Hot Tub Spa Folliculitis

What is folliculitis?

Folliculitis is infection or inflammation of the hair follicles, the small sacs beneath the skin from which hair develops and grows.

Folliculitis can develop on any part of the body, although it is most likely to occur on the scalp, face, and areas where clothing rubs against the body, such as the arms, thighs, and buttocks.

What causes folliculitis?

The most common cause is a bacterial infection. Infection with the Staphylococcus aureus bacterium causes most cases of folliculitis. Folliculitis caused by the Pseudomonas aeruginosa bacterium is usually from hot tubs or spas. People who take antibiotics for a long time are more susceptible to folliculitis caused by the Enterobacter, Klebsiella, and Proteus bacteria.

Sometimes fungi cause folliculitis, including most frequently Candida albicans. Fungal folliculitis is more often seen in people who have impaired immune systems.

Some substances such as motor oil, tar, grease, and on rare occasions, medications or viruses can also cause folliculitis.

What are the symptoms of folliculitis?

Folliculitis begins as a red, tender area at or near the base of one or more strands of hair. It turns into a small raised area of skin that contains pus (pustule) and often itches or burns. When these pustules break open, they may drain pus and/or blood.

Which factors contribute to folliculitis?

Some factors increase the risk for folliculitis, including:

Use of hot tubs, spas and other warm, moist environments that encourage bacteria and fungi to multiply.
Poor personal hygiene.
Tight-fitting clothes.
Use of antibiotics or steroid cream for long periods, which can destroy protective bacteria, leaving the skin unable to fight bacteria or fungi.
Use of cosmetics or dry skin, which can cause clogged pores.
Infection at an open wound, such as a cut, scrape, or surgical incision. This can cause bacteria or fungi to spread to nearby hair follicles.
Diseases such as diabetes and acquired immunodeficiency syndrome (AIDS) that decrease your ability to fight infection normally.

How is folliculitis diagnosed?

Your health professional will diagnose folliculitis by asking about your medical history and examining your skin.

If folliculitis appears severe, your health professional may take a sample of the fluid from inside a pustule to find out whether bacteria is causing the folliculitis. To diagnose a fungus, a biopsy of the infected area is usually done.

How is folliculitis treated?

Mild folliculitis infections are close to the skin surface and usually heal on their own in about 2 weeks. If they do not, early treatment with antibiotic ointments or antifungal creams usually clears up the condition. Shampoos are available to treat folliculitis that occurs on the scalp or beard.

Oral antibiotics or antifungal medications are usually successful in clearing up deeper, more severe folliculitis infections. A fluid sample from an infected follicle may be analyzed to help your doctor determine the specific cause of your folliculitis in order to decide which medication is best for you.

Some types of fungal folliculitis can cause scarring and become a persistent problem that needs long-term treatment.

Symptoms

The pustules that develop with deep folliculitis are usually larger, more painful, and longer-lasting than those experienced with mild (superficial) folliculitis. Deep folliculitis can also lead to other skin infections that generally cause more pain and discomfort, such as a boil (furuncle) or carbuncle. Carbuncles may also cause fever symptoms and cause you to feel ill.

Folliculitis caused by Pseudomonas aeruginosa typically appears about 72 hours after exposure in a hot tub or spa. Many small pustules appear on the trunk and sometimes the arms and legs. You may have a mild fever and feel ill. This type of folliculitis usually goes away on its own within 7 to 10 days.

Some people, especially those of African-American origin and people with tightly coiled hair, get razor bumps, also called pseudofolliculitis barbae. It develops after shaving when strands of hair curl back on themselves, grow into the skin, cause irritation, and make pimples. Pseudofolliculitis barbae is not a true folliculitis.

Some other skin conditions have symptoms similar to folliculitis.

Exams and Tests

Your health professional will examine the skin over your entire body, especially on your arms, legs, buttocks, and scalp. The skin of men's beards is also examined. A general indication of folliculitis is a hair found in the center of the pustule.

If folliculitis is diagnosed and it appears severe, your health professional may take a sample of the fluid from inside a pustule to find out which type of bacteria is causing the folliculitis. The fluid is sometimes analyzed right at the health professional's office, in which case the results are available immediately. To diagnose a fungus, a biopsy of the infected area is usually done. Fluid or biopsy samples that are sent to an outside lab will usually have the results available in a few days.

Treatment Overview

Mild cases of folliculitis sometimes heal on their own. However, folliculitis may return or get worse. If your folliculitis spreads or returns, see a health professional for proper treatment.

Mild folliculitis caused by bacteria is often treated with antibiotic ointments or creams such as bacitracin, polymyxin B sulfate (Polysporin), clindomycin, erythromycin, or mupirocin (Bactroban). Topical antiseptic cleansers may also be used, such as povidone-iodine or chlorhexidine.

Deeper or more severe infections caused by bacteria are usually treated with oral antibiotics. Dicloxacillin, erythromycin, and cephalexin (Keflex) are usually used to treat infections. Ciprofloxacin (Cipro) and ofloxacin (Floxin) are used when certain types of bacteria are causing infection.

Folliculitis caused by a fungus is most often treated with antifungal pills, such as fluconazole (Diflucan), griseofulvin (Fluvican U/F or Gris-PEG), itraconazole (Sporanox), or terbinafine (Lamisil). Sometimes, corticosteroids may also be used.

If folliculitis occurs on the scalp or beard area, a shampoo containing selenium sulfide 2.5%, selenium 1%, or 50% propylene glycol can be used.

For stubborn cases of folliculitis, laser treatment may be an option. Laser treatment destroys the hair follicle and reduces the scarring that results from folliculitis. However, hair will no longer grow in the treated area.

Home Treatment

Home treatment for folliculitis includes:

Using an antibacterial soap to wash the infected area. If the infection is on the scalp or beard, use a shampoo containing selenium or propylene glycol. Your doctor may also prescribe a ketoconazole medicated shampoo (Nizoral Topical).
Applying warm wet compresses 3 to 6 times a day to help folliculitis heal faster and stop the itching or pain. Wash your hands before applying a compress. To make a compress, moisten a clean cloth or piece of gauze with warm water. Place it over the infected area until it begins to cool (usually 5 to 10 minutes). Compresses can be made with:
- Burow's solution (5% aluminum subacetate).
- White vinegar solution, 1 Tbsp(15 mL) of white vinegar and 1.33 cups(315 mL) of water.

If you have folliculitis, call a health professional if:

It spreads or keeps coming back.
You develop other symptoms, such as fever over 101 °F(38 °C), redness, swelling, warmth, or increased pain over the infected area.

Preventing folliculitis

There are a number of steps you can take to prevent folliculitis from developing, spreading, or recurring:

Bathe or shower daily with a mild antibacterial soap. Also, bathe or shower after exercise or working around chemicals.
Avoid sharing towels, washcloths, or other personal items. If you have folliculitis, use a clean washcloth and towel each time you bathe.
Don't scratch infected areas. Organisms that cause folliculitis can be carried under your fingernails and spread to other areas of your body or to other people.
Wash your hands and under your fingernails often, especially when you or someone you are caring for has a skin infection.
If you have folliculitis, avoid shaving the infected area. If you must shave, change the razor blade each time. Trying using depilatory creams and lotions that remove hair without shaving. However, these products are not recommended for use more often than once or twice a week.
Wear loose-fitting clothing. Tighter clothes trap sweat and bacteria on your body.
Avoid using oils on your skin. Oils can trap bacteria in the pores of your skin and can cause folliculitis.
Use a mild deodorant. Strong deodorants may contribute to folliculitis.
After using public hot tubs or spas, shower immediately with antibacterial soap. If you own your own hot tub, follow the manufacturer's instructions for keeping it clean.

Folliculitis (from WebMD Health)