Correspondence
Hot-Tub Therapy for Type 2 Diabetes Mellitus
N Engl J Med 2000; 342:218-219January 20, 2000
- Article
To the Editor:
Hooper (Sept. 16 issue)1 reports interesting results of hot-tub therapy for patients with type 2 diabetes mellitus. In addition to there being potential adverse effects to the cardiovascular system, a word of caution is warranted regarding infection with pseudomonas. Whirlpool baths, hot tubs, and Jacuzzis are recognized as significant risk factors for pseudomonas folliculitis. For example, of 30 outbreaks of infection related to the use of recreational water that were reported to the Centers for Disease Control in 1989–1990, 13 outbreaks were instances of this condition.2 Fatal pseudomonas infection acquired from a Jacuzzi has been reported.3 Pseudomonas infection in patients with diabetes may be severe, notably the invasive infection known as malignant otitis externa, which is usually due to Pseudomonas aeruginosa and almost always occurs in patients with diabetes.4 The potential for pseudomonas folliculitis to develop in patients with diabetes has also been recognized.5
5 ReferencesNeil H. Cox, F.R.C.P.
Cumberland Infirmary, Carlisle CA2 7HY, United Kingdom1
Hooper PL . Hot-tub therapy for type 2 diabetes mellitus. N Engl J Med 1999;341:924-925
Full Text | Web of Science | Medline2
Herwaldt BL ,Craun GF ,Stokes SL ,Juranek DD . Waterborne-disease outbreaks, 1989-1990. Mor Mortal Wkly Rep CDC Surveill Summ 1991;40:1-21
Medline3
Parikh P ,Nalitt B ,Eisenberg ES . Case report: fatal Pseudomonas aeruginosa pneumonia and sepsis. N J Med 1995;92:165-166
Medline4
Tierney MR ,Baker AS . Infections of the head and neck in diabetes mellitus. Infect Dis Clin North Am 1995;9:195-216
Web of Science | Medline5
Aleman CT ,Wallace ML ,Blaylock WK ,Garrett AB . Subcutaneous nodules caused by Pseudomonas aeruginosa without sepsis. Cutis 1999;63:161-163
Web of Science | Medline
To the Editor:
Blood flow to the skin of a normal foot can readily increase by 100 times if necessary, to conduct heat away from challenged areas. Impaired circulation and impaired endothelial dilatation (which are common in patients with diabetes) may make this increase in blood flow impossible, and the resultant burn may not cause pain if peripheral neuropathy is present.
My late mentor, Heinz I. Lippman, found that many patients with diabetes had burns of the feet after exposure to whirlpool baths set at 33.3°C (well below body temperature). In 1960, he gathered statistics on the reasons for amputation in the Bronx, New York, during 1959. Fully half of the amputations were performed because of infected burns in patients with diabetes.
Even if burns do not occur after hot-tub therapy, prolonged soaking in water causes maceration of skin. Macerated skin is more susceptible to injury and is less likely to heal than normal skin. Therefore, my colleagues and I advise all patients in our diabetes clinic to shower or bathe in cool water and to “get in, get washed, and get out.” We never prescribe foot soaks except sometimes for 5 to 10 minutes in potassium permanganate solution for fungal infections. We never use wet-to-dry dressings but occasionally use moist-to-dry saline dressings for wetting dermatitis.
Richard K. Bernstein, M.D.
New York Diabetes Center, Mamaroneck, NY 10543-4696Author/Editor Response
Dr. Hooper replies:
To the Editor: I appreciate the expressions of concern about potential complications from hot-tub exposure. Cox correctly points out that pseudomonas folliculitis can result from the use of a hot tub and that patients with di-abetes may be particularly susceptible to infection. Contaminated water is the cause of bacterial infections, and proper maintenance of the hot tub can prevent infection. It is essential that water-purification systems be in place. The pH of the water, water filtration, and the balance of chemical disinfectants are important elements in keeping bacterial contamination to a minimum.1 In addition, showering before and after hot-tub exposure is advised.
Bernstein expresses valid concern about exposure to hot water in patients with diabetic ischemic limbs. Heat may increase the metabolic demand on an already compromised tissue. Furthermore, diabetic neuropathy can cause the patient to interpret water temperature incorrectly, which can result in a burn. Therefore, my colleagues and I agree that hot-tub therapy is not recommended for patients with ischemic limbs and that patients with diabetic neuropathy should rely on thermometer readings (37.8° to 39.4°C) rather than a subjective sense of heat. Interestingly, three patients in our study commented that their feet felt better after three weeks of hot-tub exposure, with improved sensation and a decrease in the formation of calluses.
Care should be taken with patients with orthostatic hypotension, who may fall when leaving the tub. The installation of supporting rails should be a recommended safety measure for some patients. Finally, the effect of heat stress on patients with coronary artery disease has not been studied sufficiently to recommend unrestricted use of the hot tub. In short, proper water sanitation and appropriate guidance of the patient should be considered when prescribing hot-tub therapy for type 2 diabetes mellitus. Exercise, the established treatment we were trying to simulate with hot-tub therapy, also has its own safety issues.
1 ReferencesPhilip L. Hooper, M.D.
McKee Medical Center, Loveland, CO 805381
Dadswell JV . Managing swimming, spa, and other pools to prevent infection. Commun Dis Rep CDR Rev 1996;6:R37-R40
Medline
- Citing Articles (1)
Citing Articles
1
Josianne Rodrigues-Krause, Mauricio Krause, C. O’Hagan, Giuseppe Vito, Colin Boreham, Colin Murphy, Philip Newsholme, Gerard Colleran. (2012) Divergence of intracellular and extracellular HSP72 in type 2 diabetes: does fat matter?. Cell Stress and Chaperones
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