Wilderness Dermatology: Bugs, Plants, and Other Nuisances That May Ruin Your Hike - Rhode Island Medical Society
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W ILD ERNESS ME DICIN E
Wilderness Dermatology:
Bugs, Plants, and Other Nuisances That May Ruin Your Hike
DOMINIC J. WU, MD; JENNIFER LEE, MD; AFTON CHAVEZ, MD; JOHN C. KAWAOKA, MD
A BST RA C T reaches higher in altitude, the total amount of UV radiation
Spending time outdoors can be rewarding. However, ex- exposure increases as much as 30% for every 1000 meters.4
posure to the sun, insect bites, and plant exposures may
result in a wide range of dermatologic manifestations. a. Sun Protection
In this article, we describe potential cutaneous mani- All people older than 6 months of age, regardless of skin
festations of common wilderness exposures in New En- color, should apply a broad-spectrum and water-resistant
gland including photodermatoses from prolonged sun sunscreen of at least SPF 30. It is also important to re-apply
exposure, phytodermatoses from plant exposures, and sunscreen at least every 2 hours, and after each water expo-
arthropod-bite reactions from common insects (mosqui- sure. Patients should seek shade when possible, avoid sun
tos, spiders, ticks, hymenoptera, mites and chiggers). The at peak hours between 10am–2pm, and wear sun protective
article will also address preventive and treatment strate- clothing including broad-brimmed hats and sunglasses. The
gies which may help physicians and their patients better American Academy of Pediatrics recommends that children
prepare for spending time in the wilderness. younger than 6 months of age should have minimal expo-
K E YWORD S: dermatology, wilderness, phototoxicity,
sure, wear appropriate clothing and have adequate shade.
arthropod reactions, plant exposure
b. Drug-induced Phototoxicity
Some medications can induce phototoxic rashes that resem-
ble sunburns after sun exposure. Common offenders include
NSAIDs, quinolones, tetracyclines, and diuretics. This side
INTRO D U C T I O N effect is thought to be due to UV light absorption by the
Although hiking, biking, skiing, and other outdoor pursuits medication, leading to free radical formation and cellular
are wonderful physical activities and can enhance one’s damage in sun-exposed areas. The severity of the effect is
mental wellbeing, it is vital to take appropriate preventative often dose-dependent and linked to the duration and inten-
measures to ensure the most enjoyable experience possible. sity of sun exposure. The phototoxic rash often occurs
Environmental exposure to the sun and altitude puts one within 30 minutes of UV exposure and begins with burning
at risk of sunburn and both acute and chronic skin damage. and pruritus, with or without wheals, and further develops
Insect bites can induce an array of dermatologic manifes- into a bright red edematous photodistributed rash. This may
tations that, if not appropriately managed, may result in progress to erythema, hyperpigmentation, edema, and even
serious medical complications. Plant exposures can result blistering.
in multiple cutaneous manifestations including allergic Management is supportive and involves prevention strate-
contact dermatitis, phytophotodermatitis, irritant contact gies such as sun protection, limiting sun exposure, and dose
dermatitis, and contact urticaria. reduction or elimination of the offending medication. Cool
compresses and ice packs may offer significant relief. Simi-
lar to sunburns, the patient should maintain hydration and
SU N EXP O S U RE use gentle emollients.
Prolonged ultraviolet (UV) radiation exposure may result
in cutaneous manifestations including sunburn, aging, and
malignancies. Approximately 1 in 5 people in the United INSEC TS
States may develop skin cancer in their lifetimes.1 Both In the northeast United States, the most common cutane-
UVA and UVB radiation may cause skin cancer, with UVA ous complaints from insect exposure are due to mosquitoes,
primarily responsible for chronic skin changes such as pho- mites and chiggers, gypsy moths, fleas, spiders, hymenop-
toaging, wrinkling, and lentigines.2 Even on cloudy days, up tera, and ticks. Their bites may contain toxins and irritants
to 80% of harmful UV radiation can reach the skin.3 As one that can cause a wide range of dermatologic manifestations.
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a. Mosquitos c. Ticks
Mosquitos are vectors for many diseases including West Nile Ticks can carry a multitude of diseases including Lyme dis-
virus, encephalitis, and more. Mosquito bites classically ease (Table 1). Tick bites are typically not painful, as their
present as pruritic wheals and papules, often with a central saliva contains anesthetic and anticoagulant factors.
punctum. Depending on the victim’s immune response, Lyme disease typically presents with the erythema
these bites may appear as urticaria, vesicles, or even as gran- migrans rash (red macule or thin plaque that slowly expands
ulomatous lesions.5 outwards with central clearing resembling a target). The
Prevention strategies include avoiding sites with stagnant incidence of Lyme disease has increased since 2007, and the
water, wearing light-colored long-sleeved clothing to easily geographic distribution has broadened from primarily New
identify mosquitos, utilizing mosquito nets, and wearing England, the Mid-Atlantic States, and Wisconsin to include
insect repellant. Insect repellant containing DEET 10–35% adjacent states.11 If the tick is identifiable as I. scapularis,
or picaridin 20% can be quite effective,6 and clothes can also has been attached to the host for more than 36 hours and
be washed with permethrin. is engorged in a Lyme-endemic area, prophylactic treatment
Mosquito bites are generally self-limited. Ice packs, topi- with a single dose of doxycycline 200 mg orally may be
cal steroids, and over-the-counter topicals such as pramox- administered within 72 hours of tick removal (if no other
ine 1% cream, menthol-containing products, and oral contraindications).12
antihistamines may help patients with more severe and Ticks should be removed carefully using a pair of forceps
symptomatic reactions.7 First-generation antihistamines are or a tick-removal device by grasping the tick as close to the
more sedating than second-generation agents, but tend to be skin as possible and removing the parasite with gentle, steady
more effective for pruritus. traction perpendicular to the skin without twisting.6,13
Tick bites may be prevented by wearing clothing treated
b. Spiders with permethrin. Applying DEET-containing insect repel-
Most spider bites encountered in the U.S. are harmless and lants, tucking pants into socks, wearing long-sleeved cloth-
may induce a brief localized skin reaction that spontaneously ing and pants, and performing daily tick checks can help to
resolves. However, black widow (Latrodectus mactans) and reduce potential exposure.
brown recluse (Loxosceles reclusa) spider bites may require
more directed medical care (Table 2). d. Hymenoptera (Bees, Wasps)
Female black widow spiders are more commonly found Stings from bees and wasps can be incredibly painful, and
in the South up to Southern New England and in the West. may even provoke anaphylaxis. Their stings often produce
Their bites transmit a venom containing α-latrotoxin, which immediate burning and pain at the site, followed by an
leads to a large release of acetylcholine. The bite site typi- erythematous wheal. This usually resolves spontaneously
cally appears as a painful pink edematous papule or plaque within a few hours. However, some individuals have a more
with central fang marks with possible central clearing. The exaggerated response, such as swelling greater than 6 inches
victim may then experience muscle spasms and cramps in diameter lasting up to 7 days. More severe local reactions
within an hour in the chest or abdomen that may mimic in select individuals may be due to venom-specific IgE anti-
a myocardial infarction. Treatment options include intrave- bodies in sensitized victims.5
nous benzodiazepines for muscle spasms and narcotic pain To remove a bee or wasp sting, the victim should ideally
medications. Antivenom can be considered up to 48 hours use a straight, hard surface such as the edge of a credit card
after a bite if severe pain persists after routine therapy.8 to nudge out and remove the stinger. One should avoid using
Brown recluse spiders are rare in the Northeast. The bite fingers or tweezers to remove the stinger, as this may squeeze
itself may be only slightly painful. However, soon after the additional venom into the stinging site. Some stings, such as
bite, a tender erythematous halo rash may develop. In many that of the honeybee, have venom sacs and attached muscu-
cases, this progresses to central necrosis, sometimes even lature that may continue to pump venom if the sac is not
requiring a skin graft. It is thought that sphingomyelinase removed. Intradermal skin allergy testing can be performed
D in the venom triggers platelet aggregation and activates with dilute quantities of venom to identify individuals at
thromboxane B2 which leads to skin necrosis.6,9 Treatment high risk of anaphylaxis to venom. These individuals at risk
options are controversial; however, most experts suggest for hymenopteran anaphylaxis have the option of undergo-
that overly aggressive management, such as excising the bite ing venom immunotherapy which has been shown to be
site to prevent necrosis, is harmful and not indicated. Most effective. They should always carry a preloaded epinephrine
suggest proper wound care and minor debridement, with or device for emergency administration.5,14 (Table 3)
without antihistamines or dapsone.10
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Table 1. Tick-borne Illnesses
Disease/Organism/ Vector image Cutaneous findings and Non-cutaneous findings/ Treatments
Vector clinical photo Tests
Disease: Non-cutaneous findings: Doxycycline (even in children 8
Lyme Disease Early: erythema migrans A) Early localized disease yrs old: 14–21 days
-flu like symptoms Amoxicillin in pregnant women,
Organism: children < 8 yrs old: 14–21 days
Borrelia Burgdorferi B) Early disseminated disease
For severe disseminated disease
-facial nerve palsy
- Ceftriaxone IV
Tick vectors: -joint pain
Ixodes scapularis -carditis Prophylaxis if
1) Tick is Ixodes scapularis tick and
Ixodes pacificus C) Chronic disease has been attached for approximately
-persistent neurologic and 36 hrs
Ixodes scapularis1
Ixodes ricinus rheumatologic symptoms 2) Post exposure prophylaxis within 72
hours of tick removal
-Black legged tick
Tests: 3) Local rate of infection with Borrelia
-Females: orange to red body
Erythema migrans1 -Enzyme immunoassay for IgM at least 20%
surrounding the black scutum
and IgG antibodies 4) Doxycycline isnot contraindicated
-Males: body completely dark
brown Late or chronic: Acrodermatitis When these criteria are met,
chronica atrophicans (loss of -Western blot of enzyme treat with:
subcutaneous fat with thin immunoassay positive or Doxycycline 200mg in single dose w/I
atrophic skin in chronic disease equivocal 72 hours of tick bite for adults
Doxycyline 4mg/kg in children > 8 yrs
old (max dose 200mg) w/I 72 hrs of
tick bite
Disease: See Lyme disease In severe infection, can have Non-cutaneous findings: Treatment:
Babesiosis petechiae and ecchmyoses -flu like symptoms Atovaquone and Azithromycin for
-fatigue 7-10 days
Organism: malaise
Babesia microti -fevers
-chills For severe disease treat with
Tick vector: -myalgias clindamycin IV and quinine
Ixodes scapularis -occasionally mild
hepatomegaly or splenomegaly
-Dark-colored urine due to
hemolytic anemia
Tests:
-CBC to look for hemolytic
anemia
-Reticulocyte count
-Definitive diagnosis by
Giemsa or Wright stains of
blood smears which show ring
forms and tetrads
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Table 1. Tick-borne Illnesses (continued)
Disease/Organism/ Vector image Cutaneous findings and Non-cutaneous findings/ Treatments
Vector clinical photo Tests
Disease: See Lyme disease Usually no exanthem, so Non-cutaneous findings: Doxycycline in adults and children >
Anaplasmosis presence of cutaneous findings -Fevers 8 yo
should raise suspicion for other -Malaise
Organism: diseases or coinfection -Myalgias
Anaplasma Headaches
phagocytophilium -Nausea, vomiting
-Confusion
Tick vector
Ixodes scapularis Tests:
-serology by IFA
Ixodes pacificus -ELISA
-PCR
Disease: Exanthem present in 10% of Non-cutaneous findings: Doxycycline in adults and children >
Ehrlichiosis cases -Fevers 8 yo
-Faint, blanching generalized -Malaise
Organism: erythema -Myalgias
Ehrlichia chaffeenis -Erythematous macules, Headaches
papules, petechiae -Nausea, vomiting
Tick vector: -Confusion
Amyblomma -Meningoencephalitis
americannum -Cranial nerve palsies
Female lone star tick1 Tests:
Females: characterstic dorsal -serology by IFA
white spot -ELISA
Male: scattered spots/streaks -PCR
around perimeter of body
e. Mites and Chiggers rash. Wild parsnip (Pastinaca sativa) is found throughout
Mites are small arthropods with eight legs whose bites may New England and may cause a severe phytophotodermatitis
cause pruritic papules. Its six-legged larval form is called reaction.
the chigger, which appear as tiny red insects that crawl Cutaneous manifestations include burning and painful,
around until they reach a barrier such as lining of a sock. bullous, erythematous eruptions, which may result in
The mites’ saliva sometimes provokes an allergic reaction chronic skin hyperpigmentation.15 Treatment is mostly
from the human host, producing a pruritic papule. Mite and symptomatic (with cool compresses and oral antihistamines
chigger bites classically present as grouped 1–2 mm pruritic if needed), and prevention involves avoidance of triggers.
red papules with an abrupt demarcation line around borders With appropriate sun protection and time, the post-inflam-
of clothing such as around the ankles. matory hyperpigmentation should resolve spontaneously.
These bites tend to be self-limited and may be treated
symptomatically for more severe reactions. Prevention and b. Irritant contact dermatitis
treatment strategies are similar to those for mosquitos. There are two main categories of irritant contact dermati-
tis (ICD) from plant exposures: mechanical (physical injury),
and chemical.
PHY T O D E RM ATO S E S Mechanical ICD is a result of physical trauma to the skin
Exposure to plants may result in a variety of cutaneous man- caused by a plant’s trichomes (hairs), spines, glochids (barbed
ifestations including phytophotodermatitis, irritant contact hairs), or thorns. These defense mechanisms may breach the
dermatitis, allergic contact dermatitis, and contact urticaria. epidermis and trigger a papular eruption. A classic exam-
ple of this are cacti which contain spines and sometimes
a. Phytophotodermatitis glochids, which, if a person is exposed, may present as ery-
Phytophotodermatitis is a cutaneous eruption resulting from thematous papules and nodules that spontaneously resolve
the exposure of skin to photosensitizing agents from plants with time.
such as furocoumarins (eg. psoralen) which react with UV Chemical ICD is often provoked by plant chemicals such
radiation. Some plants that are known to cause phototox- as calcium oxalate that may be transferred to the epidermis
icity include lemon, lime, celery, carrots, dill, and anise. A after physical contact with a plant, resulting in subsequent
common presentation is a patient who squeezed limes out- inflammation. Daffodils commonly cause erythema, dry
doors and subsequently developed a burning, erythematous skin, as well as scaling of the finger tips among florists due
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Table 2. Arthropod and Snake Reactions
Organism and image Presentation Treatment Organism and image Presentation Treatment
Scorpion 2
-Pain and -Remove Gypsy moth -Eczematous, -Strip bite site
paresthesias of stinger pruritic dermatitis with adhesive
bite site -Supportive -Urticaria tape to remove
-May have care caterpillar hairs
neurological or -Ice -Wash site with
cardiopulmonary -Antihistamines soap and water
complications -Topical or oral
steroids for
severe reactions
Bees, wasps, hornets -Ranges from Remove stinger, Io moth 4 -Immediate Same as gypsy
pain and local symptomatic pruritus and moth
edema at site of care stinging of
bite to urticaria, involved skin
respiratory
distress,
anaphylaxis
Fire ants 2 -Line or ring of Symptomatic
pustules with care
surrounding red or Puss caterpillar 4 -Intense burning Same as gypsy
hemorrhagic halo pain moth
-May have -Hemorrhagic
neurologic linear track marks
systemic
symptoms,
anaphylaxis
Snake bite -Fast onset Emergency:
-Crotalidae: rattlesnake, pain, swelling, visit closest
copperhead 3, and cottonmouth hemorrhage, emergency
moccasin necrosis department.
Saddle back caterpillar 4 -Immediate Same as gypsy
Antivenom, painful stinging moth
tentanus -Redness
prophylaxis, -Edema
possible
antibiotics
Black widow spider 5 -Acute edema -Antivenom
-Elapidae: coral snake (touching
-hourglass-shaped marking on -Pain -Benzodiaz-
red and yellow bands) 3
abdomen -Symptoms epines
resembling a -IV calcium
surgical abdomen gluconate
References
1. Images from: Tickborne Diseases of the United States. Center for Disease Control and Preven-
tion. Fourth Edition. 2017. Brown recluse spider 5 -Erythema -Ice
2. Images from: Insects and Scorpions. Center for Disease Control and Prevention and National
Institute for Occupational Safety and Health. Updated May 2018. https://www.cdc.gov/niosh/ -violin-shaped marking on head -Bullae -Elevation
topics/insects/fireants.html -Necrosis -Possibly
3. Images from: Venomous Snakes. Center for Disease Control and Prevention and National In- -Possible dapsone
stitute for Occupational Safety and Health. Updated May 2018. https://www.cdc.gov/niosh/
topics/snakes/default.html disseminated
4. Images from: Moths. Center for Disease Control and Prevention and Public Health Image Library intravascular
(PHIL) https://phil.cdc.gov/AdvancedSearchResults.aspx?Search=Moths&parentid=15149&-
catid=17125
coagulation
5. Images from: Venomous spiders. Center for Disease Control and Prevention and National In-
stitute for Occupational Safety and Health. Updated June 2018. https://www.cdc.gov/niosh/
topics/spiders/types.html
6. Bolognia J and Schaffer JV. (2018). Dermatology. [Philadelphia]. Elsevier Saunders.
7. Jain S. (2012). Dermatology. [New York]. Springer.
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Table 3. Wilderness Dermatology Kit
While enjoying the wilderness, it is important to protect your skin and to have the necessary tools to decrease morbidity should a dermatological
issue arise during your outdoors adventure. The authors of this article suggest stocking your dermatology wilderness pack with the following items
for prevention and treatment.
Over-the-counter Prescription-Only
These items may require prescriptions from your doctor. Consider
these items based on discussions with your doctor.
Prevention • Broad brimmed hat
• UV protective long-sleeved clothing
• Broad-Spectrum sunscreen with an SPF of 30 or more
• Sunglasses
• DEET-containing insect repellant
• Permethrin-treated clothing
Treatment • Hydrocortisone 1% cream or ointment • Clobetasol 0.05% ointment
(Ointments) • Vaseline • Hydrocortisone 2.5% ointment
• Neosporin or other antibiotic ointment • Mupirocin antibiotic ointment
• Anti-itch creams such as Sarna
Treatment • Antihistamines (eg. Zyrtec, Benadryl, Claritin, Allegra) • Prednisone 10 mg tablets
(Oral medications) • Doxycycline 100 mg tablets
Dressings • Bandaids
• Gauze
• Medical Tape
• ACE bandage
• Tegaderm dressing
to contact with calcium oxalate crystals. Reactions tend to C ONC LU SION
be self-limited and require no medical treatment. Hiking and spending time outdoors is a healthy and poten-
tially therapeutic pastime. Exposures to insects, plants, and
c. Allergic contact dermatitis the weather, however, can result in a multitude of symptom-
Allergic contact dermatitis (ACD) is a type of delayed or type atic dermatologic manifestations. Equipping oneself with
IV hypersensitivity reaction. Urushiol found in poison ivy, the knowledge of potential exposures and prevention and
poison oak, and poison sumac, is a common cause of ACD in treatment strategies can help physicians prepare patients to
the United States. Although poison ivy may appear as clus- make the most out of their time in the wilderness.
ters of three leaves, poison oak and sumac have anywhere
from three to 13 leaves. Clinically, these lesions appear as
References
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Immediate management involves removal of the plant Dermatol. . 2017 May 16. DOA 8/15/18.
4. Schneider S, Levandowski CB, Manly C, et al. Wilderness derma-
should also be washed from clothing and gear that may have
tology: mountain exposures. Dermatol Online J. 2017; 23(11):4.
touched the oils. High potency topical corticosteroids such 5. Steen CJ, Carbonaro PA, Schwartz RA. Arthropods in dermatol-
as clobetasol 0.05% cream or betamethasone dipropionate ogy. J Am Acad Dermatol. 2004;50:819-842.
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extremities for limited skin disease. For lesions on the face 2013;88(12):841-847.
7. Yosipovitch G, Maibach HI. Effect of topical pramoxine on ex-
and skinfolds, low potency topical corticosteroids such as
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hydrocortisone 2.5% cream or ointment are preferred. In 1997;37(2 Pt 1): 278.
more severe cases, long taper of oral steroids of 2–3 weeks 8. Clark RF, Wethern-Kestner S, Vance MV, et al. Clinical presen-
may be necessary. Shorter courses of oral corticosteroids tation and treatment of black widow spider envenomation: a re-
view of 163 cases. Ann Emerg Med. 1992;21(7):782-787.
may result in a rebound flare.
9. Miller DM, Brodell RT, Herr R. Wilderness dermatology: Pre-
vention, diagnosis, and treatment of skin disease related to the
great outdoors. Wilderness Env Med. 1996:146-149.
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10. Diaz JH, Leblanc KE. Common spider bites. Am Fam Physician. Authors
2007;75(6):869-873.
Dominic J. Wu, MD, Cambridge Health Alliance Department
11. Shapiro ED, Wormser GP. Lyme Disease in 2018: What is new
(and what is not). JAMA. August 2018; Epub 2 August, 2018. of Family Medicine
12. Nadelman RB, Nowakowski J, Fish D, et al. Prophylaxis with Jennifer Lee, MD, Brown University Department of
single-dose doxycycline for the prevention of Lyme disease after Dermatology
Ixodes scapularis tick bite. N Engl J Med. 2001 Jul 12;345(2):79-
84. Afton Chavez, MD, Brown University Department of
13. Flicek BF. Rickettsial and other tick-borne infections. Crit Care Dermatology
Nurs Clin North Am. 2007;19(1):27-38.
John C. Kawaoka, MD, Brown University Department of
14. Valentine MD, Schuberth KC, Kagey-Sobotka A, et al. The value
of immunotherapy with venom in children with allergy to in- Dermatology
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Correspondence
tologist. 2012:20. John C. Kawaoka, MD
Brown University Department of Dermatology
593 Eddy St, APC 1018,
Providence, Rhode Island 02903
401-444-7139
John_Kawaoka@brown.edu
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