Hot Tub Folliculitis: Diagnosis and Treatment
Diagnosis
Hot tub folliculitis is diagnosed clinically based on pruritic papulopustular lesions on the trunk and extremities appearing 8-48 hours after hot tub exposure, with confirmation by bacterial culture of Pseudomonas aeruginosa from pustule specimens. 1
Clinical Presentation
- The eruption consists of pruritic papules, papulopustules, nodules, and occasionally urticarial lesions distributed on the trunk and extremities 2
- Onset occurs 8-48 hours after exposure to contaminated whirlpools, spas, or hot tubs 1, 2
- Associated symptoms may include fever, upper respiratory complaints, axillary adenopathy, and breast tenderness 3
- Skin biopsy, when performed, shows acute suppurative folliculitis and dermal abscess formation 2
Critical Distinction
- You must distinguish hot tub folliculitis from "hot tub lung" (MAC hypersensitivity pneumonitis), which presents with subacute dyspnea, cough, and fever rather than skin lesions. 4, 1
- Hot tub lung requires respiratory symptoms, characteristic radiographic findings (diffuse nodular infiltrates, ground glass opacities), and MAC isolates from respiratory specimens 1
Treatment
For mild cases, supportive care alone is sufficient as the eruption resolves spontaneously within 7-10 days without treatment. 3, 2
Conservative Management (First-Line for Mild Cases)
- Cleanse affected areas with gentle pH-neutral soaps and tepid water, patting skin dry after showering 4
- Apply warm compresses 3-4 times daily to promote drainage and reduce inflammation 4
- Wear loose-fitting clothing to reduce friction and moisture 4
- Avoid greasy creams and manipulation of affected skin to reduce secondary infection risk 4
Antibiotic Therapy (For Severe or Persistent Cases)
- Ciprofloxacin is the first-line antibiotic treatment for Pseudomonas aeruginosa folliculitis in adults 4
- Topical clindamycin is not effective against Pseudomonas aeruginosa and should not be used 4
- Note that empiric therapy directed at Pseudomonas aeruginosa is usually unnecessary for most infections except when there are specific risk factors for true infection 5
Prevention of Recurrence
Complete avoidance of the contaminated hot tub until proper decontamination occurs is mandatory. 4
Hot Tub Maintenance Requirements
- Maintain adequate disinfectant levels in the water at all times 4
- Follow manufacturers' recommendations for regular maintenance, including draining and thorough cleaning of the tub and filtering system 4
- Recognize that Pseudomonas aeruginosa is relatively resistant to standard disinfectants and chlorine disinfection may paradoxically permit mycobacterial growth by eliminating competing flora 4
Personal Prevention Measures
- Bathe before hot tub use to reduce organic contamination 4
- Avoid spending additional time in the hot tub once any symptoms begin 4
Common Pitfalls to Avoid
- Do not allow continued hot tub exposure, as this will intensify the inflammatory response 4
- Do not prescribe topical clindamycin, as it lacks activity against Pseudomonas aeruginosa 4
- Do not pursue unnecessary diagnostic studies or costly treatment programs for typical presentations, as the condition is self-limited 3
- Do not dismiss respiratory symptoms as part of folliculitis—these indicate hot tub lung, a distinct and more serious condition requiring different management 5, 1