November 25, 2004


Problematic Pedicures

Painful mycobacterial outbreak linked to three south San Jose salons

By Kymberli W. Brady
Staff Writer

The holiday season is in the air and with it, the aroma of mulled spices and mountain pine, harvest colors that surrender to gilded displays of red and gold and festive community gatherings, where men dressed to the nines accompany women in rich velvet and flowy chiffon gowns. However, this year’s pre-party preparations come with a serious warning attached to those perfectly pedicured toes peeking out from strapy black sandals.

After getting a pedicure with her mother and sister, more than 100 open sores [furuncles] spread rapidly over this 11-year-old girl’s legs. The skin and soft-tissue infections [boils] could last nearly a year, while ongoing antibiotic therapy costs will only be surpassed by reconstructive surgery to fill in the gaps and remove the scar tissue left in the infection’s wake.

A report filed by the Santa Clara County Public Health Department on Nov. 5 issued an alert to physicians, dermatologists, internists, pediatricians and infection control practitioners—warning of a possible outbreak of mycobacterial furunculosis among women who received pedicures at three south San Jose nail salons.

“Were not sure exactly what we’re dealing with right now,” admits Teresa Chagoya, with the Santa Clara County Public Health Department. “It’s so hard for us to say at this point what the confirmed source or cause may be. All we know is that the common symptoms are non-healing lesions with a pedicure history.”

Over the past two months, 11 reports have been filed by girls and women ages 11 to 49, all exhibiting open sores [furuncles] on their legs that failed to respond to routine antibiotics. Silver Nails, [near Toys-R-Us] and Kathy Nails, [near Costco] are two of the three salons named. The third has not been made public.

The culprit is alleged to be a notuberculous mycobacterium called fortuitum that causes severe skin and soft-tissue infections [boils] that can take up to 23 days to surface and linger for an agonizing 41 to 336 days, depending on the severity of the outbreak and subsequent antibiotic therapy. Treatment can last up to six months and cost an estimated co-pay of $50 for each 30-day supply.

Pedispas, or chairs with attached footbaths and individual filtering systems provide the perfect breeding ground for fortuitum if not cleaned and sanitized regulairly, as hair, skin and toenails remain trapped in the filters and are then allowed to re-circulate, spreading the bacterium from one customer to the next.

An increasing and alarming trend
While mycobacterial infections are becoming more common, one of the largest outbreaks hit Watsonville in 2002, where over 110 cases were reported, all of which were traced to contaminated whirlpool footbaths—the same specially designed chairs found in salons throughout San Jose.

In those cases, treatment included lengthy and costly antibiotic regimens—not to mention side effects such as cramping and diarrhea. Some women even experienced scarring and disfigurement that required corrective or plastic surgery.

Although Kathy Nguyen, owner of Kathy’s Nails was out of town and unavailable for comment, her son Quan fielded questions Monday evening.

“To our knowledge we’ve never had anyone complain,” he says. “Every night we clean as requested by the State Board of Barbering and Cosmetology, using all the chemicals they ask us to use. The only time we heard about any complaints was when they came in a few days ago and asked how we cleaned. They inspected everything and said it was fine.”

During the visit, the state board collected water samples and mentioned grievances filed with the health department. Quan maintains that they have yet to field any complaints from their customers.

“I got a really vague answer from the health department,” he explains. “They said ours was one of the shops in this area, but they wouldn’t say how many complained, and we don’t know who they are.”

Quan says that his mother regularly tests her manicurists on required cleaning and safety procedures. Utensils are chemically disinfected with barbacides, germicides and viricides. Every night, filters are removed, cleaned with detergent and disinfected, while the screens are soaked in an EPA registered antiseptic for 10 minutes and then flushed. Every two weeks, as required, basins are filled with a specified bleach solution and left to soak overnight.

“After every customer, we clean and spray them [basins] with fungicide,” he added. “We also have a log, which shows which manicurist cleaned the pedispas, along with the dates and times. The Health Department said we followed procedure.”

Quan does admit that the salon has been cited and fined in the past, but not at the expense of their clientele. He claims that manicurists even examine their customer’s skin for problems or cuts prior to starting a pedicure and oftentimes suggest they wait in order to minimize irritations and complications.

“Within the last six months, we’ve only been fined for labeling some of the storage containers, but not on the safety of the spas,” he explained.

Just across the busy Blossom Hill and Almaden Expressway intersection, Nga Le, who owns Silver Nails with Vu Lam says their procedures are virtually the same, only she claims that they soak their basins with the bleach solution every week instead of the required bi-weekly mandate.

While initial examination of the salon revealed an up-to-date disinfections log, spray fungicidal at each station and EPA approved fungicidal solutions used to clean the pedispas, only test results from the water samples taken will show how well they have actually been maintained.

“Maybe they have sensitive skin,” Le insists. “Maybe they shaved just before coming or our lotion is too strong. I really do keep it clean,” she adds. “Otherwise, I wouldn’t have my business.”

And yet, the salon is no stranger to violations and hefty fines. According to State Board of Barbering and Cosmetology records, they had to shell out $1,500 on Oct. 4 for incorrect disinfecting of all six pedispas and no reported cleaning log after Sept. 22. Prior to that, they were fined $825 on June 21 for incorrect disinfecting of all six spas, improper disinfections of non-electrical items, insufficient disinfectant for total immersion, failure to dispose of non-reusable items, mislabeled containers and only using soap and water after each customer, without any sterilization procedures.

However, if a 2002 New England Journal of Medicine study is on the mark, even if the proper procedure is followed, the tenacious infections can be resistant to a variety of disinfectants and are likely to increase in prevalence—warranting further research to determine optimal cleaning procedures for salon footbaths and stricter regulations from health officials.

With the first round of test results due mid December, Chagoya continues to issue alerts and perform public outreach, searching for more victims who may inch the department closer to an answer to how widespread the problem is.

The emotional toll
The violation issued in October is Silver Nail’s second since June, one too many for Linda D. [last name withheld], who says her pedicure four months ago proved to be a painful and costly one.

“I’d only been going there a couple of months,” she remembers. “That day, it wasn’t the woman who usually did my pedicure. She didn’t even put any soap in—it was just water.”

Two days later, Linda started to break out in tiny boils across one leg. Although initially thought to be a trail of insect bites, she soon realized she needed medical attention.

“It started getting worse,” she says. “The redness started spreading around the bumps. I began to worry when they turned purple, so I went to the doctor.”

Linda was put on one antibiotic after another with little relief, until she discovered that her condition mirrored that of a friend’s 11-year-old daughter, who had been diagnosed with mycobacterial infection. Her doctor immediately changed her prescription to mirror the same treatment and in spite of the side effects she continues to endure, she considers herself lucky to have found the proper treatment early on.

As bad as it gets—but not bad enough to break a young girl’s spirit
The young girl’s ordeal however, has been far more severe. What started as a celebration at the nail shop with a mother and her two daughters over the summer, turned instead into a four-month ordeal with both children afflicted—one of whom contracted one of the most severe cases on record, and with it, permanent scaring on both her legs. Although the family has requested anonymity, they hope their message will serve as a warning to others.

“I got straight A’s and was really proud of myself,” explains the resilient 11-year-old, who admits that the past few months have been fraught with pain and frustration. “We were going on vacation and went in together to get our nails done. About two weeks later, my legs started swelling and we thought it was flea or spider bites. We found out later it was mycobacterium—it grew into my skin. I never even heard of this before or imagined I would have caught something from the water.”

The infection spread until she amassed over 100 lesions and tried several antibiotics before a regimen of Biaxin started to show positive results.

“I finally learned how to swallow a pill,” she laughs. “I’ve had to take one two times a day and will stay on it until well after it’s gone. After four antibiotics before this, this has finally started to show a change.”

Now four months into treatment, recovery is slow but progressing. She now faces a new challenge and hopes that plastic surgery will successfully repair the damage left in the infection’s wake.

While frustrated with the system and the fact that it had to affect so many people to get the health dept involved, her mother states that this should serve as a wake up call.

“It really boils down to ignorance,” she explains. “I don’t want the salons to think we are attacking them personally, I just want them to be more aware. They’re not taking the time to get educated. They’re not realizing the outcome of doing things in an un-sterile environment. They are the ones who are supposed to understand—to be knowledgeable of what they’re doing. And we need to be able to communicate with them.”

“I don’t want them to close their business,” Linda adds. “I just want someone to teach them how to keep things sterile and clean. With the antibiotic side effects and $50 out of my pocket each month, I’m getting pretty tired of it.”

“This has left pitting in my daughter’s legs,” the mother adds. “She’s going to have permanent scars. And who knows what the effects will be when you’re on medication that strong for that long. Plus, they say we’ll never know when she might get another flare-up. Helping others prevent this is our main concern now.”

Education and prevention is key to healthy pedicures
By law, salons are required to follow a pre-determined regimen of disinfectant and fungicide treatments following each use, with more stringent daily and bi-monthly sanitizing requirements that must be met in order to maintain their license to operate. If you are unfamiliar with how often your salon cleans its footbaths and filters, ask.

Additionally, the Health Department mandates all salons post a log listing all decontamination procedures. Inquire how their nail implements are sanitized. While heat works best, if they use chemical disinfectant, make sure it contains barbacides, germicides and/or viricides and soaks in the solution for at least 10 minutes between clients.

Better yet, bring your own with you and request a “no frills” portable footbath tub without a filtration system instead. That way, your only concern will be making it home without smudging the new paint job.

It is best not to shave before a pedicure. The Journal study showed that two-thirds of affected women shaved their legs just before their pedicures and tiny openings in the skin may have helped the infection take hold. Additionally, leg massages can also serve to “rub” the infection into the hair follicles.

Although past concerns focused more on choosing a polish color or selecting decorative toe art, the best offense today remains a well-educated defense—so that periodic pampering doesn’t turn into a disfiguring nightmare.

“This may be a small area, but so far, it’s grown,” says Chagoya. “We may be dealing with something bigger and we are looking for others with the same symptoms who we might need to talk to. If we can get more people to tell us, the better off we’ll be in protecting others.”

Anyone with both non-healing lesions and a history of pedicures is asked to notify their physician, who will then contact the Health Department for further tests. Those without a physician are encouraged to call the Public Health Information Line at (408) 885-3980. For more information, including consumer tips, regulations, services, fact sheets and health tips, call the Calif. Department of Consumer Affairs/Barbering and Cosmetology at (800) 952-5210 or visit www.barbercosmo.ca.gov.