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.

While 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

  
  
• •
  

  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).

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.

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

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

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

The efficacy of treating potential MRSA carriers in order to prevent spread of infection remains inconclusive.

Overview : Caused by the herpes simplex virus (HSV); HSV is common in the general population as well as among athletes, particularly wrestlers. Herpes consists of 2 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. Herpes gladiatorum is caused by HSV-1. In a typical season, 2.6% of high school wrestlers and 7.6% of college wrestlers will suffer from herpes gladiatorum; 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 will begin with flu-like 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. The rash disappears in 2 weeks without scarring.

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.

Diagnosis: The rash is usually characteristic, but a Tzanck smear can be performed in questionable cases. Viral cultures can also be performed to confirm diagnosis and type (HSV-1 vs. HSV-2).

Treatment: Treatment is with oral antivirals for 7–10 days for initial infections. Consider valacyclovir (Valtrex) 1 gm BID for 7–10 days. Treatment for recurrent infections should be valacyclovir 1 gm QD for 5 days. Consider suppression dosing for those with chronic recurrent infections approximately six times per year. The drug of choice would be valacyclovir 1 gm QD. Acyclovir can be used in place of the above but resistance does exist. The initial treatment dose is 400 mg TID for 7–10 days. The dose for recurrence is 400 mg TID for 5 days, and the suppression dose is 400 mg BID. Famciclovir can also be considered if there is resistance to both acyclovir and valacyclovir. Topical antivirals are often not effective if used alone.

Return to play: Varies by sport but most often is after a course of 5 days of oral antiviral treatment with no new systemic symptoms or lesions for 72 hours; all lesions must be dry and crusted

Overview: Caused by HSV-I 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.

Herpes simplex.

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 gm BID for 1 day, which should be started as soon as the athlete experiences the viral prodrome.

Return to sport: Varies by sport

Available literature is more consistent for return to sport with herpes gladiatorum, but in most recommendations for return with herpes labialis, the lesions should be crusted over and dry before return.

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 gm every 8 hours for 7 days and pain medications as soon as prodromal symptoms occur; physicians must be cautious not to prescribe banned substances for pain

Return to sport: Varies by sport, but most often is after a course of oral antiviral treatment with no new systemic symptoms or lesions for 72 hours; all lesions must be dry and crusted

Overview: Viral lesion that spreads skin to skin or via fomites; characterized by single or multiple discreet, flesh-colored, dome-shaped papules with a central dimple. 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; often lesion removal and 48 hours of recovery to prevent secondary infection

Overview: Verrucous plaques and papules found most often on the epidermis of the hands due to 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 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

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

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

Treatment: Removed by excision, 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

Overview: Rapidly spreading bacterial infection characterized by Staphylococcus 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.

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; bacterial culture is diagnostic

Treatment: Treatment should begin, if suspected, before the culture results are identified. Treatment is via incision and drainage and IV antibiotics such as vancomycin for serious lesions. Minor or less serious lesions are treated with oral antibiotics for 14 days. Consider trimethoprim with sulfamethoxazole (Bactrim) 2 DS BID for 14 days or doxycycline 100 mg BID for one day and then 100 mg QD for 13 days, unless an athlete will be spending time in direct sunlight; 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