# Papular urticaria and insect bite reactions - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: Insect Bites - StatPearls (NCBI Bookshelf NBK537235) - https://www.ncbi.nlm.nih.gov/books/NBK537235/ · Hydrocortisone 1% cream SmPC section 4.2 (eMC product 13103) · Egyptian National Drug Formulary - Respiratory System 2026 (chlorpheniramine maleate monograph) · Egyptian National Drug Formulary - Respiratory System 2026 (cetirizine monograph) · Calamine Lotion BP SmPC sections 4.1-4.2 (eMC product 4822) · Papular urticaria and insect bites - disease-level clinical article (papular-urticaria-insect-bites-full.txt) · Papular urticaria and insect bites - disease-level clinical article (papular-urticaria-insect-bites-clinical.txt) - Verified date: 2026-08 ## Verified against - Insect Bites - StatPearls (NCBI Bookshelf NBK537235) - https://www.ncbi.nlm.nih.gov/books/NBK537235/ - Hydrocortisone 1% cream SmPC section 4.2 (eMC product 13103) - Egyptian National Drug Formulary - Respiratory System 2026 (chlorpheniramine maleate monograph) - Egyptian National Drug Formulary - Respiratory System 2026 (cetirizine monograph) - Calamine Lotion BP SmPC sections 4.1-4.2 (eMC product 4822) - Papular urticaria and insect bites - disease-level clinical article (papular-urticaria-insect-bites-full.txt) - Papular urticaria and insect bites - disease-level clinical article (papular-urticaria-insect-bites-clinical.txt) ## Treatment metadata - Hydrocortisone — topical - Referral & safety-netting (no drug therapy) - Chlorpheniramine — 2 mg — oral.liquid - Calamine — topical - Cetirizine — 5 mg — oral.liquid ## Complete treatment card ```text PAPULAR URTICARIA AND INSECT BITE REACTIONS Sources: Insect Bites - StatPearls (NCBI Bookshelf NBK537235) - https://www.ncbi.nlm.nih.gov/books/NBK537235/ · Hydrocortisone 1% cream SmPC section 4.2 (eMC product 13103) · Egyptian National Drug Formulary - Respiratory System 2026 (chlorpheniramine maleate monograph) · Egyptian National Drug Formulary - Respiratory System 2026 (cetirizine monograph) · Calamine Lotion BP SmPC sections 4.1-4.2 (eMC product 4822) · Papular urticaria and insect bites - disease-level clinical article (papular- urticaria-insect-bites-full.txt) · Papular urticaria and insect bites - disease-level clinical article (papular-urticaria-insect-bites-clinical.txt) Review status: REVIEWED against 6 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (3) - Bites or stings often cause no symptoms at all and can go unnoticed - Sudden pain or itching, especially when the culprit insect is actually seen, strongly supports the diagnosis [itching] - Intense itching can lead to scratched, broken skin and a secondary bacterial infection [itching] SIGNS - what you find (4) - Bites typically appear as red, sometimes swollen bumps that can be single, clustered, or widespread depending on the culprit - Local redness, wheals, and hives often accompany the itchy bite site [itching · redness · urticaria] - Anaphylaxis from a bite can show hives, swelling, fast heart rate, breathing trouble, low blood pressure, and wheezing [hypotension · tachycardia · urticaria · wheeze] - Look for the culprit itself - ticks, lice, myiasis, or scabies - and remove any retained bee stinger TESTS (3) - Uncomplicated localized bites generally do not need labs or imaging - Severe envenomation warrants CBC, metabolic panel, liver tests, coagulation studies, creatine kinase, and urinalysis to check for multiorgan involvement - Thick and thin blood smears help evaluate for malaria or early Chagas disease IF NOT THIS - what else fits (2) - Necrotic ulcers after a suspected brown recluse bite need pyoderma gangrenosum, staph or strep skin infection, diabetic ulcer, fungal infection, leishmaniasis, and sporotrichosis considered - Black widow envenomation should be suspected in a patient presenting with an acute abdomen picture Source StatPearls "Insect Bites" - disease-level clinical article Status traced to the source above Rx: Main treatment | Systemic itch relief - sedating oral antihistamine | Topical soothing - suitable at any age MAIN TREATMENT - choose one, plus any add-on marked below 1. HYDROCORTISONE [1st line] Adult To be applied sparingly to the affected skin two or three times daily after gently cleansing the area. - Courses of treatment in children should generally be limited to not more than seven to ten days. Peds Adults and children: apply sparingly two or three times daily. SmPC 4.8: "Children are particularly at risk and in these patients, Hydrocortisone Cream should only be used twice daily for a maximum of ten days over a body surface area not exceeding 10% and without an occlusive dressing." For a child, follow that restriction, not the wider adult instruction. Source Hydrocortisone 1% cream SmPC section 4.2 (eMC product 13103) Why Indication and dose from the same label. SmPC 4.1 lists the product as "indicated for the treatment of eczema and dermatitis of all types, including atopic eczema, photodermatitis, otitis externa, primary irritant and allergic dermatitis, intertrigo, prurigo nodularis, seborrhoeic dermatitis and insect bite reactions." SmPC 4.2: "Adults and children: To be applied sparingly to the affected skin two or three times daily after gently cleansing the area." The disease article independently endorses the class: "Pruritus, a common manifestation, often responds to calamine lotion or intermediate- potency topical corticosteroids". Caution CHILD LIMIT - twice daily, maximum ten days, no more than 10% of body surface, no occlusive dressing (SmPC 4.8). Bites are scattered; treat the bitten spots, not the whole limb. CONTRA-INDICATED ON INFECTED SKIN - SmPC 4.3 bars the cream where the skin carries a bacterial, viral or fungal infection, and bars it equally in urticaria, in rosacea, over an ulcer, and wherever there is local infection. A scratched, crusted, weeping bite is infected until proven otherwise. READ THE LABEL'S OWN TENSION HONESTLY: section 4.1 gives the reaction to an insect bite as an indication, while 4.3 lists urticaria among the contra-indications, and 4.4 states that the cream is not recommended for itch. The label supports the inflamed bite papule; it does not support painting it on urticarial weals or using it as a general anti-itch cream. SmPC 4.4: avoid using it for long stretches in infants and children, and avoid it on the face. If it is not better in a few days, stop and reconsider the diagnosis rather than continuing steroid. Egypt NOVACORTIN 1% CREAM 15 GM PHAROPHARMA 4.75 EGP NOVACORTIN 1% OINT. 15 GM PHAROPHARMA 4.75 EGP MICORT 1% CREAM 20 GM MISR 12.50 EGP HYDROCORTISONE 1% OINT. 20 GM MISR 21.00 EGP 2. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Papular urticaria and insect bites - disease-level clinical article (papular-urticaria- insect-bites-clinical.txt) Why Carries the emergency, the commonest complication, and the prevention advice - all of which apply whichever topical or antihistamine is chosen. Caution RED FLAG - ANAPHYLAXIS: intramuscular adrenaline goes in at once, repeated every 5 to 15 minutes if it is needed. (Insect Bites - StatPearls - NCBI Bookshelf, NBK537235) The article adds that steroids, salbutamol and antihistamines must never hold the adrenaline up. (Insect Bites - StatPearls - NCBI Bookshelf, NBK537235) The warning signs to teach are urticaria all over, trouble breathing, and dizziness. (Insect Bites - StatPearls - NCBI Bookshelf, NBK537235) COMMONEST COMPLICATION - what follows most often is a bacterial infection on top, usually Staphylococcus aureus or Streptococcus pyogenes, which can go on to impetiginisation, cellulitis or lymphangitis. Watch for pain that is increasing, warmth, pus, or streaks running up the limb. Stop the scratching, and say why: teaching the family should make the point that hard scratching brings on bacterial infection, scarring, and pigment change after the inflammation settles. (Insect Bites - StatPearls - NCBI Bookshelf, NBK537235) WHY THE BUMPS PERSIST - in a child already sensitised, an exaggerated hypersensitivity can show itself as papular urticaria, or as a nodular prurigo that persists. (Insect Bites - StatPearls - NCBI Bookshelf, NBK537235) Reassure the family that recurring crops are the child's reaction, not new infestation each time - while still treating the source. PREVENTION IS THE REAL TREATMENT - long sleeves; staying indoors at the hours when insects feed most; and a repellent that works, one containing DEET, picaridin or IR3535. (Insect Bites - StatPearls - NCBI Bookshelf, NBK537235) Use a bed net where it is needed, and find and get rid of anywhere they breed - standing water for mosquitoes, infested bedding for fleas and bedbugs. (Insect Bites - StatPearls - NCBI Bookshelf, NBK537235) Basic wound care from the article: wash the area with soap and water, bring the tetanus immunisation up to date if it has lapsed, put ice compresses on, and raise a swollen limb. (Insect Bites - StatPearls - NCBI Bookshelf, NBK537235) Anyone who has had a systemic reaction before carries an adrenaline autoinjector, or the nasal spray, and knows how to use it properly. (Insect Bites - StatPearls - NCBI Bookshelf, NBK537235) 3. CETIRIZINE [add-on - not a substitute] Adult Oral: 10 mg once daily. - A short course, while the itch is severe Peds Age restriction: minimum 24 months 2 to under 6 years: 2.5 mg once to twice daily 6 to under 12 years: 5 mg twice daily, or 10 mg once daily based on severity 12 years and over: 10 mg once daily (The Egyptian formulary heads these indications as applying to adults and to children of 2 years and over, so no dose is given here below 2 years.) Source Egyptian National Drug Formulary - Respiratory System 2026 (cetirizine monograph) Why The non-sedating alternative for a child who must go to school. The indication claim comes from the disease article, not from the monograph: itching in the moderate-to- severe range may call for a short course of a systemic corticosteroid together with oral H1 and H2 antihistamines. The dose claim comes from the Egyptian formulary's cetirizine monograph, which gives a child aged 2 to 6 years 2.5 mg by mouth, once or twice a day. Stated plainly because it matters: that monograph's listed indications are relief of the nasal and ocular symptoms of allergic rhinitis, seasonal and perennial, and relief of the symptoms of chronic idiopathic urticaria - it does NOT name insect bites, unlike chlorpheniramine. Line 2 for that reason. Caution The Egyptian formulary's cetirizine indications do not include insect bites; the reason for using it here comes from the disease article's general endorsement of oral antihistamines. If you want an antihistamine whose Egyptian monograph names insect bites, that is chlorpheniramine. Do not combine with chlorpheniramine or with any other antihistamine-containing product - pick one. Less sedating than chlorpheniramine, not non-sedating: some children still get drowsy. Egypt LERGFREE 5MG/5ML SYRUP 120ML DEBEIKY 9.00 EGP EPIRIZINE 5MG/ML SYRUP 60 ML EIPICO 19.00 EGP CETRITIN 5MG/5ML SYRUP 120ML EL NILE. 28.00 EGP BADOTIRIZIN 5MG/5ML SYRUP 125ML BADR PHARMA 29.00 EGP ALERID 5MG/5ML SYRUP 120ML GLOBAL NAPI P... 30.00 EGP ALERID 10MG/ML ORAL DROPS. 10 ML GLOBAL NAPI P... 29.00 EGP -> ? strength differs, ? different route - not oral liquid HISTAZINE-1 100MG/10ML ORAL DROPS 10 ML AMRIYA 29.00 EGP -> ? strength differs, ? different route - not oral liquid SYSTEMIC ITCH RELIEF - SEDATING ORAL ANTIHISTAMINE - give alongside 4. CHLORPHENIRAMINE [add-on - not a substitute] Adult 4 mg every 4 to 6 hours; maximum daily dose: 24 mg. - A short course, while the itch is severe Peds Age restriction: minimum 24 months 2 to under 6 years: 1 mg (2.5 ml) every 4 to 6 hours; maximum daily dose 6 mg 6 to under 12 years: 2 mg (5 ml) every 4 to 6 hours; maximum daily dose 12 mg 12 years and over: 4 mg (10 ml) every 4 to 6 hours; maximum daily dose 24 mg (Not recommended for children under 2 years - the Egyptian formulary heads the oral indication with exactly that restriction. The bands above are the monograph's Pediatric dosing list. The same monograph also prints a second, higher table (2 to 5 years: 2.5 mg to 5 mg; 6 to 12 years: 5 mg to 10 mg; 12 to 18 years: 10 mg to 20 mg; all at 0.20 mg/kg) which contradicts its own list. The lower, explicitly-labelled Pediatric dosing schedule is what is printed here; the disagreement is stated rather than resolved.) Source Egyptian National Drug Formulary - Respiratory System 2026 (chlorpheniramine maleate monograph) Why Indication and dose in one document. The Egyptian formulary's chlorpheniramine maleate monograph lists, under its oral indications, controlling the symptoms of acute allergic conditions that answer to antihistamines - urticaria and insect bites among them, alongside hay fever, angioneurotic oedema, allergic and vasomotor rhinitis, food allergy, and reactions to drugs and to serum. The disease article agrees, holding that itching in the moderate-to-severe range may call for a short course of a systemic corticosteroid together with oral H1 and H2 antihistamines. This is the sedating option: useful for the child who cannot sleep for scratching. Caution SEDATION IS THE MAIN EFFECT - the Egyptian formulary puts sedation and drowsiness in its very common band, above 10%. It adds that children and elderly people are the ones most likely to show the neurological antimuscarinic effects, and to become excited rather than settled - more energy, restlessness, nervousness. NOT UNDER 2 YEARS (oral). The formulary also contra-indicates it in a premature infant or a newborn, whose susceptibility to antimuscarinic effects is greater. Contra-indications, Egyptian formulary: hypersensitivity; treatment with a monoamine oxidase inhibitor (MAOI) inside the last 14 days; coma, or the state preceding it; brain damage or epilepsy known about; and asthma that is acute. Do not give it alongside another product containing an antihistamine, the antihistamine- containing cough and cold remedies included. Check what the family is already giving. Syrup measuring: measure a liquid out with a proper measuring device, and never with a spoon from the kitchen drawer - that is how a child is overdosed. Egypt PIRAFENE 2MG/5ML SYRUP 120ML MEMPHIS 10.00 EGP ANALLERGE 2MG/5ML SYRUP 100ML KAHIRA 24.00 EGP ALLERGYL 2MG/5ML SYRUP 120ML ARAB DRUG COM... 26.00 EGP TOPICAL SOOTHING - SUITABLE AT ANY AGE - give alongside 5. CALAMINE [add-on - not a substitute] Adult The product is suitable for use by adults, children and the elderly. Apply gently with a pad of cotton wool to the affected parts as required. - As required Peds Suitable for children at the same application: apply gently with cotton wool to the affected parts as required. The SmPC states no age limit and no weight-based dose. Source Calamine Lotion BP SmPC sections 4.1-4.2 (eMC product 4822) Why Indication claim, disease article: "Pruritus, a common manifestation, often responds to calamine lotion or intermediate-potency topical corticosteroids". Dose claim, Calamine Lotion BP SmPC 4.2: "The product is suitable for use by adults, children and the elderly. Apply gently with a pad of cotton wool to the affected parts as required." (4.1: "For relief of the symptoms of mild sunburn and other minor skin conditions.") The cheap, safe, any-age option, and the one most Cairo families already have. Caution SmPC 4.4: shake the bottle, and use it on the skin only. Soothes the itch; it does not treat infection or a systemic reaction. Do not apply to broken or weeping skin. Egypt CALAMIDINE TOPICAL LOTION 120 ML EVA PHARMA 4.95 EGP -> ! also contains diphenhydramine, zinc oxide CALAMINE 15% LOTION 120 ML PHILO PHARM P... 5.00 EGP -> ! also contains zinc oxide CALAMINE LOTION 120 ML B.P 93 PHARCO 5.00 EGP -> ! also contains zinc oxide CALAZOL CREAM 20 GM MISR 5.00 EGP -> ! also contains antazoline ACNESONE LOTION 60 ML GLOBAL NAPI P... 8.50 EGP -> ! also contains hydrocortisone, sulphur VENODERM LOTION 20 ML TETRAPHARM 10.90 EGP -> ! also contains olive oil, zinc oxide CALMOHIST CREAM 60 GM DREAMS EL HAB... 25.00 EGP -> ! also contains allantoin, dimethicone, glycerin, paraffin liquid, phenoxy ethanol, sls, zinc oxide AROLYN LOTION 100ML DREAMS AL HAB... 30.00 EGP -> ! also contains allantoin, aloe vera extract, castor oil, chamomile extract, chlorhexidine, glycerin, jojoba oil, olive oil, panthenol, tea tree oil, thyme oil, vitamin e, zinc oxide Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. 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