Turkish Bath-Associated Infectious Dermatoses: A Comprehensive Review of Risk Factors, Clinical Manifestations, and Preventive Measures

Abstract

People have used the traditional Turkish bath for centuries to cleanse themselves, maintain their health, and treat various diseases. The communal use of these areas may contribute to the development and spread of certain dermatoses due to contact with water and environmental factors. Tinea pedis, verruca, molluscum contagiosum, and Pseudomonas aeruginosa folliculitis are among these infections. Undoubtedly, pseudomonal infections are the most well-known waterborne infectious diseases. Pseudomonas aeruginosa folliculitis (hot tub folliculitis), Pseudomonas hot-foot syndrome, toe web infections, ear infections, and ecthyma gangrenosum are the most common clinical presentations. Public baths may provide suitable environments for fungal colonization in cases of insufficient disinfection, long-term public use, high user density, and elevated water temperatures. Common fungal infections, including tinea pedis, tinea corporis, and tinea unguium, are most likely attributed to increased exposure to fungal pathogens and skin maceration. Scabies and pediculosis are parasitic infections that can be transmitted in communal living spaces, but their treatment also involves bathing. There are limited data on the number of infectious dermatoses acquired from Turkish baths. Given that most baths undergo frequent disinfection and the water does not remain stagnant, it can be concluded that bath-related infections are uncommon.

Currently, there is a growing interest in public spaces such as swimming pools, Jacuzzis, and saunas, particularly in large cities and resorts, for both recreational and fitness purposes. Also, public baths remain popular in certain countries such as Türkiye, which are renowned as tourist destinations. However, public baths can be potential sources of certain dermatological conditions.

In Türkiye, public baths (Turkish baths) are not only historical and touristic places but also an important part of social life. People have used the traditional Turkish bath for centuries to cleanse themselves, maintain their health, and treat various diseases.^[1,2] The communal use of these areas may contribute to the development and spread of certain dermatoses due to contact with water and environmental factors.

A traditional Turkish bath, “hammam,” is a bathing place consisting of three or four different rooms with varying heat levels. The first room is cold and humid, the second is hot and humid, the third is hot and dry, and the fourth serves as the waiting or resting area. Designed to evoke the four seasons—winter, summer, autumn, and spring—the steam bath achieves its optimal therapeutic benefits at temperatures between 43°C (110°F) and 46°C (116°F) with 100% humidity. This requires an active steam generator, a true control system, and a steam compact cabin to prevent the steam from being lost and damaging the surrounding materials.^[2] The Turkish bath, consisting of the aforementioned three or four rooms, is structured into three primary interconnected spaces, each with distinct thermal characteristics. Upon entry, guests disrobe in a cool area often called the “Soğukluk/Frigidaire.” Adjacent to this is the “Ilıklık/Warmness,” a temperate room with a continuous supply of warm, dry air designed to gradually acclimate users to elevated temperatures. The central and most significant chamber, the “Sıcaklık/Caldaria,” is intensely heated and contains smaller navel stone rooms with marble slabs (Göbektaşı). These areas offer facilities for steam baths and massages, where patrons can recline for relaxation or treatments.^[3]

Hygiene is the most important issue in the bath. All marble surfaces and floors are cleaned daily using 5% sodium hypochlorite. Slippers are cleaned by soaking them in chlorinated water for 1 hour. Also, comprehensive surface cleaning is performed once a week with lime paste provided free of charge by the Provincial Directorate of the Ministry of Health.^[4]

Although there are many health benefits of the Turkish bath, some skin infections may be transmitted from the floor and instruments in these areas. In this review, we aim to evaluate the most common infectious dermatoses encountered in Turkish baths (Table 1).

Table 1.

The main Turkish bath-related infectious dermatosis

Bacterial Infections
1. Staphylococcal and streptococcal infections 2. Pseudomonas aeruginosa infections (Pseudomonas aeruginosa folliculitis [Hot tube folliculitis], Pseudomonas hot-foot syndrome, Pseodomonal ear infection) 3. Legionella infections 4. Corynebacterial infections 5. Mycobacteria infections (Mycobacterium abscessus hand-foot disease, Mycobacterium avium infection)
Viral Infections
1. Human papillomavirus (HPV) 2. Molluscum contagiosum virus 3. Herpes simplex virus (HSV)
Fungal Infections
1. Tinea pedis, tinea corporis and tinea unguium 2. Erosio interdigitalis blastomycetica
Parasitic Infections
1. Scabies 2. Pediculosis

Bacterial Infections

Pseudomonas are a diverse group of free-living bacteria that primarily inhabit soil, seawater, and freshwater environments. Outbreaks of Pseudomonas have been linked to contamination of recreational and tap water, but the exact role water plays in the transmission of this bacterium to humans remains uncertain.^[5]

Pseudomonas aeruginosa “hot-tub” folliculitis emerges 6–48 h after immersion in water with insufficient disinfection (pH≠7.2–7.8, chlorine<0.5 mg L^-¹) and manifests as pruritic or tender 2–10 mm follicular papules/pustules on the trunk, axillae, gluteal region, or proximal limbs—rarely advancing to cellulitis or ecthyma gangrenosum in the immunocompromised—often accompanied by exotoxin-related systemic symptoms. Lesions usually self-resolve in 7–14 days, with topical chlorhexidine or benzoyl-peroxide washes and gentamicin/polymyxin adequate for most cases, while a 7–10-day course of oral ciprofloxacin is reserved for persistent, systemic, or immunosuppressed presentations.^[6–9]

Pseudomonas hot-foot syndrome—a plantar Pseudomonas aeruginosa infection classically reported in children after immersion in inadequately disinfected, abrasive-sand–substrate pools—presents within hours to a few days as markedly painful erythematous nodules and pustules limited to the soles (differential: palmoplantar eccrine hidradenitis). P. aeruginosa can be cultured from both the lesions and source water. The eruption is self-limited over ~14 days, and management is predominantly supportive, with topical—and for recalcitrant or systemic involvement, systemic—antimicrobials employed as necessary.^[10]

Toe web infections; ear infections, including acute otitis externa, malignant otitis externa, and perichondritis; and ecthyma gangrenosum can be classified as other public bath-related Pseudomonas skin disorders.^[11] Among these infections, ear infections are the most frequently reported with the use of pools and hot water.^[5] P. aeruginosa is responsible for 70% of external otitis (swimmer’s ear) cases.^[12] Swimmers spend more time in pools; therefore, they are more vulnerable to otitis externa.^[12] Ear infection results in tenderness and swelling around the periauricular area, which can be associated with nocturnal pain and headache. In later stages, purulent drainage may occasionally be observed.^[13] Pseudomonal ear infections can progress to malignant otitis externa, mastoiditis, and cranial nerve palsy.^[14]

Legionella spp. are aerobic Gram-negative aquatic bacilli transmitted via inhalation of aerosolized water from sources such as cooling-tower or air-conditioning systems.^[15] L. pneumophila causes ≈90% of cases, presenting either as severe pneumonia (Legionnaires’ disease) or the self-limited, influenza-like Pontiac fever.^[15] Rare immune- or toxin-mediated cutaneous manifestations include pruritic maculopapular or petechial rashes and, less often, cellulitis, pustules, abscesses, necrotizing fasciitis, panniculitis, or subcutaneous nodules.^[16,17] Effective therapy requires intracellularly active agents, including macrolides, fluoroquinolones, or tetracyclines, for 7–14 days.^[18]

Legionella colonization was investigated in two Turkish baths. In one of these studies, samples from eight Turkish baths in Sivas were examined, and the presence of Legionella species was not detected. The authors stated that water temperature properties were unsuitable for bacterial growth.^[19] In the second study, the baths of hotels in Alanya were examined. The temperature in these baths was measured between 25–45°C, and Legionella colonization was detected in the samples.^[20] The decrease in the prevalence of Legionella in the water from 2006 to 2013 can be considered a result of training programs aimed at raising awareness about Legionella colonization. In conclusion, the latter study shows that the water systems of Turkish baths in hotels can be colonized. Including Turkish baths and all hotel water systems in effective control programs would be an appropriate approach to prevent Legionella colonization.

Corynebacterium minutissimum causes a clinical manifestation called erythrasma in humid, inverse areas of the body, especially in individuals living in humid and hot climates. The causative pathogen can be found in the stratum corneum of infected individuals. Lesions appear as asymptomatic red-brown scaly plaques. A bright coral-pink fluorescence on Wood’s lamp examination confirms the diagnosis of erythrasma. Baths with humidity and warmth can pose a risk for erythrasma. Erythrasma can be treated systemically or topically. Effective systemic antibiotics include clarithromycin, erythromycin, and tetracycline. Apart from these agents, it has been reported that fusidic acid and Whitfield ointment, which consists of benzoic acid and salicylic acid, and 2% mupirocin ointment are also effective in eliminating the infection.^[21] Drying the body well after contact with water is important for preventing corynebacterial infections in Turkish baths.

Mycobacteria are widely distributed in the environment and rarely cause human disease. The Runyon classification divides non-tuberculous mycobacteria (NTM), excluding M. tuberculosis and M. leprae, into four groups based on growth rate and pigment production (photochromogens, scotochromogens, non-pigmented nonchromogens, and rapid growers).^[22] While NTMs typically lead to pulmonary and disseminated infections in immunosuppressed individuals, they can also cause skin and soft tissue infections. Rapidly growing mycobacteria, which typically grow in culture within one week, include three clinically significant species: Mycobacterium abscessus, Mycobacterium fortuitum, and Mycobacterium chelonae. Slowly growing NTM species, which typically take two to four weeks to grow in culture, include the Mycobacterium avium complex and Mycobacterium kansasii.^[22] Mycobacterium abscessus hand-foot disease and Mycobacterium avium infection can occur as public bath dermatoses.

Mycobacterium abscessus is an environmental atypical mycobacterium found in soil and water and is a rapidly growing organism under in vitro conditions. Mycobacterium abscessus hand-foot disease is a rarely reported mycobacterial infection among mobile pool or swimming-pool participants. Clinical manifestations present as multiple red to purple lesions. The morphology of the lesions includes macules, firm papules, nodules, and pustules. These lesions can be either painless or tender nodules, papules, and occasionally pustules on the palms and soles. The development of abscesses and ulceration was reported in the hands and feet of two patients after using a public bath in a case report, and M. abscessus was isolated from the lesions as the causative agent.^[23] The time between exposure to mycobacteria and the onset of clinical symptoms has been reported to range from 1 week to 3 months. Some infections resolve spontaneously, but many are treated with clarithromycin or an alternative systemic antibiotic. Typically, this infection is resistant to anti-tuberculosis agents.^[24]

Mycobacterium avium infection is generally observed as part of a systemic infection, especially in immunosuppressed patients, and pure cutaneous involvement of M. avium is rare. Cutaneous infections caused by M. intracellulare can present in various forms, including abscesses, nodular lesions, erythematous plaques with yellow-crusted bases, or ulcerations. In some cases, deeper infections such as panniculitis, tenosynovitis, and fasciitis have also been reported.^[25] Drug therapy for M. avium infection is often ineffective, and surgical excision of the affected tissue is generally recommended, especially for the cutaneous form.^[26,27] Given the susceptibility associated with the aforementioned infections, patients with immunocompromised conditions should avoid going to the Turkish bath as much as possible, as with other public places.

Viral Infections

Verruca vulgaris is usually seen in children and young adults. In a previous study, people who used locker rooms and those who used shared showers were compared in terms of plantar verrucae frequency. A significantly higher rate of verrucae was detected in the second group. These findings show that wet areas open to the public, including Turkish baths where bare feet come into contact, are important factors in HPV transmission.^[28] In another study, HPV types 6, 16, 18, and 31, which cause genital lesions, were not detected by polymerase chain reaction on the floors of pools and seating areas. Therefore, it is speculated that genital verruca is unlikely to be transmitted in this way. Although it is recommended that individuals using common areas cover their verruca with tape or wear protective stockings, it is uncertain whether these measures prevent transmission.^[29]

Molluscum contagiosum (MC) is a benign, highly contagious dermatosis of childhood characterized by 3–5 mm umbilicated waxy papules and is transmitted via direct contact, fomites, or potentially contaminated water. Prevalence is doubled among children who frequently visit swimming pools—lesions often clustering on axillary and lateral thoracic surfaces—and sharing items such as towels further increases transmission.^[30–32]

Herpes simplex viruses (HSV) belong to the Herpesviridae family and have subtypes including HSV-1 and HSV-2. HSV-1 is typically transmitted through infected oral secretions during close person-to-person contact and causes herpes labialis infection. After the initial infection, HSV-1 enters a latent phase in the sensory ganglia and may be reactivated in the mucosa and skin under certain conditions. Genital herpes simplex is a common sexually transmitted viral infection worldwide. Although most genital infections are caused by HSV-2, HSV-1 can also cause genital herpes, and the incidence of HSV-1 genital disease is increasing.^[33]

A severe case of eczema herpeticum requiring hospitalization and intravenous acyclovir therapy was reported in a 10-year-old girl after sitting in a sauna with a friend who had active herpes labialis.^[34] Notably, patients with atopic dermatitis are more prone to eczema herpeticum. Therefore, individuals with atopic dermatitis and recurrent herpes simplex infection should be cautious when visiting public baths.

Fungal Infections

Common fungal infections, including tinea pedis, tinea corporis, and tinea unguium, are most likely attributed to increased exposure to fungal pathogens and skin maceration. Public baths may provide suitable environments for fungal colonization in cases of insufficient disinfection, long-term open use, high numbers of users, and high water temperatures. Epidermophyton floccosum, Trichophyton mentagrophytes, and Trichophyton rubrum are the main responsible pathogens in this respect. Tinea pedis manifests as either interdigital erythema with scaling, peeling, and maceration—especially between the fourth and fifth toes—hyperkeratotic thick scaly erythematous plaques on the soles, heels, and sides of the feet, or vesiculobullous intensely pruritic vesicles/bullae on an erythematous base. Tinea corporis presents as a pruritic scaly annular erythematous plaque with an active border on the trunk or extremities, whereas onychomycosis is characterized by subungual hyperkeratosis, onycholysis, nail dystrophy, discoloration, and crumbling.^[35–37] Local or systemic antifungal treatments are typically administered for 6 to 12 weeks to treat dermatophyte infections.^[36]

Aspergillus species are heat-tolerant fungi that grow well in the temperature range of 20–50°C.^[38] Aspergillosis typically occurs in immunocompromised individuals and primarily presents as a pulmonary infection. However, primary cutaneous aspergillosis, though rare and potentially life-threatening, can also occur. Its clinical manifestations vary, often presenting as ulcerating nodules.^[39] Treatment for cutaneous aspergillosis typically involves systemic antifungal therapy such as voriconazole and amphotericin B.^[39] During showering, people are exposed to fungal conidia and hyphal fragments via bioaerosols released into the environment. Inhalation of water droplets by immunosuppressed patients may result in infection with Aspergillus species. Thus, special attention should be paid to these patients if they wish to use public baths.^[38]

Erosio interdigitalis blastomycetica is a Candida infection that affects the fingers or toes (usually in adults). Exposure to water is one of the most important predisposing factors. Its morphological presentation initially appears as a white and macerated area in the interdigital region. Unlike the fingers, the softened white superficial epidermal tissue of erosio interdigitalis blastomycetica on the toes may not separate from the underlying epidermal layers, as the thicker foot skin maintains its integrity. If separation occurs, the underlying tissue erodes and appears erythematous. Clinical differential diagnoses include erythrasma, irritant contact dermatitis, psoriasis, and bacterial, fungal, or mixed toe infections.^[40] Treatment typically includes keeping the affected area dry and applying topical antifungals.

Although the warm and humid environment of baths is suitable for fungal colonization, to date, there are no reports on the fungal flora of Turkish baths. In a study conducted in Türkiye, fungal pathogens could not be isolated from the marble floors of baths, central massage platforms (göbektaşı), or towels (peştemal). In communal bath settings, slippers constitute a principal reservoir for dermatophytes implicated in tinea pedis and onychomycosis, whereas loincloths exhibit negligible fungal colonization. Routine high-temperature laundering and the exclusive use of personal or single-use footwear and grooming implements are therefore recommended to reduce transmission. Therapeutic management requires 6–8 weeks of topical or systemic antifungals, during which patients should avoid public baths, use moisture-wicking socks and breathable footwear, and ensure meticulous foot-drying after water exposure.^[4]

Ultraviolet-C (UV-C) can be used for its germicidal properties. The use of UV-C gained importance during the COVID-19 pandemic.^[41] In a previous study, it was reported that UV-C radiation is effective in inactivating potentially pathogenic strains of dermatophyte fungi, including T. mentagrophytes and T. rubrum.

In conclusion, the risk of fungal contamination is low, especially in the high-temperature parts of Turkish baths.^[4] However, fungal infections may still be acquired, particularly from shared items and adjacent low-temperature areas. Adequate protective measures, such as the use of personal or disposable slippers and effective cleaning after bathing, should be taken to avoid mycotic infections in bathers.

Parasitic Infections

Sarcoptes scabiei hominis is a whitish-brown, eight-legged mite. Scabies is the infestation of the skin by the Sarcoptes scabiei mite. Classic scabies presents as an intensely itchy rash with a characteristic distribution, and mites settle on the epidermis. The interdigital areas, wrists, axillae, breast areola, umbilical region, and anogenital region are common areas of involvement.^[42] Characteristic features include nocturnal pruritus, erythematous papules, and excoriations in these areas. Treatment for scabies typically involves topical or oral medications such as permethrin, ivermectin, and sulfur ointment.^[42]

It has been reported that scabies increased during the COVID-19 pandemic. Increased cases of scabies as a result of “stay-at-home” policies highlighted the connection between increased interaction in confined spaces and the spread of scabies.^[43,44] Scabies outbreaks can occur in institutional settings such as long-term care facilities and prisons. Hygiene is very important in preventing the transmission of scabies. In this context, areas such as Turkish baths may be considered a supportive tool by providing hygiene, as long as measures are taken to avoid contact with potentially infected individuals and their belongings.

Human pediculosis comprises head (Pediculus humanus capitis), body (P. h. corporis), and pubic (Pthirus pubis) lice. Head lice are ubiquitous and child-predominant, surviving ≈55 hours off-host; body lice dwell and oviposit in clothing seams, feeding intermittently on trunk skin and persisting ≤3 days without a host; pubic lice are chiefly sexually transmitted, may involve eyelashes, and spread via fomites. All forms produce pruritic erythematous papules, excoriations, and adherent nits.^[45] As in scabies, hygiene is very important in preventing the transmission of pediculosis and is also part of treatment. Although infestations such as scabies and pediculosis are transmitted through close contact and shared objects, there is a theoretical risk of transmission in public areas such as bathhouses. However, the low risk and the fact that bathing is part of the treatment complicate the role of bathhouses in this context.

Conclusion

Public baths (Turkish baths) are not only historical and touristic places but also an important part of social life. People have used the traditional Turkish bath for centuries to cleanse themselves, protect their health, and treat various diseases. The communal use of these areas may contribute to the development and spread of certain dermatoses due to contact with water and environmental factors. Bacterial, viral, fungal, and parasitic infections can be transmitted from Turkish baths and are classified as infectious dermatoses. Among these, pseudomonal infections are the most well-known waterborne infectious diseases.

Disclosures

Conflict of Interest

The authors declare that there is no conflict of interest.

Financial Disclosure

The authors declared that this study has received no financial support or any funding.

Use of AI for Writing Assistance

No artificial intelligence was used to generate content in this document.

Authorship Contributions

Concept – O.K., A.K.; Design – O.K., A.K.; Supervision – O.K., A.K.; Data collection &/or processing – P.O.C., G.Y.; Analysis and/or interpretation – P.O.C., G.Y.; Literature search – O.K., P.O.C.; Writing – O.K., P.O.C., G.Y., A.K.; Critical review – O.K., P.O.C., G.Y., A.K.

Peer-review

Externally peer-reviewed.