Hot tub folliculitis in children: an underrecognized and benign clinical condition-is systemic antibiotic therapy necessary?

Abstract

Hot tub folliculitis is a superficial skin infection caused by Pseudomonas aeruginosa (P. Aeruginosa), most commonly associated with exposure to inadequately disinfected hot tubs, whirlpools, or swimming pools. Although well documented in adults, this condition remains underrecognized in pediatric practice, where it may be misinterpreted as a more serious dermatologic or systemic infection. We report two cases of P. aeruginosa-associated hot tub folliculitis in otherwise healthy children who developed recurrent erythematous papulopustular eruptions involving the trunk and extremities after water exposure. In both cases, microbiological confirmation of P. aeruginosa led to heightened clinical concern, leading to unnecessary systemic antibiotic therapy or referral to pediatric infectious disease specialists despite the absence of systemic symptoms or immunocompromising conditions. The diagnosis was ultimately established through careful clinical evaluation and recognition of the exposure history. Both patients experienced complete resolution with topical therapy and supportive care alone. These cases highlight how detection of P. aeruginosa in pediatric patients may drive overtreatment disproportionate to disease severity. Consistent with the literature, hot tub folliculitis in immunocompetent children typically follows a benign, self-limiting course, and systemic antibiotics are rarely required. Increased awareness among clinicians is essential to improve diagnostic accuracy, avoid unnecessary antimicrobial use, and support appropriate conservative management.