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Swimmer's Dermatoses Hong Kong J. Dermatol. Venereol. (2013) 21, 15-21 Review Article Swimmer's dermatoses SC Ng and TS Cheng Swimmer's dermatoses are not uncommon in dermatological practice with the increased popularity of swimming and aquatic leisure activities. There is a wide variety of dermatological conditions related to swimming or aquatic leisure activities, the exposed aquatic environment or their equipments. These include infections such as swimming pool granuloma caused by Mycobacterium marinum or cutaneous larva migrans, and non-infectious entities such as sea- bather's eruption or contact dermatitis to swimming equipment. Keywords: Aquatic, dermatoses, swimmer, swimming Introduction in 1896 in Athens.1 People swim in the swimming pool, fresh or salt water with their body immersed Swimming has been recorded since prehistoric in water for certain duration and exposed to times around 7000 years ago from Stone Age aquatic organisms and allergens or irritants in the painting. It is a popular leisure or sport nowadays, water or from the equipments, which can lead to and was part of the first modern Olympic Games cutaneous infection, allergic or irritant reactions. Skin infections caused by faecal organisms may be more common in contaminated rivers and skin Social Hygiene Service, Department of Health, irritation can occur from blue-green algae in Centre for Health Protection, Hong Kong inland waters. The use of communal changing SC Ng, MBBS, MRCP(UK) room facilities may increase the risk of spread of TS Cheng, FHKCP, FHKAM(Medicine) warts and tinea pedis. Occasionally, unusual skin infections such as protothecosis can be acquired.2-4 Correspondence to: Dr. SC Ng Hence, swimmer's dermatoses are not uncommon Fanling Integrated Treatment Centre, 6/F, Fanling Health with a wide variety of entities as shown in Centre, 2 Pik Fung Road, Fanling, New Territories Table 1. 16 SC Ng and TS Cheng Table 1. Classification of swimmer's dermatoses Infectious Non-infectious • Swimming pool granuloma or fish-tank granuloma • Sea bather's eruption caused by Mycobacterium marinum • Seaweed dermatitis caused by direct contact with • Swimmer's ear (acute or chronic otitis externa) Lyngbya majuscule • Swimmer's itch (cercarial dermatitis) • Sting by jellyfish, sea lice and other stinging • Seal finger (Mycoplasma infection resulting from anemones seal bites to the hand) • Coral, sea urchin injuries • Cutaneous larva migrans • Contact dermatitis • Pseudomonas folliculitis and periporitis Bathing suits, goggles, snorkel masks, life jackets, • Others: cutaneous warts, tinea pedis, secondary sunscreen ingredient, water plants and inhabitants bacterial infection of wounds (e.g. Staphylococcus of the water aureus, Vibrio vulnificus), cellulitis, necrotising • Others: Sunburn, dry skin (swimmer's xerosis), fasciitis, protothecosis chlorine irritation and aquagenic acne, cold urticaria, aquagenic pruritus, abrasions from wetsuit folds, bikini bottom Infectious entities of swimmer's laboratory media in 7-10 days if cultured at 30- dermatoses 33°C. i) Swimming pool granuloma or fish-tank Cutaneous infection with M. marinum requires a granuloma (Mycobacterium marinum portal of entry through the abraded skin. The infection) incubation period is about two to three weeks, Mycobacterium marinum is a slow growing and occasionally up to nine months. A solitary mycobacterium that causes disease in freshwater bluish-red inflammatory nodule or pustule and saltwater fish and sporadically in humans. appears at the inoculated site which then forms a The first human disease was reported in 1951, crusted ulcer, suppurative abscess or verrucous when the organism was found in granulomatous nodule. Lesions are most common on the skin lesions of individuals who swam in a dominant hand and fingers of fish fanciers, and contaminated swimming pool in Sweden. It is the on the elbows, knees and feet of swimmers. commonest atypical mycobacterial cutaneous M. marinum may present with a sporotrichoid infection.5-8 spread in approximately 20%-33% of cases9 and occasionally causes deeper infections The distribution of M. marinum is worldwide with (e.g. tenosynovitis, septic arthritis or rarely higher prevalence in temperate climates. Its osteomyelitis). The inhibition of M. marinum vectors include fresh or saltwater fish, snails, growth at 37°C accounts for its ability to shellfish, dolphins and water fleas. When cleaning infect the cooler body extremities; however, fish tanks at home or in the workplace (e.g. fish immunocompromised patients may have markets, restaurants), trauma to the hands may disseminated diseases. result in exposure to M. marinum. It can also be contacted from cracks in masonry, mud and even The histologic features range from non-specific chlorinated water, as this organism is fairly inflammation in the first few months to well-formed resistant to chlorine. It will grow on ordinary tuberculoid granulomas in older lesions with Swimmer's dermatoses 17 fibrinoid masses rather than caseation. Langhans' penetration. If the individual is not sensitised to giant cells are not always present, and intracellular the cercariae, lesions subside within 12 hours. acid-fast bacilli (longer and broader than tubercle Otherwise, lesions may evolve over 10-20 hours bacilli) are detectable in only about 10% of cases. in sensitised patients into intensely itchy papules, Epidermal changes including ulceration and which can coalesce into plaques and last 1-2 pseudoepitheliomatous hyperplasia may occur in weeks. In severe cases with repeated exposure to chronic lesions. cercariae, lesions may evolve into vesicles and pustules, and fever and headache can occur. Cultures are important to exclude other cutaneous sporotrichoid infections including leishmaniasis, Mild corticosteroid creams, calamine lotion or oral sporotrichosis and other atypical mycobacterial antihistamine can be beneficial for symptomatic infections (e.g. M. kansasii, M. chelonei). A positive relief. Cool compresses, baking soda or colloidal culture of M. marinum can be obtained in 70- oatmeal bathing have been recommended. 80% of cases if grown between 30 and 33°C. Antibiotics may be used to treat secondary Imaging should be considered to rule out deep infections and oral steroids can be considered in infection especially in treatment-refractory cases. severe reactions. M. marinum is usually sensitive to clarithromycin, iii) Cutaneous larva migrans minocycline, doxycycline, amikacin, ciprofloxacin, This is a parasitic skin manifestation caused by moxifloxacin and trimethoprim-sulphamethoxazole.7 hookworm larvae that usually affect cats, dogs Based on in-vitro susceptibility and clinical response in and other animals. Humans can be infected by a 16 culture-positive case series, clarithromycin is the walking barefoot, sitting or lying unprotected on drug of choice for confirmed or suspected cases.9 sandy beaches that have been contaminated with Two agents should be considered for serious animal faeces. It is also known as creeping infections (e.g. clarithromycin and ciprofloxacin). eruption as the larvae migrate under the skin's The antibiotic(s) should be continued for one to surface and cause itchy red lines or tracks. The two months after resolution of symptoms, typically wandering thread-like line is about 3 mm wide, for a total of three to four months. Treatment commonly on the feet, hands and buttocks, in a failure is more usually related to involvement of bizarre and serpentine pattern.12 deeper structures than to the antibiotic regimen. Causes of creeping eruption include Ancylostoma ii) Swimmer's itch (cercarial dermatitis) brasiliense, A. caninum, A. ceylonicum, Uncinaria This follows penetration of the skin by cercariae stenocephala and Bunostomum phlebotomum. of avian schistosomes for which humans are not These are all hookworms of various animals, of the primary host. Swimmer's itch develops on an which the dog hookworm, A. brasiliense is the exposed area of skin 12-24 hours after contact commonest cause of creeping eruption in human. with these larvae forms, usually in fresh water, The larvae advance at a rate of a few millimetres when they mistakenly penetrate the person's skin to a few centimetres each day, and are somewhere instead of its usual host (e.g. duck).3 Outbreaks in front of the head of the track.13 are more common in temperate climates in summer. The risk is increased by the time spent in The disease can be clinically diagnosed and is the water and when there is an onshore wind.2,10,11 self-limiting. Larva currens (the urticarial weal caused by subcutaneous larvae of Strongyloides The initial symptom may be a prickling sensation stercoralis migrating several centimeters per hour), soon after leaving the water. Erythematous migratory myiasis (tortuous, thread-like red line macules appear 10-15 minutes after larval that ends in a terminal vesicle due to larvae of 18 SC Ng and TS Cheng flies of the genera Gasterophilius and Hypoderma) external auditory canal. Freshwater swimming and gnathostomiasis (intermittent, migratory, appears to be a particular risk factor. Failure to subcutaneous swellings) must be distinguished. dry the ears completely after swimming, Eighty-one percent of A. brasiliense lesions shampooing or showering may be contributory disappear in four weeks, while some persist for factors.15 many months. vi) Seal finger Ivermectin in a single dose of 200 µg/kg body Seal finger is a finger infection caused by weight is the main treatment, and albendazole Mycoplasma species (e.g. M. phocacerebrale)
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