The bite of a brown recluse spider is very toxic and thus needs a regimen that speeds recovery and minimizes tissue loss. To date, limited resources are known of any such successful regimen. I have constructed and have been using a regimen since 2010 that has proven to minimize and prevent tissue loss if implemented in the first 24 to 48 hours. I would not hesitate to use it as far out as even 96 hours or more. I would like to provide and share my knowledge and discovery of the results and success of this effective treatment regimen discovered for brown recluse spider bites so that others may benefit from it.
Exposures
Most of these observations and treatments prescribed were done in my office and some at Cox Hospital emergency room both which are in Springfield, Mo. It was a longitudinal, observational study using convenience samples of more than 20 patients with bites. A majority of the bites treated have had the spider recovered. A few did not, but those bites presented with actual punctum or double punctum and typical appearance. Some of the bites encountered and treated were severe with very large areas of erythema and swelling, some with lymphangitic streaking, widespread toxic rash, fever, and myalgias. Emphasis cannot be stressed enough that early initiation of treatment is critical!! It is also extremely important to not disturb the site with any type of surgical intervention (e.g. I and D, debridement, or drain placement). If wound breakdown should occur, usual wound care should be used.
Design and Treatment
This regimen consists of the following: tetanus booster (if not up to date); gram positive antibiotic therapy (usually Cephalexin 500 bid); aspirin (1 full-strength/day) prednisone 80–100 mg/day as a single a.m. dose until bite area has lost the majority of its surrounding erythema and induration (usually 6–7 days), then drop down to 60 mg/day for a few days and gradually tapering off in about 3–4 weeks; gastric protection; and pain relief. Any patient medium-sized and up should start with the 100 mg (80 mg in very small people) dose of prednisone per day as a single a.m. dose. It is very important not to split doses. This dose is reduced to 80 mg/day as soon as toxicity clears (usually 2 to 4 days) and erythema is reduced. Further tapering is based on response.
Data and Patients
I have successfully treated over 20 patients that presented with brown recluse spider bites with this regimen when it was instituted in the time frame described without significant tissue loss. Minor bites were not included. I will present two patients in this article.
Patient 1 was a 38-year-old white male seen two days post-brown recluse spider bite on the left posterior thigh. He presented with a temperature 101, stated he felt “bad” with malaise. The site had the following characteristics: a 20 cm area of erythema and swelling, 10 cm induration, 4 cm bullous grey-white-blue center, 1 cm stab wound, (I and D attempt by walk-in clinic). The regimen for this patient consisted of the following: tetanus up to date, cephalexin 500 bid, prednisone 100mg/day, one coated aspirin daily, Domeboro® compresses, Spandex/Telfa/Bactroban®, Prilosec OTC®. Followed up two days later (four days post-bite), and the patient was afebrile and felt fine, erythema and swelling were decreased, induration was 7 cm × 5 cm, bullous area unchanged, prednisone level was decreased to 80 mg/day with directions to go to 60mg/day in three days. Followed up nine days post bite, and the erythema and swelling were gone, 4 cm induration remained, central area was 2 cm, ½ cm of white/blue avascularity was noted, prednisone taper schedule initiated (serum AM Cortisol levels checked). Followed up 16 days post bite and found there was a 3 cm induration and a 1 cm ulcer (at stab wound site). The final result was complete healing with no tissue loss and minimal scarring
Patient 2 presented with a brown recluse bite on left anterior thigh three days post bite. (See photos, above.) Patient saw urgent care facility prior to seeing my office, and they treated the site with I and D with drain placement. The site had the following characteristics: 20 cm × 20 cm margin of erythema and swelling, 5 cm of induration, 3 cm of white-grey-bluish center with stab wound and drain, and lymphangitic proximal toxic streaking. The patient was afebrile but “achy”. The regimen for this patient consisted of the following: tetanus up to date, prednisone 100 mg/day × 2, then 80 mg/day, one coated aspirin daily, Prilosec OTC®, cephalexin 500 bid, drain removal, Dome Boro/Bactroban. Followed up 10 days post-bite and found the erythema decreased in intensity to faint pink and swelling had decreased. There was a 5 cm × 4 cm whitish area centrally with 2 cm × 2 cm × 1 cm purpuric area containing the iatrogenic “wound”. At this point, the prednisone was decreased to 60 mg/day. Followed up 21 days post-bite and found the erythema and swelling are gone, induration 3 cm × 2 cm, hypovascular area smaller, prednisone tapering initiated. Followed up five weeks post bite and found 2 cm × 1½ induration. On the 34th day post bite, a 4 mm ulcer remained. On the 55th day post bite, area was completely healed and only a tiny scar remains.
Conclusion
This appears to be one of the largest case reports of brown recluse spider bites in the literature. (https://www.uptodate.com/contents/approach-to-the-patient-with-a-suspected-spider-bite-an-overview accessed 7/20/2017) They were all managed by the author using the same treatment program outlined in the manuscript. The treatment regimen was well tolerated and rapidly ended toxicity. Relative predictors of tissue loss are size of area of induration, size of area of hypo-vascularity and the time between the brown recluse spider bite and this regimen being started. It is hoped that this treatment will be further studied and of help to physicians especially those who infrequently treat brown recluse spider bites.
Biography
Troy Major, MD, MSMA member since 1978, is a Dermatologist in Springfield, Mo.
Contact: ddoc09@yahoo.com
Reprinted with permission, Greene County Medical Society Journal.
