What treatment and ointment can help a 29-year-old female with a history of recent urinary tract infection (UTI) and yeast infection, who presents with external skin irritation and burning sensations upon touch, after exposure to a hot tub?

Hot Tub-Associated External Skin Irritation with Burning

This patient most likely has Pseudomonas aeruginosa folliculitis from hot tub exposure, and treatment should include topical hydrocortisone 1% cream applied 3-4 times daily for symptomatic relief of the external burning and irritation, while the infection typically resolves spontaneously within 7-10 days. 1, 2

Understanding the Clinical Picture

The combination of recent hot tub exposure, urinary tract symptoms, and external skin burning with irritation strongly suggests Pseudomonas aeruginosa folliculitis (hot tub folliculitis), which typically develops 8-48 hours after contaminated water exposure 3, 2, 4. The external burning sensation she describes is characteristic of this condition, which presents with pruritic papules, papulopustules, nodules, and urticarial lesions 2.

Immediate Symptomatic Management for External Burning

For the external skin irritation and burning:

• Hydrocortisone 1% cream applied to affected external areas 3-4 times daily provides anti-itch and anti-inflammatory relief 1
• Before application, gently clean the affected area with mild soap and warm water, rinse thoroughly, and pat dry 1
• This is appropriate for adults and safe for external genital/anal areas when used as directed 1

Key Clinical Distinctions

The patient has been treated for both UTI and yeast infection, but the external burning with skin irritation after hot tub exposure points to a separate dermatologic process rather than vulvovaginal candidiasis, which would present with internal vaginal symptoms 5. Vulvovaginal candidiasis typically causes vaginal pruritus, discharge, and internal dysuria—not primarily external skin burning upon touch 5.

Expected Clinical Course

Pseudomonas folliculitis is self-limited:

• The eruption usually resolves spontaneously within 7-10 days without specific antimicrobial treatment 2, 4
• Symptoms clear without intervention in most cases 4
• Systemic antibiotics are generally not required unless there are severe systemic symptoms (high fever, significant leukocytosis, extensive lesions) 3, 6

When to Consider Systemic Antibiotics

Systemic treatment is warranted only if:

• High leukocyte counts and persistent fever develop 3
• Painful erythematous nodules on palms/soles appear (hot hand-foot syndrome) 3, 6
• Axillary lymphadenopathy or breast tenderness occurs 4
• In such cases, culture-directed therapy is preferred; piperacillin-tazobactam 4g/0.5g IV twice daily has been used successfully 6

Critical Pitfalls to Avoid

• Do not treat with antifungal agents for this external burning—this is not vulvovaginal candidiasis requiring azole therapy 5
• Do not prescribe systemic antibiotics empirically for uncomplicated hot tub folliculitis, as it resolves spontaneously 2, 4
• Avoid fluoroquinolones (like ciprofloxacin) in children and adolescents, though this patient is 29 years old 6
• Ensure proper hot tub maintenance to prevent recurrence—adequate chlorination and disinfectant levels are essential 2, 4

Addressing the UTI Component

If true UTI symptoms persist (dysuria, frequency, urgency, suprapubic pain), ensure proper urine culture was obtained before treatment 7. Mixed flora represents contamination and should not be treated 7. For symptomatic UTI in women, first-line options include nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin when local resistance is <10% 7.

Follow-Up Recommendations

• Reassess in 7-10 days to confirm resolution of the folliculitis 2
• If symptoms worsen or systemic signs develop (fever, lymphadenopathy), obtain bacterial culture from pustules and consider systemic antibiotics 3, 4, 6
• Discontinue hot tub use until proper disinfection is confirmed 2, 4