Hot Tub Folliculitis

Rhonda Goodman, PhD, ARNP, FNP-BC; Teresa Vitous, DNP, ARNP, FNP-BC

Disclosures

Dermatology Nursing. 2010;22(3):47-49. 

Abstract and Introduction

History

A 56-year-old female presented with an uncomfortable rash on her abdomen. She was vacationing in Florida and had spent much of her time in the hotel swimming pool and hot tub. The patient noted many small children, some wearing diapers, had been in the hotel swimming pool. The rash consisted of multiple discrete papules evolving across her left flank and spreading to the left side of the abdomen, crossing over the midline of the umbilical area to the right side of the abdomen (see Figures 1–3). Many of the papular lesions had coalesced into a large plaque along her left flank. The lesions were erythematous, not warm to the touch, and not tender to the touch, although they caused itchiness. There were no vesicular lesions, no weeping, no crusting, and no open lesions. The patient had previously seen a physician, was diagnosed with shingles, and was prescribed acyclovir 800 mg by mouth five times daily for 10 days. She had taken oatmeal baths and used a topical cream to alleviate the intense itching, but was unsuccessful.

Figure 1.

The rash consisted of multiple discrete papules evolving across her left flank and spreading to the left side of the abdomen, crossing over the midline of the umbilical area to the right side of the abdomen.

Figure 2.

Many of the papular lesions had coalesced into a large plaque along her left flank

Figure 3.

The lesions were erythematous, not warm to the touch, and not tender to the touch, although they caused itchiness.

Description

Superficial folliculitis is an inflammation of the upper section of the hair follicle, and may be caused by an injury to the follicle, by infection, or by a chemical irritation of the follicle. If the inflammation extends deeper, including the length of the follicle, it is then called sycosis.

Location

The lesions may erupt on any part of the body, but most often are found on the hairy areas, including the face, chest, thighs, buttocks, and groin. Actions contributing to the eruption of lesions are shaving, plucking hairs, waxing, and the occlusion of hairy areas with clothing or ointments, such as topical steroids. Natural occlusion may occur in the intertriginous areas, such as the axillae and groin.

Etiology

The infection is commonly caused by staphylococcus aureus; however, other organisms, such as pseudomonas, dermatophytes, or candida, may be causative agents. Public hot tubs that are under-chlorinated may contain pseudomonas aeruginosa, which may produce a wide area of erythema, such as seen in this patient (see Figures 1-3). Her history of relaxing in a public pool and hot tub, along with her presenting symptoms, would be consistent with pseudomonas. Hot tub folliculitis lesions will erupt on the trunk or buttocks after a person sits in a hot tub. In addition, hot and humid tropical climates would precipitate the growth of these organisms.

Hallmark of the Disease

The patient usually presents with papules and pustules, which may or may not be tender, but are almost always pruritic. The papulopustular lesions may be on an erythematous base and they may open and form secondary lesions of crusts. The pustules are discrete and scattered or they may be grouped in clusters, depending upon the offending source of infection. Fever and other systemic symptoms, such as lymphadenopathy, are uncommon unless the infection involves deep folliculitis lesions, such as furuncles or carbuncles. In addition, the lesions may be pyogenic.

Diagnosis

A thorough history is the best diagnostic tool which aids in the formation of the correct diagnosis. Gather data concerning the lesions: location, onset, duration, pattern, size, itching, drainage, pain, fever, and chills. Ask about the patient's recent activity, especially those involving public water recreational areas. An inspection of the lesions may reveal erythema, warmth, tenderness, swelling, and evidence of pus. The adjacent lymph nodes should also be palpated. The clinical diagnosis may be reached by the analysis of empirical data. However, the diagnosis may be confirmed by isolating bacterial culture from the pustular lesions, which are scraped off with a blade and evaluated in a laboratory.

Treatment

The lesions may resolve spontaneously within 7 days; however, to expedite the recovery process, the lesions may be cleansed with an antibacterial soap or Hibiclens cleanser, followed by a thorough rinse. If the skin involvement is minor, a topical antibiotic, such as mupirocin 2% applied three times daily for 7–10 days, is warranted. However, if the lesions are more severe or persistent, adults may be prescribed cephalexin 500 mg by mouth twice daily for 10 days, ofloxacin 400 mg by mouth twice daily for 10 days, dicloxacillin 250 mg by mouth four times daily for 10 days, or ciprofloxacin 500 mg by mouth twice daily for 10 days. If necessary, the oral and topical antibiotics may be used concurrently. For relief of itching, the patient may use an over-the-counter (OTC) hydrocortisone cream 1% applied twice daily for 10 days as needed, and loratadine or diphenhydramine orally. This patient was treated with 10 days of oral cephalexin 500 mg, a Medrol® dosepak (methylprednisolone), and OTC hydrocortisone 1% cream. The rash was almost completely resolved within 3 days.

Normal Course

If a severe case of hot tub folliculitis is untreated, it can recur or become chronic unless pre-disposing conditions are corrected. The evolution of the lesions may progress to deeper follicular infection with abscesses, such as furuncles and carbuncles. Hot tub folliculitis may leave hyperpigmented spots for a few months after the resolution of the lesions.

Patient Education

The patient should be educated on the importance of taking warm showers after being in hot tubs, pools, or physiotherapy spas. Antibacterial soap should be used to cleanse the body of possible microorganisms. The patient should not scratch the affected areas, as organisms which cause folliculitis may be harbored beneath fingernails and spread to other areas of the body. Handwashing should be emphasized with particular attention to the fingernails. Wet clothing or swimsuits should be washed in warm water with antibacterial detergent to decrease the risk of contamination. The rash is likely to be worse in tropical climates where swimsuits hold contaminated water against the skin. Loose-fitting clothing would be a better choice in these instances. Occlusive lotions should be avoided. Also, there is an increased risk of infection if the patient has diabetes, malnutrition, anemia, a history of skin infections, or open cuts or sores. Hot tubs and pools should be cleaned regularly with the appropriate amount of chlorine. Patients should avoid public hot tubs and pools unless they are certain of the proper maintenance.

Nursing Measures

Gently wash the infected skin twice daily with antibacterial soap. For relief of discomfort, apply warm moist washcloths or compresses to the affected areas for 20 minutes four times daily. Compresses may be made with Burrow’s solution or a diluted vinegar solution. Oatmeal lotion or OTC hydrocortisone cream may be applied to alleviate pruritus. Educate the patient on the prevention measures mentioned above. Nurses may also advocate for public policy concerning the regulation of pool and hot tub maintenance in public facilities.

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