Hot Tub Rash Information

Hot tub folliculitis (Pseudomonas folliculitis), or "hot tub rash," is a bacterial skin condition you can get from using an improperly maintained hot tub or swimming pool. It causes a red, itchy, and bumpy rash anywhere from a few hours to a few days after being in the water.

Hot tub folliculitis is caused by the bacteria Pseudomonas aeruginosa, which infects the hair follicles. The bacteria is commonly found in recreational water and natural sources of water, such as lakes and rivers. It is also frequently caused by Staphylococcus aureus and the fungus Aspergillus Nigus.

This article covers the symptoms and causes of hot tub folliculitis. It also discusses how it is diagnosed, treatment options, and prevention tips.

Hot Tub Rash Symptoms

A hot tub folliculitis rash is itchy, bumpy, and red. While it looks like acne, the rash will come on faster than pimples do. When it first appears, hot tub folliculitis looks like small bumps (papules) that are bright to dark red. As the rash gets worse, the bumps get bigger—up to 3 centimeters in diameter. 

The bumps can also be filled with fluid (pus) and can form around hair follicles. Some bumps may stay as small papules or superficial small pustules. While the most common symptom is a rash, other symptoms of hot tub folliculitis may include:

• Swollen, infected nipples
• Feeling generally unwell
• Fever
• Fatigue
• Sore throat
• Headache
• Swollen lymph nodes
• Nausea

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What Causes Hot Tub Rash?

Hot tub folliculitis is caused by the bacterium Pseudomonas aeruginosa (P. aeruginosa), which infects the upper portion of hair follicles. This is the same microbe that causes swimmer’s ear (otitis externa).

The bacteria Pseudomonas aeruginosa is typically found in warm, poorly-maintained water, and people get it by being in that water. The longer you soak in water tainted with Pseudomonas, the greater your chances of getting hot tub folliculitis.

Hot tub folliculitis is not contagious and will not spread through skin-to-skin contact. It is unlikely that there would be enough bacteria on a person's skin to contaminate someone else.

As the name suggests, hot tub folliculitis is common in hot tubs where the chlorine or pH levels aren't properly maintained. However, there are other potential sources including:

• Whirlpools and physiotherapy pools
• Swimming pools, particularly those used by a large number of people
• Warm lakes, rivers, or streams
• Waterslides
• Contaminated inflatable pool toys
• Bath sponges
• Wearing a wet bathing suit for too long or wearing one that wasn't thoroughly washed and dried
• Loofahs, nylon bath poufs, and bath scrubbers

Who Is at Risk?  

Anyone can get hot tub folliculitis, but children tend to get it more often than adults. Some people are more likely to get it than others, including:

• People with a weakened immune system
• People with eczema, dermatitis, or other skin disorders
• People who have recently shaved or waxed
• Young children and older adults

Diagnosis

A healthcare provider can usually diagnose hot tub folliculitis just by looking at it. Additional testing usually is not needed.

However, if home remedies and your healthcare provider's recommended care don't clear up the rash, a skin sample might be taken to determine the cause. This can be done by taking a sample of fluid from the blisters or a small skin biopsy.

These tests can be ordered if there is any doubt as to what is causing the rash. Hot tub folliculitis looks similar to other skin conditions such as:

• Acne
• Contact dermatitis
• Other types of folliculitis
• Other bacterial infections (such as Staphylococcus aureus)
• Insect bites
• Nodular scabies

Treating Hot Tub Rash

Pseudomonas aeruginosa cannot survive on healthy skin, so the rash usually resolves on its own after seven to 10 days. Treatment, if needed, can include home or over-the-counter (OTC) remedies, or prescription medications. However, hot tub rash often clears up on its own within 10 days.

Until then, several home remedies may help relieve symptoms and speed up healing. Ask your healthcare provider before trying any of these home treatments for hot tub rash:

• A warm, damp washcloth or compress applied to the infected area several times a day can relieve pain.
• OTC anti-itch medicines, such as 1% hydrocortisone, can also ease discomfort. Ask your provider or pharmacist for recommendations.
• Diluted white vinegar compresses are sometimes recommended, as acetic acid (the acid found in vinegar) has been shown to kill Pseudomonas. General guidelines call for half water, half vinegar mixture applied as a compress to the infected area for 15 minutes at a time, twice daily.

If home care isn't doing the trick, or if your rash is severe, your healthcare provider may prescribe a topical antimicrobial such as gentamicin cream or Polymyxin B spray. For widespread, resistant cases of hot tub rash, the oral antibiotic Cipro (ciprofloxacin) can be prescribed.

When to Call Your Provider

You should call your healthcare provider if:

• Your rash has not gotten better after 14 days.
• Your rash is getting more painful or spreading.
• You get boils or large lumps.
• Your breast tissue or nipples are painful.
• You feel increasingly ill or have a fever.

Prevention

Showering after coming in contact with contaminated water does not prevent hot tub rash infection, but there are a few things you can do to lower your risk:

• Keep your hot tub and pool clean: If you do not properly maintain and treat your hot tub, it could grow bacteria. If someone develops a rash a few hours to days after using your hot tub, it may have the bacteria that causes hot tub folliculitis. Keep in mind that water can look clean and still have bacteria in it. If you have a pool or hot tub, clean and chlorinate it regularly. Make sure that the water filtration system is continuously working. Frequently monitor disinfectant levels and change water as needed.
  
• Clean up after being in the water: After using a hot tub or swimming pool, change out of your wet bathing suit and into clean, dry clothing as soon as possible. Sitting around in a wet suit raises the risk of developing the rash. Launder your swimwear after wearing it.
• Find out about public pool maintenance: Learn how often public swimming or bathing facilities are tested. Public pools, hot tubs, therapy pools, waterslides, or other recreational bathing areas are usually high-traffic and easily contaminated. These should be tested at least two times per day.
• Keep your shower items clean: Disinfect or change loofahs and bath poufs regularly. You can do this by soaking them in a diluted bleach and water mixture for five minutes and rinsing them completely.

Summary

Hot tub folliculitis can cause a rash but it’s usually not serious. If the rash does not clear up on its own after about a week, you may need treatment for it. Since the rash can also look like other skin conditions, you should let your provider know if the rash isn’t getting better with time and treatment. 

The best way to avoid hot tub rash is to make sure the water you’re swimming in (like a pool or hot tub) is clean and regularly maintained. It’s also helpful to clean off after spending time in the water.