Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

symptomatic disease

1st line – antipruritic and/or antihistamine

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ACUTE
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symptomatic disease
1st line – 

antipruritic and/or antihistamine

Oral antihistamines (e.g., hydroxyzine) minimise pruritus but do not change the duration or appearance of rash.[6][12][33] The antipruritic effect is primarily mediated through their sedative effect.

Topical antipruritics (e.g., pramocaine/camphor/calamine ointment or doxepin cream) provide symptomatic relief.

Primary options

hydroxyzine: children ≤40 kg: 2 mg/kg/day orally given in divided doses every 6-8 hours when required; children >40 kg and adults: 25 mg orally every 6-8 hours when required, maximum 100 mg/day

-- AND / OR --

pramocaine/camphor/calamine topical: children >2 years of age and adults: apply to the affected area(s) up to four times daily when required

or

doxepin topical: (5%) children: consult specialist for guidance on dose; adults: apply to the affected area(s) up to four times daily when required

Plus – cleaning with or without professional extermination

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ACUTE
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symptomatic disease
Plus – 

cleaning with or without professional extermination

Treatment recommended for ALL patients in selected patient group

Eradication and preventative measures, including environmental cleaning (e.g., laundering clothing and bedding, vacuuming furniture, examination of mattresses), should be instituted once a diagnosis of bed bug infestation has been made.[3][7]​[12]​​​ Professional extermination is usually necessary in ongoing infestations.[2]​[3]​​​​[7]

Immediately following treatment, all bedding and cloth items (e.g., clothing, drapery, pillows) should be laundered in water temperatures greater than 55°C (approximately 130°F).[16] Alternatively, items can be placed in a hot air clothes drier for at least 30 minutes in order to decontaminate. For heat-sensitive items, freezing at -20°C (approximately -5°F) for 8 hours per 2.5 kg of item weight can be used.[16]

If bed bug infestation is present in the patient's home/living accommodation, they should be advised that eradication is essential. All areas where bed bugs may find refuge should be inspected (e.g., furniture, crevices in walls, and mattresses) and cleaned. Consumers should choose a pest management service that is specifically trained in bed bug management, because insecticide resistance and treatment failure is not an uncommon problem.[16]​[34]​​[35]

Consider – low- to mid-potency topical corticosteroid

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ACUTE
|
symptomatic disease
Consider – 

low- to mid-potency topical corticosteroid

Additional treatment recommended for SOME patients in selected patient group

In patients with more significant discomfort, the use of low- to mid-potency topical corticosteroids may hasten rash resolution and decrease pruritus.[6][12]

Agents include triamcinolone or hydrocortisone.

Topical corticosteroids should generally be used for no longer than 2 weeks.

Primary options

hydrocortisone topical: (2.5%) children and adults: apply sparingly to the affected area(s) twice daily

OR

triamcinolone acetonide topical: (0.1%) children and adults: apply sparingly to the affected area(s) twice daily

Consider – oral corticosteroid

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ACUTE
|
symptomatic disease
|
with severe/widespread reaction
Consider – 

oral corticosteroid

Additional treatment recommended for SOME patients in selected patient group

In patients with more severe/widespread reactions (e.g., diffuse cutaneous eruption with disabling pruritus), a short course of oral corticosteroids should be considered.

Treatment course: 7 to 14 days.

Primary options

prednisolone: children: 1 mg/kg/day orally; adults: 40-60 mg orally once daily

Plus – oral or topical antibiotic

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ACUTE
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symptomatic disease
|
with secondary infection
Plus – 

oral or topical antibiotic

Treatment recommended for ALL patients in selected patient group

Due to disruption of the skin barrier from inflammation and scratching, skin may be secondarily infected with staphylococci (usually Staphylococcus aureus) or streptococci (usually Streptococcus pyogenes).​[5]

Treatment with oral antibiotics or topical antimicrobials is effective.

In the UK, tetracycline and doxycycline are licensed for use in children aged 12 years and over.

Primary options

cefalexin: children: 25-50 mg/kg/day orally given in 4 divided doses; adults: 250-500 mg orally four times daily

OR

tetracycline: children >8 years of age: 25-50 mg/kg/day orally give in 4 divided doses; adults: 500 mg orally twice daily

OR

doxycycline: children >8 years of age: 2.2 mg/kg orally twice daily; adults: 100 mg orally twice daily

OR

clindamycin: children: 10-20 mg/kg/day orally given in 3-4 divided doses; adults: 150-300 mg orally three to four times daily

OR

mupirocin topical: (2%) children >2 months of age and adults: apply to the affected area(s) three times daily

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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