Management of occupational Hymenoptera allergy

Certain outdoor activities show a particularly high risk for being stung by Hymenoptera species. Avoidance of such stings is preferable for preventing unwanted local or systemic sting reactions. The purpose of this review is to evaluate the current knowledge on risk factors and management of Hymenoptera venom allergy. We will specifically focus on patients with an intense occupational exposure to Hymenoptera venom.

Repeated stings were found to increase the risk for subsequent severe anaphylactic sting reactions. The male preponderance for severe anaphylactic sting reactions probably reflects in part a sex-specific occupational exposure being higher in males. When selecting a specific venom for therapy, current knowledge of cross-reactivity between venoms of various species should be considered. If available, venom immunotherapy should be performed using the venom of the culprit insect. Recently, a pilot study also showed the efficacy of venom immunotherapy when treating large local reactions.

If an intensely exposed patient presents with a systemic anaphylactic sting reaction, efficacy of venom immunotherapy should be demonstrated by a tolerated sting challenge before allowing this patient to return to his/her occupation. Patients with bee venom allergy and an intense exposure should be treated with an increased maintenance dose of 200 μg bee venom. Patients with a history of large local reactions should be provided with an emergency kit, which should contain oral antihistamines and corticosteroids. In patients in whom local sting reactions induce symptoms of high clinical significance, an off-label use of venom immunotherapy may be discussed.