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.^[28]

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. Pseudomonas may be cultured in patients with epidermal growth factor inhibitor‒related folliculitis.^[29]

Physical Examination

The predominant manifestation of Pseudomonas folliculitis 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. See the images below.

Erythematous papulopustules of pseudomonas folliculitis. Courtesy of Mark Welch, MD.

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Erythematous papulopustules of pseudomonas folliculitis, with significant perilesional flare. Courtesy of Andy Montemarano, MD.

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Pseudomonas folliculitis. Courtesy of Hon Pak, MD.

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Other systemic signs of Pseudomonas folliculitis 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^[30]
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)^[31]

Rarely, lesions may progress to chronically draining subcutaneous nodules.

Differential Diagnoses

Gregory DW, Schaffner W. Pseudomonas infections associated with hot tubs and other environments. Infect Dis Clin North Am. 1987 Sep. 1(3):635-48. [QxMD MEDLINE Link].
Highsmith AK, Le PN, Khabbaz RF, Munn VP. Characteristics of Pseudomonas aeruginosa isolated from whirlpools and bathers. Infect Control. 1985 Oct. 6(10):407-12. [QxMD MEDLINE Link].
McCausland WJ. Pseudomonas aeruginosa rash associated with whirlpool. JAMA. 1976 Nov 29. 236(22):2490-1. [QxMD MEDLINE Link].
Price D, Ahearn DG. Incidence and persistence of Pseudomonas aeruginosa in whirlpools. J Clin Microbiol. 1988 Sep. 26(9):1650-4. [QxMD MEDLINE Link].
Ratnam S, Hogan K, March SB, Butler RW. Whirlpool-associated folliculitis caused by Pseudomonas aeruginosa: report of an outbreak and review. J Clin Microbiol. 1986 Mar. 23(3):655-9. [QxMD MEDLINE Link].
Rose HD, Franson TR, Sheth NK, Chusid MJ, Macher AM, Zeirdt CH. Pseudomonas pneumonia associated with use of a home whirlpool spa. JAMA. 1983 Oct 21. 250(15):2027-9. [QxMD MEDLINE Link].
Jacobson JA. Pool-associated Pseudomonas aeruginosa dermatitis and other bathing-associated infections. Infect Control. 1985 Oct. 6(10):398-401. [QxMD MEDLINE Link].
Hlavsa MC, Cikesh BL, Roberts VA, Kahler AM, Vigar M, Hilborn ED, et al. Outbreaks Associated with Treated Recreational Water - United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2018 May 18. 67 (19):547-551. [QxMD MEDLINE Link].
Lacour JP, el Baze P, Castanet J, Dubois D, Poudenx M, Ortonne JP. Diving suit dermatitis caused by Pseudomonas aeruginosa: two cases. J Am Acad Dermatol. 1994 Dec. 31(6):1055-6. [QxMD MEDLINE Link].
Saltzer KR, Schutzer PJ, Weinberg JM, Tangoren IA, Spiers EM. Diving suit dermatitis: a manifestation of Pseudomonas folliculitis. Cutis. 1997 May. 59(5):245-6. [QxMD MEDLINE Link].
Bottone EJ, Perez AA 2nd, Oeser JL. Loofah sponges as reservoirs and vehicles in the transmission of potentially pathogenic bacterial species to human skin. J Clin Microbiol. 1994 Feb. 32(2):469-72. [QxMD MEDLINE Link].
Frenkel LM. Pseudomonas folliculitis from sponges promoted as beauty aids. J Clin Microbiol. 1993 Oct. 31(10):2838. [QxMD MEDLINE Link].
Maniatis AN, Karkavitsas C, Maniatis NA, Tsiftsakis E, Genimata V, Legakis NJ. Pseudomonas aeruginosa folliculitis due to non-O:11 serogroups: acquisition through use of contaminated synthetic sponges. Clin Infect Dis. 1995 Aug. 21(2):437-9. [QxMD MEDLINE Link].
Schets FM, van den Berg HH, Baan R, Lynch G, de Roda Husman AM. Pseudomonas aeruginosa on vinyl-canvas inflatables and foam teaching aids in swimming pools. J Water Health. 2014 Dec. 12 (4):772-81. [QxMD MEDLINE Link].
Böni R, Nehrhoff B. Treatment of gram-negative folliculitis in patients with acne. Am J Clin Dermatol. 2003. 4(4):273-6. [QxMD MEDLINE Link].
Roser DJ, van den Akker B, Boase S, Haas CN, Ashbolt NJ, Rice SA. Pseudomonas aeruginosa dose response and bathing water infection. Epidemiol Infect. 2014 Mar. 142(3):449-62. [QxMD MEDLINE Link].
Teraki Y, Nakamura K. Rubbing skin with nylon towels as a major cause of pseudomonas folliculitis in a Japanese population. J Dermatol. 2015 Jan. 42 (1):81-3. [QxMD MEDLINE Link].
Evans MR, Wilkinson EJ, Jones R, Mathias K, Lenartowicz P. Presumed Pseudomonas folliculitis outbreak in children following an outdoor games event. Commun Dis Public Health. 2003 Apr. 6(1):18-21. [QxMD MEDLINE Link].
Fox AB, Hambrick GW Jr. Recreationally associated Pseudomonas aeruginosa folliculitis. Report of an epidemic. Arch Dermatol. 1984 Oct. 120(10):1304-7. [QxMD MEDLINE Link].
Yu Y, Cheng AS, Wang L, Dunne WM, Bayliss SJ. Hot tub folliculitis or hot hand-foot syndrome caused by Pseudomonas aeruginosa. J Am Acad Dermatol. 2007 Oct. 57(4):596-600. [QxMD MEDLINE Link].
Gustafson TL, Band JD, Hutcheson RH Jr, Schaffner W. Pseudomonas folliculitis: an outbreak and review. Rev Infect Dis. 1983 Jan-Feb. 5(1):1-8. [QxMD MEDLINE Link].
Malterud K, Thesen J. [Whirlpool and pseudomonas infection--a local outbreak]. Tidsskr Nor Laegeforen. 2007 Jun 28. 127(13):1779-81. [QxMD MEDLINE Link].
Mena KD, Gerba CP. Risk assessment of Pseudomonas aeruginosa in water. Rev Environ Contam Toxicol. 2009. 201:71-115. [QxMD MEDLINE Link].
MMWR. An outbreak of Pseudomonas folliculitis associated with a waterslide--Utah. MMWR Morb Mortal Wkly Rep. 1983 Aug 19. 32(32):425-7. [QxMD MEDLINE Link].
Tate D, Mawer S, Newton A. Outbreak of Pseudomonas aeruginosa folliculitis associated with a swimming pool inflatable. Epidemiol Infect. 2003 Apr. 130(2):187-92. [QxMD MEDLINE Link].
Lutz JK, Lee J. Prevalence and antimicrobial-resistance of Pseudomonas aeruginosa in swimming pools and hot tubs. Int J Environ Res Public Health. 2011 Feb. 8(2):554-64. [QxMD MEDLINE Link]. [Full Text].
Matsui K, Okazaki K, Horikoshi Y, Kakinuma R, Kondo M. A case of congenital folliculitis caused by Pseudomonas aeruginosa in a preterm neonate. Jpn J Infect Dis. 2017 Feb 28. [QxMD MEDLINE Link].
Berger RS, Seifert MR. Whirlpool folliculitis: a review of its cause, treatment, and prevention. Cutis. 1990 Feb. 45(2):97-8. [QxMD MEDLINE Link].
Tohyama M, Hamada M, Harada D, Kozuki T, Nogami N, Monden N, et al. Clinical features and treatment of epidermal growth factor inhibitor-related late-phase papulopustular rash. J Dermatol. 2020 Feb. 47 (2):121-127. [QxMD MEDLINE Link].
Agger WA, Mardan A. Pseudomonas aeruginosa infections of intact skin. Clin Infect Dis. 1995 Feb. 20(2):302-8. [QxMD MEDLINE Link].
Ratnam S, Hogan K, March SB, Butler RW. Whirlpool-associated folliculitis caused by Pseudomonas aeruginosa: report of an outbreak and review. J Clin Microbiol. 1986 Mar. 23(3):655-9. [QxMD MEDLINE Link].
Centers for Disease Control and Prevention. Healthy Swimming/Recreational Water. Your Disinfection Team: Chlorine & pH. Available at http://www.cdc.gov/healthywater/swimming/pools/disinfection-team-chlorine-ph.html. Accessed: September 12, 2014.

Media Gallery

Erythematous papulopustules of pseudomonas folliculitis. Courtesy of Mark Welch, MD.
Erythematous papulopustules of pseudomonas folliculitis, with significant perilesional flare. Courtesy of Andy Montemarano, MD.
Pseudomonas folliculitis. Courtesy of Hon Pak, MD.

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Author

Charles B Toner, MD Assistant Professor, Department of Dermatology, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Mohs Surgeon, Skin Cancer Surgery Center; Mohs Surgeon, Charles County Dermatology; Mohs Surgeon, Georgia Dermatology and Skin Cancer Center

Charles B Toner, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, Association of Military Surgeons of the US, Association of Military Dermatologists, American Medical Association, American Society for Dermatologic Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

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 Center

Stephen J Krivda, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, American Society of Dermatopathology, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Lester F Libow, MD Dermatopathologist, South Texas Dermatopathology Laboratory

Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Leonard Sperling, MD Chair, Professor, Department of Dermatology, Uniformed Services University of the Health Sciences

Leonard Sperling, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Pseudomonas Folliculitis Clinical Presentation

History

Physical Examination

References

Tables

Contributor Information and Disclosures

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