Presumed Pseudomonas folliculitis outbreak in children following an outdoor games event

In early summer 2001, an outbreak of atypical rash occurred among children from 24 junior schools who attended an outdoor games event. The event comprised a series of five water games including a water slide, and within 24 hours of attending the event 151/593 (26%) children developed a papulopustular rash. The rash had a characteristic distribution, predominantly over the lower trunk and buttocks, with some involvement of the arms and legs. Pseudomonas aeruginosa was isolated from a water butt used to draw water for the games, and from the tank of a fire engine that supplied the water. Similar outbreaks, due to Pseudomonas folliculitis, have been previously described and in immunocompromised people this can be associated with serious illness. We recommend that superchlorinated water be used for water play events and that care be taken to avoid abrasive surfaces.

Folliculitis decalvans--a retrospective study in a tertiary referred centre, over five years

Folliculitis decalvans is a rare condition affecting mainly the scalp leading to scarring alopecia. Aetiology of the condition is still unknown, abnormal host response to Staphylococcus aureus has been postulated. We present a retrospective analysis of six cases of folliculitis decalvans presented to National Skin Centre (NSC), Singapore for the past five years, 1995-2000. The mean age of presentation was 39 years and ages ranged from 17 to 62 years. There were five male patients and one female patient. Duration of symptoms at presentation varied from six months to seven years. Occipital and vertex areas of the scalp were the only regions involved. Staphylococcus aureus was isolated in three patients; in one patient culture yielded negative results and no culture was done in the other two patients. All our patients were treated with several separate courses of systemic antibiotics which include doxycycline, erythromycin, minocycline, co-trimoxazole, cloxacillin, erythromycin, rifampicin and clindamycin. In addition one patient was treated with fucidic acid and zinc sulphate. The disease ran a protracted course with temporary improvement while on antibiotic and flare up of disease when antibiotics were stopped. The effectiveness of early treatment with rifampicin has been highlighted in some case reports in the past. We did use rifampicin in one of our patients. Our concern over emergence of antibiotic resistance, if used widely, may not permit us to use rifampicin on a wide scale.

A case of Trichosporon cutaneum folliculitis and septicaemia

Trichosporon cutaneum, a saprophytic fungal organism normally found in the soil, has been increasingly recognized as a cause of life-threatening systemic illness in immunosuppressed patients including those with leukaemia. Cutaneous involvement occurs in about 30% of patients with T. cutaneum septicaemia although disseminated folliculitis has not been described to our knowledge. We now describe a case of T. cutaneum follicultis due to fungaemia in a neutropenic patient.

Urticaria associated with dermatophytosis

BACKGROUND

Although urticaria has been reported in association with tinea or other fungal infections, usually this relationship is considered coincidental.

CLINICAL CASE

We report the case of a patient that developed two episodies of generalised urticaria associated with dermatophytosis. An allergologic studied was performed. Skin prick tests with a battery of common inhalant allergens and foods were negative. A culture of scrapings from lesions was performed and Epidermophyton floccosum colonies were identified. The patient was treated with oral antihistamines and topical clotrimazole and the skin lesion and urticaria healed in 14 days in the first episode and in 10 days in the second one.

CONCLUSIONS

Our results suggest a relationship between dermatophytosis and urticaria. Therefore, the allergologist should be aware of tinea infection as a cause of urticaria.

Citrobacter koseri in scalp folliculitis

Gram-negative folliculitis, an uncommon condition, is most often seen in older patients who have acne and who either have received prolonged courses of antibiotic therapy or have used antibacterial cleansers that selectively inhibit gram-positive organisms. Citrobacter infections are uncommon, and dermatologists seldom encounter them. In the past, these infections occurred in hospitals, particularly in neonatal intensive care units. Bacteremias also occur in elderly or immunocompromised patients. In this article, we present a case of Citrobacter koseri scalp folliculitis in an otherwise healthy patient.

[A case of Folliculitis barbae Candidomycetica]

A 71-year-old man was referred to our department on January 30, 1998 with hard red papules that had developed on the philtrum in mid-January. On January 2, the patient had received high-dose steroid therapy (pulse therapy) for cluster asthma attacks and antibiotics at the Department of Internal Medicine of our hospital. Infiltrative, protruding reddish plaques were observed on the philtrum, which contained a number of small pustules at sites corresponding to hair follicles. There was partial opacity and slight irregularity of the nail plates on the first and second toes of the right foot. Fungal elements were detected from a lesion on the mustache and the nail. Histological examination of the lesion on the philtrum revealed infiltration of inflammatory cells comprising neutrophils, lymphocytes, and macrophages around the hair follicles. Beard hair and nail cultures revealed Candida albicans A, indicating that the patient had candidal sycosis and candidal onychia. He was treated with oral fluconazole (100 mg/day). The lesion was clinically improved within 50-days. Recently, extensive use of steroids and antibiotics has produced an increase in reports of patients with Folliculitis barbae Candidomycetica. We believe that the present case was also induced by high-dose steroid therapy and antibiotics.

The pseudomonas hot-foot syndrome

BACKGROUND

Between March and May 1998, there was an outbreak of a clinically distinct skin eruption on the soles of the feet of children who used a community wading pool.

METHODS

We reviewed the medical records of 40 children in whom this syndrome developed between March and May 1998. We treated 17 children and advised the attending physicians on the care of the other 23. Follow-up data were obtained for up to one year.

RESULTS

Exquisitely painful erythematous plantar nodules developed in 40 children (age, 2 to 15 years) within 40 hours after they had used a wading pool whose floor was coated with abrasive grit. Culture of the plantar pustules from one child yielded Pseudomonas aeruginosa with a pattern on pulsed-field gel electrophoresis that was identical to that of a strain of P. aeruginosa cultured from the pool water. A skin-biopsy specimen from this patient showed a perivascular and perieccrine neutrophilic infiltrate, and a specimen from another patient showed a dermal microabscess. Thirty-seven patients were treated symptomatically; three others were treated with cephalexin. All patients recovered within 14 days, but three children had recurrences of the painful plantar nodules within 24 hours after using the pool again. Folliculitis developed in one patient.

CONCLUSIONS

The "pseudomonas hot-foot syndrome" is characterized by the acute onset in children of exquisitely tender plantar nodules and a benign, self-limited course. This community outbreak developed after exposure to pool water containing high concentrations of P. aeruginosa.

Common bacterial skin infections

Skin infections account for a significant portion of dermatologic disease, often resulting in or as a consequence of a disruption in the skin's integrity. This article covers the presentation, diagnosis, and treatment of the more common bacterial infections. The infections presented herein include impetigo, ecthyma, folliculitis, carbuncles/furuncles, cellulitis, toxic shock syndrome, and ecthyma gangrenosum. Once a diagnosis is made, treatment is based on the culture and antibiotic sensitivities of the offending organisms.

Seborrhoeic dermatitis and Pityrosporum (Malassezia) folliculitis: characterization of inflammatory cells and mediators in the skin by immunohistochemistry

BACKGROUND

The fact that Pityrosporum ovale plays a part in seborrhoeic dermatitis is well established but the mechanism of this relationship has not been established.

OBJECTIVES

To compare the number and type of inflammatory cells and mediators in skin biopsies from normal and lesional skin from the trunk and scalp in patients with seborrhoeic dermatitis, Pityrosporum (Malassezia) folliculitis and in normal skin from healthy controls.

METHODS

The skin biopsies were stained using the labelled Streptavidin-biotin

METHOD

The following markers were studied: CD4, CD8, CD68, HLA-DR, NK1, CD16, C1q, C3c, IgG, CD54 (ICAM-1), interleukin (IL) -1alpha, IL-1beta, IL-2, IL-4, IL-6, IL-10, IL-12, tumour necrosis factor-alpha and interferon-gamma.

RESULTS

HLA-DR+ cells were seen in the highest number, and were higher in lesional skin compared with normal skin from both patients and healthy volunteers. ICAM-1 expression was also increased in lesional skin. C1q and the interleukins showed an increased cellular and intercellular staining in patients compared with healthy controls and the intercellular staining was often more intense in lesions compared with non-lesional skin. Staining was often more intense when Malassezia (Pityrosporum ovale) yeast cells were present.

CONCLUSIONS

An increase in NK1+ and CD16+ cells in combination with complement activation indicates that an irritant non-immunogenic stimulation of the immune system is important. The result with the interleukins showed both an increase in the production of inflammatory interleukins as well as in the regulatory interleukins for both TH1 and TH2 cells. Similarities to the immune response described for Candida albicans infections indicate the role of Malassezia in the skin response in seborrhoeic dermatitis and Pityrosporum folliculitis.

Pseudomonas dermatitis/folliculitis associated with pools and hot tubs--Colorado and Maine, 1999-2000

During 1999-2000, outbreaks of Pseudomonas aeruginosa dermatitis and otitis externa associated with swimming pool and hot tub use occurred in Colorado and Maine. This report summarizes these outbreaks and provides recommendations for swimming pool and hot tub operation and maintenance, particularly when using offsite monitoring of water disinfectant and pH levels or when cyanuric acid is added to pools as a chlorine stabilizer.

Acneiform dermatoses

Acneiform dermatoses are follicular eruptions. The initial lesion is inflammatory, usually a papule or pustule. Comedones are later secondary lesions, a sequel to encapsulation and healing of the primary abscess. The earliest histological event is spongiosis, followed by a break in the follicular epithelium. The spilled follicular contents provokes a nonspecific lymphocytic and neutrophilic infiltrate. Acneiform eruptions are almost always drug induced. Important clues are sudden onset within days, widespread involvement, unusual locations (forearm, buttocks), occurrence beyond acne age, monomorphous lesions, sometimes signs of systemic drug toxicity with fever and malaise, clearing of inflammatory lesions after the drug is stopped, sometimes leaving secondary comedones. Other cutaneous eruptions that may superficially resemble acne vulgaris but that are not thought to be related to it etiologically are due to infection (e.g. gram-negative folliculitis) or unknown causes (e.g. acne necrotica or acne aestivalis).

Pseudomonas aeruginosa folliculitis after shower/bath exposure

BACKGROUND

Pseudomonas aeruginosa folliculitis (PF) can develop after exposure to contaminated water in heated swimming pools, whirlpools, and hot-tubes, or after diving suit dressing.

METHODS

We observed and studied 14 cases of PF after shower/bath exposure, an underestimated pathogenic event. Cutaneous and environmental microbiological evaluations were performed.

RESULTS

In our cases, the clinical expression of dermatitis was constant, PF being a clinically well recognizable skin infection, presenting with follicular, macular, and papulopustular lesions located on the lateral aspect of the trunk, axillary folds, hips, buttocks, and suprapubic area. In all cases, Pseudomonas aeruginosa was isolated from lesional skin; seven cases were serotyped revealing, in three cases, serotype 0 : 1, in two cases 0 : 8, in one case 0 : 10, and in one case 0 : 11. In three families, Pseudomonas aeruginosa was isolated in the well water. In a further three families, Pseudomonas aeruginosa was isolated from bathroom and kitchen components.

CONCLUSIONS

Based on our experience, we suggest that shower/bath exposure should be definitively included amongst the possible pathogenic events causing PF. Pseudomonas aeruginosa is responsible for a number of clinical pictures, e.g. otitis externa, conjunctivitis, toe web intertrigo, green nail syndrome, infection of burns and wounds, and folliculitis. Pseudomonas aeruginosa folliculitis (PF) has been reported to develop as a consequence of exposure to contaminated water in heated swimming pools, whirlpools, and hot-tubes, or related to diving suits and leg waxing.1-4 We observed 14 cases of PF after shower/bath exposure. This is probably an underestimated pathogenic event; to our knowledge, only one case has been reported to date.5 In our patients, the clinical expression of dermatitis was constant, PF being a clinically well recognizable skin condition.

Case report. Folliculitis barbae caused by Candida albicans

Folliculitis barbae candidomycetica is a very rare disease and in the scientific literature this manifestation of candidosis is rarely described. In most cases, a connection with predisposing factors is suspected, although in the cases cited this connection was not frequently proved. Furthermore, in our patient who was suffering from a folliculitis candidomycetica no predisposing factors or illnesses were apparent. For this reason, the importance of such aetiological factors of Candida folliculitis must be critically discussed. Effective drugs for use in treatment are fluconazole, itraconazole and ketoconazole.

Clinical features and treatment of Malassezia folliculitis with fluconazole in orthotopic heart transplant recipients

Orthotopic heart transplant recipients need immunosuppressive treatment and are at an increased risk for opportunistic infections such as Malassezia folliculitis. During a 4-month period (July to October 1990), 11 such cases were identified and treated; all were male with mean age of 43+/-9 years and on standard triple immunosuppressive therapy. Skin scrapings in potassium hydroxide (KOH) preparation with microscopy and/or culture identified either Malassezia furfur or Malassezia pachydermatis as the etiologic agent. A treatment with topical preparation (clotrimazole 1% and selenium sulfide lotion) was effective in 6 patients, whereas the rest received systemic fluconazole treatment with satisfactory outcome; all lesions were resolved within 3 weeks. Fluconazole appears to be an effective agent with excellent therapeutic outcome when administered for 3 weeks.