Current Issues:  Infectious Skin Conditions in Sports

Matthew R. Doyle, MS, LAT, ATC

February 10, 2005

University of Iowa

Department of Intercollegiate Athletics

Case Study

n    19 y.o. male wrestler

n    Requests evaluation of lesion on forehead

n    Reports throat is swollen and painful

–   lymphadenopathy

n    History of lesion at site four weeks earlier

n    Prior to lesion he experienced tingling, burning, and itching

Case Study

Infectious Skin Conditions

n    Familiar with derm terms

n    Grouped vesicles on erythematous base

n    Prodromal Stage

n    Vesicle stage

n    Ulceration and crusting stage

n    HSV-1 or herpes simplex gladiatorum

Infectious Skin Conditions

n    Primary Objective to discuss current research related to:

–   Herpes Simplex Virus (HSV) shedding

–   HSV treatment

–   CA-MRSA (Community Acquired Methicillin-resistant Staphylococcus Aureus)

Infectious Skin Conditions

n    Objectives: Briefly review common conditions in sports

–   Identification and description

–   Treatment options

–   Participation guidelines

Infectious Skin Conditions

n    Objectives: Review risk management guidelines

n    Skin Infection Prevention Program

n    Abrasions and wounds increase likelihood of infection

NCAA Guidelines: Categories of Skin Infections

n    Bacterial

–   Impetigo, cellulitis, carbuncle, staphlococcal disease, folliculitis, hidradentitis suppurativa

n    Fungal

–   Tinea corporis

n    Parasitic

–   Pediculosis

–   Scabies

n    Viral

–   Herpes simplex

–   Herpes zoster

–   Molluscum contagiosum

Dermatoses associated with swimming and other aquatic sports

n       Bacterial Infections

n       Hot tub folliculitis (pseudomonas aeruginosa)

n       Otitis externa (pseudomonas aeruginosa)

n       Pseudomonas hot foot syndrome (pseudomonas aeruginosa)

n       Swimming pool granuloma (Mycobacterium marinum)

n       Other infections

n       Tinea pedis (dermatophytes)

n       Plantar warts (human papillovirus)

n       Seabather's eruption (Edwarsiella lineate, Lunuche unguiculata)

n       Swimmer's itch (Schistosome larva)

n       Dermatoses caused by swim gear

n       Scuba diver facial dermatitis

n       Diving suit dermatitis

n       Purpura goggelorum

n       Bikini Bottom

n       Miscellaneous dermatoses

n       Swimmer's xerosis

n       Surfer's nodule

n       Waterslide alopecia

n       Swimmer's shoulder

n       Green hair

n       Aquagenic urticaria

n       Melanoma

–     Metelitsa A, et al. Diagnoses of sports-related dermatoses. Int J Dermatol. 2004 Feb:43(2): 113-9.

Infectious Skin Conditions

n    Fungal infections (dermatophyte)

–   Named according to location

n  Tinea capitus-head

n  Tinea corporis- parts of body not covered with hair

n  Tinea cruris- groin (“jock itch”)

n  Tinea pedis- foot (“athlete’s foot”)

–   Population

n  Tinea Corporis Gladiatorum

Infectious Skin Conditions

n    Fungal infections

–   Tinea corporis (Ringworm):

n   Circular patches with red, raised, scaly borders and central clearing.  May be mildly pruritic.

Infectious Skin Conditions

n    Contagiousness 

–   Depends on host’s immune response

–   Person to person vs. fomites

–   Favorable conditions (warm, moist, occlusive conditions)

Infectious Skin Conditions

n    Fungal infections

–   Diagnosis

n  Clinical appearance

–   Can mimic eczema, herald patch of pityriasis rosea

n  KOH, scrapings under microscope

–   Treatment

n  Topical- cidal antifungals best (Naftin, Lamisil)

n  Systemic- if widespread or in locations with hair

n  Unknown minimum duration of therapy

Infectious Skin Conditions

n    Tinea corporis gladiatorum prevalence ranges from 20-77%

n    Trichophyton tonsurans

n    Transmission by skin to skin contact

n    Tx and prevention with fluconazole

n    No definitive approach to treatment and prevention

n   Adams, BB. Tinea corporis gladiatorum. J Am Acad Dermatol. 2002 Aug: 47(2): 286-90.

Fungal Infections: Guidelines for return to participation

n    NCAA

n   3 days of topical treatment with cidal antifungal for T. corporis

n   2 weeks systemic therapy for T. capitus

n   Extensive disease or cluster of lesions in area that cannot be “adequately covered” can disqualify wrestler

n   Covering routine:

–   Selenium sulfide/ketocnazole washing of lesion

–   Application of topical cidal antifungal

–   Gas permeable dressing (Op-site, Bioclusive)

–   Pro-Wrap and stretch tape

–   Dressing changes after each match

n   Activity of lesion can be judged by

–   KOH and Review of therapeutic regimen

–   Ultimately up to discretion of examining physician- can disqualify athlete even with note from treating physician

Infectious Skin Conditions

n    Herpes Simplex infections

–   Herpes Simplex Virus (HSV)

n  Type 1- tend to be around mouth- “herpes labialis”

n  Type 2- tend to be genital lesions

n  Gladiatorum- type 1 anywhere as result of contact

n  Zoster- reactivation of varicella zoster (chicken pox) along unilateral dermatome.

Infectious Skin Conditions

n    HSV

–   Type 1/Gladiatorum

n  Primary outbreak

–   Systemic symptoms: fever, malaise

–   Widespread oropharyngeal symptoms with labialis infection

–   Vesicular lesions on erythematous base

–   May last 1-2 weeks

n  Recurrent outbreaks less severe

–   Latency of  HSV: survives in nerve root ganglion

–   Reactivated by stress, sleep deprivation, sun exposure

–   Outbreak shorter (days-week)

Infectious Skin Conditions

n    HSV

–   Diagnosis

n   Clinical suspicion

n   Contact with infection

n   Testing

–   Tzank smear

–   Viral culture

–   Antibodies

–   PCR-DNA

Infectious Skin Conditions

n    HSV

–   Complications

n  Widespread infection (team, opponent, camp)

n  Secondary infections

n  Ocular infection-> visual impairment

Infectious Skin Conditions

n    HSV Treatment

n  No cure

n  Anti-virals reduce intensity and duration of outbreak

–   Reduce viral shedding

n  If used prophylactically, may prevent outbreak

–   Reduce asymptomatic shedding

–   Watch for ocular involvement

–   Disqualification

Infectious Skin Conditions

n    HSV Treatment (primary infection)

–   Acyclovir 200 mg 5 times a day for 10 days

–   Famciclovir 500 mg 3 times a day for 7 days

–   Valacyclovir 1000 mg two times a day for 7 days

Infectious Skin Conditions

n    HSV Treatment (recurrent infection)

–   Acyclovir 200 mg 5 times a day for 7 days

–   Famciclovir 125 mg 2 times a day for 5 days

–   Valacyclovir 500 mg two times a day for 5 days

–   Penciclovir and docosonal (topical) minimally reduces pain, virus shedding, and accelerates healing of HSV-1

Infectious Skin Conditions

n    HSV Prophylaxis

–   Valacyclovir 1000 mg/day during first two years

–   Valacyclovir 500 mg/day after two years

–   Acyclovir 400 mg 2 times a day has been significantly less effective

n    Anderson, BJ. The effectiveness of valacyclovir in preventing reactivation of herpes gladiatorum in wrestlers. Clin J Sport Med 1999;9(2):86-90

Infectious Skin Conditions

n    HSV

–   Guidelines for return

n   http://www.ncaa.org

n   http://www.iahsaa.org/skinform.pdf

–   No systemic symptoms AND

–   No new blisters for 3 days AND

–   No moist lesions (lesions must be dry with firm, adherent crust) AND

–   Must be using appropriate dosage of systemic antiviral therapy for at least 5 days

–   Lesions can’t be covered to allow participation

Infectious Skin Conditions

n    Polymerase chain reaction (PCR) detection of HSV has advanced the understanding of both the magnitude and frequency of shedding as well as the impact of antiviral therapy.

Infectious Skin Conditions

n    Factors that affect HSV shedding

–   Site

–   Time since acquisition

–   Immune status

–   Virus type

Infectious Skin Conditions

n    HSV shedding

–   During prodrome and reactivation

–   Also while asymptomatic

n    HSV-1 less studied than HSV-2

n    Antivirals reduce excretion of virus during a 5 day time lag

n    Does this decrease transmission/infection?

n    Infection Threshold

Infectious Skin Conditions

n    Bacterial Infections

–   Impetigo

n  Secondary infection

n  Staphylococcus or streptococcus

n  “honey colored crust”

n  Surrounding redness

n  Treatment

–   Cephalexin 500 mg qid for 7-10 days

–   Topical ointment like Bactroban

Infectious Skin Conditions

n    Bacterial Infections

–   Furuncles and Carbuncles:

n  Furuncle= boil

n  Carbuncle

n  Treatment

–   Oral antibiotics

–   Warm compresses

–   Incision and drainage

–   Watch for signs of worsening infection/ cellulitis

Infectious Skin Conditions

n    Bacterial Infections

–   Folliculitis

n  Hair follicles appear red, inflamed and may have pustular heads

n  No generalized redness

n  Often at site of irritation from clothing, brace, etc.

n  Treatment

–   Antibacterial washes

–   Keep dry

–   Watch for signs of worsening infection

–   Oral antibiotics if necessary

Infectious Skin Conditions

n    Bacterial Infections

–   NCAA Guidelines for participation

n  No new lesions for 2 days

n  Must have 3 days of appropriate antibiotic therapy and have no moist, exudative or draining lesions currently

n  Gram staining of questionable lesion if available

n  Active lesions cannot be covered to allow participation

Infectious Skin Conditions

n    Bacterial Infections

–   Methicillin-resistant Staphylococcus aureus or MRSA

–   Appearance of previously discussed bacterial infections

n    Centers for Disease Control and Prevention issued alert in August 2003,reporting clusters of infections in athletes since 2000

Infectious Skin Conditions

n    Bacterial Infections

–   Community Acquired/Associated) CA-MRSA

n  Historically associated with health-care institutions, but this pathogen has different risk factors

–   Risk factors:

n  Cuts, scrapes, open wounds, skin trauma from turf burns and shaving (skin breakdown)

–   Transmitted by skin to skin contact, sharing towels, or equipment

Infectious Skin Conditions

n    CA-MRSA

–   Diagnosis made in the outpatient setting or by culture

–   Patient has no history of MRSA infection, hospitalization (nursing home etc.),surgery

–   No permanent indwelling catheters or medical devices that pass through skin

Infectious Skin Conditions

n    CA-MRSA

n    Unique properties of virulence factors and genetic material

n    Outbreak wound isolates

–   Standard Microbiologic Testing Procedures

n   carried mecA and SCCmech type IVa gene alleles for methicillin resistance, as well as Panton-Valentine leukocidin toxin gene

Infectious Skin Conditions

n    CA-MRSA

–   Typically limited to skin and soft tissue vs. deep

–   More susceptible to 4 antimicrobial classes

–   Microbiologically distinct from HA-MRSA

n  Mutated from a separate strain in the community

Skin Infection Prevention

n      Instruct athletes to check skin daily for breaks or abnormalities, teach them how to identify infected wounds

n      Make sure all wounds are reported, examined, cleaned, and appropriately treated;  Cover all wounds including scrapes, scratches, and cuts

n      Have team physician evaluate skin lesions and manage disposition of participation

n      Shower after each workout using soap (don't share soap)

n      Do not share towels or personal items, uniforms, or equipment (as possible)

n      Wear clean workout gear each practice that has been laundered in hot soapy water

n      Report any unusual skin lesions as soon as detected

n      Screen athletes routinely

Skin Infection Prevention

n      Wipe and clean all training equipment following use with appropriate disinfectant spray, including mats, cardio equipment, weights

n      Clean, cover, and continually observe open wounds

n      Do not leave dirty towels, workout gear, and other equipment in lockers or workout areas

n      Isolate and treat infections until deemed non-contagious

n      In a skin sore is present, dry the infected area last with towel to avoid spreading the infection to uninfected areas

n      Routinely disinfect locker rooms, showers, weight rooms, and training areas

n      Practice sound nutritional practices for recovery and immune system support

n       Avoid overtraining and over-reaching stresses during practice and competition