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Bed Bugs

Basics

  • Nocturnal, wingless blood parasites, 5-7 mm oval, reddish-brown
  • Cimex lectularius (temperate urban), Cimex hemipterus (tropical)
  • Reside in crevices of mattresses, box springs, headboards, baseboards
  • Bites provoke immune reactions: from minimal to pruritic maculopapular rash, urticarial, or anaphylactoid responses
  • Do not transmit known pathogens

Epidemiology

  • Increasing incidence and treatment difficulty due to travel, pesticide changes, secondhand furniture
  • Infestation prevalence rising 10-30% in US public spaces (schools, hospitals, hotels)
  • Over 75 Cimicidae species; only 3 bite humans (lectularius, hemipterus, Leptocimex boueti)

Etiology and Pathophysiology

  • Attraction to body warmth and CO2
  • Host immune responses to salivary proteins mediate symptoms: IgG for urticaria, IgE for bullous reactions
  • Bites cause skin reactions via immunologic hypersensitivity

Risk Factors

  • Immunocompromise
  • Frequent travel and high hotel turnover
  • Use of secondhand furniture

Prevention

  • Vacuum regularly, reduce clutter, seal cracks
  • Launder bedding/clothing >130°F (50°C) for 2 hours or freeze at ≤20°F (-5°C) for ≥5 days
  • Professional extermination services often needed; canine detection available
  • Traps using CO2 and heat effective but costly

Diagnosis

History

  • Recent travel, possible bed bug sightings, blood specks on sheets
  • New pruritic lesions on exposed skin areas on awakening

Physical Exam

  • Erythematous, pruritic papules in irregular linear patterns
  • Lesions mostly on face, neck, arms, legs, shoulders
  • May present as papular urticaria, bullous lesions, or anaphylaxis

Differential Diagnosis

  • Urticaria, insect/spider bites
  • Scabies
  • Dermatitis herpetiformis

Diagnostic Tests

  • Skin scraping with mineral oil (negative helps exclude scabies)
  • Skin biopsy: nonspecific perivascular eosinophilic infiltrate consistent with arthropod bite

Treatment

General Measures

  • Address skin symptoms, eradicate infestation, and behavioral health impact
  • Self-limited; lesions resolve in 1-2 weeks

Medication

  • Oral antihistamines (diphenhydramine, hydroxyzine)
  • Topical antipruritics (pramoxine, calamine, doxepin cream)
  • Low-to-mid potency topical corticosteroids for up to 2 weeks
  • Systemic corticosteroids in severe cases
  • Treat secondary infections with antibiotics targeting Staph/Strep (cephalexin, doxycycline, clindamycin, mupirocin)
  • Epinephrine for anaphylaxis

Additional Therapies

  • CDC recommends integrated pest management: clutter removal, sealing cracks, heat treatment, vacuuming, nonchemical pesticides
  • Emerging methods include xenointoxication (oral arthropodicidal agents)

Ongoing Care

Follow-up

  • Usually not needed unless severe or anaphylactoid reactions
  • Behavioral health support as needed

Patient Monitoring

  • Inspect hotel rooms (mattresses, luggage racks) before use
  • Reduce clutter, keep luggage off beds

Patient Education

  • Avoid scratching to reduce superinfection risk
  • Regularly inspect bedding, furniture, and luggage
  • Refer to CDC and EPA resources for detailed pest control guidance

Complications

  • Bed bug dermatitis and allergic reactions
  • Asthma exacerbations, anaphylaxis (rare)
  • Psychological distress: insomnia, anxiety, depression, delusional parasitosis
  • Secondary bacterial infections
  • Rare transmission of blood-borne diseases

Clinical Pearls

  • 90% infestations occur within 3 feet of the bed
  • Bed bugs resistant to many OTC pesticides (permethrin, cyfluthrin, bifenthrin)
  • Heat treatment effective for eradication, tropical species require higher temperatures