Skin Problems in the Athlete

Increase in methicillin-resistant Staphylococcus aureus (MRSA) transmission is of concern in the contact sports of wrestling, fencing, and football.

Other etiologies for skin infections include other bacterial, viral, and fungal infections. Other skin issues apart from infections can occur in sports.

Although the overall incidence of skin infections is low, prevention is possible.

Skin lesions are most often transmitted from person to person but can also be from fomites.

Risk factors for skin infections include:

• Previous history of infection

• Compromised host immunity

• Close contact sports

• Poor personal hygiene

• Body shaving, waxing

• Antibiotic overuse

• Sharing of towels, razors, uniforms, and equipment

• Facility and equipment cleanliness

History of past infections and treatment should be noted.

Routine skin checks are recommended in all sports, particularly in high-risk sports (e.g., wrestling, football, and rugby). The NCAA recommends skin checks several times a week, and the National Federation of High Schools (NFHS) also has published guidelines. Skin checks should be performed with the athlete in briefs, and sports bra if female, in room with good lighting with a chaperone. Athlete positioning should be feet shoulder-width apart with arms adducted at 90 degrees and thumbs pointed superiorly. Special attention should be given to hairline and scalp.

Infection spread can be decreased by withholding infected athletes from practice and/or competition until completely treated.

Good hygiene should be promoted with immediate bathing after practices/games and trimming of nails.

• Wash uniforms, towels, and equipment immediately after their use.

• Instruct athletes to dry the area of any skin lesion last and discard the towel.

• Regularly wash hands with soap and water or an alcohol-based hand gel.

• Avoid sharing of equipment, uniforms, towels, clothing, bedding, bar soap, razors, and toothbrushes.

Wound coverage as the primary treatment or prevention of spread of a skin lesion is never appropriate.

Skin lesions should be covered only after they are noninfectious to prevent secondary infection. Consider prophylactic medication for those with frequent outbreaks.

Student-athletes should be encouraged to immediately report skin wounds and lesions.

Equipment and other surfaces that multiple athletes have had contact with should be frequently cleaned.

In wrestling specifically, cleaning techniques are critical to prevent disease transmission. Best practices should include:

• Clean all mats with a residual disinfectant.

• Encourage the backward-mopping technique for cleaning mats.

• Encourage hand washing or hand gel by wrestlers immediately before each match.

• Encourage annual influenza vaccination for all wrestlers.

Education of coaches, officials, and healthcare practitioners regarding common skin lesions should be conducted at least annually.

Overview: Caused by the herpes simplex virus (HSV); HSV is common in the general population and among athletes, particularly wrestlers. Herpes consists of two types, HSV-1 or HSV-2, but can be mixed and found anywhere on the body. HSV-I is associated with cold sores and fever blisters. HSV-2 is associated with genital herpes. Ninety-four to ninety-seven percent of herpes gladiatorum (HG) is caused by HSV-1. In a typical season, 2.6% of high school wrestlers and 7.6% of college wrestlers will suffer from HG, and up to 87.4% of infections are subclinical and go undiagnosed. It spreads skin to skin via an active rash or rash fluid, from fomites to skin, or by respiratory droplets or saliva. Breaks in the skin barrier can increase the risk of infection. Stress, either physical or emotional, and sun exposure can increase the likelihood of infection. The virus incubation period is typically 2–14 days.

Presentation: One in four infected with primary HG will begin with flulike symptoms approximately 2–24 hours before appearance of rash. Rashes may have a prodrome of itching or burning. In wrestling, common appearance of the rash is usually on the right side of the wrestler’s face, neck, or arm, which are points of most contact with the mat or site of dominant arm or dominant tie-up side. The rash disappears in 2 weeks without scarring. Recurrent HG usually involves fewer vesicles that are present for a shorter duration and systemic symptoms are much less common.

Physical examination: The rash begins as a burning or tingling sensation on the skin, which is already in its contagious phase. This area then becomes the site of red bumps that form clusters of tiny blisters filled with cloudy fluid on an erythematous base. The blisters collapse to form yellowish-brown scabs, which form in 2–4 days. Reactivation of the virus in ganglia, usually due to a stressor, including lack of sleep or poor nutrition, will cause the rash to occur in the individual in the same dermatomal or peripheral nerve pattern.

Diagnosis: The rash is usually characteristic; however, viral cultures and HSV polymerase chain reaction can also be performed to confirm diagnosis and type (HSV-1 vs. HSV-2). Tzank smear is no longer recommended.

Treatment: Treatment is with oral antivirals for 10–14 days for initial infections. Consider valacyclovir (Valtrex) 1 g BID. Treatment for recurrent infections should be valacyclovir 1 g BID for 5–7 days. Consider suppression dosing for those with chronic recurrent infections approximately six times per year. The drug of choice would be valacyclovir 500 mg PO daily if recent infection was longer than 2 years ago and valacyclovir 1 g PO daily if most recent infection was less than 2 years prior. Famciclovir can also be considered if there is resistance to valacyclovir. Topical antivirals are often not effective if used alone.

Return to play: Varies. Return for wrestling for the NCAA for primary or secondary HG is after a course of 5 days of oral antiviral treatment with no new lesions for 72 hours, all lesions must be dry and crusted, there is no apparent secondary bacterial infection, and in the case of primary HG, there are no systemic symptoms. Return for wrestling for the NFHS for primary HG is 10 days of antiviral treatment for cutaneous lesions only and 14 days if there are systemic symptoms, all lesions crusted over, and no new lesions for 48 hours. Return for wrestling for the NFHS for secondary HG is 5 days of antiviral therapy, all lesions crusted over, and no new lesions for 48 hours. In all cases of return, coverage of lesions alone is inappropriate to allow participation.

Overview: Caused by HSV-1 and is spread skin to skin or by fomites ( Fig. 40.1 ); the infection is seen around the lips, beginning as vesicles on an erythematous base that break and then crust over. The virus can express itself during times of physical or emotional stress or from environmental factors such as direct sunlight.

Presentation: Begins with prodrome of pain or pruritus at the site of lesion, followed by clear vesicles on an erythematous base that eventually break and crust over. The athlete becomes infectious during the prodrome and is infectious until the lesions crust. Infection course is generally 7–14 days.

Physical examination: Clear vesicles on an erythematous base around the lip and possibly between the nose and lip that evolve into areas of ruptured vesicles on an ulcerated base.

Diagnosis: Characteristic rash, but viral culture is definitive

Treatment: Treatment includes oral antivirals: consider valacyclovir 2 g BID for 1 day, which should be started as soon as the athlete experiences the viral prodrome.

Return to sport: Varies, but for specific NCAA and NFHS guidelines for wrestling, see “Herpes Gladiatorum” section.

Overview: Reactivation of the herpes virus expressed in the dermatome of the infected nerve root. Reactivation is usually preceded by a pain prodrome along the same root, usually initiated by either physical or emotional stress. Vaccination may decrease the risk of developing postherpetic neuralgia.

Presentation: Usually begins with a painful prodrome, followed by infection along the affected nerve root

Physical examination: Initial infection is papules changing to vesicles, then pustules in a dermatomal pattern before crusting over during the course of a week. Regional lymph glands are often swollen and tender.

Diagnosis: Characteristic dermatomal rash, but viral culture is diagnostic

Treatment: Via oral antivirals: consider valacyclovir 1 g TID for 7 days or acyclovir 800 mg PO five times a day for 7 days and pain medications as soon as prodromal symptoms occur; physicians must be cautious not to prescribe banned substances for pain. Prophylaxis can be via varicella zoster virus (VZV) vaccination or history of VZV vaccination.

Return to sport: Varies, but for specific NCAA and NFHS guidelines for wrestling see “Herpes Gladiatorum” section.

Overview: Viral lesion from Poxviridae family that spreads skin to skin or via fomites; characterized by single or multiple discreet, flesh-colored, dome-shaped papules with a central dimple. If ruptured, caseous material is released with high viral content inducting spread. The rash most often occurs in contact athletes, on the face, trunk, or hands.

Presentation: Athletes have these lesions, painless and nonpruritic, in clusters for several weeks to months and often only present when their spread is noticed.

Physical examination: Clustered, dimpled papules found on face, trunk, or hands

Diagnosis: Characteristic rash, but also identified by observation under microscope or biopsy

Treatment: Mechanical via curettage, electrotherapy, or cryotherapy; chemical and immunologic methods can also be used

Return to sport: Data inconclusive; lesion removal and coverage with bio-occlusive dressing is suggested, but 48 hours of recovery to prevent secondary infection is often recommended.

Overview: Verrucous plaques and papules found most often on the epidermis of the hands caused by the human papilloma virus. They can, however, be seen anywhere on the body. Warts on the plantar surface of the athlete’s foot, most often the heel or ball, can cause a change in the athlete’s ambulation.

Presentation: Painless papules or plaques most often on hands, present for weeks to months; athletes usually try self-removal before presentation via over-the-counter preparations, cutting, scraping, or picking. Can be painful with local trauma to area.

Physical examination: Seen anywhere, but usually on hands and feet; papules with a typical scaly “cauliflower” appearance

Diagnosis: Distinguished from calluses by the presence of hemorrhages seen when the wart is shaved; no normal skin lines in the wart

Treatment: Removed by curettage, cryotherapy, or use of salicylic acid; immunotherapy is also successful in wart resolution. Treatments may have to be repeated. Care must be taken not to permanently damage or destroy skin with continued attempts at removal. If a wart is present in a sensitive area, paring and covering may be used in-season with definitive treatment after the season. Warts should be covered; low risk of transmission. The wart can be protected by use of doughnut pads or moleskin until definitive treatment can be administered. Use of footwear in locker rooms and shower areas can prevent transmission.

Return to sport: No restrictions, but should cover area with bio-occlusive dressing

Overview: Extremely infectious respiratory virus, now the seventh virus from the coronavirus family. There is no known cure or standardization of treatment, though several have been proposed as of this writing. Mode of transmission is primarily via respiratory droplets but can be from fomites and poor hygiene. The SARS-CoV-2 pandemic continues to be an evolving worldwide healthcare situation that will continue to change at the time of the writing of this text.

Presentation: COVID-19 presentations can differ from no or mild symptoms to severe illness. Symptoms typically appear 2–10 days after exposure to the virus and include fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle aches, headache, new loss of taste or smell, and sore throat. Dermatologic presentations can include a morbilliform rash, urticaria, vesicular eruptions, acral lesions (“COVID toes”), and livedoid eruptions. More rarely, rash consistent with drug-related intertriginous and flexural exanthema and petechial rash. Cardiac manifestations and complications can also occur. Please reference Chapter 35 : “Cardiac Disease in Athletes.”

Physical examination: Dermatologic findings of infection can begin either at the distal extremities (i.e., acral lesions) or on the trunk and spread. There can be multiple cutaneous presentations of SARS-CoV-2 that differ in morphology in the same patient at the same time.

Diagnosis: Difficult, as there can be multiple cutaneous presentations that differ in morphology in the same patient simultaneously. Suspicion and exposure of entire patient with continued examination is necessary. Complete history and biopsy can be assistive. Testing for COVID-19 is evolving, and the current gold standard is a polymerase chain reaction test using nasopharyngeal or oropharyngeal specimens.

Prevention: Measures include avoiding close contact with individuals when ill, hygiene measures such as hand washing, avoiding touching of the face, covering a cough, the use of face masks, and cleaning and disinfecting measures. The PfizerBioNTech, an mRNA vaccine, is fully authorized by the Food and Drug Administration (FDA) for protection against SARS-CoV-2 for those 16 years and older consisting of 2 injections given 21 days apart with full vaccination status reached 2 weeks after the second shot. It is currently under emergency use status for those from 12 years to 15 years administered as above using the adult dose. The PfizerBioNTech vaccine has emergency use authorization for children ages 5 to 11 using the same ingredients as the adult vaccine but given in an age-appropriate dose that is one-third of the adult dose using smaller needles. Two vaccines are currently under emergency use authorization from the FDA for protection against SARS-CoV-2 with full approval expected to be granted. The first is Moderna, an mRNA vaccine, authorized for those 18 years and older consisting of 2 injections given 28 days apart with full vaccination status reached 2 weeks after the second shot. The second vaccine is the Johnson and Johnson’s Janssen vaccine, which is a single shot viral vector vaccine authorized for those 18 years and older with full vaccination status reached 2 weeks after the injection. Currently, the FDA is recommending booster shots 6 months after the mRNA vaccination series for those 65 and older or over age 18 who live in long-term care settings, have underlying medical conditions, or work or live in high-risk settings. All adults 18 and over are eligible for a booster shot if they received the viral vector vaccination. For both the mRNA vaccines and the viral vector vaccine, any of the SARS-CoV-2 vaccines authorized for use in the United States may be administered. Information concerning vaccination continues to be dynamic with the above being the most updated information as of the time of the writing of this text.

Treatment: There is no pathognomonic cutaneous manifestations of SARS-CoV-2, and several of the drugs used to support patients can produce cutaneous manifestations. These patients are often extremely ill and hospitalized, and research is ongoing to determine the clinical value, prediction of time course, and dictation of treatment for those with SARS-CoV-2 cutaneous manifestations. Cardiac manifestations and their workup will be discussed in Chapter 35 : “Cardiac Disease in Athletes.”

Overview: Rapidly spreading bacterial infection characterized by S. aureus that is resistant to several antibiotic classes; the most common strain seen in athletes is community-acquired (CA-MRSA) species. Spread is via skin-to-skin contact, fomites, crowding, poor hygiene, scratching, and compromised skin integrity. As many as 76% of college wrestlers are carriers of CA-MRSA.

Presentation: Most often confused with spider bites or simple pustules

Physical examination: Infection begins with a small pimple-like lesion that quickly progresses to a hot, erythematous, inflamed, painful indurated area much larger than the original lesion; can occur on any part of the body

Diagnosis: Challenging, as the infection looks like other common infections; Gram stain and bacterial culture are diagnostic

Treatment: Treatment should begin, if suspected, before the culture results are identified. Treatment is via incision and drainage, if applicable, and intravenous (IV) antibiotics such as vancomycin for serious lesions. Minor or less serious lesions are treated with oral antibiotics for 7 to 14 days. Consider trimethoprim with sulfamethoxazole (Bactrim) 2 DS BID or doxycycline 100 mg BID, unless the athlete will be spending time in direct sunlight, for 7–14 days. Clindamycin 400 mg PO TID or linezolid 600 mg PO BID can be used also for 7–14 days. It is recommended to add mupirocin 2% ointment TID to the noted antibiotic regimens; prevented by not sharing uniforms, towels, or equipment. Area of infection should be dried last after showering, and the towel must be immediately laundered. Treatment of chronic carriers is controversial.

Return to sport: After complete antibiotic course with wounds dried and crusted and formation of no new lesions. It is not enough just to cover active infectious lesions to allow competition by the athlete.

Prevention: The efficacy of treating potential MRSA carriers via decolonization in order to prevent spread of infection remains inconclusive. When attempted, the combination of chlorhexidine washes combined with 2% mupirocin ointment is recommended. Written policies for identification and treatment of skin infections and procedures for equipment cleaning may decrease CA-MRSA infections.

Overview: Caused by beta-hemolytic Streptococcus or S. aureus. Infection usually begins as small red blisters on erythematous skin. Blisters then break, forming characteristic honey-colored scabs that may be pruritic. If left untreated, impetigo can cause renal damage. Infection usually resolves within 2 weeks without scarring. Spread is either skin to skin or via fomites; can spread by scratching or drying after shower.

Presentation: Often begins as a small lesion; often, if initial rash begins around the mouth, it can be confused with herpes labialis

Physical examination: Most often seen on face or forehead, but can occur anywhere

Diagnosis: Characteristic rash, but Gram stain with bacterial culture is definitive

Treatment: Small areas may be treated with antibiotic creams or ointments

Consider 2% mupirocin (Bactroban) TID for 7–14 days. Oral antibiotics should be used for larger areas. Consider clindamycin 400 mg PO TID, cephalexin 250 mg PO QID, or dicloxacillin 250 mg PO QID 7–14 days combined with mupirocin 2% ointment TID. Consideration should be given to immediate treatment for MRSA, if suspected. Infection often prevented by not sharing uniforms, towels, or equipment. Area of infection should be dried last after showering and the towel immediately laundered.

Return to sport: Return is not advisable until all blisters have crusted and 3 days of antibiotic treatment have been completed without new lesions for 48 hours before competition. It is not enough just to cover active infectious lesions to allow competition by the athlete.

Overview: Infection of the dermis and subcutaneous tissues usually by group A Streptococcus and/or S. aureus.

Cellulitis most often occurs after a break in the skin such as a laceration, abrasion, or puncture wound (see Fig. 40.2 ); can spread skin to skin or by fomites

Presentation: Often begins with a gradual onset of pain and swelling that may or may not be associated with a recent break in the skin

Physical examination: Presents initially as a painful, erythematous, swollen patch that spreads as the infection spreads; the infection can be associated with fever and chills

Diagnosis: Characteristic rash of an erythematous, edematous patch; Gram stain or bacterial culture and/or blood cultures are diagnostic

Treatment: Oral antibiotics, and if severe, IV antibiotics. Oral antibiotics can include cephalexin 250 mg PO QID or dicloxacillin 250 mg PO QID for 7–14 days. Warm compresses, pain medications, and incision and drainage can be helpful. Marking location and looking for spread beyond the line of demarcation can be suggestive of antibiotic resistance. Consideration should be given to immediate treatment for MRSA, if appropriate.

Return to sport: Three days of antibiotic treatment have been completed without new lesions for 48 hours before competition, afebrile, cessation of pain, and healing of wound. It is not enough just to cover active infectious lesions to allow competition by the athlete.

Overview: Characterized by red-ringed papules, pustules, or crusts at hair follicles most commonly caused by S. aureus, Candida, or Pseudomonas aeruginosa, demodex (see Fig. 40.2 ). Steroids may also cause folliculitis. Infection may evolve to boils or carbuncles.

Presentation: Seen in areas of body that have been shaved or areas with friction from equipment or uniforms; spread is via skin to skin or fomites

Physical examination: Seen in areas of friction such as groin, thighs, buttocks, or gluteal folds

Diagnosis: History and characteristic rash, but Gram stain and bacterial culture are diagnostic

Treatment: Removal of irritant, topical antiseptics, antibiotic creams or ointment, and good hygiene; significant cases involving bacteria require cephalexin 250 mg PO QID or dicloxacillin 250 mg PO QID for 7–14 days.

Return to sport: No restriction with lesion coverage

Overview: Folliculitis seen in athletes who use hot tubs or whirlpools caused by P. aeruginosa type 0:11

Presentation: Appears on areas of skin submerged in the water, particularly the axilla and the groin; systemic symptoms, including fever, chills, lymphadenopathy, and fatigue, may occur. Rash duration is usually 7–10 days.

Physical examination: Small erythematous papules that may convert to green pustules seen in the axilla or the groin

Diagnosis: Characteristic rash, but definitive diagnosis via Gram stain and bacterial culture

Treatment: Often self-limiting.

Oral antibiotics should be considered for patients who have systemic symptoms. The affected hot tubs and whirlpools should be drained and cleaned with discovery of infection.

Return to sport: No restriction; cover with bio-occlusive dressing

Overview: Hair follicle infection by S. aureus or Streptococcus from trauma or direct contact with a furuncle on another athlete (see Fig. 40.2 ). Fomites can also spread infection.

Presentation: Begins as infection of hair follicle that often evolves to a loculated pustule

Physical examination: Usually on the upper extremities or trunk and present as erythematous nodules with or without purulence; often painful

Diagnosis: Lesion appearance; Gram stain and bacterial culture are diagnostic

Treatment: Purulent lesions should be incised and drained. Treatment is via topical or cephalexin 250 mg PO QID or dicloxacillin 250 mg PO QID for 7–14 days; if suspicious, presumptive treatment for MRSA should be considered before culture results are obtained. Infection can often be prevented by not sharing uniforms, towels, or equipment. Area of infection should be dried last and the towel immediately laundered.

Return to sport: Three days of antibiotic treatment have been completed without new lesions for 48 hours before competition and lesion coverage with a bio-occlusive dressing

Overview: Acne breakout, including papules, pustules, comedones, nodules, and cysts, that is caused by bacterial infection in an area of tight-fitting clothing or ill-fitted equipment such as helmets or shoulder pads (see Fig. 40.2 ). Friction, heat, and occlusion lead to acne mechanica.

Presentation: The equipment causes erythema and friction at the site of contact with the skin. The site then often becomes infected.

Physical examination: Rash appears as erythematous papules and pustules on the back, shoulders, chin, or forehead.

Diagnosis: Characteristic rash in area of equipment/clothing; Gram stain and bacterial culture are definitive

Treatment: Topical antibiotics and astringents. More severe outbreaks can be treated with oral antibiotics. Good hygiene, wicking undergarments, and refitting of equipment can help prevent further breakout.

Return to sport: No restrictions

Overview: Bacterial infection caused by Kytococcus sedentarius, Dermatophilus congolensis, Corynebacterium, Actinomyces, or Streptomyces. These bacteria secrete proteinases that destroy the keratin of the stratum corneum of the skin, producing depressed lesions and pits on the sole of the foot but can be on hands as well (see Fig. 40.2 ).

Presentation: Infection in areas of macerated tissue from extended exposure to moist, warm conditions in nonbreathable shoes seen with cross-country runners or marathoners. Most cases exhibit no discomfort, but multifocal erosions can cause pain. Patients may have foul-smelling infectious lesions for months before presentation because of sulfur production from bacterial by-products.

Physical examination: The rash appears as scaly pits with associated foot odor.

Diagnosis: Characteristic rash or bacterial culture is definitive.

Treatment: Infection is treated with topical mupirocin, clindamycin, or erythromycin. Benzoyl peroxide may be helpful. Topical 20% aluminum chloride or botulinum toxin injection may decrease hyperhidrosis to create a less hospitable bacterial environment. The infection can be prevented with good hygiene, synthetic socks, and allowing ventilation of the feet.

Return to sport: No restrictions

Overview: Occurs when inappropriately cut nails or nails damaged from sport grow into the subcutaneous tissue causing infection by Streptococcus and S. aureus (see Fig. 40.2 ).

Presentation: Pain, inflammation, and erythema, followed by purulent drainage at the advancing nail edge

Physical examination: Seen on any toe

Diagnosis: Lesion appearance; bacterial culture is diagnostic

Treatment: Incision and drainage of the purulent pocket and trimming or cutting back of the nail; oral antibiotics, pain medications, and warm compresses also used; prevention by appropriate nail trimming and wearing of appropriately fitting footwear. Surgical destruction of part of the nail bed is often curative.

Return to sport: Passing of functional testing