Bites of recluse spiders

Authors:
Richard S Vetter, MS
David L Swanson, MD
Section Editors:
Daniel F Danzl, MD
Stephen J Traub, MD
Deputy Editor:
James F Wiley, II, MD, MPH

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Sep 2016. | This topic last updated: Jul 19, 2016.

INTRODUCTION The entomology of recluse spiders (Genus Loxosceles) and the

clinical manifestations, diagnosis, differential diagnosis, and management of their bites will
be reviewed here.

An overview of spider bites and the management of bites of other spiders are discussed
separately. (See "Approach to the patient with a suspected spider bite: An overview".)

ENTOMOLOGY OF RECLUSE SPIDERS Spiders of the genus Loxosceles are known

colloquially as recluse spiders, violin spiders, fiddleback spiders, and in South America, by
the nonspecific name "brown spiders." These terms are used when describing
multiple Loxoscelesspecies as a group. When the common name "brown recluse spider" is
used here, it refers only to the one species, L. reclusa, which is widespread and commonly
found in homes in the indigenous Central Midwestern United States.

Loxosceles spiders have gained notoriety in the medical literature and lay press because
their bites sometimes become necrotic [1,2]. However, this is a relatively uncommon
sequela, and is largely limited to areas of the United States where these spiders are
endemic (figure 1). Outside of these regions, the vast majority of necrotic skin lesions are
caused by other disorders [3-6]. (See 'Differential diagnosis' below.)

Appearance and identification Recluse spiders are rather nondescript brown spiders
(picture 1 and picture 2). The most accurate method of identifying a recluse spider involves
counting the eyes. Most spiders have eight eyes in two rows of four. In contrast, recluse
spiders have six eyes, with a pair in front, a pair on both sides, and a gap between the
pairs (picture 3). With the naked eye or low magnification, the eye pairs (dyads) may
appear as individual eyespots.

Identifying a recluse spider on the basis of body markings is less reliable. The brown
recluse is described as having a violin pattern on its anterior cephalothorax, although this
has led to widespread misidentification of common, harmless spiders as brown recluse
when the dark markings on spiders' bodies are mistakenly interpreted as violins [7,8].
Additionally, the violin marking is absent in many juvenile and recently-molted brown
recluses as well as in some southwestern recluse species. Other features of recluse
spiders include monochromatic legs, a monochromatic abdomen, and fine hairs (but not
conspicuous spines) on the legs (picture 2).

The most common spider mistaken for Loxosceles in the United States
is Kukulcania (picture 4), which has a darkened pattern on the cephalothorax near the
eyes of the tan males that can be mistaken for a violin pattern [9]. Female Kukulcania are
black or dark brown, velvety in texture, and resemble small tarantulas, although people still
mistake them for brown recluse spiders. Kukulcania spiders are found in the southern third
of the United States from the San Francisco Bay through southern California, east through
Texas to Florida and north to North Carolina and Virginia. They are frequently found in
homes, although verified bites from these spiders are virtually unknown.

Geographic location There are over 110 Loxosceles species in the world, although
only a few have extensive distributions and also exist where humans live. Most species
are found in North and South America (table 1) [9]. Recluse bites are rare elsewhere,
although they have been reported in South Africa and Australia.

In the United States, recluse spiders are found in limited areas of the South, West,
and Midwest (figure 1) and rarely outside these endemic areas [10]. The brown
recluse, L. reclusa, is the most widespread and the best known of North American
recluse spiders. It is asynanthropic spider (ie, its population numbers increase in
association with humans) and these spiders are commonly encountered within homes
in endemic areas [11,12].
In South America, Loxosceles spiders of medical importance are found in Brazil and
Chile. The most common species involved in envenomations are L. laeta, L.
intermedia, and L. gaucho. Loxosceles laeta is often considered the most dangerous
of the recluse spiders, in part because it is the species that attains the largest body
size.
The Mediterranean recluse, L. rufescens, has been transported around the world
and continues to establish isolated populations inside buildings on many continents. It
has been found in many American cities, where these spiders tend to develop dense
populations within isolated buildings. However, despite these infestations, verified
bites from Mediterranean recluse are exceedingly rare.

Habitat Recluses are found mostly inside homes (eg, basements, attics, behind
bookshelves and dressers, and in cupboards). As their name implies, these spiders prefer
dark, quiet areas that are rarely disturbed (table 1). Out of doors, they are found under
objects, such as rocks or the bark of dead trees.

CLINICAL MANIFESTATIONS OF BITES Loxoscelism is the term for the medical

manifestations of bites by recluse spiders. In this review, the term is used to refer to both
local and systemic symptoms resulting from bites, although toxicologists sometimes use
the term to refer exclusively to the systemic symptoms.

The literature pertaining to loxoscelism is in general inadequate because of the lack of

documentation of a proven spider bite, which is the proven presence of the culprit spider in
the vicinity [13]. Reports of larger series of patients carrying the diagnosis of loxoscelism
only have proven bites in 7 to 14 percent of cases [14,15].

Venom properties Loxosceles venom contains a large number of enzymes and

biologically active substances, of which sphingomyelinase D is the most important. This
enzyme is unique in nature to Loxosceles and its sister genus, Sicarius, but is absent in all
other spiders including other closely related haplogyne spiders [16].

Sphingomyelinase is believed responsible for skin necrosis and the systemic

manifestations of Loxosceles envenomation. It activates complement, induces neutrophil
chemotaxis, induces apoptosis of keratinocytes and other cells, and initiates the
generation of potent collagen and elastin-degrading metalloproteinases [17].

Clinical history Recluse spiders (like most spiders) typically bite humans only as a
desperate last line of defense as they are being crushed between flesh and some object.
This happens most frequently indoors, as a result of rolling over on the spider in bed or
putting on clothing or footwear that has been left in closets or on the floor, in which the
spider has sought refuge.

Recluse spider bites typically occur on the upper arm, thorax, or inner thigh. Bites on the
hands or face (ie, uncovered areas) are rare.

Recluse bites can be sustained out of doors, although these spiders are not known to be
found in living vegetation. Patients reporting a painful bite while reaching into living foliage
are more likely to have sustained an insect sting or puncture by thorns or other sharp plant
matter.

Findings following bites Symptoms may be divided into local signs at the bite site,
skin necrosis, and, less commonly systemic effects.

Local effects The initial bite of a Loxosceles spider is usually painless, although they
can occasionally be painful or cause a burning sensation [18].

The site can sometimes be identified by two small cutaneous puncture marks with
surrounding erythema. The bite is usually a red plaque (picture 5) or papule, which often
develops central pallor. Occasionally, vesiculation around the site may occur (picture 6).
The pain typically increases over the next two to eight hours, and may become severe. In
most cases, this lesion is self-limited and resolves without further complications in
approximately one week [19]. However, in some patients, the lesion will develop a dark,
depressed center over the ensuing 24 to 48 hours, culminating in a dry eschar that
subsequently ulcerates (picture 7). (See 'Necrosis' below.)

Some patients develop urticaria or a morbilliform rash in the hours after the bite; this has
been suggested by some as evidence of a prior bite, although the phenomenon has not
been studied formally.

Necrosis Experts in the past have estimated that approximately 10 percent of recluse
spider bites become necrotic [19-21]. However, many necrotic skin lesions are erroneously
attributed to spider bites. Thus, the true frequency of skin necrosis after a bite is unclear
[22].

The progression of necrosis from a recluse spider bite typically occurs over several days.
The original papule or plaque develops a dusky red or blue color in the center of the
lesion, and a dry, depressed center may herald necrosis. There may be anesthesia in the
center. An eschar forms and subsequently breaks down to form an ulcer. The lesion may
enlarge in a gravitational manner (picture 8) [23].

A fully developed necrotic lesion is usually 1 to 2 cm in diameter, although skin loss can be
more extensive and ulcers as large as 40 cm or more have rarely been described. These
most typically occur over fatty tissue on the buttocks and thighs.

Lesions usually stop extending within 10 days of the bite, and most lesions heal by
secondary intent over several weeks, without scarring (picture 9) [23]. Some necrotic
lesions take months to heal fully. Permanent scarring or requirement for surgical repair is
uncommon [24]. (See 'Dermal necrosis' below.)

Systemic findings Systemic symptoms are an infrequent complication of recluse bites,

and do not correlate with local findings. The following nonspecific signs and symptoms
may appear over several days following a recluse bite [18]:

Malaise
Nausea and vomiting
Fever
Myalgias

Life-threatening effects Rare complications following a recluse spider bite include

angioedema, acute hemolytic anemia, disseminated intravascular coagulopathy,
rhabdomyolysis, myonecrosis, renal failure, coma, and death [25-28]. The risk of these
complications fromLoxosceles bites is extremely low in the United States [19].
(See "Hemolytic anemia due to drugs and toxins", section on 'Insect, spider, and snake
bites'.)

By contrast, these complications are more common with loxoscelism from the South
American species L. laeta [23]. (See 'South American recluse spider bites' below.)
Based upon small case series, Loxosceles bites can be very severe in children [23];
however, the literature is not clear on the frequency of complications because of reporting
ambiguities and lack of documentation of the actual culprit spider.

One retrospective case series from the southern United States reported 26 children with
the diagnosis of recluse spider bite at discharge [29]. All had an admission diagnosis of
cellulitis and documentation was not clear on how the discharge diagnosis was confirmed.
In three cases, a "spider" was seen. Clinical findings included 22 patients with skin
necrosis with 3 patients developing total desquamation several days after the bite, 13 who
developed hemolytic anemia, 7 with rhabdomyolysis, and 3 with progression to acute renal
failure. There was a bimodal peak for hemolysis at days 2 through 3 and days 4 through 9.
Five patients required management in an intensive care unit. Therapy was supportive, and
there were no deaths.

In a case report of a suspected recluse spider bite in a six-year-old child, profound

hemolysis (hemoglobin <2.0) and vascular collapse developed but responded to nine
single-volume plasma exchanges, aggressive transfusions, inotropes, and mechanical
ventilation [27].

Unexplained severe hemolysis in an indigenous area (figure 1 and table 1) may suggest a
surreptitious Loxosceles envenomation [30]. There are rare reports of death in small
children occurring within 24 hours of a presumed recluse spider bite [26,31].

DIAGNOSIS A presumptive diagnosis of a spider bite is most often based on the history
of feeling a bite and clinical presentation of a wound that may be necrotic. An assay
for Loxosceles venom has been developed but is not commercially available [32]. Of note,
the diagnosis of a spider bite can be considered definitive only if the patient has a
consistent skin lesion (picture 5 and picture 6 and picture 8) and both of the following
criteria are fulfilled:

A spider was observed inflicting the bite.

The spider was recovered, collected, and properly identified by an expert
entomologist.

If both of the above conditions are not met, then other conditions such as vasculitis,
infection, vascular problems, or other relevant disorders must be excluded.

Because systemic effects may precede skin findings, a working diagnosis of recluse spider
bite may be made for children with acute hemolysis of unknown etiology in regions where
the recluse spider is found. However, other etiologies for acute, severe hemolytic anemia
must also be excluded. (See 'Pediatric considerations' below.)

The general approach to a patient suspected of having a spider bite, as well as the
differential diagnosis of an uncomplicated (lacking signs of necrosis) spider bite, are
reviewed separately. (See "Approach to the patient with a suspected spider bite: An
overview".)

Further evaluation Patients with clinical manifestations limited to local effects do not
require laboratory evaluation.

Patients with systemic findings (eg, malaise, nausea and vomiting, fever, and myalgias),
especially children, warrant evaluation for acute hemolysis, rhabdomyolysis, and acute
kidney injury as follows (see "Clinical manifestations and diagnosis of rhabdomyolysis",
section on 'Evaluation and diagnosis' and "Diagnosis of hemolytic anemia in the adult"):

Complete blood count with peripheral smear

Reticulocyte count
Type and screen (including Coombs testing) for patients with signs of hemolytic
anemia
Total and direct serum bilirubin
Aspartate aminotransferase and alanine aminotransferase
Serum lactate dehydrogenase
Serum haptoglobin for patients with signs of hemolytic anemia
Serum electrolytes
Serum calcium and phosphate
Serum uric acid for patients with signs of rhabdomyolysis
Blood urea nitrogen and creatinine
Creatine kinase
Rapid urine dipstick for blood and for urobilinogen with reflex to urinalysis if positive
Prothrombin time (PT) with international normalized ratio (INR)
Activated partial thromboplastin time (aPTT)
Fibrinogen and D-dimer (if INR or aPTT is prolonged)
Electrocardiogram (patients with findings of rhabdomyolysis and electrolyte
abnormalities)

DIFFERENTIAL DIAGNOSIS Numerous conditions have been mistaken for a necrotic

recluse spider bite (table 2). The most common disorders in the differential diagnosis are
presented in this section (table 3).

Solitary ulcerated lesion Conditions that can cause single ulcerated lesions include
infections, trauma, vascular diseases, pyoderma gangrenosum, and vasculitides.

Infections Common infections that can become necrotic include staphylococcus and
streptococcal infections, deep fungal infections, and atypical mycobacterial infections
(table 2). However, in most instances of cutaneous infection, there is initial swelling with
elevation of the central region above the level of the surrounding skin and ulceration is
rare. By contrast, necrotic recluse bite wounds tend to have limited swelling above the skin
surface with the exception of vesicles and ulcerate early on in the process (picture 8).

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) skin

infections can begin with singular papules or pustules that may evolve to necrotic lesions
[33,34]. CA-MRSA is far more prevalent than spider bites. CA-MRSA strains both in the
United States and in Europe have an enhanced virulence that has resulted in the more
striking clinical manifestations, compared with non-MRSA. Infections occur both
sporadically and as institutional epidemics in nursing homes, prisons, military barracks,
and athletic facilities. Risk factors and epidemiology of CA-MRSA are discussed
separately. (See "Methicillin-resistant Staphylococcus aureus (MRSA) in adults:
Epidemiology" and "Methicillin-resistant Staphylococcus aureus infections in children:
Epidemiology and clinical spectrum", section on 'Epidemiology and risk factors'.)

A patient who had recently traveled to the tropics and presented with a skin ulcer would
require evaluation for the various infections that can cause ulcerating lesions (table 4).
(See "Skin lesions in the returning traveler".)

Vascular disease Foot and ankle ulcers can be seen in patients with chronic venous
insufficiency, arterial insufficiency, or diabetes mellitus, and a history of the underlying
disease should alert clinicians to this possibility. These ulcers are distinguishable by
various characteristics (table 5). (See "Diagnostic evaluation of chronic venous
insufficiency".)

Pyoderma gangrenosum Pyoderma gangrenosum is an idiopathic disorder in which

dark, blue-red papules progress to necrotic ulcerating lesions. Patients may report a
history of antecedent trauma at the site or have signs of systemic illness. Borders are
typically irregular with undermined edges, and the lesion may have a purulent base
(picture 10 and picture 11). Lesions may be bullous. (See "Pyoderma gangrenosum:
Pathogenesis, clinical features, and diagnosis".)

Vasculitis Cutaneous vasculitis results from inflammation of the small or medium-sized

blood vessels in the skin. Small blood vessels are capillaries, post-capillary venules, and
non-muscular arterioles in the superficial and mid-dermis (<50 micrometers). Medium-
sized vessels consist of 50 to 150 micrometer vessels with muscular walls in the deep
dermis and subcutis. Cutaneous vasculitis occurs in a wide variety of clinical settings
(table 6). Ulceration and tissue necrosis occur when vasculitis results in reduced vascular
perfusion in the skin (picture 12A-B). Superficial ulcers can occur in patients with small
vessel vasculitis; deep ulcers are usually the result of medium vessel disease. Less
commonly, vasculitis and necrotizing vasculitis may present with singular lesions that show
eschar or ulceration (picture 13) that may resemble pyoderma gangrenosum.
(See "Evaluation of adults with cutaneous lesions of vasculitis", section on 'Cutaneous
findings'.)
Patients with vasculitis may have the presence of systemic findings consistent with
connective tissue disease, recent symptoms of infection, or introduction of a medication
within the past 7 to 10 days which helps to differentiate them from victims of recluse spider
bites. However, skin biopsy is most definitive to establish the diagnosis of vasculitis.
(See "Evaluation of adults with cutaneous lesions of vasculitis", section on 'Clinical
assessment' and "Evaluation of adults with cutaneous lesions of vasculitis", section on
'Biopsy'.)

Pustular dermatosis of the dorsal hand Pustular dermatosis of the dorsal hand is an
ulcerating condition that is characterized by one or more ulcers on the hand. The lesions
may be bullous or bullous hemorrhagic initially. This condition has been felt to be related to
pyoderma gangrenosum and Sweet syndrome [35].

Systemic reactions The systemic symptoms of recluse spider envenomation (eg,

malaise, nausea and vomiting, fever, and myalgias) are sufficiently nonspecific that an
accompanying lesion with an identifiable biting spider is essential for making the diagnosis
of a spider bite. (See'Diagnosis' above.)

TREATMENT For patients with ulceration or systemic complaints, the evidence

supporting the use of Loxoscelism specific treatments (eg,dapsone, antivenom) is lacking
[36]. Care providers should weigh the relative risks versus potential benefits with the
understanding of the controversies surrounding effectiveness.

Patients with local effects The treatment of acute local findings following a recluse
spider bite involves local wound care, pain management, and, if indicated, tetanus
prophylaxis.

Wound care and general measures Initial treatment measures following any spider
bite include:

Clean the bite with mild soap and water.

Apply cold packs, taking care not to freeze the tissue.
Maintain the affected body part in an elevated or neutral position (if possible).
Administer pain medication as needed. Some patients will respond to nonsteroidal
antiinflammatory medications, while others may require opioids.
Administer tetanus prophylaxis if indicated (table 7).

Most bites can be managed with minimal intervention and heal without scarring. Resolving
bites should be monitored for the development of secondary bacterial infection.

Antibiotics are prescribed only if there are signs of infection such as increased erythema,
fluctuation, and suppuration. If infection is suspected, it should be treated with antibiotics
for cellulitis, as outlined in the table (table 8). (See "Cellulitis and erysipelas".)
Dermal necrosis For patients with recluse spider bites that have a dusky center or
other signs of developing necrosis, no proven therapy, other than antivenom
administration, exists. Antivenom is suggested for patients with moderate to severe dermal
necrosis who present for care within 48 hours after recluse spider bite occurring in South
America. (See 'South American recluse spider bites' below.)

In the absence of antivenom (not available in the United States), we suggest that patients
with dermal necrosis receive only symptomatic and supportive wound care; the use
of dapsone should be avoided. Dapsone has been advocated by some, but there is no
clear benefit from existing evidence and substantial risk of adverse effects including
aplastic anemia, methemoglobinemia, and dapsone hypersensitivity [37,38]. In addition,
adverse side effects may confound the monitoring of patients with possible systemic
loxoscelism.

We suggest not performing early surgical excision and/or curettage of a necrotic lesion.
However, once the lesion is demarcated and clinically stable, debridement and wound
care may permit better healing. In one series of eight patients, vacuum-assisted wound
closure was used to promote healing of necrotic lesions [39] and, in one animal trial, this
method was associated with more rapid wound healing [40]. A small minority of necrotic
lesions later require surgical revision of scars, including skin grafting.

Several other therapies have been proposed or performed but are not recommended:

Tetracycline Application of topical tetracycline has been shown to reduce the

progression of dermonecrotic lesions in rabbits exposed toLoxosceles
intermedia venom but awaits further study in humans [41].
Insufficiently studied treatments Therapies which have not been adequately
studied in humans include antihistamines, glucocorticoids, empiric administration of
topical or systemic antibiotics, vasodilators, heparin, nitroglycerin, hyperbaric oxygen,
dextran, and local electric shock [38,41-43].
Early surgical interventions Early surgical excision and/or curettage of a
necrotic lesion is potentially harmful [42,44-46]. One retrospective study of 31 patients
with bites affecting the upper extremity or hand concluded that painful and recurrent
wound breakdown occurred more often with early surgical excision [45].

Patients with systemic toxicity Patients with systemic toxicity may demonstrate
nausea, fever, malaise, vomiting, myalgias, or pallor within a few days of a spider bite. The
severity of systemic toxicity does not correlate with toxicity at the bite site. Patients with
systemic findings warrant laboratory studies to assess for hemolytic anemia,
rhabdomyolysis, and kidney injury. Hospital admission is indicated for patients with signs
of hemolytic anemia, rhabdomyolysis, or disseminated intravascular coagulopathy.
(See 'Further evaluation' above.)
Acute hemolytic anemia Although hemolytic anemia following a recluse spider bite
can be severe, it is typically self-limited. The primary treatment consists of blood
transfusions for patients with a rapidly falling hematocrit or uncompensated anemia.
Consultation with a hematologist is encouraged.

Antivenom is suggested for patients with acute hemolytic anemia after South American
recluse spider bites. (See 'South American recluse spider bites' below.)

Plasma exchange has been performed in one case of severe hemolytic anemia in a child
with profound hemolysis (hemoglobin <2.0) and vascular collapse with ultimate survival
[27]. However, the need for this invasive treatment is rare following recluse bites and
should only be performed in consultation with a pediatric hematologist.

Rhabdomyolysis The recommended approach to rhabdomyolysis following spider

bites is extrapolated from crush injuries and is discussed in detail separately. Initial therapy
consists of rapid infusion of isotonic saline to establish urine output of 200 to
300 mL/hour (4 ml/kgper hour in children) with a goal of preventing renal failure.
(See "Prevention and treatment of heme pigment-induced acute kidney injury (acute renal
failure)", section on 'Volume administration'.)

Antivenom is suggested for patients with rhabdomyolysis after a South American recluse
spider bite. (See 'South American recluse spider bites'below.)

Disseminated intravascular coagulopathy Patients with systemic toxicity after a

recluse spider bite warrant studies to assess for the presence of disseminated
intravascular coagulopathy (DIC). (See 'Further evaluation' above.)

The treatment of DIC is discussed separately. (See "Disseminated intravascular

coagulation in infants and children", section on 'Treatment' and"Clinical features,
diagnosis, and treatment of disseminated intravascular coagulation in adults", section on
'Treatment'.)

Antivenom is suggested for patients with DIC after a South American recluse spider bite.
(See 'South American recluse spider bites' below.)

South American recluse spider bites The bites of South

American Loxosceles species (eg, L. gaucho) are more severe than those of recluse
spiders found in the United States and carry a higher risk of dermal necrosis and systemic
effects. Consultation with a physician experienced with the management of bites by South
American recluse spiders is encouraged prior to the administration of antivenom.

Management is determined by the severity of effects and whether the patient has acute
local skin findings alone or also has signs of systemic envenomation. (See 'Patients with
local effects' above and 'Acute hemolytic anemia' above and 'Rhabdomyolysis' above.)
In addition, antivenoms for the treatment of recluse spider bites are available in Brazil,
Chile, and Peru, although not in the United States. We suggest that patients with
presumed spider bites by Loxosceles gaucho, L. laeta, and L. intermedia (ie, species
indigenous to Brazil, Chile, and Peru) who have systemic findings at any time after a bite
or who have moderate to severe dermal necrosis and present for care within 48 hours
receive antivenom rather than supportive care alone [47,48]. Mild allergic reactions
consisting of nausea or urticaria have been described in 7 to 20 percent of patients who
receive the antivenom [47,49]. Given the frequency of reactions and the potential for
anaphylaxis, antivenom administration in an acute care setting (eg, emergency department
or intensive care unit) is recommended, if at all possible.

Observational studies in humans and animal trials suggest that South American recluse
antivenoms may reduce the risk of dermatonecrosis, as well as systemic envenomation
and its severe complications (eg, hemolysis, renal failure, and disseminated intravascular
coagulation). However, definite benefit in humans is not well established [18,47,49-51].
This antivenom is not FDA-approved for use and is not available in North America.

PEDIATRIC CONSIDERATIONS Systemic loxoscelism is rare, but may occur more

commonly in children. Because systemic effects may precede skin findings, loxoscelism
should be considered in the differential diagnosis of acute hemolysis of unknown etiology
occurring in the pediatric age group in regions in which recluse spiders are indigenous.
(See 'Life-threatening effects' above.)

All children with any systemic signs after a presumed recluse spider bite warrant
hospitalization and evaluation for acute hemolysis and rhabdomyolysis. Treatment is
supportive. (See "Hemolytic anemia due to drugs and toxins", section on 'Insect, spider,
and snake bites' and"Prevention and treatment of heme pigment-induced acute kidney
injury (acute renal failure)".)

Children who do not have systemic findings may be discharged home after local wound
care and general measures. However, because hemolysis has been described up to
seven days after a spider bite [29], caretakers must have clear instructions to promptly
seek medical care if any systemic findings (eg, vomiting, fever, myalgias, or hematuria)
occur. In addition, re-evaluation of the child at three and seven days after the bite,
regardless of symptoms, is suggested.

Case reports of Loxosceles bites during pregnancy have documented no adverse effects
on fetal outcomes [19].

DISCHARGE INSTRUCTIONS AND AFTER CARE Patients should be counseled

about how to care for the bite site and advised to watch the site for signs of secondary
bacterial infection (eg, fever, spreading redness, pus formation or drainage), as well as
progressive skin changes that suggest early necrosis (ie, enlargement of the lesion
or black/blue color changes).
Parents of children with a presumed recluse spider bite should be instructed to seek
prompt medical care if systemic findings (eg, fever, vomiting, myalgias, or hematuria)
occur.

Patients who are concerned about avoiding future recluse bites should be counseled to
shake out clothes, shoes, gloves, and other items that have been unused or lying on the
floor before putting them on.

Beds should be modified so that only the legs of the bed touch the floor: they should be
moved away from the wall, bedding should be tucked in and ruffles removed, and items
should not be stored beneath it.

Insecticides may be effective for controlling recluse populations within the home; however,
these must be properly administered by a pest control professional. Placement of sticky
traps next to baseboards but out of reach of curious children and pets is another useful
method to eliminate brown recluse spiders from a building.

ADDITIONAL RESOURCES Guidance on the recognition and management of brown

recluse spiders can be obtained by contacting a regional poison control center (in the
United States call 1-800-222-1212, elsewhere consult the listing of international poison
control centers maintained at the World Health Organization website).

INFORMATION FOR PATIENTS UpToDate offers two types of patient education

materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are
written in plain language, at the 5th to 6th grade reading level, and they answer the four or
five key questions a patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Spider bites (The Basics)")

SUMMARY AND RECOMMENDATIONS

Recluse spiders (Genus Loxosceles) are one of a handful of spiders throughout the
world which are capable of inflicting medically significant bites in humans. They are
nondescript brown spiders (picture 1) that can be more reliably identified by their
distinctive eye pattern (three pairs) (picture 3). They are found mostly in certain parts
of North and South America. In the United States, recluse spiders are limited to areas
of the South, West, and Midwest (figure 1). (See 'Entomology of recluse
spiders' above.)
Recluse spider bites are usually sustained indoors, as a result of rolling over on the
spider in bed or putting on clothing or footwear in which the spider has sought refuge.
These spiders are not aggressive and generally bite humans only when being
crushed between flesh and some object. (See 'Habitat' above and 'Clinical
history' above.)
Patients presenting with possible spider bites should always be questioned carefully
regarding the circumstances surrounding the bite. Other disorders are responsible for
most lesions attributed to spider bites (table 2), unless the patient witnessed the
spider inflicting the bite and can retrieve the spider for identification by an
entomologist. (See "Approach to the patient with a suspected spider bite: An
overview"and 'Diagnosis' above.)
Loxoscelism is the term for the medical manifestations of bites by recluse spiders.
The initial bite of a Loxosceles spider is typically painless, although some patients
describe sharp pain or burning. The bite is usually a red plaque (picture 5), which can
sometimes be identified by two small cutaneous puncture marks with surrounding
erythema. In most cases, this lesion is self-limited and resolves without further
complications. Patients with clinical manifestations limited to local effects do not
require laboratory evaluation. (See 'Local effects' above and'Further
evaluation' above.)
The progression of necrosis from a recluse spider bite typically occurs over several
days (picture 7 and picture 8). These generally heal by secondary intent over several
weeks, without scarring (picture 9). Treatment consists of cleansing of the bite site,
analgesia for mild to moderate pain, and tetanus prophylaxis (table 7), as needed.
(See 'Local effects' above and 'Wound care and general measures' above.)
For bites by recluse spiders, other than South American species, we suggest that
patients with dermal necrosis receive only symptomatic and supportive wound care;
no antivenom exists for these species and the use of dapsone should be avoided.
(Grade 2C). (See 'Dermal necrosis' above.)
We suggest not performing early surgical excision and/or curettage of a necrotic
lesion (Grade 2C). However, once the lesion is demarcated and clinically stable,
debridement and wound care may permit better healing. (See 'Dermal
necrosis' above.)
We suggest that patients with presumed spider bites by Loxosceles gaucho, L.
laeta, and L. intermedia (ie, species indigenous to Brazil, Chile, and Peru) who have
systemic findings at any time after a bite or who have moderate to severe dermal
necrosis and present for care within 48 hours receive antivenom (Grade 2C).
Consultation with a physician experienced with the management of bites by South
American recluse spiders is encouraged prior to the administration of antivenom.
(See 'South American recluse spider bites' above.)
 Systemic toxicity may appear over several days following a bite and include malaise,
nausea and vomiting, fever, and myalgias. Patients with systemic findings warrant
ancillary studies as suggested in the topic. Systemic toxicity is more common in small
children than adults. (See 'Systemic findings' above and 'Further evaluation' above
and 'Pediatric considerations' above.)
Hospital admission is indicated for patients with signs of hemolytic anemia,
rhabdomyolysis, or disseminated intravascular coagulopathy. For bites by species
other than South American recluse spiders, treatment is condition-specific and is
primarily supportive. (See 'Acute hemolytic anemia' above
and 'Rhabdomyolysis' above and 'Disseminated intravascular coagulopathy' above.)
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