An Overview of Hot Tub Folliculitis

Empty hot tub.

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Hot tub folliculitis is a skin condition that emerges anywhere from a few hours to a few days after using an improperly maintained hot tub or swimming pool. Folliculitis is a rash due to inflammation of hair follicles and is typically caused by a bacterial or fungal infection. This condition is also called hot tub rash or Pseudomonas dermatitis.

Symptoms

Hot tub folliculitis is a rash that is itchy, bumpy, and red. It resembles acne, however, the rash appears much more quickly.

The rash can erupt anywhere on the body that has come in contact with contaminated water. Lesions most often appear on parts of the body that have been exposed to wet clothing and swimsuits.

Initially, hot tub folliculitis causes a profusion of small, grainy bumps called papules. These papules are bright to dark red.

As the rash progresses, the bumps become larger and more tender nodules that may be up to three centimeters in diameter. The papules also have central pustules. Pus-filled blisters can also form around hair follicles.

The nipples, in both men and women, can be infected and become swollen and tender.

It's rather uncommon, but some people with hot tub folliculitis also feel generally unwell and may develop symptoms of:

  • Fever
  • Fatigue
  • Headache
  • Sore throat
  • Nausea
  • Swollen lymph nodes

The rash can appear anywhere from a few hours to five days after exposure to contaminated water.

Causes

Hot tub folliculitis is a bacterial infection of the upper portion of the hair follicles, most often caused by the bacterium Pseudomonas aeruginosa (P. aeruginosa). This is the same bacteria that is also responsible for otitis externa, or swimmer's ear.

These bacteria thrive in warm water—even in water that is sufficiently chlorinated. When you soak or swim in contaminated water, the bacteria can infect the hair follicles of your skin.

The longer you soak in water that is tainted with Pseudomonas, the greater your chances of developing hot tub folliculitis.

Water can look clear and clean and still be harboring the Pseudomonas bacteria.

Hot tub folliculitis is most commonly contracted from hot tubs in which the chlorine levels or the pH levels aren't properly maintained.

And while it's called "hot tub" folliculitis, this isn't the only place where you can pick up this skin condition. It's also possible to get it from:

  • Whirlpools and physiotherapy pools
  • Swimming pools
  • Warm lakes, rivers, or streams
  • Waterslides
  • Contaminated inflatable pool toys
  • Bath sponges

It can also occur from wearing a wet bathing suit that was not thoroughly washed and dried prior to use, or staying in a wet bathing suit for too long.

An often overlooked cause of hot tub folliculitis are loofahs, nylon bath poufs, or other bath scrubbies. These, too, can carry the Pseudomonas bacterium. Consider this possibility if you contract hot tub folliculitis and haven't been soaking in a hot tub or pool, or if you're having recurrent cases of the condition.

Anyone can contract the hot tub folliculitis, but you're more likely to get it if:

  • You have a compromised immune system.
  • Your skin's barrier is already compromised, due to eczema, dermatitis, or even recent shaving or waxing.
  • Young children and older adults are also more at risk.

Children tend to be more at risk for contracting hot tub folliculitis, likely because they stay in the water longer.

The rash is not spread through personal contact with infected lesions.

Diagnosis

A doctor should be able to diagnose hot tub folliculitis just by looking at it and knowing that the patient has recently used a hot tub. Additional testing usually isn't necessary.

However, if the typical treatment protocol doesn't clear up the rash, a skin sample may be taken to determine the cause. This can be done by taking a sample of fluid from the blisters, or a small skin biopsy. The samples are examined under a microscope to look for Pseudomonas bacteria.

These tests may also 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:

  • Contact dermatitis
  • Other types of folliculitis
  • Other types of bacterial infection, such as Staphylococcus aureus
  • Insect bites
  • Nodular scabies

Treatment

Pseudomonas aeruginosa cannot survive on healthy skin, so the rash usually resolves on its own after seven to 10 days.

Until then, there are several home remedies you can try to help relieve symptoms and speed healing. (The rash typically responds well to home remedies, but you should consult your doctor before trying any at-home remedy.)

  • Apply a warm, damp washcloth or compress to the infected area several times a day. This will help relieve any pain and help the area drain.
  • Over-the-counter anti-itch medicines, such as 1% hydrocortisone, can also help ease discomfort. Ask your doctor or pharmacist for recommendations.
  • Dilute 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. Always ask your doctor before trying this remedy though, for more personalized recommendations.

Since the rash is relatively benign and self-resolving, hot tub folliculitis doesn't usually require a specific treatment method.

However, if home care isn't doing the trick, or if your rash is severe, your doctor may prescribe topical antimicrobials such as gentamicin cream or Polymyxin B spray.

In widespread, resistant cases, oral antibiotics such as ciprofloxacin may be prescribed.

You should call your doctor if:

  • The rash hasn't improved after 14 days
  • The rash getting worse, increasingly painful, or spreading
  • You've developed boils, or large lumps
  • Your breast tissue or nipples are painful
  • You're feeling increasingly ill, or have a fever

The rash may leave hyperpigmented (darkened) areas of skin even after hot tub folliculitis has completely healed. This discoloration can fade over time, but it can take up to 18 months for this to happen. If hyperpigmented skin bothers you, there are treatments that can help fade discolored areas more quickly.

Prevention

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

  • Change out of wet suits ASAP. 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 your risk of developing the rash.
  • Make sure that the hot tubs and swimming pools that you use are clean. If you have a pool or hot tub, clean and chlorinate it regularly. Make sure that the water filtration system is continuously working to eliminate dead skin. Frequently monitor disinfectant levels and change water as needed.
  • Disinfect or change loofahs and bath poufs regularly. You can do this by soaking the item in dilute bleach and water mixture for 5 minutes and rinsing completely.
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Article Sources

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial policy to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Teraki Y, Nakamura K. Rubbing skin with nylon towels as a major cause of pseudomonas folliculitis in a Japanese population. J Dermatol. 2015 Jan;42(1):81-3. doi:10.1111/1346-8138.12712

  2. Nagoba BS, Selkar SP, Wadher BJ, Gandhi RC. Acetic acid treatment of pseudomonal wound infections--a review. J Infect Public Health. 2013 Dec;6(6):410-5. doi:10.1016/j.jiph.2013.05.005

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