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Hot Tub Folliculitis

By: boonDOCS

When the well is dry, we know the worth of water.
-Benjamin Franklin

Water is essential to life and prosperity, but it can also bring pain, discomfort, and - in some circumstances! - complete social awkwardness. In honor of "April showers," we invite you to this month's boonDOCS series on "Water-Related Injuries!"

As we power through the spring and dive deep into summer weather, you might be thinking about warming up your hot tub. Sure it has been sitting dormant for the past few months, but ever since you rented the movie, "Hot Tub Time Machine," you have been imagining all the things you could be doing in that magical mystery of bubbling hot water. But be warned! An unseen danger may lurk with each dip you take.

What Is It?

Folliculitis is simply a general term for a bacterial infection of the hair follicles. It is limited to the top layer of skin (the epidermis) and does not usually penetrate down to the deeper soft tissue, so it is deemed a "superficial" infection. A few inflamed follicles together form a carbuncle, and when the infection gets so bad that it does penetrate those deeper tissues, it is called a furuncle or boil. Ugly sounding names for some pretty nasty looking lesions!

Hot Tub Folliculitis is a relatively common simple folliculitis caused by exposure to contaminated water. The main symptom is a tender, itchy skin rash that is usually concentrated in areas under swim garments (your swimsuit helps hold the contaminated water close to your skin!). The rash consists of pink or red bumps that are 2-10mm in diameter and can contain pus (almost like a "pimple") and typically appears around 8-24 hours after being exposure. It typically lasts no more than about 7 to 10 days and goes away on its own.

Common sites of infection include the groin/buttock area, abdomen, armpits, chest, back, and upper arms and legs. Keep in mind, though, that this infection can get into anywhere we have hair follicles, which is unfortunate for us humans since we have hair practically everywhere - about 5 millions hairs per human, in fact!

What Else Could This Be?

The rash seen in Hot Tub Folliculitis can resemble several other conditions depending on its location and the story that goes with it. For example, Sea Bather's Eruption or Swimmer's Itch might be considered. Likewise, other forms of impetigo or even run-of-the-mill acne might look like similar. Whatever you do, though, do NOT pop those pustules! We know it's tempting, but it's just what Pseudomonas wants you to do. First off, it may help bacteria spread or get even deeper into your skin. Secondly, those red bumps filled with pus are made up of a bunch of cells called neutrophils. Neutrophils are one of your body's primary weapons against infection; so, leave those whiteheads alone, and let your body do its thing!

Other Symptoms to Look For?

In addition to feeling a little embarrassed and grossed out, people affected by Hot Tub Folliculitis may develop malaise and fatigue and a low-grade fever. Headache, sore throat, and swollen, tender lymph nodes have also been reported. The good news is that the condition typically clears on its own over a couple of days. You may want to utilize some anti-itch medication such as hydrocortisone 1% cream so you don't go crazy.

When Should You Worry?

Keep an eye on that rash! If the pustules don't clear in several days or if the lesions get large and painful, you may have developed a more serious infection that needs a physician's attention. Other symptoms that should get you to the doctor's office are fever, swollen lymph nodes, breast tenderness, very tender rash, or just plain feeling awful. At that point, you might even need a topical or oral antibiotic like ciprofloxacin.

What Causes It?

The culprit behind Hot Tub Folliculitis is a bacterium called Pseudomonas aeruginosa. It is a Gram-negative, aerobic, rod-shaped bacterium. The species name "aeruginosa" is a Latin word meaning copper rust, referring to the blue-green pigment that give these bacteria their characteristic color on cultures (think "Statue of Liberty" in terms of color). It has evolved to be so dangerous because it uses something called virulence factor exotoxin A to prevent its host (i.e., humans and animals) from making proteins. Subsequently, infected cells die, and necrosis sets in! On top of all that, the little buggers have figured out how to beat some of our best antibiotics.

Pseudomonas is considered an opportunistic pathogen and is especially dangerous to people with weakened immune systems and those in hospital-type settings. Much like you, Pseudomonas enjoys the hot steaminess of whirlpools, hot tubs, and swimming pools - especially when those water sources are inadequately chlorinated. Pseudomonas also likes to hang out on loofah sponges, swimsuits, and old sneakers. It's a tough little bug that can wreak havoc in hospitals (especially if it gets into the plumbing system), and it is frequently resistant to common antibiotics.

What Else Does Pseudomonas Cause?

In addition to hair follicles, P. aeruginosa can cause infections in many other parts of the body:

  • Burn wounds - burns infected with P. aeruginosa can be fatal
  • Heart - can cause an infection called endocarditis, and occurs in IV drug users
  • Lungs - called pneumonia, and occurs in people with Cystic Fibrosis or weak immune systems
  • Blood - called sepsis, and is usually acquired in the hospital
  • Ear - external ear infections usually occur in elderly people who are diabetic and swimmers (i.e., swimmer's ear)
  • Eye - especially in contact lens-wearers
  • Urinary tract and kidneys - occurs in people who are hospitalized or living in nursing homes
  • Bone - called osteomyelitis and occurs in people who are diabetic, IV drug users, or children who have suffered a puncture wound to the foot (through an old dirty sneaker, for example)

How Can You Prevent It?

To prevent Pseudomonas from ruining your dip in the hot tub or pool, remember to properly chlorinate the water supply. Let loofahs, sponges, and swimsuits dry out completely before reusing them. Some other helpful hints from the U.S. Center for Disease Control and Prevention (CDC) include the following:

  • Remove your swimsuit and shower with soap after getting out of the water.
  • Clean your swimsuit after getting out of the water.
  • Ask your pool/hot tub operator if disinfectant (for example, chlorine) and pH levels are checked at least twice per day (hot tubs and pools with good disinfectant and pH control are less likely to spread germs).
  • Use pool test strips to check the pool or hot tub yourself for adequate disinfectant (chlorine or bromine) levels. CDC recommends for pools and hot tubs that:
    • Pools: free chlorine (1-3 parts per million or ppm)
    • Hot Tubs: free chlorine (2-4 ppm) or bromine (4-6 ppm).
    • Both hot tubs and pools should have a pH level of 7.2-7.8.

If you find improper chlorine, bromine, and/or pH levels, tell the hot tub/pool operator or owner immediately. Also, take the time to have your hot tub and pool regularly serviced.

If you are worried about using a public pool or hot tub, here are 4 questions to ask the maintenance guy before taking the plunge:

  • What was the most recent health inspection score for the hot tub?
  • Are disinfectant and pH levels checked at least twice per day?
  • Are disinfectant and pH levels checked more often when the hot tub is being used by a lot of people?
  • Are the following maintenance activities performed regularly:
    • Removal of the slime or biofilm layer by scrubbing and cleaning?
    • Replacement of the hot tub water filter according to manufacturer's recommendations
    • Replacement of hot tub water?

For further information on protecting yourself and others when using hot tubs and pools, please see CDC's "For Swimmers and Hot Tub Users." With these simple precautions, you should be able to swim through pool and hot tub season completely Pseudomonas-free!

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