Case Summaries

Cutaneous DCS with Transient Neurological Symptoms after a Hot Shower

After a hot shower, a diver experiences blotchy rash and welts along with blurred vision and some dizziness.

Reported Story

I am an advanced diver with more than 200 lifetime dives. I completed a total of nine dives over four days while vacationing in Mexico. All dives were on air with appropriate safety stops and at least an hour surface interval between multiple dives on the same day. I planned my dives using my dive computer.

I completed two dives on day one. The first was to a maximum depth of 61 fsw (18 msw) for 45 minutes with a five-minute safety stop. I do not have a recorded depth of my second dive; however, my bottom time was 40 minutes with a five-minute safety stop. I completed two dives on the second day. The first was to a maximum depth of 70 fsw (21 msw) for 46 minutes with a five-minute safety stop. An hour later I dived to a maximum depth of 51 fsw (15 msw) for 50 minutes with a three-minute safety stop. My first dive of day three was to a maximum depth of 67 fsw (20 msw) for 45 minutes with a five-minute safety stop. After the second dive of the day to a maximum depth of 51 fsw (15msw) for 50 minutes and a three-minute safety stop, I started to itch. I disregarded the itching since it seemed to resolve after showering.

I completed three dives on day four. The first dive of the day was to 82 fsw (24 msw) for 40 minutes with a five-minute safety stop. Following a 65-minute surface interval I completed a shallow dive to 35 fsw (10 msw) for 55 minutes with a three-minute safety stop. After returning to the hotel to eat lunch I did a shore dive to 17 fsw (5 msw) for 54 minutes with no safety stop.

Approximately three hours after surfacing from my last dive of day four I returned to where I was staying and took a shower, during which my skin started to intensely itch. The itching continued to worsen, and I developed pain in my lower back near my hips and in my right breast. I experienced blurred vision and some dizziness that subsided after I ate dinner. I noticed that my skin also had a blotchy rash and welts.


I called the DAN emergency hotline, and a medic referred me to a physician who was near where I was staying. The physician evaluated my symptoms and diagnosed me with cutaneous decompression sickness (DCS), or skin bends. The physician was very informative and explained that the nitrogen was more prone to the fatty parts of the body, which explained why I was having pain in my hips and right breast. He told me to return for a follow-up evaluation the next day.

The pain and blotches disappeared the day after my diagnosis. The physician gave me strict orders not to dive any more during this trip. I returned home from my vacation and experienced some soreness, which I attributed to acclimating to altitude change. DAN did everything to get me the help I needed, and I am really glad I had DAN dive accident insurance. I cannot imagine what my experience would have been without it.

Comments

The presentation and evolution of the signs and symptoms described here are not uncommon. What this diver experienced is almost identical to what other divers have reported. It is important to remember that in approximately 20 percent of the cases that report skin manifestations there are accompanying neurological symptoms — e.g., blurred vision, dizziness and confusion. Whether or not there are obvious neurological symptoms, an evaluation by a dive-knowledgeable physician is always recommended because some of the neurological symptoms can be subtle. Historically, treatment is primarily surface-level oxygen. In cases with neurological symptoms the evaluating physician may opt for treating the diver in the chamber, which is an appropriate option.

Some divers experience skin bends only once in their dive history, while others might experience symptoms on multiple, random occasions. The reason for the occurrence and the exact mechanism producing the symptoms is not clearly understood; but, as explained to this diver, the areas generally affected are those that tend to have adipose (fatty) tissue. Initially there is itching usually followed by the mottled or bruised appearance of the skin you see in the photograph. Too often the itching and mottling is attributed to other causes.

Typical skin reactions and/or rashes appear differently. Being able to recognize the difference is critical. As the diver described, there is also pain or soreness in the deeper tissues instead of just being superficial. Divers will describe the soreness as similar to having overworked muscles to the point of fatigue. This deep soreness is another means to help differentiate between a common rash and cutaneous DCS.

If you suspect skin bends, discontinue diving and, if possible, seek a medical evaluation by a physician. The appropriate first aid is breathing oxygen at the surface, but do not postpone getting a neurological examination. No further diving for the duration of the trip is the best recommendation. If you decide that continuing to dive is an acceptable risk, you need to wait until all mottling and soreness have completely resolved. Diving before complete resolution will likely cause a return of symptoms and a potential worsening of symptoms. If you are one of the rare individuals who experiences skin bends on multiple occasions, further evaluation for potential underlying problems is recommended. DAN can work with your physician to discuss the evaluation process.

— Marty McCafferty, EMT-P, DMT