UCONN Emergency Medicine Interest Group

EM Images #3

In IMAGES on June 10, 2011 at 9:34 PM

Syndicated from the UCONN EM Residency website; credit to Dr. London for images and text.

This is a case of a 13 year old otherwise healthy female who presents to the ED with a rapidly progressive rash over the past 2 days which initially started on her trunk and then spread to her extremities. There is no face, neck or mucosal involvement. The rash is pustular rather than vesicular and is follicular in distribution. This came on several days after going in a hot tub which was newly opened for the season. She is fully vaccinated for varicella.

What is the first-line treatment for this disease?

First, the diagnosis, if you have not already guessed it: hot tub folliculitis.

Given Pseudomonas as the causative organism, ciprofloxacin is the first line recommendation. After a discussion of the risks and benefits of quinolone therapy in a 13 year old (including the rare but black-boxed warning regarding the risk of tendon rupture) the patient was given a 10 day course with the recommendation for precautionary avoidance of athletic activity for two weeks.”

Hot tub folliculitis is a dermatitis contracted from contact with a bacterial organism, most commonly Pseudomonas aeruginosa, in contaminated water. The water in which one most often meets Ps. aer. is in a hot tub or whirlpool:

“P. aeruginosa is frequently found in whirlpools and hot tubs, sometimes in 94-100% of those tested at concenrations of <1 to 2,400 CFU/mL. The high concentrations found probably result from the relatively high temperatures of whirlpools, which favor the growth of P. aeruginosa, and the aeration which also enhances its growth. The organism is usually found in whirlpools when the chlorine concentrations are low, but it has been isolated even in the presence of 3.00 ppm residual free chlorine (Price and Ahearn 1988). Many outbreaks of folliculitis and ear infections have been reportedly associated with the use of whirlpools and hot tubs that contain P. aeruginosa (Ratnam et al. 1986). Outbreaks have also been reported from exposure to P. aeruginosa in swimming pools and water slides. Although P. aeruginosa has a reputation for being resistant to disinfection, most studies show that it does not exhibit any marked resistance to the disinfectants used to treat drinking water such as chlorine, chloramines, ozone, or iodine.” (from ref. 1)

Less frequently, the organism may be Aeromonas hydrophila, mimicking Pseudomonas aeruginosa. (ref. 2). Hot tub folliculitis is usually a mild dermatitis/folliculitis characterized by erythematous nodules and papules (which may be on palms and soles) and/or small erythematous pustular lesions on face and trunk, more characteristic. It often occurs without systemic concomitants but may include low grade fever, malaise and may, infrequently, require hospitalization. Although it usually involves one or two hot tubbers, it may affect many people, as the report from St. Louis, in which 33 children were infected, with two requiring hospitalization (ref. 3), or more strikingly, from Wales early in the knowledge of this risk, when 151 children developed folliculitis from Pseudomonas from a water slide. (ref. 4).

Differential Dx includes: staphylococcal folliculitis, contact dermatitis, impetigo, and herpes (simplex or zoster), and eosinophilic pustular folliculitis (Ofuji’s disease).

The answer to prevention: chlorinated water. (refs 1 and 5)

The answer to treatment: often no treatment is needed since the eruption looks angrier than its effects on the patient. If one does choose to treat, an oral Pseudomonas-effective antibiotic is needed, e.g., a fluoroquinolone (which will also treat Aeromonas). Special caution must be exercised and consent obtained for children since concern still exists for musculoskeletal injury in this age group, especially arthropathies.

1. Mena KD, Gerba CP. Risk assessment of Pseudomonas aeruginosa in water. Rev Environ Contam Toxicol. 2009;201:71-115. Review. PubMed PMID: 19484589.
2. Julià Manresa M, Vicente Villa A, Gené Giralt A, González-Enseñat MA. Aeromonas hydrophila folliculitis associated with an inflatable swimming pool: mimicking Pseudomonas aeruginosa infection. Pediatr Dermatol. 2009 Sep-Oct;26(5):601-3. PubMed PMID: 19840320.
3. Yu Y, Cheng AS, Wang L, Dunne WM, Bayliss SJ. Hot tub folliculitis or hot hand-foot syndrome caused by Pseudomonas aeruginosa. J Am Acad Dermatol. 2007 Oct;57(4):596-600. Epub 2007 Jul 19. PubMed PMID: 17658195.
4. Evans MR, Wilkinson EJ, Jones R, Mathias K, Lenartowicz P. Presumed Pseudomonas folliculitis outbreak in children following an outdoor games event. Commun Dis Public Health. 2003 Apr;6(1):18-21. PubMed PMID: 12736966.
5. Pseudomonas dermatitis/folliculitis associated with pools and hot tubs- Colorado and Maine, 1999-2000. MMWR Morb Mortal Wkly Rep, 2000. 49(48): p. 1087-91.


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