|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)
(1) Plastic Surgery Unit, Barzilai Medical Centre,
(2) Department of Plastic Surgery, Soroka Medical Centre and Faculty of Health Sciences,
Ben Gurion University of the Negev, Beer-Seba
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
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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outbreak of Pseudomonas folliculitis associated with a water-slide in Utah. JAMA,
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survey on outbreaks associated with whirlpool spas. Am. Public Health, 74: 7256,1984.
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.
This paper was
received on 25 July 1996.
Address correspondence to: Dr A.M.
Baruchin, Barzilai Medical Centre, 78306 Ashkelon, Israel.