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What’s The Diagnosis 23

A patient presents with a rash to her back for the past 24 hours. It doesn’t itch, but it does burn at times. She hasn’t had the rash before. She had no fever. There were no new exposures to soaps, detergents, etc.  She was wearing no new clothing. She did begin bowling in her bowling league two days before the rash appeared. History of hypertension only. Taking lisinopril and aspirin daily. No other complaints.

The distribution of the rash provides a clue to the diagnosis.

What’s the diagnosis? How should the rash be treated?

Scroll down past the pictures for the answer.

WTD 23 - 2 WTD 23 - 1 Close Up

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Answer: Hot Tub Folliculitis (Pseudomonas folliculitis)

The final diagnosis was not shingles. This rash looks similar to shingles (zoster), but the lesions with shingles (and chicken pox) tend to be vesicles (filled with clear fluid) and not pustules (filled with white/yellow material). Also, shingles almost always involves only one side of the body and one strip of skin (a single “dermatome“).

Before I asked the patient the question that led to the diagnosis, the rash seemed to be some type of contact dermatitis. It spared the middle of the back (along her spine) and it spared the area above her shoulders and below her waist. There was just a little bit of the rash on the front of her legs. So I started asking her. Are you *sure* you didn’t wear any new clothes in the past few days? A leotard maybe? New underwear? Go swimming and wear a new swimsuit?

Remember how the patient just started her bowling league a couple of days before the rash began? Guess what she did after the game. She went and sat in one of her teammate’s hot tubs and drank beer. The nozzles from the hot tub were pointed right at her sides.

This is a classic case of Hot Tub Folliculitis. Causative organism is pseudomonas aeruginosa. The rash is usually multiple painful red spots and some have pus in the center as shown in the last picture above. Treatment is generally … nothing. The rash goes away on its own in a few days to a week. Domeboro solution may soothe the rash. Some sources recommend dilute vinegar compresses to help speed healing. Oral antibiotics (usually fluoroquinolones like Cipro and Levaquin) generally don’t help much, but may be needed if the rash doesn’t resolve.

More sites with information on Hot Tub Folliculitis include Wikipedia, WebMD, and About.com.

One comment

  1. Shingles!

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