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Infections & Outbreaks: Overview

Bacterial Skin Infections

Skin infection  
Mycobacterial skin infection sores
Bacterial skin infection outbreaks hit northern California in 2000 and 2004.  Hundreds of nail salon clients suffered from severe and persistent sores on the lower legs that left scars after finally healing, usually after months on antibiotics. 
 
Two types of rapidly growing mycobacteria were linked to the outbreaks:  Mycobacterium fortuitum and Mycobacterium chelonae.
 
According to a study in The New England Journal of Medicine, rapidly growing mycobacteria are found everywhere in soil and water, including chlorinated municipal water systems.
 
Mycobacteria are known to cause localized skin infections, such as cellulitis (a potentially serious bacterial infection of your skin that appears as a swollen, red area that feels hot and tender) and soft-tissue abscesses. 
 
Prior to the California outbreaks, reported cases usually involved surgical or clinical devices contaminated with water from a hospital or municipal water system.  Sporadic infections due to contamination of a wound from soil or water had also been reported.
 
"We believe that these rapidly growing mycobacterial infections associated with nail salons are underrecognized and may increase in prevalence," stressed the authors of The New England Journal of Medicine article.
 
The authors concluded that medical professionals "...should consider rapidly growing mycobacteria in the...diagnosis of hard-to-treat...soft-tissue infections of the lower extremity...."

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Transmission of Mycobacteria

Mycobacterium chelonae  
Mycobacterium chelonae
According to public health officials investigating the northern California outbreaks, improperly cleaned and disinfected foot spas set the stage for the multiple infections.
 
Improperly cleaned and disinfected foot spas allowed biofilm such as skin, hair, oils, lotions and other residues to build up.  Biofilm acted as an effective breeding ground for the mycobacteria, which grew to high concentrations by gaining a foothold in the biofilm.
 
Several reported infection cases in Oregon, and other states nationwide, show that mycobacteria can be a potential problem anywhere proper and required health, safety and infection control steps aren't followed.
 
Nail salon practitioners can most effectively prevent the build-up of biofilm in foot spas by using surfactant or enzymatic soaps or detergents before disinfection.  These types of cleaners break down biofilm much better than other types of cleaners and improve the effectiveness of disinfectants.

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Shaving Legs May Increase Risk

Shaving Legs  
Avoid shaving before a pedicure
With high concentrations of mycobacteria growing in biofilm and circulating through foot spas, clients with breaks or cuts in their skin were the most likely to be infected.  Breaks or cuts in the protective layers of the skin provided a ready route for the mycobacteria to enter the body.
 
At least one third of those infected in the northern California outbreaks had shaved their legs prior to their pedicures.  The Oregon Health Licensing Agency (OHLA) and Board of Cosmetology recommend pedicure clients avoid shaving their legs or having any other type of hair removal (including laser hair removal and waxing) performed at least 24 hours prior to a pedicure.
 
Why?  Hair removal may create smaller, even microscopic, breaks or cuts in the skin that are not readily visible but that are still large enough for even smaller mycobacteria to gain entry.

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What Are the Symptoms?

Folliculitis  
Routine antibiotic treatment may be ineffective
According to the industry trade publication Nails, mycobacterial infections appear initially as "pimply bumps that turn purplish, then seep and spread" into "ugly, pus-filled sores."
 
The sore or sores on the lower leg usually do not heal and may appear as thick, knotted areas that resemble a spider or insect bite.
 
A skin infection lasting at least two weeks may be a mycobacterial infection if it includes at least one of the following features:
  • Negative routine bacterial culture (taken by a physician or other appropriate medical professional)

  • Failure to respond to antibiotic treatment

  • The physician's suspicion of a mycobacterial infection
The time frame from exposure to observable infection is approximately three weeks to a month.
 
These infections contrast with the usually fast healing and non-scarring sores typical of folliculitis.  According to MayoClinic.org, folliculitis usually appears as small, white-headed pimples around one or more hair follicles.
 
Folliculitis infections may itch but are not usually painful. Folliculitis often heals without treatment in a few days, but deep or recurring folliculitis may need medical treatment.

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Infection Outbreaks

The first reported bacterial outbreak linked to improperly cleaned and disinfected foot spas infected at least 110 people with Mycobacterium fortuitum. Outbreak linked to one high-volume nail salon.
 
San Jose, CA (2004)  More than 140 clients of nail salons were infected, this time with Mycobacterium chelonae (a microbial cousin to M. fortuitum) from 34 different salons.  Three nail salons were linked to the majority of infections. Nearby Contra Costa County experienced a smaller outbreak affecting at least six clients.
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Did Pedicures Cause Deaths?

The following individual cases were reportedly, but have not been conclusively, linked to infections from nail salons:
 
Fort Worth, TX (2006) Kimberly Jackson, a 46-year-old paraplegic, died of a heart attack from a blood infection caused by a staphylococcal infection on her foot.  Jackson reportedly received the infection after being cut on her heel with a pumice stone during a pedicure.
 
Related News Link:  Family Sues Salon over Death after Pedicure
 
San Jose, CA (2006)   Jessica Mears, a 43-year-old woman with Lupus, an autoimmune disease that can affect various parts of the body, including the skin, joints, heart, lungs, blood, kidneys and brain, died after suffering from a mycobacterial infection for more than a year.  Mears received a pedicure at one of the salons linked to an infection outbreak in San Jose in 2004.
 
Indian Wells, CA (2007)  Gerry Ann Schabarum, 70, wife of former California Assemblyman and longtime Los Angeles County Supervisor Pete Schabarum, died after fighting a staphylococcus infection for more than a year.  A Pasadena Weekly article reported that a pedicure "may have been responsible" for the death of Schabarum, who suffered from rheumatoid arthritis.
 
Related News Link:  Another Pedicure Death Traced to Dirty Nail Salon

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State of Health May Raise Risk

Medical symbol  
One thing in common among the deaths reportedly caused by infections from nail salon pedicure services was the health condition of the clients. The clients who died had pre-existing medical conditions that made it more difficult to fight off an infection.
 
Oregon regulations require nail salons and estheticians to obtain and keep client records, including information on any health condition that may affect services provided. 
 
For more information, click on Client Records: Required.
 
OHLA and the Board of Cosmetology highly recommend that if you have a medical condition that makes you more susceptible to infection, be sure your nail salon is strictly following state health and safety requirements. 
 
For more information, click on Nail Salons: Consumer Information.

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MRSA: Resistant to Antibiotics

Methicillin-resistant staphyloccocus aureus, or MRSA, causes similar harmful skin infections but is usually more difficult to treat. Public health officials have found MRSA in locker rooms, jails, fitness centers and anywhere else skin-to-skin contact or common supplies such as towels are used.
 
MRSA may also be potentially transmitted in the salon setting if practitioners do not follow required health, safety and infection control standards.  Simple precautions such as thorough hand washing (which is a state requirement of practitioners between each client) help prevent such infections from occurring.
 
Click here for more information on MRSA from the Centers for Disease Control and Prevention (CDC) of the US Department of Health and Human Services.

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