Bed bug infestation
Celine Bernardeschi dermatologist 1, Laurence Le Cleach dermatologist 1, Pascal Delaunay
parasitologist-entomologist 2, Olivier Chosidow professor of dermatology 1 3
1AP-HP, Groupe Hospitalier Henri-Mondor, Department of Dermatology, Créteil, France; 2Laboratoire de Parasitologie-Mycologie, Hôpital de l’Archet,
Centre Hospitalier Universitaire de Nice-Université de Nice-Sophia Antipolis/Inserm U1065, Nice, France; 3UPEC-Université Paris Est-Créteil
Bed bugs are bloodfeeding insects that seem to be resurging in
developed countries,1possibly due to international travel and
changes in pest control practices.2Diagnosis of bed bug
infestation relies on clinical manifestations of bites and direct
observation of the arthropod, which is rarely recognised by those
who are bitten.3Evidence is lacking on the bed bug’s capacity
to transmit disease, management of eradication, and the
economic impact of infestations. This summary of the available
evidence on the diagnosis and management of bed bug
infestation aims to help general practitioners identify the clinical
signs of bed bug bites and help patients identify and manage
What are bed bugs?
The two main species of bed bugs are Cimex lectularius and
Cimex hemipterus, which are found in tropical zones and
temperate areas, respectively. They are brown, wingless, flat,
2-5 mm long insects that resemble apple seeds. If in doubt,
contact an entomologist for precise identification. The bugs
have a multi-stage developmental life cycle and require a human
blood meal every 3-5 days to progress from one stage to another
(fig 1⇓).1After contamination by a few bed bugs, their number
increases exponentially. They can survive for one year without
Where are bed bugs found?
Over the past 10 years, bed bugs—which had almost disappeared
after the second world war—have increasingly been found in
low budget and upmarket hotels, hostels, bed and breakfasts,
private homes, night trains, cruise ships, and even nursing
Bed bugs are usually transported passively, mainly in clothing
and luggage, but also on furniture (such as mattresses). Less
commonly, they spread actively from room to room in
communities, mostly through electric wiring or ventilation ducts.
During the day they hide in dark places—such as spaces under
baseboards, loose or peeling wallpaper, and crevices in furniture
and mattresses—and they feed at night. They fear light and
usually avoid smooth or glossy surfaces, such as tiles.2Despite
being easily visible, most people cannot recognise bed bugs—in
a survey conducted in three counties in the United Kingdom,
only 10% of 358 people identified them from pictures (fig 2⇓).3
How common are bed bug infestations?
The idea of a resurgence is based on Australian and European
observational studies that have shown increases in pest manager
interventions (700% increase between 1997-2000 and 2001-04
in Australia,100% rise from 2002 (383 cases) to 2006 (770
cases) in Sweden). There were also increases in calls received
about bed bugs in two London boroughs between 2000 (87 calls)
and 2006 (334 calls), and more inquiries about species (nine
samples of bed bugs submitted to the Department of Medical
Entomology, Institute of Clinical Pathology and Westmead
Hospital, Sydney, Australia in 1997 compared with 37 samples
in 2000). The identification of bed bugs in Australian
laboratories also increased between 2001 and 2004 as did the
number of bed bugs intercepted by Australian customs officials
between 1999 and 2003.5-7
The reasons for this resurgence are unknown. Contributing
factors may include increased domestic and international travel.8
As a consequence, bed bugs, which were most common among
the disadvantaged social classes in the first half of the last
century, can now be encountered in all economic contexts. Other
factors are enhanced resistance to pyrethroid insecticides,2 9
perhaps because of multiple mutations conferring metabolic
resistance,10 and the fact that newer techniques for controlling
cockroaches with bait do not kill bed bugs.11
What are the symptoms of bed bug
Because bed bugs feed at night and inject an anaesthetic when
biting, the initial bite is not felt and most patients have no
reaction; moreover, symptom onset, caused by allergic reactions
to saliva, can be delayed.2In 2009, an ethics committee approved
experiment,12 conducted by laboratory scientists who volunteered
Correspondence to: O Chosidow, Service de Dermatologie, Hôpital Henri-Mondor, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil
Cedex, France firstname.lastname@example.org
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Bed bug infestation seems to be re-emerging worldwide
The diagnosis of bed bug infestation starts with consultation for clinical reactions to bites but symptoms vary greatly
Suspect bed bug bites whenever a patient consults for papules positioned in groups of three or four bites forming a “breakfast-lunch-dinner”
curve or line
Eradication requires patient education and the help of pest eradication professionals to identify pests and perform non-chemical and
Sources and selection criteria
We focused on articles published since October 2008 to update Goddard and colleagues’ systematic review.2We searched PubMed and
Embase databases until July 2012, using the search terms “bedbugs [Mesh] OR bed bugs OR bed bug OR Cimex”. We also manually
searched textbooks, newspapers, and websites, mainly those listed by the Centers for Disease Control and Prevention (www.cdc.gov/nceh/
ehs/topics/bedbugs.htm). Our selection criteria were case reports on more than five patients, and results related to humans in the field of
prevention and elimination of bed bugs or clinical manifestations of their bites.
to be bitten by bed bugs placed on their arms, confirmed that
reactions to bites manifest up to 11 days later. In a recent
questionnaire based study, only 30% of people living in bed
bug infested households reported skin reactions.13
A 2009 systematic review of 18 articles on clinical reactions to
bed bug bites reported the most common reactions to be 2-5
mm pruritic maculopapular lesions with a central haemorrhagic
punctum, corresponding to the bite site, that are usually located
on uncovered areas of the body.2Skin lesions, such as three or
four bites forming a curve or line (“breakfast-lunch-dinner
alignment,” fig 3A⇓), are suggestive of but not specific to bed
bugs. Other cutaneous symptoms include isolated pruritis,
papules, nodules (fig 3B), and bullous eruptions (fig 3C).14
Some isolated case reports have reported systemic reactions,
such as diffuse urticaria (fig 3D), asthma, and anaphylaxis.2Bed
bug infestation is usually looked for after a clinical diagnosis
of bed bug bites. Similar symptoms in people sharing a bed,
onset of the lesions after travelling or sleeping away from home,
detection of bed bug faecal matter (small dark marks) in or
around the bed, or disappearance of symptoms after changing
sleeping place should trigger suspicion of infestation. However,
the discovery of bed bugs on site confirms active infestation.
What are the differential diagnoses of bed
The most common differential diagnoses are other arthropod
bites,15 especially those of fleas, which form similar three or
four bite lines or curves. Scabies can be confounding but differs
from bed bug bites by the absence of visible puncta and the
predominance of scratching in sites such as forearms, nipples,
and genitals (table 1⇓).
In addition to arthropod bites, there are several dermatological
differential diagnoses.16 These include erythema multiforme,
which is characterised by target lesions on the extremities, and,
sometimes, mucous membrane erosions; Sweet’s syndrome or
acute febrile neutrophilic dermatosis, which includes
papulonodular lesions on the extremities associated with general
symptoms, such as arthralgias, fever, and leucocytosis; bullous
dermatitis, which can affect the mucous cavities and unlike bed
bug bites, can be seen on covered areas of the body; and
vasculitis, which is characterised by polymorphous lesions,
usually on the lower limbs, and sometimes affecting several
organs. When such manifestations are seen, refer the patient to
a dermatologist for further investigations, including a skin
biopsy, if necessary.
What complications can arise from bed
Scratching can cause secondary infection—usually
Staphylococcus aureus or Streptococcus spp—of skin lesions
Evidence for disease transmission is less clear. Some pathogens
have been detected in or on bed bugs. These include hepatitis
B virus, Trypanosoma cruzi,1hepatitis C virus,18 HIV,2
Aspergillus spp, and, more recently, meticillin resistant S
aureus,19 but no study has yet demonstrated their vectorial
role—their capacity to transmit diseases to humans.1
The psychological burden of bed bug infestation remains to be
Although the economic impact is not known, bed bugs result
in loss of productivity and costs include those of pest managers’
interventions and replacement of infested furniture.11
How are bed bug infestations managed?
Bed bug control is difficult, mainly because of the parasite’s
hiding behaviour, and also because chemical and non-chemical
technologies need to be combined for optimal effect.1“Integrated
pest management (IPM)” combines detection of the pest with
non-chemical and chemical elimination strategies.
A randomised study conducted in 16 highly infested dwellings,
divided into two groups, compared IPM using traps containing
a killing agent and chemical treatment with diatomaceous earth
dust (D-IPM) versus IPM in which bed bugs were sprayed with
chlorfenapyr (S-IPM) but traps were not used.20 Both groups
received patient targeted information provided by a brochure.
They were also given advice on searching mattresses for hiding
bugs; laundering bed linens weekly; and steaming floors, bed
frames, sofas, and other infested furniture and sites. Insecticides
were applied every two weeks over 10 weeks. Bed bug counts
decreased by 97.6% and 89.7% after the intervention in the
S-IPM and D-IPM groups, respectively.
Such eradication strategies were grouped together in documents
called “Codes of practice” written by experts in Europe, the
United States, and Australia,21 but their use, although
recommended by some municipalities, is not mandatory.
How should bed bug bites be treated?
Guidelines based on expert opinions recommend treating the
symptoms of bed bug bites with topical steroids (such as
hydrocortisone 1%) once or twice a day for no longer than seven
days.22 Prescribe systemic antihistamines only when pruritis is
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BMJ 2013;346:f138 doi: 10.1136/bmj.f138 (Published 22 January 2013) Page 2 of 8
associated with sleeping difficulties.22 Antibiotics, either topical
(such as mupirocin or fusidic acid three times a day for 7-10
days) or systemic, might be needed for secondary impetigo,
depending on its severity.23
How can bed bugs be identified and
Professionals need to educate patients on how to identify bed
bugs and prevent spread (box). GPs can educate patients to use
a “search and destroy” strategy by providing basic knowledge
about the parasite. They should stress that each insect needs to
bite a human every three to five days to grow and reproduce
but can survive for one year without feeding, and how to detect
and identify the arthropod (fig 4A⇓) or its faecal traces (fig 4B)
in suspected areas, mostly mattresses and cracks and crevices
in wooden furniture. This detection strategy should be applied
Small case series suggest that washing at 60°C, tumble drying
at 40°C, or dry cleaning is effective against all life stages.24 A
recent trial also suggested that freezing can be used to
decontaminate infested clothing.24 However, because bed bugs
can survive for up to one year without feeding, keeping an
infested room vacant is not an effective option.1Disposal of
highly infested items, together with physical removal of bed
bugs and mattress covers and vacuuming, are recommended by
pest managers’ codes of practice,21 even though scientific
evidence of their efficacy is lacking.
The silicates (mostly diatomaceous earth dust) are somewhere
between non-chemical and chemical treatments, and require
further investigation before being used in pest management
Although insecticides can be bought in supermarkets and on
the internet, for efficacy and safety reasons they must be used
only by professionals. Clinicians should be aware that misuse
of insecticides may have clinical consequences. The Centers
for Disease Control and Prevention recently identified 111 cases
of illness attributed to insecticide misuse in an attempt to control
bed bugs.25 Pyrethroids were implicated in 89% of those events
and caused neurological, respiratory, and gastrointestinal
The three main groups of currently used insecticides for bed
bug infestations are pyrethroids (the most common),26 insect
growth regulators, and carbamates. The organophosphates, like
dichlorvos, are no longer used in Europe except in impregnated
strips.27 Several large well conducted experimental studies have
found high levels of bed bug resistance to all available
products.9 28 Moreover, product formulation may influence their
efficacy—a laboratory study showed that pyrethroid dusts kill
bed bugs more effectively than sprays.29
Because of different resistance levels among bed bugs, a
combination of insecticides should be applied to all harbourage
areas: mattress seams; cracks in furniture, box springs, and bed
frames; peeling wallpaper; and under carpets and floorboards.21
It is unclear how often these techniques should be applied, but
because insecticides have a limited ovicidal effect, expert
guidelines recommend a second look by the pest manager, with
eventual retreatment 4-20 days after the first intervention. The
length of this waiting time depends on the average temperature
of the infested site.
How can infestation be prevented?
Evidence is lacking about the effectiveness of prevention
procedures. Experts recommend washing mattress encasement
and bed linens at temperatures above 60°C,21 and advise against
purchasing second hand mattresses or furniture. However, it is
not recommended that mattresses are pretreated with insecticides
or preventive insecticide applications.
Early detection of the bed bugs may be an effective way to
prevent their spread. Notably, experimental studies have shown
the efficacy of bed bug traps in attracting the parasites,
especially when combined with carbon dioxide and heat,30 but
their ability to control infestation without the addition of
chemical techniques has not been assessed. Results of a
comparative study indicated that canine detection may be an
option but is operator dependent,31 and further evaluation of this
method is needed.
Acknowledgments: Thanks to Tu-Anh Duong, Arnaud Canet, Sebastien
Larréché, and Pierre Wolkenstein for their collaboration and Janet
Jacobson for editorial assistance.
Contributors: OC conceived the project, which was drafted by CB and
revised by all authors. OC finally approved the article. All authors are
Funding: No special funding received.
Competing interests: All authors have completed the ICMJE uniform
disclosure form at www.icmje.org/coi_disclosure.pdf (available on
request from the corresponding author) and declare: no support from
any organisation for the submitted work; no financial relationships with
any organisations that might have an interest in the submitted work in
the previous three years; no other relationships or activities that could
appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; externally peer
1 Delaunay P, Blanc V, Del Giudice P, Levy-Bencheton A, Chosidow O, Marty P, et al.
Bedbugs and infectious diseases. Clin Infect Dis 2011;52:200-10.
2 Goddard J, deShazo R. Bed bugs (Cimex lectularius) and clinical consequences of their
bites. JAMA 2009;301:1358-66.
3 Reinhardt K, Harder A, Holland S, Hooper J, Leake-Lyall C. Who knows the bed bug?
Knowledge of adult bed bug appearance increases with people’s age in three counties
of Great Britain. J Med Entomol 2008;45:956-8.
4 Delaunay P, Blanc V, Dandine M, Del Giudice P, Franc M, Pomares-Estran C, et al.
Bedbugs and healthcare-associated dermatitis, France. Emerging Infect Dis
5 Doggett S, Greary M, Russell R. The resurgence of bed bugs in Australia. Environ Health
6 Richards L, Boase CJ, Gezan S, Cameron MM. Are bed bug infestations on the increase
within Greater London. J Environ Health Res 2009;9:17-22.
7 Kilpinen O, Vagn Jensen KM, Kristensen M. Bed bug problems in Denmark, with a
European perspective. In Robinson WH, Bajomi D, eds. Proceedings of the 6th
International Conference on Urban Pests. OOK-Press Kft, 2008:395-9.
8 US Department of Health and Human Services. Joint statement on bed bug control in the
United States from the US Centers for Disease Control and Prevention (CDC) and the
US Environmental Protection Agency (EPA). 2010. www.cdc.gov/nceh/ehs/publications/
9 Tawatsin A, Thavara U, Chompoosri J, Phusup Y, Jonjang N, Khumsawads C, et al.
Insecticide resistance in bedbugs in Thailand and laboratory evaluation of insecticides
for the control of Cimex hemipterus and Cimex lectularius (Hemiptera: Cimicidae). J Med
10 Zhu F, Wigginton J, Romero A, Moore A, Ferguson K, Palli R, et al. Widespread distribution
of knockdown resistance mutations in the bed bug, Cimex lectularius (Hemiptera:
Cimicidae), populations in the United States. Arch Insect Biochem Physiol 2010;73:245-57.
11 Doggett SL, Dwyer DE, Peñas PF, Russell RC. Bed bugs: clinical relevance and control
options. Clin Microbiol Rev 2012;25:164-92.
12 Reinhardt K, Kempke D, Naylor RA, Siva-Jothy MT. Sensitivity to bites by the bedbug,
Cimex lectularius. Med Vet Entomol 2009;23:163-6.
13 Potter Mf, Haynes KF, Connelly K. The sensitivity spectrum: human reactions to bed bug
bites. Pest Control Technol 2010;38:70-4.
14 DeShazo RD, Feldlaufer MF, Mihm MC Jr, Goddard J. Bullous reactions to bedbug bites
reflect cutaneous vasculitis. Am J Med 2012;125:688-94.
15 Steen CJ, Carbonaro PA, Schwartz RA. Arthropods in dermatology. J Am Acad Dermatol
16 Rook A, Burns T. Rook’s textbook of dermatology. Wiley-Blackwell, 2010.
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BMJ 2013;346:f138 doi: 10.1136/bmj.f138 (Published 22 January 2013) Page 3 of 8
Look for brown insects no bigger than apple seeds on the mattress, sofa, and curtains and in darker places in the room (especially
cracks in the walls, crevices in box springs, and furniture)
Look for black spots on the mattress or blood traces on the sheets
Contact a pest management company
Wash clothes at 60°C or freeze delicate clothing, vacuum, and clean your home before the pest manager visits
Collaborate with professionals who are used to dealing with bed bug infestation to increase eradication efficacy
Carefully examine secondhand furniture to assure the absence of bed bugs before purchase so as not to contaminate your home
When sleeping in a hotel, even an upmarket establishment, lift mattresses to look for bed bugs or black spots
Do not leave luggage in dark places, near furniture, or close to your bed. Before going to bed, close suitcases and put them in the
bathroom—in the bathtub or shower stall
Tips for non-specialists
Inform patients who are about to travel of the resurgence of bed bugs and teach them how to recognise the arthropod
Suspect bed bug infestations in patients who consult for pruritic linear papules, especially when similar symptoms are found in people
sharing a bed, and onset of the lesions after travelling or sleeping away from home Look for atypical skin reactions (blisters, crusts,
necrosis) or general symptoms (fever) that may justify skin biopsy or further dermatological investigations
Encourage infested patients to call a pest manager as soon as the pest has been identified
Prescribe a mild potency topical steroid treatment once or twice a day for seven days to treat symptomatic bed bug bites
Additional educational resources
Resources for healthcare professionals
University of Kentucky (www.ca.uky.edu/entomology/entfacts/entfactpdf/ef636.pdf)—Comprehensive lesson on bed bugs
Centers for Disease Control and Prevention (www.cdc.gov/nceh/ehs/topics/bedbugs.htm)—Link to various articles on bed bugs
NHS Choices (http://nhs.uk/conditions/bites-insect/pages/introduction.aspx)—Clinical knowledge summary about insect bites
Resources for patients
Easing bedbug anxiety: what you need to know about the recent bedbug resurgence. Harvard’s Women’s Health Watch 2011;18:7
Up to Date (www.uptodate.com/contents/bedbugs?source=search_result&search=bedbugs&selectedTitle=1~10)—Provides accurate
general knowledge about bed bugs
Bed-Bugs.co.uk (http://bed-bugs.co.uk/)—Provides an interesting picture gallery of bed bugs and their bites, together with practical tips
Pest Control UK (www.pestcontrol-uk.org/pests/bed-bugs)—DIY control of bed bugs
Questions for future research
What are the risk factors for bed bug infestation?
What are the psychological complications of bed bug bites?
Can bed bugs transmit diseases to humans?
What is the best eradication strategy?
What are the mechanisms of pesticide resistance?
Are prevention approaches (sniffing dogs, resin strips, traps) effective?
17 Heukelbach J, Hengge UR. Bed bugs, leeches and hookworm larvae in the skin. Clin
18 Silverman AL, Qu LH, Blow J, Zitron IM, Gordon SC, Walker ED. Assessment of hepatitis
B virus DNA and hepatitis C virus RNA in the common bedbug (Cimex lectularius L.) and
kissing bug (Rodnius prolixus). Am J Gastroenterol 2001;96:2194-8.
19 Lowe CF, Romney MG. Bedbugs as vectors for drug-resistant bacteria. Emerging Infect
20 Wang C, Gibb T, Bennett GW. Evaluation of two least toxic integrated pest management
programs for managing bed bugs (Heteroptera: Cimicidae) with discussion of a bed bug
intercepting device. J Med Entomol 2009;46:566-71.
21 Doggett SL; Australian Environmental Pest Managers Association. A code of practice for
the control of bed bug infestations in Australia. Westmead Hospital, 2011. www.medent.
22 Management of simple insect bites: where’s the evidence? Drug Ther Bull 2012;50:45-8.
23 Koning S, van der Sande R, Verhagen AP, van Suijlekom-Smit LWA, Morris AD, Butler
CC, et al. Interventions for impetigo. Cochrane Database Syst Rev 2012;1:CD003261.
24 Naylor RA, Boase CJ. Practical solutions for treating laundry infested with Cimex lectularius
(Hemiptera: Cimicidae). J Econ Entomol 2010;103:136-9.
25 Centers for Disease Control and Prevention (CDC). Acute illnesses associated with
insecticides used to control bed bugs-seven states, 2003-2010. Morb Mortal Wkly Rep
26 Davies TGE, Field LM, Williamson MS. The re-emergence of the bed bug as a nuisance
pest: implications of resistance to the pyrethroid insecticides. Med Vet Entomol
27 Lehnert MP, Pereira RM, Koehler PG, Walker W, Lehnert MS. Control of Cimex lectularius
using heat combined with dichlorvos resin strips. Med Vet Entomol 2011;25:460-4.
28 Kilpinen O, Kristensen M, Jensen K-MV. Resistance differences between chlorpyrifos
and synthetic pyrethroids in Cimex lectularius population from Denmark. Parasitol Res
29 Romero A, Potter MF, Haynes KF. Bed bugs; are dusts the bed bug bullet? Pest Manag
30 Wang C, Gibb T, Bennett GW, McKnight S. Bed bug (Heteroptera: Cimicidae) attraction
to pitfall traps baited with carbon dioxide, heat, and chemical lure. J Econ Entomol
31 Wang C, Cooper R. Detection tools and techniques. Pest Control Technol 2011;39:72,
74, 76, 78-9.
32 Chosidow O. Scabies and pediculosis. Lancet 2000;355:819-26.
BMJ 2013;346:f138 doi: 10.1136/bmj.f138 (Published 22 January 2013) Page 4 of 8
33 Del Giudice P, Blanc-Amrane V, Bahadoran P, Caumes E, Marty P, Lazar M, et al.
Pyemotes ventricosus dermatitis, southeastern France. Emerg Infect Dis 2008;14:1759-61.
Accepted: 03 January 2013
Cite this as: BMJ 2013;346:f138
© BMJ Publishing Group Ltd 2013
BMJ 2013;346:f138 doi: 10.1136/bmj.f138 (Published 22 January 2013) Page 5 of 8
Table 1| Bed bug bites versus other arthropod bites: main clinical and epidemiological features*
ContextTiming of pruritusLocationClinical features on examinationArthropod
TravellingMorningUncovered areas3-4 bites in a line or curveBed bugs
Pet owners or rural livingDaytimeLegs and buttocks3-4 bites in a line or curveFleas
Worldwide distributionAnopheles spp night; Culex
spp night; Aedes spp day
Potentially anywhereNon-specific urticarial papulesMosquitoes
Children, parents, or contact with
AnyScalp, ears, and neckLive lice on the head associated with
itchy, scratched lesions
Homeless people, developing
AnyBackExcoriated papules and
hyperpigmentation; live lice inside clothes
Sexually transmitted, households or
NightInterdigital spaces, forearms,
Vesicles, burrows, nodules and
non-specific secondary lesions
Sarcoptes scabiei mites
Pet owners or hikersAsymptomaticPotentially anywhereErythema migrans or ulcerTicks
People exposed to woodworm
contaminated furniture (P
ventricosus is a woodworm parasite)
Any time when inside habitatUnder clothesComet sign,33 a linear erythematous
Rural livingImmediate pain, no itchingFace and armsNecrosis (uncommon)Spiders
*It is difficult to diagnose a bite. Diagnosis relies on an array of arguments, none of which is specific by itself; it is the association of elements that is suggestive.
Any arthropod bite can be totally asymptomatic.
BMJ 2013;346:f138 doi: 10.1136/bmj.f138 (Published 22 January 2013) Page 6 of 8
Fig 1 The life cycle of the bed bug (adapted from Delaunay and colleagues1)
Fig 2 Bed bug nymph (1-4 mm) and adult (5-7 mm): Cimex lectularius
BMJ 2013;346:f138 doi: 10.1136/bmj.f138 (Published 22 January 2013) Page 7 of 8
Fig 3 Clinical manifestations of bed bug bites: three or four skin lesions are often seen in a “breakfast (1), lunch (2), dinner
(3)” distribution (A) or “wheel” distribution (B). Atypical bullous lesions (C) and urticaria (D)
Fig 4 To educate patients to the “search and destroy” strategy, GPs should show them pictures of (A) bed bugs and their
typical hideouts and (B) bed bug faecal traces on the mattress
BMJ 2013;346:f138 doi: 10.1136/bmj.f138 (Published 22 January 2013) Page 8 of 8