What is Hot Tub Folliculitis?

Hot tub (spa pool) folliculitis is an infection of the hair follicles caused by a bacterium Pseudomonas aeruginosa, which often thrives in new, poorly chlorinated, especially wooden hot tubes or whirlpools (Picture 1).

Hot tub - spa pool

Picture 1. Hot tub

Symptoms of Hot Tub Folliculitis

Within eight hours to five days (or even 14 days) of exposure to the bacteria, red, itchy bumps appear on the skin and may later develop into small pus-filled blisters (pustules). The rash is likely to be worse in areas where swimsuit holds contaminated water against the skin; face and neck are rarely, and palms and soles are never affected (1). Rarely, an earache, sore throat or eyes, runny nose, headache, nausea, vomiting, mild fever, breast tenderness, or painful lymph nodes may appear (1). Red wheals up to 3 cm wide may occasionally encircle the bumps (2).

Pictures of Hot Tub Folliculitis

Risk Factors for Hot Tub Folliculitis

Pseudomonas folliculitis is more likely to occur in persons with:

  • Prolonged water exposure
  • Many bathers in one hot tub
  • Frequent use of hot tubes (1)

Diagnosis of Pseudomonas Folliculitis

In diagnosis, a personal medical history may help a lot. A history of using hot tub in 2 days before a rash eruption, and other members of the party using the same hot tub and getting the same rash both speak for Pseudomonas folliculitis. A doctor may usually give diagnosis on the basis of physical examination, and further tests are not needed. In doubtful cases, a swab from open pustules can be taken and sent to a microbiology laboratory. Pseudomonas folliculitis, without knowing a history, may be hard to differ from staphylococcal folliculitis (pictures of staphyloccocal folliculitis).

Treatment of Hot Tub Folliculitis

Mild cases do not require treatment and resolve in 2-10 days (1). There is no evidence that mild pseudomonas folliculitis responds to antibiotics (1). Compresses with 5% acetic acid (white vinegar), 2-4 times a day for 20 minutes may bring some relief.  Extensive or repeated spa pool folliculitis can be treated with oral ciprofloxacin (1).

The responsible pool should be properly cleaned and disinfected with adequate chlorination or other method.

Complications of Hot Tub Folliculitis

Pseudomonas folliculitis rash may leave hyperpigmented spots for few months after rash disappearance (2).

Prevention of Hot Tub Folliculitis

The following measures can help in preventing Pseudomonas skin infections:

  • Chlorination with maintaining 2mg/l of free chlorine (bromine can be even a better choice), (1)
  • Complete drying of sponges between baths

Showering after using hot tubs does not seem to prevent pseudomonas folliculitis (1). Pseudomonas folliculitis is not spread by skin to skin contact (2).

How to Treat Hot Tubs?

Here are some information about how to treat spa pools, and here is more info from CDC about healthy swimming.

Related Articles:

References:

  1. Hot tub folliculitis (emedicine.com)
  2. Hyperpigmentation in pseudomonas folliculits (dermatology.about.com)
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Article reviewed by Dr. Greg. Last updated on November 8, 2011