Original Article
Seabather's Eruption
N Engl J Med 1993; 329:542-544August 19, 1993
- Abstract
Background
Seabather's eruption is an annoying pruritic dermatitis that appears on the areas covered by the bathing suit as an erythematous macular or papular dermatitis, with or without urticaria. It occurs sporadically in Florida, the Caribbean, and as far north as Bermuda. The cause is not known.
Methods
We collected information in Nassau County, Long Island, New York, about cases of all types of water-related dermatitis reported by beach personnel, health providers, and affected swimmers from 1970 through 1991. Concurrently, we surveyed all Nassau County swimming waters, especially during the summer season (June through September), for the presence of organisms capable of causing dermatitis. In 1980 a sudden epidemic of a severe, unfamiliar dermatitis in ocean bathers prompted increased surveillance of cases and waters. Planula larvae of the phylum Cnidaria were collected from the ocean and beaches and inside bathing suits. They were examined, photographed, tested on healthy subjects, and observed in the laboratory for metamorphosis.
Results
Three outbreaks of seabather's eruption have occurred on Long Island since 1975. The first, in August 1975, affected a small number of swimmers on the eastern end of Long Island. In 1980 there were thousands of cases along the entire south shore of the island, and in 1990 there were hundreds in the same area. In nonepidemic years, five or fewer cases have been reported yearly. Surveillance for larvae revealed them to be present during the swimming season in epidemic years, but in nonepidemic years they did not appear until autumn, after the swimming season. Applying larvae to the skin of healthy subjects produced a dermatitis indistinguishable from seabather's eruption. All larvae metamorphosed in the laboratory to the adult sea anemone Edwardsiella lineata.
Conclusions
Seabather's eruption, previously reported only as sporadic cases in southern climates, has occurred sporadically and in outbreaks 1000 miles north of most previously described cases. These Long Island episodes were probably caused by the planula larvae of E. lineata.
Media in This Article
Figure 1
Larvae of E. lineata.Figure 2
A Four-Year-Old Girl with Seabather's Eruption.Article Activity
- Article
Seabather's eruption is an annoying pruritic dermatitis that occurs primarily on areas of the body covered by the bathing suit shortly after a swimmer leaves the ocean. The eruption was first identified in persons who had bathed off the southeast coast of Florida1. Additional cases have been reported in the Caribbean, on the west coast of Florida, and in Bermuda2. The cause of seabather's eruption is not known. In this report, we describe outbreaks of seabather's eruption in northern areas, the results of a program of surveillance for water-based dermatitis, and observations on the cause of seabather's eruption.
Case Reports
In August 1975, one of us was notified of cases of an unfamiliar dermatitis affecting areas of skin under the bathing suits of a few swimmers at the ocean beaches of Suffolk County on eastern Long Island.
In mid-August 1980, the Office of Marine Ecology, Nassau County Department of Health, New York, began to receive reports of an unidentified pruritic dermatitis affecting seabathers. From August 16 to September 6, up to 35 separate incidents, each involving from one to several hundred cases, were reported daily by lifeguards, beach supervisors, physicians, other health personnel, and private citizens. Millions of pink round or oval ciliated larvae, 2 to 3 mm long, were found in the ocean, and thousands were observed on the sand at the water's edge; many affected swimmers had up to a dozen in their bathing suits. The larvae were identified as planulae of the phylum Cnidaria (formerly Coelenterata), which comprises jellyfish, corals, hydroids, and sea anemones. Each larva had more than 200 nematocysts, the stinging mechanisms that are activated by a physical or chemical stimulus. The nematocyst typically has a coiled, barbed, hollow thread through which toxin is forcefully injected into a swimmer. Three healthy women on the staff of the Department of Health consented to an experiment in which two or three larvae were placed 1 mm apart on the back of a metal spoon; the spoon was then pressed and rubbed firmly for five seconds against the abdomen and the flexor surface of the forearm. Each subject reported stinging sensations within several minutes, and within 3 to 30 minutes a pruritic erythematous macular or papular rash developed that was indistinguishable from that on affected swimmers. In the laboratory, the larvae metamorphosed into the adult sea anemone Edwardsiella lineata (formerly called Edwardsiella leidyi, previously called Edwardsia leidyi).
From 1981 through 1989 and again in 1991, only one to five cases of seabather's eruption were reported and investigated each year, primarily in swimmers and scuba divers in September and October. In 1990, 36 reports involving a total of 50 to 60 cases were investigated. During one 10-day period that year, one of us saw in his pediatric practice six members of three unrelated families with seabather's eruption; all had been swimming along a 100-mile stretch of southeastern Long Island.
Surveillance for Larvae
In 1981, in response to the 1980 epidemic, the Office of Marine Ecology expanded its marine-biologic monitoring to include a water-sampling program for E. lineata in the ocean and in the south-shore estuaries to aid in predicting the occurrence of seabather's eruption. The surveillance began in June and ended in November. Larvae were found yearly and, as in 1980, were found variously within the harmless comb jelly Mnemiopsis leidyi (phylum Ctenophora), free-swimming among M. leidyi, or free-swimming without M. leidyi nearby. At first, comb jellies without larvae were found. By midsummer, up to seven larvae were observed in the body of the comb jellies. As the summer progressed, some larvae were still found in the comb jellies, but many were free swimming. In 1980 and 1990, free-swimming larvae were found in early August, whereas in the other years the free-swimming larvae did not appear until September and October (after the end of the traditional swimming season).
While living in the comb jelly, the larvae assume the shape of thin worms, 10 to 20 mm long. When they emerge, the larvae change within minutes to the round, oval, or cylindrical 2-to-3-mm-long form shown in Figure 1Figure 1
Larvae of E. lineata.. In 1980 and 1990, when there were outbreaks of seabather's eruption, the ocean water contained up to 100 larvae per liter. More were seen in 1980 than in any other year. The number of cases in any one year depended most heavily on the date of appearance of free-swimming larvae; also important were the number of larvae in the sea water, the number of comb jellies, the percentage with multiple larvae, and the weather in August and September (whether or not it was conducive to swimming).Clinical Observations
The rash of seabather's eruption occurred primarily on parts of the swimmer's body covered by the bathing suit. The most severe dermatitis occurred where the suit pressed most closely on the skin -- waist, bathing-suit straps, buttocks, elastic thigh band, abdomen, and breasts. The first manifestation of the eruption was a stinging sensation usually noted when the bather came into shallow water or left the water entirely. Swimmers who sought relief by leaping into freshwater swimming pools or by showering with the bathing suit on reported immediate exacerbation of the stinging sensations. Within a few minutes to several hours after the swimmer left the water, a macular, papular, or macular-papular rash, with or without urticaria, usually occurred (Figure 2Figure 2
A Four-Year-Old Girl with Seabather's Eruption.). In more severe cases, the individual papular lesions spread and coalesced to cover large areas. The rash and pruritus typically lasted for three to seven days. In swimmers with more severe reactions, including those with a history of allergy, the rash and pruritus lasted as long as six weeks. Systemic symptoms such as malaise, headache, chills and fever, nausea, and abdominal cramps occurred in less than 10 percent of cases and typically lasted several days. In two cases reported in 1980, systemic symptoms were severe enough to warrant hospitalization. Treatment by physicians was symptomatic, with oral and topical antipruritic drugs, topical glucocorticoids, and in severe cases, oral glucocorticoid therapy.Discussion
The suggestion that the larvae of E. lineata were the cause of seabather's eruption on Long Island is based on several observations. Seabather's eruption occurred only when many free-swimming larvae of E. lineata were found in the ocean; when no cases were reported, larvae were not found in the ocean or people were not swimming at that time. During outbreaks, larvae were found in the bathing suits of affected swimmers; each of the larvae has over 200 stinging mechanisms capable of injecting toxin into the skin. Application of E. lineata larvae to the skin of healthy subjects caused dermatitis indistinguishable from seabather's eruption. Moreover, at the time of the 1980 and 1990 outbreaks, there were no other organisms in the ocean waters capable of causing dermatitis.
The distribution of seabather's eruption, at least along the mid-Atlantic and northeast coast of the United States, probably depends on the range of both E. lineata and the comb jelly M. leidyi. Verrill3 reported in 1898 that the larvae of E. lineata were frequently found as parasites in the interior of this comb jelly off the south coast of New England. In 1912 Mayer4 described three species of mnemiopsis and their range; one, M. leidyi, was found from Massachusetts to South Carolina. It is likely, therefore, that cases of seabather's eruption caused by E. lineata have occurred along the Atlantic coast from Massachusetts to South Carolina.
The typical case on Long Island occurs when a swimmer is in the ocean with larvae that wash into the bathing suit and become trapped. Occasionally, comb jellies containing larvae become trapped in the bathing suit. When the swimmer leaves the ocean, the layer of water between body and suit drains, subjecting the trapped larvae to pressure and friction. This activates the nematocyst, and toxin is injected into the skin. Prolonged wearing of a contaminated suit, strenuous exercise, or rinsing with fresh water increases the severity of the skin reaction because of changes in the physical or chemical environment that activate previously quiescent nematocysts. The dermatitis may recur as long as two weeks after the initial episode, when the suit is worn again. Over time, the larvae die, but nematocysts do not desiccate readily and are still able to discharge toxin5.
On Long Island,6 the vast majority of skin rashes under bathing suits are seabather's eruption. Other Long Island sea organisms that have occasionally caused pruritus, stinging, or dermatitis primarily under the bathing suit are minute hydromedusa jellyfish, crab larvae in the triple-spine zoea stage, shrimplike amphipods, and isopods (relatives of the terrestrial sow bug). Cercariae of trematode worms cause typical swimmer's itch, which may occur under the suit but primarily affects exposed areas. Only cases caused by hydromedusae (also nematocyst-induced) are likely to be misdiagnosed as seabather's eruption. Water sampling should determine the etiologic agent.
Thirty-two years ago, Grauer and Arnold7 described an algae-induced seaweed dermatitis under the bathing suits of swimmers in Hawaii. However, the dermatitis in these cases was characterized by the formation of blisters and deep desquamation and, therefore, is very different from the seabather's eruption seen in New York or Florida. Recently, another planula larva, of the jellyfish Linuche unguiculata, was identified as the probable cause of seabather's eruption in Florida8. Whereas the larvae of E. lineata (2 to 3 mm long) can be seen with the naked eye, the larvae of L. unguiculata are only 0.5 mm long and are virtually invisible.
We conclude that seabather's eruption, originally reported as sporadic cases in southern climates, has occurred both sporadically and in outbreaks 1000 miles north of most previously reported cases. The cause is thought to be the planula larval stage of organisms of the phylum Cnidaria and specifically, in the Long Island region, of the sea anemone E. lineata.
Presented at the Ninth International Colloquium on Oceanographic Medicine, October 22-24, 1990, Nice, France.
We are indebted to Dr. Warren Rosenfeld of the Department of Pediatrics, Winthrop University Hospital, for his encouragement and assistance; and to Dr. Paul Schneiderman, Syosset, New York, for Figure 2.
Source Information
From the Office of Marine Ecology, Nassau County Department of Health (A.R.F.), and the Department of Pediatrics, Winthrop University Hospital (P.R.J.), both in Mineola, N.Y.
Address reprint requests to Dr. Freudenthal at the Biology Department, C.W. Post Campus, Long Island University, Brookville, NY 11548.
- References
References
1
Sams WM . Seabather's eruption. Arch Dermatol Syph 1949;60:227-237
Web of Science2
Waisman M. Seabather's eruption. In: Demis DJ, Dobson RL, McGuire J, eds. Clinical dermatology. 9th ed. Vol. 4. Unit 18-22. Philadelphia: Harper & Row, 1989:1-3.
3
Verrill AE . New American Actinians. Am J Sci 1898;6:493-498
CrossRef4
Mayer AG. Ctenophores of the Atlantic coast of North America. Carnegie Institution of Washington publication no. 162. Philadelphia: J.B. Lippincott, 1912.
5
Phylum Coelenterata: hydroids, jellyfishes, sea anemones, corals. In: Halstead BW. Poisonous and venomous marine animals of the world. Vol. 1. Invertebrates. Washington, D.C.: Government Printing Office, 1965:344.
6
Freudenthal AR. Hazards at the beach. Vol. 4. of Edu-facts. Mineola, N.Y.: Nassau County Dept. of Health, 1982.
7
Grauer FH ,Arnold HL Jr . Seaweed dermatitis: first report of a dermatitis-producing marine alga. Arch Dermatol 1961;84:720-732
Web of Science | Medline8
Tomchik RS ,Russell MT ,Szmant AM ,Black NA . Clinical perspectives on seabather's eruption, also known as “sea lice.” JAMA 1993;269:1669-1672
CrossRef | Web of Science | Medline
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