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Dermatology > BACTERIAL INFECTIONS
Pseudomonas Folliculitis
Article Last Updated: May 17, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: Stephen J Krivda, MD, Assistant Professor of Dermatology, Uniformed Services University of the Health Sciences; Chief of the Integrated Department of Dermatology, Chief of Dermatology Service, Director of Dermatopathology, Staff Dermatopathologist, Walter Reed Army Medical Center; Head, Department of Dermatology, Staff Dermatologist and Dermatopathologist, National Naval Medical
Stephen J Krivda is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Association of Military Dermatologists, and Phi Beta Kappa
Coauthor(s):
Charles B Toner, MD, Head, Department of Dermatology, Naval Hospital, Guam
Editors: Leonard Sperling, MD, Chair, Professor, Department of Dermatology, Uniformed Services University of the Health Sciences; Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center; Lester F Libow, MD, Dermatopathologist, South Texas Dermatopathology Laboratory; Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Author and Editor Disclosure
Synonyms and related keywords:
Pseudomonas aeruginosa folliculitis, whirlpool folliculitis, hot tub folliculitis, gram-negative folliculitis
Background
Pseudomonas folliculitis is a relatively recently recognized, community-acquired skin infection, which results from the bacterial colonization of hair follicles after exposure to contained, contaminated water (eg, whirlpools, swimming pools, water slides, bathtubs). First reported in 1975 in association with whirlpool contamination, the skin infection is caused by strains of Pseudomonas aeruginosa that are acquired secondary to skin contamination.
The rash has also been described following the use of diving suits in both seawater and fresh water immersion, and, less commonly, following the use of contaminated bathing objects (eg, synthetic and natural sponges). Pseudomonas folliculitis has occurred after skin depilation and with no obvious recreational exposure. Perioral Pseudomonas folliculitis may be associated with long-term use of antibiotics for acne vulgaris.
Pseudomonas folliculitis also occurs as an acneiform eruption in patients on long-term tetracycline therapy for acne.
Pathophysiology
The ubiquitous bacterial organism, P aeruginosa, found in soil and fresh water, gains entry through hair follicles or via breaks in the skin. Bacterial serotype O:11 is the most commonly reported isolate for water-associated Pseudomonas folliculitis, but other serotypes that have been reported include O:1, O:3, O:4, O:6, O:7, O:9, O:10, and O:16. Serotype O:11 is possibly more invasive or better adapted to survive in halogenated water. Minor trauma from wax depilation or vigorous rubbing with sponges may facilitate the entry of organisms into the skin. Hot water, high pH (>7.8), and low chlorine level (<0.5 mg/L) all predispose to infection.
Frequency
United States
The actual incidence is difficult to assess because of the transient nature of the bather population.
Mortality/Morbidity
Most cases resolve without any adverse reactions.
Race
No racial differences in incidence are known.
Sex
No sexual differences in incidence are known.
History
Pseudomonas folliculitis is characterized by a rash, described as a dermatitis or a folliculitis.
- The rash onset is usually 48 hours (range, 8 h to 5 d) after exposure to contaminated water, but it can occur as long as 14 days after exposure.
- Lesions begin as pruritic, erythematous macules that progress to papules and pustules. Lesions are most prevalent in intertriginous areas or under bathing suits.
- The rash usually clears spontaneously in 2-10 days, rarely recurs, and heals without scarring, but it may cause desquamation or leave hyperpigmented macules.
Physical
The predominant manifestation of the illness is dermatitis (79%).
- Pseudomonas folliculitis is characterized by follicular papules, vesicles, and pustules, which may be crusted.
- Lesions involve exposed skin, but they usually spare the face, the neck, the soles, and the palms.
- Lesions progress to erythematous papulopustules that range in size from 2-10 mm in diameter, with a pinpoint central pustule.
- The rash is not unique in appearance and is most often confused with insect bites.
- Other systemic signs that can occur with the rash include the following:
- Low-grade fever (4%), often accompanied by headache (15%) and malaise/fatigue (19%)
- Otitis media and otitis externa
- Breast tenderness in both women and men (The glands of Montgomery on the nipple may become infected or may involve frank mastitis [11%].)
- Painful lymphadenopathy
- Conjunctivitis
- Rhinitis
- Pneumonia (rare)
- Urinary tract infection (UTI) (rare)
- Rarely, lesions may progress to chronically draining subcutaneous nodules.
Causes
- Three primary environmental conditions are known to be associated with outbreaks of Pseudomonas folliculitis.
- Prolonged water exposure
- Excessive numbers of bathers
- Inadequate pool care
- Risk factors include the following:
- Crowding
- Youth
- Wearing of snug bathing suits
- Frequency and duration of exposure
- Outbreaks have been associated with waterslides and similar water attractions. Superchlorinated water has been advised to decrease the incidence of outbreaks. Inflatable pool toys have also been implicated as a source of infection.
Contact Dermatitis, Irritant
Other Problems to be Considered
Bromide sensitivity
Staphylococcal folliculitis
Lab Studies
- The diagnosis is best verified by results of bacterial culture growth from either a fresh pustule or a sample of contaminated water.
- Gram stain of a pustule may also be performed.
Histologic Findings
Standard hematoxylin and eosin preparation displays a severe follicular epithelial inflammatory response, which may result in follicular distention and rupture. The pilar canal is filled with a dense polymorphonuclear leukocytic infiltrate, often accompanied by a brisk perifollicular lymphocytic infiltration. Both the epidermis and the infected apocrine glands remain intact.
Medical Care
P aeruginosa is usually a self-limited infection, clearing in 2-10 days. Despite the discomfort caused by the rash, no treatment is necessary. Systemic spread is typically not observed.
- P aeruginosa is resistant to nearly all common topical and oral antibiotics, and no indication exists that the course of the skin condition is altered with treatment.
- Symptomatic relief may be achieved through the use of acetic acid 5% compresses for 20 minutes twice a day to 4 times a day.
- In patients with associated mastitis, in those with persistent infections, or in those who are immunosuppressed, a course of ciprofloxacin (500 or 750 mg PO bid) is advised.
Systemic antibacterials for uncomplicated Pseudomonas folliculitis infections have shown no benefit. Persistent infections may benefit from a standard 7- to 10-day course of ciprofloxacin.
Drug Category: Antibacterials
Bactericidal antibacterials inhibit bacterial growth and proliferation.
| Drug Name | Ciprofloxacin (Cipro) |
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| Description | Member of fluoroquinolone family of synthetic, broad-spectrum antibacterials. Contains piperazine moiety responsible for antipseudomonal activity. Interferes with DNA gyrase normally needed for synthesis of bacterial DNA. |
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| Adult Dose | 750 mg PO bid for 7-14 d |
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| Pediatric Dose | <18 years: Not recommended
>18 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT); food delays absorption, resulting in peak concentrations closer to 2 h after dosing rather than 1 h; however, overall absorption is not substantially affected; dairy products (eg, milk, yogurt) reduce absorption (avoid concurrent use) |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy; phototoxicity may occur with exposure to sunlight |
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Deterrence/Prevention
- Proper maintenance and chlorination of pools, hot tubs, whirlpools, and spas are essential to decrease the population of Pseudomonas species.
- The Centers for Disease Control Suggested Health and Safety Guidelines for Public Spas and Hot Tubs recommend a free chlorine concentration of 1-3 mg/L and a pH of 7.2-7.8.
- However, P aeruginosa has been recovered from adequately chlorinated water containing 2 mg/L of free chlorine.
- Bromine is considered an acceptable alternative to chlorine and is considered more effective in hot water with a longer period of activation.
- Complete drying of sponges between uses is essential because P aeruginosa does not survive drying.
- Showering after exposure to contaminated water does not seem to prevent disease.
| Media file 1:
Erythematous papulopustules of pseudomonas folliculitis. Courtesy of Mark Welch, MD. |
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Media type: Photo
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| Media file 2:
Erythematous papulopustules of pseudomonas folliculitis, with significant perilesional flare. Courtesy of Andy Montemarano, MD. |
 | View Full Size Image | |
Media type: Photo
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| Media file 3:
Pseudomonas folliculitis. Courtesy of Hon Pak, MD. |
 | View Full Size Image | |
Media type: Photo
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Pseudomonas Folliculitis excerpt Article Last Updated: May 17, 2006
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