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Dermatologic Conditions in the Athlete Population

By Jacob Mathew, Jr. DO, FACOI, FACP, CHSE, FAWM

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

hsv_glad_29989.jpg  hsv_glad_42662.jpg

 

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

molluscum_8036.jpg  molluscum_129193.jpg

 

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)

Tinea capitis

capitis_98132.jpg   

 

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.

 

Tinea cruris

cruris_94316.jpg  cruris_94318.jpg


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.

 

Onychomycosis

onychomycosis_6391.jpg  onychomycosis_6400.jpg


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.


Warts 

common_wart_13842.jpg  common_wart_85710.jpg

 

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.

 

Impetigo

impetigo_2421.jpg  impetigo_1814.jpg


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.

 

Folliculitis 

folliculitis_28639.jpg folliculitis_800.jpg

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_57314.jpg mrsa_57841.jpg

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.

 

 TABLE 1 | Common treatments to consider based on the condition          
Condition Description Return to play
Tinea capitis
  • Fluconazole 100-200 mg for 3-6 weeks
  • Griseofulvin 375-1000 mg for 6-12 weeks
  • Itraconazole 200 mg for 2-4 weeks
  • Ketoconazole 200-400 mg for 2-4 weeks

NCAA and NFHS: after 14 days of treatment

Tinea pedis
  • Butenafine (Lotrimin Ultra) 1% cream twice daily for 1 week or once daily for 4 weeks
  • Ciclopirox 0.77% topical twice daily for 4 weeks (Raza Aly, 2003)
  • Luliconazole 1% cream daily for 2 weeks

No restrictions

Tinea corporis
  • Butenafine (Lotrimin Ultra) 1% cream one daily for 2 weeks
  • Ciclopirox 0.77% topical twice daily for 4 weeks
  • Luliconazole 1% cream daily for 1 week

NCAA: After 72 hours of treatment, with covering of lesions

NFHS: After 72 hours of treatment, with a release statement by the team physician and covering of lesions

Tinea versicolor
  • Selenium sulfide 2.5% shampoo for 5-10 minutes, then rinse. Complete for 1 week
  • Ketoconazole shampoo for 5-10 minutes, then rinse. Complete daily for 1-4 weeks
  • Extensive cases may require oral antifungal therapy

No restrictions

Viral (herpes)

Primary treatment (for 14 days):

  • Acyclovir 400 mg 5 times daily
  • Famciclovir 500 mg 3 times daily
  • Valacyclovir 1000 mg twice daily to 3 times daily

Treatment for recurrence (for 5 days):

  • Acyclovir 400 mg 3 times daily
  • Famciclovir 125 mg twice daily
  • Valacyclovir 1000 mg twice daily

Chronic suppression (daily):

  • Acyclovir 400 mg 3 times daily
  • Famciclovir 125 mg twice daily
  • Valacyclovir: < 10 episodes per year: 500 mg daily; ≥ episodes per year: 1 g daily

Primary infection:

  • NCAA: All vesicles must have crusted over (no active lesions), with no systemic symptoms reported for at least 72 hours, and on oral therapy for at least 120 hours
  • NFHS: On oral therapy for at least 10 days with no new lesions in the past 2 days, and all lesions should be crusted

Recurrent infection:

  • NCAA: no active lesions and on oral therapy for at least 120 hours
  • NFHS: On oral therapy for at least 120 hours, with no new lesions in the past 48 hours, with all current lesions crusted over
Molluscum contagiosum (Burris, n.d.)

Lesions will resolve within 6-13 months if no treatment is rendered

  • Cryotherapy
  • Curettage
  • Laser therapy
  • Topical blistering agent (cantharidin)

Genital lesions:

  • Cryotherapy
  • Podophyllotoxin 0.5% topical twice daily for 3 days (can repeat after 4 days of treatment)
  • Imiquimod cream 3 times per week (wash off after 6 hours) for 16 weeks
  • NCAA/NFHS: site must be covered, and lesion must have been removed
  • NFHS: must also be at least 24 hours out from lesion removal)
Verrucae
  • Cryotherapy
  • Curettage
  • Laser therapy
  • Topical blistering agent

NCAA/NFHS: Use mask if on face, cover otherwise for other body parts

MRSA, uncomplicated

Incision and drainage if abscess present.

Treat with antibiotics for 5-10 days:

  • Clindamycin 300-450 mg by mouth 3 times daily
  • Trimethoprim-sulfamethoxazole 1-2 double-strength tablets twice daily
  • Doxycycline 100 mg by mouth twice daily
  • Linezolid 600 mg by mouth twice daily

NCAA/NFHS: no new lesions in 48 hours

Cellulitis (non-purulent)
  • Clindamycin 300-450 mg by mouth 4 times daily for 5 days
  • Penicillin V 250-500 mg by mouth every 6 hours for 5 days
  • Cephalexin 500 mg by mouth every 6 hours for 5 days
  • NCAA: no active infections allowed
  • NFHS: lesions must have scabbed over
Folliculitis

 See MRSA above

  • NCAA: can cover lesions if infection deemed inactive
  • NFHS: all lesions must be scabbed
Impetigo

If suspected MRSA, see cellulitis treatment above

Topical:

  • Mupirocin 2% ointment 3 times daily for 5-7 days
  • Retapamulin 1% ointment twice daily for 5 days
  • Fusidic acid 2% cream 3 times daily until healed

Oral (if numerous lesions):

  • Dicloxacillin 250 mg by mouth 4 times daily for 7 days
  • Cephalexin 250 mg 4 times daily for 7 days

 NCAA/NFHS: no draining lesions

Scabies (Taplin D, 1990)  

Topical permethrin 5% applied as a thin layer to all skin surfaces (neck down to toes); keep on for 8-14 hours, then wash off. Continue this daily for 1 week. Do not place on mucous membranes or the eyes.

Oral treatment with ivermectin can also be used in patients who cannot use topical at 200 mcg/kg once, then given again 2 weeks later.

  • NCAA: must have completed treatment and have negative results on mineral oil preparation
  • NFHS: must be 24 hours from treatment with no evidence of infestation

 

National Collegiate Athletic Association (NCAA) and the National Federation of State High School Associations (NFHS).

References

  1. Burris, K. (n.d.). Molluscum Contagiosum. Retrieved from DynaMed: https://www.dynamed.com/condition/molluscum-contagiosum
  2. Ely John W, R. S. (2014). Diagnosis and Management of Tinea Infections. Am Fam Physician, 702-710.
  3. Gehris, R. P. (2018). Dermatology. In B. J. Zitelli, S. C. McIntire, & A. J. Nowalk, Zitelli and Davis' Atlas of Pediatric Physical Diagnosis (pp. 275-330).
  4. Johnson, J. (2016, May). Skin Infections in Athletes. Retrieved from OrthoInfo.
  5. Likeness, L. (2011). Common Dermatologic Infections in Athletes and Return-to-Play Guidelines. The Journal of the American Osteopathic Association, 373-379.
  6. Raza Aly, G. F. (2003). Ciclopirox Gel in the Treatment of Patients With Interdigital Tinea Pedis. Int J Dermatol, 29-35.
  7. Sahoo, A. K., & Mahajan, R. (2016). Management of tinea corporis, tinea cruris, and tinea pedis: A comprehensive review. Indian Dermatol Online J., 77-86.
  8. Taplin D, M. T. (1990). Comparison of crotamiton 10% cream (Eurax) and permethrin 5% cream (Elimite) for the treatment of scabies in children. Pediatr Dermatol.

 

 

 

 

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