ARTICLE
A 34-year-old man was referred to our Department to evaluate the presence
of a pruritic eruption.
The clinical history revealed that the lesions had developed on his
buttocks one week earlier and had then spread to involve the trunk and
limbs.
The physical examination revealed multiple, follicular papules and pustules
with a marked erythematous border, 3 to 4 mm in diameter, on the trunk
(Fig. 1).
A few scattered lesions were also present on the upper parts of the
arms and legs. Examination of the oral and genital mucosa did not reveal
any abnormality.
There was no history of fever and the patient was in good general health.
Past medical history was insignificant and routine biochemical and haematological
investigations were normal. A biopsy specimen was taken from a lesion
for routine histological analysis. Its histological aspect is shown in
Figures 2
and 3. What is your diagnosis?
Pseudomonas
aeruginosa
folliculitis
A biopsy specimen of a papule (Figs.
2 and 3)
demonstrated acute suppurative folliculitis (no organisms were seen),
perifollicular abscess consisting of polymorphonuclear leukocytes and
rare lymphocytes and histiocytes. Moderate exocytosis was present in the
follicular outer root sheath.
Microbiological culture of purulent material from a pustule revealed
Pseudomonas aeruginosa, identified as serotype 0:11, sensitive
to ciprofloxacin but resistant to penicillin, tetracycline, ceftriaxone
and trimethoprin. The clinical features and microbiological culture were
consistent with the diagnosis of Pseudomonas aeruginosa folliculitis.
Further discussion with the patient disclosed
that he had bathed in tub with hydrojet circulation several days before
the rash appeared.
Antibiotic therapy was initiated both systemically with ciprofloxacin
500 mg twice daily and topically with gentamycin cream. Within two weeks
the rash had resolved leaving mild desquamation. The 2 month follow-up
revealed no recurrence.
Comments
Pseudomonas aeruginosa is only encountered rarely among the normal
bacterial skin flora [1]. Pseudomonas aeruginosa folliculitis is
rare and usually associated with exposure to contaminated water facilities
such as hot tubs [2-3], swimming pools [4] and whirlpools [5]. The development
of Pseudomonas folliculitis relates to several factors, including
water temperature, chlorine content and prolonged exposure to water. Since
high water temperatures make disinfection more difficult and favour Pseudomonas
growth, Pseudomonas folliculitis has been most commonly associated
with the use of hot tubs and whirlpools.
Superhydration of the stratum corneum has also been recognized as a
factor promoting cutaneous Pseudomonas infections, as it leads
to high surface concentrations of Pseudomonas that may then invade
the skin [6].
Pseudomonas folliculitis has also been
observed after recreational use of diving suits [7], as well as after
depilation of the legs [8], use of a contaminated moisturizing cream [9]
and contaminated synthetic sponges [10-11] and sporadically with no obvious
recreational or non-recreational exposure [12].
The eruption is characterized by follicular, maculopapular, pustular
and vesicular lesions. Systemic symptoms including fever, itching, general
malaise, painful axillary adenophathy and otitis may be present. Differential
diagnoses include staphylococcal folliculitis, viral eruption (Herpes,
Varicella), follicular eczema, insect bites, swimmer's itch, scabies
and papular sarcoidosis.
A diagnosis of Pseudomonas folliculitis is best verified by results
of culture growth.
The course of the disease appears to be self-limiting. In most cases
the rash subsides spontaneously within seven to ten days but occasionally
recurs, and has a protracted course despite treatment. The medical treatment
of Pseudomonas folliculitis remains controversial. Pseudomonas
aeruginosa is resistant to the commonly used topical and oral antibiotics.
Most of the systemic antibiotics effective against Pseudomonas aeruginosa
have potential side effects and are probably not indicated on a long term
basis in this usually self-limited entity [8]. In cases with associated
systemic symptoms and persistent infection, a course of ciprofloxacin
can be given.
CONCLUSION
Acknowledgements
Investigation supported by the University of Bologna. Funds for selected
research topics.
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