Brown Recluse Spider Envenomation Treatment & Management
- Author: Thomas C Arnold, MD, FAAEM, FACMT; Chief Editor: Joe Alcock, MD, MS more...
Emergency Department Care
Treatment of brown recluse envenomation is directed by the severity of the injury. General wound management consists of local debridement, elevation, and loose immobilization of the affected area.
Because the activity of sphingomyelinase D is temperature dependent, application of local cool compresses is helpful and should be continued until progression of the necrotic process appears to have stopped.
Dapsone, because of its leukocyte inhibiting properties, frequently has been recommended by authorities to treat local lesions. However, because of the potential for adverse effects associated with dapsone use, especially in the setting of G-6-PD deficiency, appropriate caution should be exercised if using this medication. To date, no well-controlled studies have shown dapsone to affect clinical outcome in human brown recluse envenomations; therefore, it is not routinely recommended.[11, 12]
Other treatments such as colchicine, steroids, antivenom, nitroglycerin patches, and surgical excision have been reported, but insufficient data exist to support their clinical use today.[13, 14]
Some evidence indicates that hyperbaric oxygen therapy is beneficial in an animal model for reducing skin lesion size, but controlled human studies of this technique have not been performed.[11, 15, 16]
Patients exhibiting signs of systemic toxicity should be admitted and evaluated for evidence of coagulopathy, hemolysis, hemoglobinuria, renal failure, or further progression of systemic illness.
Urinalysis can provide early evidence of systemic involvement (eg, hemoglobinuria, myoglobinuria) and can be performed easily at the bedside in all patients.
Consult a plastic surgeon or other specialist with experience in wound management in patients who might require delayed skin grafting or have a prolonged recovery period.
The images below show the progression of a brown recluse spider bite wound, which needed a skin graft for healing.
Gehrie EA, Nian H, Young PP. Brown Recluse spider bite mediated hemolysis: clinical features, a possible role for complement inhibitor therapy, and reduced RBC surface glycophorin A as a potential biomarker of venom exposure. PLoS One. 2013. 8(9):e76558. [Medline]. [Full Text].
Vetter RS. Arachnids misidentified as brown recluse spiders by medical personnel and other authorities in North America. Toxicon. 2009 Sep 15. 54(4):545-7. [Medline].
Vetter RS, Barger DK. An infestation of 2,055 brown recluse spiders (Araneae: Sicariidae) and no envenomations in a Kansas home: implications for bite diagnoses in nonendemic areas. J Med Entomol. 2002 Nov. 39(6):948-51. [Medline].
Vetter RS, Bush SP. Reports of presumptive brown recluse spider bites reinforce improbable diagnosis in regions of North America where the spider is not endemic. Clin Infect Dis. 2002 Aug 15. 35(4):442-5. [Medline].
Miller LG, Spellberg B. Spider bites and infections caused by community-associated methicillin-resistant Staphylococcus aureus. Surg Infect. 2004 Fall. 5(3):321-2. [Medline].
Mowry JB, Spyker DA, Brooks DE, McMillan N, Schauben JL. 2014 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 32nd Annual Report. Clin Toxicol (Phila). 2015 Dec. 53 (10):962-1147. [Medline]. [Full Text].
McDade J, Aygun B, Ware RE. Brown recluse spider (Loxosceles reclusa) envenomation leading to acute hemolytic anemia in six adolescents. J Pediatr. 2010 Jan. 156(1):155-7. [Medline].
Rosen JL, Dumitru JK, Langley EW, Meade Olivier CA. Emergency Department Death From Systemic Loxoscelism. Ann Emerg Med. 2012 Feb 1. [Medline].
McGlasson DL, Green JA, Stoecker WV, Babcock JL, Calcara DA. Duration of Loxosceles reclusa venom detection by ELISA from swabs. Clin Lab Sci. 2009 Fall. 22(4):216-22. [Medline].
Graham WR Jr. Adverse effects of dapsone. Int J Dermatol. 1975 Sep. 14(7):494-500. [Medline].
Phillips S, Kohn M, Baker D, Vander Leest R, Gomez H, McKinney P, et al. Therapy of brown spider envenomation: a controlled trial of hyperbaric oxygen, dapsone, and cyproheptadine. Ann Emerg Med. 1995 Mar. 25(3):363-8. [Medline].
King LE Jr, Rees RS. Dapsone treatment of a brown recluse bite. JAMA. 1983 Aug 5. 250(5):648. [Medline].
Burton KG. Nitroglycerine patches for brown recluse spider bites. Am Fam Physician. 1995 May 1. 51(6):1401. [Medline].
Lowry BP, Bradfield JF, Carroll RG, Brewer K, Meggs WJ. A controlled trial of topical nitroglycerin in a New Zealand white rabbit model of brown recluse spider envenomation. Ann Emerg Med. 2001 Feb. 37(2):161-5. [Medline].
Maynor ML, Moon RE, Klitzman B, Fracica PJ, Canada A. Brown recluse spider envenomation: a prospective trial of hyperbaric oxygen therapy. Acad Emerg Med. 1997 Mar. 4(3):184-92. [Medline].
Hobbs GD, Anderson AR, Greene TJ, Yealy DM. Comparison of hyperbaric oxygen and dapsone therapy for loxosceles envenomation. Acad Emerg Med. 1996 Aug. 3(8):758-61. [Medline].
Carlton PK Jr. Brown recluse spider bite? Consider this uniquely conservative treatment. J Fam Pract. 2009 Feb. 58(2):E1-6. [Medline].
de Roodt AR, Estevez-Ramírez J, Litwin S, Magaña P, Olvera A, Alagón A. Toxicity of two North American Loxosceles (brown recluse spiders) venoms and their neutralization by antivenoms. Clin Toxicol (Phila). 2007 Sep. 45(6):678-87. [Medline].