use of UpToDate is subject to the Terms of Use.

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83. Cuéllar A, Rodríguez A, Halpert E, et al. Specific pattern of flea antigen recognition by
IgG subclass and IgE during the progression of papular urticaria caused by flea bite.
Allergol Immunopathol (Madr) 2010; 38:197.
84. Uppal SS, Agnihotri V, Ganguly S, et al. Clinical aspects of centipede bite in the
Andamans. J Assoc Physicians India 1990; 38:163.
85. Guerrero AP. Centipede bites in Hawai'i: a brief case report and review of the literature.
Hawaii Med J 2007; 66:125.
86. Yildiz A, Biçeroglu S, Yakut N, et al. Acute myocardial infarction in a young man caused
by centipede sting. Emerg Med J 2006; 23:e30.
87. Senthilkumaran S, Meenakshisundaram R, Michaels AD, et al. Acute ST-segment
elevation myocardial infarction from a centipede bite. J Cardiovasc Dis Res 2011; 2:244.
88. Fung HT, Lam SK, Wong OF. Centipede bite victims: a review of patients presenting to
two emergency departments in Hong Kong. Hong Kong Med J 2011; 17:381.
89. Medeiros CR, Susaki TT, Knysak I, et al. Epidemiologic and clinical survey of victims of
centipede stings admitted to Hospital Vital Brazil (São Paulo, Brazil). Toxicon 2008;
52:606.
90. Logan JL, Ogden DA. Rhabdomyolysis and acute renal failure following the bite of the
giant desert centipede Scolopendra heros. West J Med 1985; 142:549.
91. Washio K, Masaki T, Fujii S, et al. Anaphylaxis caused by a centipede bite: A "true" type-I
allergic reaction. Allergol Int 2018; 67:419.
92. Niruntarai S, Rueanpingwang K, Othong R. Patients with centipede bites presenting to a
university hospital in Bangkok: a 10-year retrospective study. Clin Toxicol (Phila) 2021;
59:721.
93. Chaou CH, Chen CK, Chen JC, et al. Comparisons of ice packs, hot water immersion, and
analgesia injection for the treatment of centipede envenomations in Taiwan. Clin Toxicol
(Phila) 2009; 47:659.

94. Balit CR, Harvey MS, Waldock JM, Isbister GK. Prospective study of centipede bites in
Australia. J Toxicol Clin Toxicol 2004; 42:41.
95. Kramer L, Weinberger M, Tanksley S, Shoemaker J. Pruritic Papular Dermatitis From Bird
Mites. J Allergy Clin Immunol Pract 2022; 10:1642.

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96. Hinkle NC. Delusory parasitosis. American Entomologist 2000; 46:17.

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GRAPHICS

Various types of insect mouthparts

Piercing-sucking mouthparts differ primarily in the number and arrangement of the stylets (needle-
like blades) and the shape and position of the lower lip of insect mouthparts, termed the labium.
Often, what is called the proboscis of an insect with piercing-sucking mouthparts is an ensheathment
of several components such as the labrum, stylets, and labium. For example, mosquitoes have a
proboscis composed of six stylets (two mandibles, two maxillae, the hypopharynx, and labrum-
epipharynx), ensheathed in an elongated, cylindrical labium (B). Horse flies, deer flies, black flies, and

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biting midges basically have the same type of mouthparts: blade-like (A). Most of the stylets are
flattened compared with those found in mosquitoes. The mandibles are flattened and move
transversely in a scissor-like fashion, and the maxillae are thrust in and out of the wound, causing
pooled blood in the host's tissues. In tsetse flies, teeth on the labellum aid the labium for penetrating
the skin (C). Movements of the fly's head further enable the labium to gain access to capillaries in the
skin. Members of the insect order Hemiptera, or true bugs, have a hardened, three-segmented beak
that they insert into plants or prey for feeding or human/animal hosts for blood feeding (E).

Other arthropods such as spiders, mites, and ticks also have piercing-sucking mouthparts, but the
structures are derived from different morphologic features than those of insect mouthparts. Mites
and ticks have a head-like gnathosoma for feeding. The gnathosoma consists of mouthparts and
palps and forms a tubular structure for obtaining food and passing it into the digestive tract. The
cutting-piercing mouthparts of mites and ticks are called chelicerae. Chelicerae may cause tearing of
skin, as in the case of scabies mites, or piercing, as in the case of chiggers. In ticks, there is an
additional anchoring hypostome, which is a very prominent structure and bears teeth on its ventral
surface. The true bugs, such as bed bugs, kissing bugs, and assassin bugs, have the labium formed
into a prominent three- or four-segmented cylindrical proboscis (E).

Modified from: Typical mouthparts of medically important diptera. In: Laboratory Guide to Medical Entomology with Notes on
Malaria Control, US Naval Medical School, Bethesda, 1943, p. 19.

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Recluse spider bite with vesiculation

This verified recluse spider bite shows central and surrounding vesiculation.

Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights reserved.

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Bullous arthropod (insect) bite

A bulla is present in the site of an insect bite.

Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights reserved.

Graphic 60230 Version 3.0

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Bullous arthropod bite

Multiple erythematous papules consistent with arthropod bites are present on the foot. An intact,
fluid-filled bulla is present at the site of one lesion.

Graphic 52794 Version 2.0

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Necrotic brown recluse spider bite

Large erythematous exfoliative plaque with central eschar due to brown recluse bite.

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Papular urticaria

This healthy adolescent returned from a hike in the woods with itchy bumps on their legs the day
before they were evaluated. Note the central crusts where they had been scratching. Linear
collections of insect bite like this are referred to as "breakfast, lunch, and dinner."

Copyright © Bernard Cohen, MD, Dermatlas; http://www.dermatlas.org.

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Papular urticaria

This healthy 4-year-old developed a recurrent pruritic eruption on the arms and legs. Covered areas
were only rarely involved. Note the healing lesions with postinflammatory hyperpigmentation and
violaceous centers.

Copyright © Bernard Cohen, MD, Dermatlas; http://www.dermatlas.org.

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Staphylococcal folliculitis

Multiple follicularly based, inflammatory papules and pustules are present on the leg.

Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights reserved.

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Folliculitis

Small, inflammatory papules and pustules are present in this patient with folliculitis.
Postinflammatory hyperpigmentation is also present.

Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights reserved.

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Lymphomatoid papulosis

Multiple inflammatory papules are present on the trunk. Some lesions have overlying crust.

Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights reserved.

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Pityriasis lichenoides et varioliformis acuta

Multiple inflammatory papules are present. Some lesions demonstrate necrosis and crusting.

Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights reserved.

Graphic 57911 Version 5.0

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Target lesions of erythema multiforme

Target lesions with central bullae are present on the hand.

Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights reserved.

Graphic 79955 Version 8.0

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Skin excoriations in chronic methamphetamine abuse

Many chronic methamphetamine abusers suffer multiple small skin excoriations from unremitting
picking, as seen in the photograph above.

Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights reserved.

Graphic 86746 Version 5.0

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Female mosquito feeding on blood

Only female mosquitoes feed on blood.

Reproduced from: US Centers for Disease Control and Prevention Public Health Image Library. Photo courtesy of James
Gathany. Available at: https://phil.cdc.gov/Details.aspx?pid=6764 (Accessed on July 25, 2019).

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Mosquito bite lesions of varying ages on child's leg

Copyright © 2003 by Jerome Goddard. Reproduced with permission.

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Large indurations resulting from mosquito bites

Copyright © Wendy Varnado, PhD. Mississippi State Department of Health. Reproduced with permission.

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Hard ticks have three motile life stages – larva, nymph, and adult

Copyright © 2014 by Jerome Goddard. Reproduced with permission.

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Adult female black-legged deer tick, Ixodes scapularis

Note that the legs do not necessarily appear black.

Copyright © Blake Layton, PhD. Mississippi State University Extension Service. Reproduced with permission.

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An adult female Ixodes pacificus (Western blacklegged tick)

Champman AS, Bakken JS, Folk SM, et al. Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain
Spotted Fever, Ehrlichoioses, and Anaplasmosis-United States: A practical guide for physicians and other health-care and
public health professionals. MMWR Recomm Rep 2006; 55(RR-4):1.

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Adult female American dog tick, Dermacentor variabilis

Copyright © Blake Layton, PhD. Mississippi State University Extension Service. Reproduced with permission.

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Adult female Rocky Mountain wood tick, Dermacentor andersoni

Copyright © Blake Layton, PhD. Mississippi State University Extension Service. Reproduced with permission.

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Adult female lone star tick, Amblyomma americanum

Copyright © Blake Layton, PhD. Mississippi State University Extension Service. Reproduced with permission.

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Adult black fly

Copyright © 2010 by Jerome Goddard. Reproduced with permission.

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Black fly in the process of biting

Copyright © Wendy Varnado, PhD. Mississippi State Department of Health. Reproduced with permission.

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Black fly bite behind ear

Copyright © Wendy Varnado, PhD. Mississippi State Department of Health. Reproduced with permission.

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Black fly bite causing periorbital angioedema

Courtesy of Patricia Stewart, MD.

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Adult horse fly

Copyright © Blake Layton, PhD. Mississippi State University Extension Service. Reproduced with permission.

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Horse fly bite, two weeks post-bite

The photograph shows a black fly bite that was sustained two weeks earlier and has developed mild
necrosis and a central pustule of secondary infection.

Copyright © 2014 by Jerome Goddard. Reproduced with permission.

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Adult sand fly

Reproduced from: US Centers for Disease Control and Prevention Public Health Image Library. Photo courtesy of James
Gathany. Available at: https://phil.cdc.gov/Details.aspx?pid=10277 (Accessed on August 8, 2019).

Graphic 121934 Version 1.0

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Stable fly head showing bayonet-like proboscis

Copyright © 2019 by Jerome Goddard. Reproduced with permission.

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Biting midge

Copyright © 2019 by Jerome Goddard. Reproduced with permission.

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Typical flea

Copyright © 2011 by Jerome Goddard. Reproduced with permission.

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Flea bites thigh

Insect bites. These flea bites are grouped in a characteristic nonfollicular pattern.

Reproduced with permission from: Goodheart HP, MD. Goodheart's Photoguide of Common Skin Disorders, 2nd Edition.
Philadelphia: Lippincott Williams & Wilkins, 2003. Copyright © 2003 Lippincott Williams & Wilkins.

Graphic 54271 Version 1.0

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Flea bites ankle

Four flea bites clustered on an ankle.

Reproduced with permission from: Goodheart HP, MD. Goodheart's Photoguide of Common Skin Disorders, 2nd Edition.
Philadelphia: Lippincott Williams & Wilkins, 2003. Copyright © 2003 Lippincott Williams & Wilkins.

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Centipede

The figure shows a large tropical species of centipede. Centipedes can deliver venomous bites
through the modified first pair of legs.

Copyright © 2016 by Jerome Goddard. Reproduced with permission.

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Biting mite

Although most mites are visible with the naked eye, magnification is needed for proper identification.

Copyright © 2019 by Jerome Goddard. Reproduced with permission.

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Chigger bites

Multiple small erythematous papules are present on the lower leg.

Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights reserved.

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Scabetic burrow

Erythematous, linear scabetic burrow.

Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights reserved.

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