A Dermatologist’s Guide to Battling Bed Bugs

Dr. Keller:
You’re listening to DermConsult on ReachMD. I’m Dr. Matthew Keller and we recently got the chance to speak with Dr. Omer Ibrahim who shared key strategies for diagnosing, treating, and preventing bed bug bites. Here’s Dr. Ibrahim now.

Dr. Ibrahim:
So we have seen an increase in the infestations with bed bugs worldwide, especially in the United States and this is due to several reasons.  Back in the 40s,  DDT was introduced as a pesticide insecticide that actually was used to kill bed bugs and it was very effective, and it has since been banned and there have been lots of pesticides that have been released since. But there has been an issue with pesticide resistance. So, these bed bugs have actually formulated these very complex mechanisms, they’re almost like superbugs, to be honest, that have formulated these very complex mechanisms to resist these pesticides and actually these pesticides stopped working on them. So that’s definitely one factor why bed bugs have increased in incidence.

Another reason is ease and frequency of travel. So, I think back in 2014 according to the United Nations world travel report, they estimated about 1.4 billion people traveled internationally of some sort across country lines and they estimate that number by 2030 to be at 1.8 billion. So, people are traveling back and forth from bigger cities to larger cities, larger cities to bigger cities, from towns to farmlands. So, from “developed” countries to less developed countries, so there’s a lot of international travel. So, people bring these bugs and these insects with them as well.

Another reason why bed bugs have increased in incidence as well was increasing population. So, it goes without saying that the population worldwide is increasing and larger cities, for example Chicago and New York they’re getting larger and they’re getting denser. So, people are for lack of better term living on top of one another. And so more densely populated cities, more densely populated areas, that increases your risk of transmitting something like a bed bug from one person to another. And so, these are a few of the reasons why we’ve seen an increase in bed bugs. 

So, when looking at bed bug bites, or looking at bug bites in general, you always want to first take a step back and ask the patient where are the bites? Because usually bug bites, specifically bed bug bites, are usually found either in the waistband area or on exposed areas. So, like the arms and the legs. Sometimes you can get it on the eyelids, as well, because. if you’re asleep in bed, the bugs are more attracted to the locations that are easily accessible, so like the arms and the legs and the face sometimes. So that’s one thing you would want to look at is where exactly are these bites. 

What the bites look like, and this is what I look for, they look like what we call erythematous or red to pink; sometimes they’re macules, which are flat or papules, which are tiny little raised bumps. They’re very intensely itchy to most people.  And one of the telltale signs that I almost always look for is the breakfast, lunch, and dinner sign. So, you look for two to three bites in a row. They’re almost always in almost a linear fashion because what’s thought to happen is the bug gets on your skin, takes one bite, moves over, takes another bite, moves over, takes another bite. That’s the breakfast, lunch, and dinner sign. That’s almost always, if I see that, the diagnosis of bug bites comes to mind. Keep in mind  I said bug bites, not bed bugs bites. So, when you look at someone’s bites or look at someone’s skin, you’re like, ‘OK, these are bug bites’, it’s almost impossible to tell what kind of bites they are.

So, then this is where you get into history. You have to ask the patient when do you notice most of these bites occurring? Are they worse in the morning, you’re fine during the day? A when you wake up in the next morning, are there more bites to be found? Because that could be a sign that something is biting you in the middle of the night, and that’s usually bed bugs. You also want to ask are they itchy, are they not? Does anyone else in your household have similar rashes or similar itchy spots? You want to ask when they occur, does anyone else have something similar, where they are on the body, are they itchy, and last but not least, ask them have they seen anything in their bed? Have they seen specks of blood? Have they seen any sort of signs of any bugs or any infestations around their bed or anywhere in their house?

If there’s any doubt as to what’s causing these bug bites referral to a board-certified dermatologist is always a good idea. Because we can also do a skin biopsy and we can rule out things like just run-of-the-mill eczema versus some of these autoimmune, bolus diseases or blistering diseases. We can diagnose bug bites specifically under the microscope but not the type of bug.

So, once you’ve made that diagnosis, whether clinically or histologically, dermatologic treatment is mainly symptomatic. So first and foremost, topical steroids are the first thing that you want to try. Topical steroids, like hydrocortisone 2.5% or desonide, 0.05% for the face, triamcinolone 0.1% for body fold areas or anywhere on the body, and then clobetasol 0.05% for like anywhere on the body, I would avoid the body folds. You ask the patient to apply it to anywhere that’s itchy or anywhere there’s a rash twice a day for up to two weeks at a time.

You always want to look out for secondary bacterial infections. So, let’s face it, you dig at your skin, you start scratching, you could potentially cause breaks in the skin where you can introduce bacteria. You look for signs of redness, pain,  brown/yellow crusting, that could be sign of a bacterial infection. You need to treat that with topical or systemic antibiotics. Like I said, dermatologic treatment is mainly symptomatic until you get into your eradication techniques and treatments. 

So, when a patient gets diagnosed and you give them dermatologic symptomatic treatment, the real work really comes to the at-home treatment. And at-home treatment can be costly. It can cost upwards of a couple thousand dollars. So before you even call profession exterminator, patients should go and examine the home. And honestly, bed bugs are honestly a misnomer because they don’t always just live in beds. They can be in your mattress, in your bed, in your linens, it can be in wallpaper seams, in electrical sockets. They can live on furniture, as well, and they can live on dirty clothing. And they can actually survive for weeks and weeks and weeks, up to even several months without feeding, in between feedings. So, they can be alive for a long time. So, inspection for the bugs or feces or blood specks is the first step.

Second step is to contact professional exterminators. Exterminators have special insecticides, as well as special equipment they can use to heat up rooms, because that’s one of the ways you can kill bed bugs is to heat up a room to a certain temperature for at least 90 minutes, sufficient enough to kill bed bugs.  The infested areas should be vacuumed daily and vacuumed bags and unwanted items should be sealed in plastic before throwing them away. Mattresses and furniture should be sealed in plastic bags, and they should be treated with heat, steaming, or pesticides, if possible. And in general, you want to make sure that any possible area is treated and treated sufficiently because if they’re not treated sufficiently, the bugs can actually become resistant to treatment.

Prevention is key and this is something that I always do when I go to a hotel room. These are very important points that a person should follow when you go to hotel rooms. Number one, that luggage carrier that’s almost in every closet, take it out, put it out, put your luggage off the floor and put it on that luggage holder. So just make sure that your bag is elevated because when the bag is on the floor, which granted, I’m guilty of doing that a lot when I’m lazy, just open the bag and leave it on the floor, bed bugs can actually jump in and that’s how bed bugs get into your clothes, and then that’s how you transport them back home. So, keep your bag on a luggage rack. Number two, when I take off my shoes, put them into the closet and if there’s a shelf, put them on the shelf. You want to keep the shoes off the floor because bed bugs can crawl out of the walls in the middle of the night, jump in your shoes and that’s how you can take them back home.

Dr, Keller:
That was Dr. Omer Ibrahim sharing key preventative and management strategies for bed bug bites. For ReachMD, I’m Dr. Matthew Keller. To find more episodes in our series, please visit ReachMD.com/DermConsult, where you can Be Part of the Knowledge. Thanks for listening.