Posted on: 02/14/09

The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.

Pseudomonas folliculitis (commonly called “hot tub rash”, “hot tub dermatitis”)

Background
Pseudomonas folliculitis is a community-acquired skin infection resulting from the bacterial colonization of hair follicles after exposure to contaminated bodies of contained water found in whirlpools, swimming pools, water slides, bathtubs, etc. The rash has also been found following the use of diving suits in both seawater and fresh water immersion, and, less commonly, following the use of contaminated bathing objects such as synthetic or natural sponges. Outbreaks have also been associated with waterslides, inflatable pool toys and similar water attractions. Pseudomonas folliculitis may also occur as an acne outbreak in patients on long-term tetracycline therapy.

Causes
The bacterial organism which causes the infection is found primarily in soil and fresh water and gains entry through hair follicles or cuts in the skin. The cause or source of the infection is difficult to assess because of the transient nature of the bather population, and most cases self-resolve without any adverse reactions. Certain hair removal procedures, such as in bikini waxing, or vigorous rubbing of the skin (such as with sponges or exfoliates) may facilitate the entry of the organism into the skin. Hot water, high pH (above 7.8) and low chlorine level (below .5 ppm) form the ideal breeding environment.
Other environmental conditions associated with folliculitis outbreaks:
•    Prolonged soaking
•    Large number of bathers
•    Inadequate sanitation and water maintenance
Other high risk factors associated with folliculitis include:
•    Crowding
•    Youth
•    Snug Bathing suits
•    Repeat exposure

Symptoms
Pseudomonas folliculitis is characterized by a rash, described by physicians as dermatitis or as folliculitis (inflammation of the hair follicle).  The rash onset is usually within 48 hours after exposure to contaminated water, but it can occur as long as 14 days after exposure.  Lesions begin as small macules (red spots) that later develop into larger “pimple” like bumps ranging in size from 2mm to 10mm with a central pustule. Lesions are most prevalent in areas where the skin rubs together, rubs against the surface of the pool or spa, or rubs against bathing suits. The rash may easily be confused with insect bites. Extremely high pH or extremely low pH may cause similar (but less severe) topical symptoms. Usually, the lesions will NOT be present on hairless areas of the body, such as the face, neck, palms or soles of the feet. Occasionally infected individuals will experience fever accompanied by headache or fatigue. Nipple glands on both men and women may also become infected.  The rash usually clears spontaneously in 2-10 days, rarely recurs, and heals without scarring, but it may cause peeling or leave flat, light pigmented streaks on the skin.

Treatment
Consult with your doctor before undergoing any treatment. Your doctor may prescribe a topical ointment or cream which will help reduce irritation.
You should NOT re-enter the hot tub until symptoms are completely gone and the tub has been properly cleaned and sanitized.

Steps to Properly sanitize an infected hot tub:
1.    Super-Chlorinate the hot tub.  Apply 99% sodium dichlor-trizenitroine at the rate of 2 Tbls per 200 gallons.
2.    With a vinyl bristle brush, and an additional chlorine solution using the same product, scrub along the waterline, including pillows, etc.
3.    Completely drain and rinse the tub with fresh water.
4.    Remove, clean, and disinfect filters using a filter cleaning agent combined with high pressure rinsing. Rinsing filters in your sink or shower will not adequately clean them.
5.    Refill, restart the tub, adjust Alkalinity and pH, then superchlorinate.

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