Hot tub rash is an infection of the skin (dermatitis) or of the hair follicles in the skin (folliculitis) acquired from contact with contaminated water. The infection occurs most commonly after swimming in hot tubs or spas, but contaminated swimmingpools or lakes may also spread the infection.
Folliculitis is an inflammatory condition affecting hair follicles. It appears as a small red tender bump occasionally surmounted with dot of pus surrounding a hair. Older lesions that have lost the pus appear as red bumps surrounding the opening of the follicle absent the hair. One to hundreds of follicles can be affected anywhere that hair is present. Actually, acne vulgaris, the facial rash that teenagers develop, is a type of folliculitis.
Anyone can develop folliculitis rash in areas where hair follicles are present on the body. Lesions of folliculitis most frequently involve areas such as the face, scalp, chest, back, buttocks, groin, and thighs. It does not affect the eyes, mouth, palms, or soles, where there are no hair follicles. Folliculitis probably affects all humans to some extent at some time during their lives. Folliculitis never involves the palms, soles, or eyelids because these areas are devoid of hair follicles.
Certain groups of people are more prone to develop folliculitis. People with diabetes and those with a compromised immune system (such as from HIV/AIDS, hepatitis, chronic diseases, cancer, systemic chemotherapy, immune-suppressing drugs) may be more prone to develop folliculitis.
Folliculitis can be caused by a large number of infectious organisms. However, frequently folliculitis is sterile and seems to be induced by irritating chemical substances, drugs, occlusive clothing, and physical irritants like shaving. Differentiating these causes is very important if the physician is going to be able to treat the condition successfully.
Acne vulgaris occurs almost universally in teenagers at puberty. Acne vulgaris is usually not considered a folliculitis, but it specifically affects the hair follicles of the face, chest, and back.
Systemically administered or topically applied steroids (cortisone-containing medications) are a well-known cause of folliculitis. Certain anti-cancer drugs produce a form of folliculitis.
Machinists exposed to insoluble cutting oils that are used to decrease the friction while machining metal parts can develop a folliculitis on the exposed skin.
Staphylococci are bacteria that commonly inhabit the skin. One species, S. aureus, is a frequent cause of folliculitis. Occasionally, this organism may be insensitive to a number of commonly used antibiotics (such as methicillin-resistant Staphylococcus aureus, or MRSA). In this situation, it is very important that a culture of the organism with sensitivities be performed so the ideal antibiotic is selected to treat the infection.
Folliculitis from a fungus infection can occur on the face and on the lower legs. It is often exacerbated by shaving. It can also occur on the trunk (Pityrosporum folliculitis).
Folliculitis from a virus infection often affects the face and is from herpes simplex virus affecting the lips, commonly known as a cold sore.
There are a variety of rare, inflammatory, scarring types of folliculitis that can result in permanent hair loss.
Eosinophilic folliculitis is an uncommon condition that is poorly understood and occurs occasionally as a response to certain drugs, in immunosuppressed patients (AIDS and bone marrow cancers), and in infants, affecting the scalp.
Razor-burn folliculitis is very common on the male neck and women's legs and is caused by shaving. Repeated passes by the razor produces tiny cuts that allow bacteria to enter the skin and invade the deeper hair follicles. Additionally, excessively close shaving may cause trapping of small hairs beneath the skin surface, causing more inflammation. Occasionally waxing (which utilizes warm paraffin that once solidified is then ripped away removing incased hairs) can produce folliculitis.
Treatment involves stopping shaving with a razor for a few days to a few weeks and using antibacterial washes and topical antibiotics. Additional treatments include laser hair removal, electrolysis, electric razors, or cream depilatories like Neet or Nair. Frequently, shaving less vigorously and leaving a small bit of stubble is advisable.
Hot tub folliculitis is most often caused by the bacteria Pseudomonas aeruginosa. This bacterial infection is likely to occur from bathing in poorly maintained hot tubs. It is most common on the back and causes scattered pinpoint, small red to purple bumps all over the torso. These may be very itchy or have no symptoms at all. Typically, there is a history of sitting in a hot tub days prior to the start of the bumps. It is good practice to rinse off the skin in a shower after this sort of bathing.
The hot tub should be tested and possibly treated by trained pool and spa personnel for bacterial overgrowth. Affected patients may be more prone to recurrences in the future and should be cautious about hot tub use. Although this condition often resolves without treatment, it may be useful to rinse the skin with dilute vinegar.
Pseudofolliculitis barbae is a very common ingrown hair condition on the beard area (lower face and neck) of men. Typically, there are groups of small red bumps on the beard area that may flare with repeat shaving. Pseudofolliculitis tends to be worse with very curly or kinky hair. It can be quite debilitating especially if one's employment requires a closely shaven appearance. Cutting the hair close to or below the follicular orifice results in hairs that penetrate into the follicular wall as they twist and grow. These trapped hairs cause irritation and inflammation at the hair follicles.
Treatment goals include avoiding overly aggressive shaving, trial of the "bumps-free razor," and antibacterial benzoyl peroxide shaving gels. Other treatment options include professional laser hair removal, electrolysis, electric razors, or a prescription drug called eflornithine (Vaniqa).
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Although most folliculitis is not contagious, folliculitis caused by an infectious agents may be transmitted through person-to-person skin contact, shared razors, or through Jacuzzis or hot tubs. It is possible to give the infection to someone else through close skin contact. Some people are simply more prone to developing folliculitis because of their overall health, possible altered immune status, exposure history, and other predisposing skin conditions like eczema or severely dry skin.
The diagnosis of folliculitis is generally based on the appearance of the skin. In some situations, a microbial culture of pus from the pustule will help to detect an infection. It may be necessary to pull out some of the affected hairs and examine these microscopically using potassium hydroxide in order to detect fungal infections or other infectious organisms. Occasionally, a small skin biopsy may be used to help the doctor confirm the diagnosis. Infectious causes include bacteria, fungi, viruses, and parasites. Usually, no specific blood tests are needed in the diagnosis of common folliculitis.
There are many treatment options and skin care recipes for treating folliculitis. The specific treatment depends on the cause of the folliculitis.
Home therapy for mild cases of bacterial folliculitis includes use of an over-the-counter antibacterial wash like benzoyl peroxide (Clearisil, Proactiv), chlorhexidine (Hibiclens), or Phisoderm twice a day. The best results may be achieved with combination therapy using topical products and antibacterial washes.
Holistic treatment for folliculitis may include soaking the affected area in a tub of diluted white vinegar (1 part vinegar to 4 parts of water) or soaking in a bathtub with very diluted Clorox bleach (¼ cup of Clorox bleach in a bathtub full of water).
Bacterial folliculitis may be treated with antibacterial skin washes and topical and/or oral antibiotics. It is important to keep in mind that as with any condition, no therapy is uniformly effective in all people. A doctor may need to help evaluate the cause of the folliculitis.
Moderate cases of bacterial folliculitis may be treated by a routine of twice-daily application of a topical antibiotic, such as clindamycin lotion or metronidazole lotion. A five- to 30-day course of an oral antibiotic like cephalexin (Keflex), dicloxacillin (Dynapen), doxycycline, minocycline (Dynacin, Minocin), ciprofloxacin (Cipro), or levofloxacin (Levaquin) may be used for folliculitis that is more resistant. After initial clearing with stronger medications, a milder maintenance antibacterial wash and topical antibiotic may be recommended.
Fungal or yeast folliculitis is often treated with an antifungal shampoo or body wash such as ketoconazole (Nizoral shampoo) twice daily. More resistant or deeper fungal folliculitis may require the addition of a topical antifungal cream such as miconazole (Lotrimin) or terbinafine (Lamisil) and an antifungal pill such as fluconazole (Diflucan).
Persistent skin discoloration called hyperpigmentation may be treated with prescription fading creams like hydroquinone 4%, kojic acid, and azelaic acid 15%-20%. Over-the-counter fading creams with 2% hydroquinone like Porcelana may be somewhat effective.
The individual follicle usually heals rapidly within a few days.
Most cases of folliculitis are completely curable. There are very uncommon, long-standing cases of folliculitis that may not be curable. Often these more resistant cases may be controlled with proper treatment and medication. Folliculitis sometimes clears completely by itself without treatment. Most patients may expect a short course with easy clearing.
Complications are infrequent since folliculitis is usually a self-limited skin condition. Rarely, the infected bumps may enlarge, causing an abscess (furuncles or carbuncles) or painful cysts requiring minor surgical drainage. Deeper or more extensive skin infections called cellulitis can be a rare complication.
Another potential complication includes temporary skin discoloration called post-inflammatory hypopigmentation (lighter than the regular skin color) or hyperpigmentation (darker then the regular skin color). This altered skin color may occur after the inflamed red bumps have improved or after a temporary flare.
Permanent scarring is uncommon but may occur from picking, overly aggressive scrubbing, or other deep inflammation.
Most family physicians, internists, or dermatologists are able to care for folliculitis.
The prognosis with folliculitis is very good. Overall, folliculitis tends to be an easily treated and curable skin condition. Often, it is a noncontagious, self-limited condition. Rarely, more widespread folliculitis may be cosmetically disfiguring and psychologically distressing.
Prevention efforts include good skin hygiene, avoiding unsanitary hot tubs and pools, not sharing razors, avoiding shaving too closely, changing out razors blades regularly, and keeping the skin moist and well hydrated.
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