Annals of Burns and Fire Disasters - vol. IX - n. 4 - December 1996

PSEUDOMONAS FOLLICULITIS ACQUIRED FROM HOT TUBS AND WHIRLPOOLS: AN OVERVIEW

Baruchin AN.,(1) Shapira A.,(1) Scharf S.,(1) Rosenberg L.(2)

(1) Plastic Surgery Unit, Barzilai Medical Centre, Ashkelon, Israel
(2) Department of Plastic Surgery, Soroka Medical Centre and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Seba

SUMMARY. Pseudomonas aeruginosa folliculitis occurs in persons who bathe in contaminated water. Most cases are associated with recreational and therapeutic activity involving the use of public hot baths, whirlpools, swimming-pools or saunas. The rash consists of erythernato-papulopustular lesions on the trunk and extremities. The eruptions usually resolve spontaneously within a week or little more. Awareness of this condition and its benign course is essential to diagnosis and treatment in order to avoid unnecessary diagnostic testing and therapeutic measures.

Since 1975, numerous cases of Pseudomonas folliculitis have been reported in persons using public hot baths, whirlpools, swimming-pools, saunas, waterslides and physiotherapy pools in health spas, hotel health clubs, apartment complexes, holiday resorts, massage parlours, fitness facilities and also in private homes.'-' The baths - mainly hot tubs and whirlpools - are designed for recreational and therapeutic use and for physiological and psychological relaxation.

Pseudomonas aeruginosa is a ubiquitous, gram-negative rod with a special predilection for warm and moist areas. It can be found in soil, sinks, drains, shower-floors, carpeting, filters and even tap water.
The skin of the axillae, the anogenital regions and the toe webs of healthy persons may provide a site for Pseudomonas aeruginosa, which in the immunocompromised host may cause severe septicaemia.
The mean incubation period is 48 h (range 8 h to 5 days) following exposure to contaminated water. The initial picture is that of folliculitis, which is maculovescicular on an erythematous base; at a later phase, the eruption consists of pruritic papules, papulopustules, and vesicular and urticarial lesions (Fig. 1).
The eruptions characteristically involve the trunk and proximal extremities but may also involve the distal extremities, axillae and buttocks. The neck and face are less frequently involved (perhaps because bathers are reluctant to submerge their heads in the hot tub). The rash may be accompanied by malaise, headache, nausea, vomiting, abdominal cramps, sore eyes, rhinitis, sore throat, fever, swollen breasts and axillary lymphadenopathy. The symptoms may last for several weeks but generally the infection is self-limiting and resolves spontaneously in 7 to 10 days, without the need of any specific treatment.
A hot tub provides an ideal environment for Pseudomonas, with more than 62% of random cultures showing some positive growth. The organism is well suited to a wet and warm atmosphere and is able to withstand temperatures up to 41 'C. Chlorine does not disinfect bath water adequately as the organism may still be present in concentrations up to 3mg/1 (total residual concentration of chlorine).' In addition, much of the chlorine is inactivated by the bathers' ammonium secretions. Organic carbons in the form of desquamated skin and bodily secretions provide nutrients for this organism. All these factors contribute to the creation of an active breeding ground for Pseudomonas. Infection is facilitated by dilatation of the pores and superhydration of the stratum corneurn due to the high temperature.
Biopsy specimens of skin lesions obtained from affected skin showed typical histopathological and bacteriological findings. The epidermis was unremarkable. Pseudomonas aeruginosa can often be cultured from fresh pustules. It can also sometimes be cultured in water samples from the hot tub and whirlpools. Various scrotypes of Pseudomonas, including 0:11, 0:10 and 0:9, were involved."' Acute suppurative folliculitis consisted of distension and disruption of central hair follicles, the pilar canal of which was filled with a dense polymorphonuclear inflammatory cell infiltrate. In the surrounding dermis there was a moderately dense, perivascular inflammatory cell infiltrate composed of mononuclear cells and polymorphonuclear leucocytes. A Brown-Brerm stain for the identification of bacteria was negative.
The organism probably invades via follicular orifices and discharges its toxins (including proteolytic, keratolytic and lecitholytic enzymes) in the deeper tissues, with resulting inflammation. It has been shown under experimental conditions of superhydration of the stratum corneum that Pseudomonas may proliferate and cause a vesiculopapular eruption similar to that seen in patients with folliculitis from the use of whirlpools. Since the organism is aerobic, it does not survive, and the condition is therefore self-limiting. Areas covered by constrictive clothing such as bathing suits are particularly susceptible to infection because it may occlude follicular orifices already inoculated with Pseudomonas. The invasion is facilitated by the dilatation of the follicular orifices in the presence of high temperatures and chemical irritants in the water. A new variant of the syndrome has recently been observed, characterized by its occurrence in divers who wear diving suits.` Pseudomonas aeruginosa is known not to survive in sea water or on beaches, and this contamination is therefore likely to be due to water used during rinsing or showering. It has also been speculated that the humid microclimate maintained in the alveoli of neoprene is favourable to the survival of Pseudomonas aeruginosa. This self-limiting and benign condition may be mistaken for a more serious problem, e.g. atypical virus, severe contact dermatitis, or some other serious infection presenting a rash. The differential diagnosis for Pseudomonas folliculitis should therefore include: scabies, insect bites, swimmer's itch, sea bather's eruption, contact dermatitis, viral eruptions, papular urticaria miliaria, bacterial folliculitis (other than Pseudomonas), iododerma, bromoderma, perforating folliculitis, herpes, sepsis, and skin infections associated with chronic meningococcal or gonococcal septicaemia and Mycobacterium marium (swimming-pool granuloma). 1,5,13,14

RESUME. La folliculite due à la Pseudomonas aeruginosa se produit chez les personnes qui se baignent dans de l'eau contaminée. La plupart des cas sont associés à des activités récréatives et thérapeutiques qui nécessitent l'emploi de services publics comme les bains chauds, les bains à remous, les piscines ou les saunas. Léruption cutanée est constituée de lésions érythymato-papulopustuleuses sur le tronc et les extrémités. Normalement l'éruption guérit spontanément entre une semaine ou un peu plus. Il faut tenir compte de cette maladie et de son cours bénin pour formuler le diagnostic et les soins corrects et pour éviter de pratiquer des mesures diagnostiques et thérapeutiques inutiles.

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7. Chandrasekar P.H., Rolston KXI., Kannangara D.W. et al.: Hot tubassociated dermatitis due to Pseudomonas aeruginosa, case report and review of the literature. Arch. Dermatol., 20: 1233-40, 1984.
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9. Khabbaz R.F., McKinley T.W., Goodman R.A. et al.: Pseudomonas aeruginosa serotype 0:9, a new cause of whirlpool associated dermatitis. Am. J. Med., 74: 73-7, 1983.
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12. Perrota D.M., Jones R.E,, Bradely R. et al.: An outbreak of Pseudomonas folliculitis associated with a water-slide in Utah. JAMA, 250: 1259, 1983.
13. Spitalney K.C., Vogt R.L., Whiterell L.E.: National survey on outbreaks associated with whirlpool spas. Am. Public Health, 74: 7256,1984.

14. Lacour J.P., El Baze P., Castanet J. et al.: Diving suit dermatitis caused by Pseudomonas aeruginosa: two cases. J. Am. Acad. Dermatol., 31: 1055-6, 1994.