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Aquatic Sports Dematoses. Part 2 in the Water: Saltwater Dermatoses

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Aquatic Sports Dematoses. Part 2 in the Water: Saltwater Dermatoses Review Aquatic Sports Dematoses. Part 2 – In the Water: Saltwater Dermatoses Brook E. Tlougan1, MD, Joshua O. Podjasek2, MD, and Brian B. Adams3, MD, MPH 1Ronald O. Perelman Department of Abstract Dermatology, New York University The second part of this three-part series on water-related dermatoses will discuss dermato- School of Medicine, New York, NY, logic conditions seen in athletes exposed to saltwater. The vast majority of the following USA, 2Department of Dermatology, dermatoses result from contact with organisms that inhabit saltwater, including bacteria, Mayo Clinic, Rochester, MN, USA, and 3Department of Dermatology, University cnidarians, and echinoderms. This review also will include other dermatoses affecting salt- of Cincinnati School of Medicine and water athletes and should serve as a guide for dermatologists, sports medicine physicians, Veterans Affairs Medical Center, and other medical practitioners in recognition and treatment of these dermatoses. Cincinnati, OH, USA Correspondence Brook E. Tlougan, MD Department of Dermatology NYU Skin and Cancer Unit 560 1st Ave, H-100 New York, NY 10016 USA E-mail: [email protected] Drs Tlougan, Podjasek, and Adams have no conflicts of interest. a painful, rapidly progressive cellulitis along with sys- Introduction temic symptoms and a mortality rate > 50%. Severe local The second part of this three-part series on water-related tissue swelling with hemorrhagic bullae occurs com- dermatoses will discuss dermatologic conditions seen in monly.3 The infection affects males more frequently than athletes exposed to saltwater. The vast majority of the females as a result of the female hormone estrogen, which following dermatoses result from contact with organisms provides protection against the V. vulnificus endotoxin that inhabit saltwater, including bacteria, cnidarians, and via an unknown mechanism.4 echinodermata (Table 1). This review will also include Treatment: Infections with V. vulnificus require doxy- other dermatoses affecting saltwater athletes. cycline 100 mg intravenously or orally twice daily along with ceftazidime 2 g intravenously every 8 h. Therapy includes wound care, with possible debridement and even Organism-related dermatoses amputation.4 Vibrio vulnificus infections Background: Vibrio vulnificus, a gram-negative, motile, Protothecosis curved bacterium, resides in ocean filter feeders (e.g. oys- Background: Prototheca wickerhamii and Prototheca ters and clams). The organism lives in warm seawater zopfii, achlorophyllic algae, inhabit both streams and lakes, and can cause two distinct syndromes in swimmers. but commonly dwell in sewage, slime flux, and animal Clinical: A primary septicemia results from consump- waste.5 Reports of approximately one hundred human tion of undercooked seafood, especially raw oysters.1 cases of protothecosis exist world-wide, with cases in Eur- Patients experience fever, diarrhea, nausea, vomiting, and ope, Asia, Australia, and the United States. Most reports even septic shock soon after consumption.2 Typically, describe cutaneous infections; olecranon bursitis as well as within 24 h of the onset of symptoms, patients experience disseminated or systemic manifestations may occur.6 the characteristic skin lesions, which consist of severe cel- Clinical: Patients present with non-tender, pyoderma- lulitis with ecchymoses and bullae.2 like lesions or infiltrating papules and plaques on exposed The second syndrome, a necrotizing wound infection sites. However, reports of both herpetiform7 and verru- 8 994 secondary to direct inoculation, causes athletes to develop cous variants also exist in the literature. International Journal of Dermatology 2010, 49, 994–1002 ª 2010 The International Society of Dermatology Tlougan, Podjasek, and Adams Aquatic Sports Dermatoses: Part 2 Saltwater Review 995 Table 1 Summary of organism-related saltwater dermatoses Dermatosis Causative organism Clinical Presentation Vibrio vulnificus infection Vibrio vulnificus (Bacterium: Gram negative, motile, 1. Primary septicemia followed by cellulitis after consumption of curved rod) undercooked seafood 2. Necrotizing wound infection with rapidly progressive cellulitis after direct inoculation Protothecosis Prototheca wickerhamii, Prototheca zopfii Nontender, pyoderma-like lesions or infiltrating papules and plaques (Achlorophyllic algae) on exposed sites Staphylococcal impetigo Staphylococcus aureus (Bacterium: Gram positive Erythematous papules, plaques, and pustules with associated cocci in clusters) honey-colored crust and sometimes vesicles or bullae Portuguese man-of-war Physalia physalis, Physalia utriculus (Cnidaria: Pruritic, erythematous, patterned, urticarial plaques that may sting Hydrozoa) become violaceous and develop vesicles or necrosis Fire coral dermatitis sting Millepora dichotoma, Millepora platyphylla (Cnidaria: Erythematous, burning lesions (caused by formic acid) at sites of Hydrozoa) contact Jellyfish sting Pelagia, Chrisaora, Stomolophus, Cyanea, and Stinging sensation initially followed by urticarial or papulovesicular Linuche genera (Cnidaria: Scyphozoa) lesions distributed linearly Irukandji syndrome Carukia barnesi (Cnidaria: Cubozoa) Painless, erythematous patch with papules at the sting site with prominent systemic symptoms Irukandji-like syndromes Carybdeid genus (Cnidaria: Cubozoa) Painless, erythematous patch initially with increasing pain and papules developing at the sting site and with possible subsequent systemic symptoms Sea anemone dermatitis Actinodendron plumosum, Triactis producta, and Stinging sensation followed by swelling, erythema, petechial others (Cnidaria: Anthozoa) hemorrhages, and ecchymoses Seabather’s eruption Larvae of adult sea anemone Edwardsiella lineata Stinging sensation and pruritus followed by vesicles, papules, and and the thimble jellyfish Linuche unguiculata pustules with or without urticaria occurring in areas beneath the (Cnidaria: Anthozoa) swimming suit Sponge diver’s dermatitis Small sea anemones attached to sponges (Cnidaria: Erythematous wheals that may become vesicular and ulcerate Anthozoa) Ghost anemone dermatitis Haloclava producta (Cnidaria: Anthozoa) Delayed stinging sensation followed by pruritic, erythematous, edematous, necrotic plaques at points of contact Red sea coral dermatitis Dendronephthya nipponica (Cnidaria: Anthozoa) Urticarial plaques followed by a vesiculobullous eruption and chronic dermatitis, usually of the hands and arms Starfish dermatitis Starfish; usually Acanthaster planci, the ‘‘crown of Immediate, intense, burning sensation with occasional embedding of thorns starfish’’ (Echinodermata: Stelleroidea) spines in the skin Sea urchin dermatitis Sea urchins, such as Diadema antillarum Painful erythema and edema usually on palms or soles with (Echinodermata: Echinoidea) occasional embedding of spines in the skin Sea cucumber dermatitis Sea cucumbers, such as Parastichopus californicus Burning, irritant dermatitis on exposed skin caused by holothurin (Echinodermata: Holothuroidea) Sponge dermatitis Phylum Porifera Minor abrasions or stinging sensation followed by pain, pruritus, and swelling caused by crinitoxins Seaweed dermatitis Lyngbya majuscula (Blue-green algae) Stinging, burning, or itching sensation followed by a blistering erythematous desquamative dermatitis most commonly in areas covered by bathing suits (perineal and perianal areas) Red tide dermatitis Unicellular phytoplankton, such as Ptychodiscus Erythematous, urticarial eruption on exposed skin brevis Treatment: Treatment consists of antimycotic agents Clinical: Early in the disease process, well-defined, ery- such as ketoconazole,9,10 itraconazole,11 fluconazole,12 thematous papules develop. Later, lesions appear as ery- and amphotericin B.13 thematous papules and plaques with honey-colored crusts with or without pustules. Rarely, patients may present Staphylococcal impetigo with discrete vesicles and bullae (Fig. 1); coexistent regio- Background: Authors have reported a strong association nal adenopathy and pharyngitis may occur.16 between marine water contact and staphylococcal skin Treatment: Focal and limited infections only require infections.14,15 One study found that those with contact topical mupirocin. Extensive lesions may necessitate oral with marine water experience staphylococcal skin infec- antibiotics such as dicloxacillin or cephalexin. Patients tion 18.1 times more commonly than those without mar- with MRSA respond to topical mupirocin, but may ine contact.15 require oral doxycycline, trimethoprim/sulfamethoxazole ª 2010 The International Society of Dermatology International Journal of Dermatology 2010, 49, 994–1002 996 Review Aquatic Sports Dermatoses: Part 2 Saltwater Tlougan, Podjasek, and Adams athletes may also experience dizziness, nausea, weakness, and possibly death.16 Treatment: Please refer to the ‘‘Cnidarial Dermatoses’’ introductory paragraph for management. Swimmers should wear a diving suit upon entering high-risk waters to prevent skin contact with the organism.16 Fire coral Background: The fire coral, Millepora dichotoma, does not belong to the true coral family, but rather represents Figure 1 Bullous staphylococcal impetigo is characterized by another type of a hydrozoan.19 Accidental contact by collarettes of scale, superficial vesicles, and honey colored water athletes commonly occurs because fire coral may crust look like seaweed. Clinical: Athletes present with deeply erythematous, burning lesions caused by the formic acid on the fire or clindamycin. As a result of the increasing
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