Unless otherwise stated, all treatments and doses are for adults and not weight based for the pediatric population.
So, what are we talking about here?
When we think of the athletic population and medicine, our minds will most often think of concussion and return-to-play guidelines. While this topic carries tremendous importance on its own, it is pivotal also to think of the myriad contagious dermatologic conditions that are spread via direct and indirect contact in athletes. It is estimated that 21% of health conditions in college athletes and almost 9% in high school athletes are related to skin diseases, half of which involve the head, face, or neck. (Likeness, 2011) Cultures have found that the most common culprits are methicillin-resistant and methicillin-sensitive Staphylococcus and Streptococcus as well as tinea and viruses such as herpes.
As a provider, you will have such players presenting to you in hopes that you can not only diagnose the condition but also help get them back to playing as soon as possible. As a result, earlier recognition and understanding the risks posed to others are pivotal to preventing spread and to determining if your patient can return to play during treatment or if an extended absence until completing treatment is necessary.
How common are skin conditions in the athletic population, and what causes them?
As mentioned above, rates vary depending on the age of the patient. About half involve the head, neck, and face from direct contact with an infected opponent. (Likeness, 2011) Looking broadly, bacterial sources are seen in 30% of cases, with viruses accounting for 20% and fungi about 20% in high school athletes specifically. We see a drastic change when looking at the collegiate population, with herpes gladiatorum accounting for 47% of cases, bacterial infections (specifically impetigo) for 37%, and fungal infections (tinea) for 7%. (Likeness, 2011) It is unknown what accounts for the changes seen between these age groups.
Let’s review some of the more common conditions I will encounter as a provider.
Herpes Simplex Virus:
Herpes gladiatorum is a very common skin infection caused by herpes simplex virus type 1 (HSV-1), with infection rates in the United States reaching up to 90% in adults. While HSV-1 can be treated, there is no cure. Alternating active and inactive states based on stress levels lead to the presence or absence of clinical symptoms (typically presenting as a cluster of vesicular, fluid-filled lesions with surrounding erythema). Systemic symptoms such as fever and lymphadenopathy may also be reported. Regardless of the presence of clinical symptoms, transmission to uninfected individuals is possible. While common infections can be treated by the primary care provider, any involvement of the eye should prompt urgent ophthalmologic referral. Treatment involves antiviral therapy (see Table 1 below); however, without treatment, the vesicles will heal within 7-10 days. Recurrence typically appears in the same location as the initial infection.
Mollusca:
Molluscum contagiosum is caused by the pox virus, with associated lesions called Mollusca, and is typically encountered in young children and teens. If you see this in adults, you should always consider human immunodeficiency virus (HIV) as well. Mollusca are often small (3-4 mm in diameter), pink, and dome-shaped with a dimple in the center. The infection can be spread by skin-to-skin contact or through contact in wet environments, such as pools, with someone who has the infection. Mollusca lesions are typically seen in clusters on the body’s flexural regions (axilla, elbow creases, and posterior knees). (Johnson, 2016)
Tinea infections: (Ely John W, 2014)
Look for patchy hair loss with crusted sores. It is essential to start treatment as soon as possible, as an abscess with permanent hair loss can occur if the infection is left untreated.
Also called “jock itch.” This is a dermatophyte infection occurring in the groin, seen mostly in young adult males. Interestingly, the scrotum will be spared, but the upper inner thighs will be the primary area of involvement. If you see scrotal involvement, consider Candida.
Fungal infections of the nails, presenting as thickened, discolored nails (typically yellow), are very common and increase in frequency with age. Don’t be fooled — it may be easy to attribute the changes simply to trauma, but a heightened awareness for infection can help prevent permanent nail damage from occurring due to delayed treatment.
These skin growths due to human papillomavirus (HPV) are most commonly seen in the feet of athletes who do not wear shower shoes or who walk barefoot when roaming locker room floors. They will present as flesh-colored outgrowths, but overlying punctate, black lesions are consistent with warts, rather than callouses, which can look similar.
Staphylococcus aureus
Staphylococcus is the most commonly transmitted bacterial skin infection in athletes, presenting as folliculitis, impetigo, or abscesses.
Look for clusters of erythematous, round, scaly patches, often covered with honey-colored crust. Patients will complain of rapid spread of the infection, typically within 24-48 hours. Typical involvement is of the lower face, but, if not treated immediately, it is not uncommon to see the extremities and torso involved.
Look for small, white pustules within individual hair follicles. Any areas with hair are at risk, such as the scalp, axilla, and legs. Diffuse involvement should increase suspicion for inoculation via shaving (ask if the patient is sharing a shaver, or if they are using the same blade for the entire body).
Methicillin-resistant S aureus (MRSA)
MRSA is a strain of S aureus infection that is resistant to penicillin and its analogs. Understanding the local antibiotic resistance patterns in your region (or from that in which the athlete resides) can prevent spread of the infection due to inadequate treatment. Look for a solitary abscess or milder forms such as impetigo and folliculitis. Abscesses require incision and drainage. Concurrent oral antibiotic use is left up to the discretion of the treatment provider, but compliance with the Infectious Diseases Society of America (IDSA) guidelines is highly advised. Overall, long courses of antibiotic therapy are often required, with trimethoprim-sulfamethoxazole (Bactrim), doxycycline, or clindamycin. Consider eradication protocols if colonization is suspected.
For recurrent outbreaks, recommend chlorhexidine solution (an antiseptic body wash) for skin decolonization and a prescription antibiotic nasal ointment for nasal decolonization.
How can my patient prevent from getting infected?
General precautions include washing hands frequently with soap and water, showering immediately after practice (rather than waiting until getting home), using shower shoes when in a communal shower, consistent washing of gear and uniforms, not sharing any personal hygiene items, and using a towel on shared gym equipment.
