Natural spa springs are diffused all over the world and their use in pools is known since ancient times. This review underlines the cultural and social spa context focusing on hygiene issues, public health guidelines and emerging concerns regarding water management in wellness or recreational settings. The question of the "untouchability" of therapeutic natural waters and their incompatibility with traditional disinfection processes is addressed considering the demand for effective treatments that would respect the natural properties. Available strategies and innovative treatments are reviewed, highlighting potentials and limits for a sustainable management. Alternative approaches comprise nanotechnologies, photocatalysis systems, advanced filtration. State of the art and promising perspectives are reported considering the chemical-physical component and the biological natural complexity of the spa water microbiota.