Dermatolgic Disorders in Sport. Sports Medicine and the NFL The Playbook 13 David E. Olson, MD. Objectives

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1 Dermatolgic Disorders in Sport Sports Medicine and the NFL The Playbook 13 David E. Olson, MD Objectives Review basic functions of the integumentary system Recognize common infectious dermatoses seen in athletes Understand participation concerns for common infectious dermatoses Differentiate infectious from inflammatory dermatologic conditions seen in athletes Recognize common traumatic skin conditions seen in athletes 1

2 Functions of skin Physical barrier Protect against mechanical injury Bacteriocidal effects Prevents loss of body fluids Reduces penetration of UV radiation Helps regulate body temperature Sensory organ Provides surface for grip Vitamin D production Outpost for immune surveillance Terminology of Skin lesions Macule Papule Nodule Pustule Cyst Wheal Vesicle Bulla Scale Plaque Ulcer Furuncle Carbuncle Callus Fissure 2

3 Epidemiology Skin infections are the most common infectious disease outbreaks in sports Common infections: Staph, MRSA Herpes Tinea Implications for participation Need to prevent spread to other athletes Epidemiology Common non-infectious conditions Eczema Acne Contact Dermatitis Psoriasis Less common Exercise-induced urticaria 3

4 Staph infections > 12 million physician visits for skin and soft tissue infections each year Staph/MRSA most common cause of infectious disease outbreaks in athletics Highly virulent Staph in the community 25-30% of general population colonized with staph in nares, 1.5% with MRSA colonization - Athletes may have higher rates of staph carriage Oller et al, Journal of Athletic Training 2010 MRSA found on athletic equipment and facility surfaces Turf, door knobs, training tables, showers, sinks, etc Stanforth et al, J of Environmental Health

5 Risk Factors for Staph Infections Sharing towels, soaps, lotions Skin trauma Skin to skin contact between players Sharing of athletic equipment Cohen PR, Clinics in Dermatology (2008) 5

6 Clinical Features Spider bite Erythema Tenderness Pustule or fluctuance +/- Demarcated borders Furuncles, pustules, abscess, cellulitis Culture for definitive diagnosis Treatment Abscess- Incision and drainage Antibiotics- cover for MRSA Clindamycin Trimethroprim-Sulfamethoxazole Doxycycline Linezolid Close follow-up; IV antibiotics if not improving 6

7 NCAA participation guidelines BACTERIAL INFECTIONS: 1. Wrestler must have been without any new skin lesion for 48 hours before the meet or tournament. 2. Wrestler must have no moist, exudative or purulent lesions at meet or tournament time. 3. Gram stain of exudate from questionable lesions (if available). 4. Active purulent lesions shall not be covered to allow participation. Prevention Hygiene: Don t share towels or equipment! Education for athletes and staff Early recognition of skin infection Early evaluation and treatment Education program and use of sani-hands wipes Decreased incidence of CA-MRSA infection by 75% Sanders, JC. Journal of Community Health Nursing, 2009; 26:4,

8 Prevention Surveillance of nasal colonization? colonization did not correlate with infection Garza et al CJSM 2009 NFL Infectious Disease News - Jan 13 The Reduce MRSA Trial Screening vs No screening/universal Decon Decolonization Chlorhexadine body wash for 1 or more MRSA on the team Mupirocin nasal application Hidadrenitis suppurativa -chronic inflammation and abscesses of sebaceous and apocrine sweat glands - double comedone -sinus tracts common Staph Mimickers RX: long-term antibiotics 8

9 Psuedomonas spp. Contaminated pools/hot tubs Urticarial plaques with central papule or pustule Bathing suit distribution Spontaneous resolution 7-10 days Acetic acid 5%, silver sulfadiazine cream Prevention- proper hot tub/pool maintenance Hot tub folliculitis Erysipelas Inflammatory cellulitis Lymphatic streaking prominent Tense, deeply erythematous, warm Raised, Sharp borders Streptococci 9

10 Herpes Simplex Virus (HSV) Most Common skin infection in collegiate wrestlers Seen in up to 40% Not as common in football but still there! Up to 80% of general population have positive HSV-1 Antibodies Transmission of HSV Direct contact with virus (via skin or mucosal surface) Reactivation of latent virus Average time from exposure to symptoms - 8 days (range 4-11 days) Viral shedding can occur for several days prior to skin findings 10

11 Clinical features Grouped vesicles on erythematous base Later stages- crusts and erosions Head, face, neck are most common sites Primary infection- may have systemic symptoms Treatment Primary infection Valacyclovir 1000mg BID x 7 days Famciclovir 500mg TID x 7 days Acyclovir 200mg five times per day x 10 days Recurrent infection Valacyclovir 500mg BID for 7 days Expedites viral clearance by 1.7 days Expedites clinic resolution by 2 days Anderson BJ, CJSM

12 Prevention Isolate athletes with active infections Education of athletes, coaches Prophylactic medications Valacyclovir 1000 mg daily prevents recurrent infections among wrestlers NCAA participation guidelines HERPES SIMPLEX Primary Infection 1. Wrestler must be free of systemic symptoms of viral infection (fever, malaise, etc.). 2. Wrestler must have developed no new blisters for 72 hours before the examination. 3. Wrestler must have no moist lesions; all lesions must be dried and surmounted by a FIRM ADHERENT CRUST. 4. Wrestler must have been on appropriate dosage of systemic antiviral therapy for at least 120 hours before and at the time of the meet or tournament. 5. Active herpetic infections shall not be covered to allow participation. 12

13 NCAA Participation guidelines HERPES SIMPLEX: Recurrent infection 1.Blisters must be completely dry and covered by a FIRM ADHERENT CRUST at time of competition, or wrestler shall not participate. 2. Wrestler must have been on appropriate dosage of systemic antiviral therapy for at least 120 hours before and at the time of the meet or tournament. 3. Active herpetic infections shall not be covered to allow participation Herpes Mimickers Herpes Zoster Shingles Reactivation of dormant chicken pox in dorsal root ganglion Prodrome of tingling, prickling sensation Vesicles follow dermatome does not cross midline 13

14 Molluscum Contagiosum 1-2 mm shiny, fleshcolored, dome-shaped firm papule Localized, self-limited viral infection Skin-to-skin transmission or autoinoculation Curettage to remove lesions prior to participation Impetigo More common in children Occurs on face or extremities honey crust appearance Due to Staphylococci or Streptococci Can be seen as secondary infection of HSV Highly contagious 14

15 Clinical features Honey colored crusts May see vesicles or bullae Pustules Removing crusts will leave erythematous erosions, crusts reform Treatment Treatment Topical Mupirocin 2% ointment TID for small lesions Cephalexin 250mg QID Doxycycline 100mg BID TMP-SMX BID NCAA guidelines- must be fully resolved (typically 7 days) 15

16 Tinea Corporis Trichophyton tonsurans most common organism Also most common cause of Tinea capitis Transmission through direct skin-to-skin contact Tinea Corporis: Clinical features Erythematous, scaling plaque Well-defined, raised borders Central healing Often itchy Head, Neck, Upper extremities May not have classic ring shape 16

17 Treatment Topical antifungals Ketoconazole 2%, Clotrimazole 1% (OTC) Terbinafine (prescription) Apply cream for at least 2 weeks, continue 1 week after resolution Oral antifungals if not resovling Fluconazole Itraconazole Griseofulvin Oral vs Topical therapy Kohl et al, CJSM 1999: 27 High school wrestlers with Tinea corporis Time to 50% symptom improvement 11.9 days topical vs 10.1 days oral Time to 50% reduction in lesion area 18.7 days topical vs 17.2 days oral Time to 50% Culture eradication 22.1 days topical vs 11.1 days oral 17

18 NCAA participation guidelines TINEA INFECTIONS (ringworm) 1. A minimum of 72 hours of topical therapy is required for skin lesions. 2. A minimum of two weeks of systemic antifungal therapy is required for scalp lesions. 3. Wrestlers with extensive and active lesions will be disqualified. Wrestlers with solitary, or closely clustered, localized lesions will be disqualified if lesions are in a body location that cannot be properly covered. 4. The disposition of tinea cases will be decided on an individual basis as determined by the examining physician and/or certified athletic trainer. Prevention No Sharing of towels or other equipment Cover abraded skin Early recognition and treatment of lesions Prophylactic medications Fluconazole 100mg for 3 days, repeat at week six Reduced tinea prevalence from 64.7% to 3.5%; Adams BB, CJSM 2009 Itraconazole 200mg BID for 1 day, every 2 weeks Hazen PG & Weil ML, J Am Acad Dermatol

19 Tinea Mimickers Nummular Eczema Psoriasis Tinea Mimickers Contact Dermatitis Granuloma Annulare 19

20 Tinea Mimickers Lyme disease Erythema migrans Deer tick Target rash Asymptomatic Hx of travel to endemic area Treat with Doxycycline Tinea Versicolor Lipophilc yeast Heat and humidity Adolescence and young adults Usually asymptomatic Neck, trunk, upper arms hypopigmented or pink colored RX: selenium sulfide lotion, topical or oral antifungals Other Tineas 20

21 Other Tineas Tinea pedis Athlete s foot Interdigital Chronic scaly infection on plantar surface Acute vesicular Topical antifungals Shower shoes Foot powders, dry socks Corynebacterium overgrowth Moist, occluded feet Discrete pits on soles Strong odor Pitted keratolysis RX: topical erythromycin Synthetic socks, keep feet dry 21

22 Pityriasis Rosea Self-limited, often asymptomatic May have mild URI before rash Herald patch 1-2 cm Oval, scaly Smaller lesions over 1-2 weeks Trunk, proximal extremeties Resolves over 4-12 weeks Cold-induced Exercise-induced Drug-induced Pink plaques, wheals, confluent Dynamic process RX: antihistamines Urticaria 22

23 Traumatic skin disorders in athletes Nail dystrophies Runner s toe Tennis toe Soccer Chronic trauma to longest toe Nail thickening and discoloration May lose nail plate Calluses Traumatic skin disorders in athletes Chronic, repetitive friction Hypertrophy of skin Blisters Acute friction 23

24 Traumatic skin disorders in athletes Jogger s nipples painful, erythematous and crusted erosions Friction between skin and shirt Prevent with petroleum jelly or adhesive patches Talon noire intraepidermal bleeding from shearing forces applied to the skin Black macules on heels of basketball players Mogul s palm Palms of skier s Traumatic skin disorders in athletes Acne Mechanica erythematous papules and pustules distributed on the shoulders, upper back and chin Occurs beneath heavy protective equipment Shower after practice Moisture-wicking clothing under protective gear 24

25 Conclusions Skin infections are common in athletes MRSA, Herpes Simplex, Tinea Athletes should seek medical attention before particpating with active, wet or draining infections Education is key for prevention Early recognition, not sharing towels, etc Many inflammatory and traumatic conditions affect athletes as well With practice and recognition Derm issues aren t so scary!! Resources Adams BB. Dermatologic Disorders in the Athlete. Sports Med 2002;32: Johnson R. Herpes gladiatorum and other skin diseases. Clin Sports Med 2004;23: Turberville SD et al. Infectious Disease Outbreaks in Competitive Sports. Am J Sports Med. 2006; 34: Pazyar N. A review of applications of tea tree oil in dermatology. International Journal of Dermatology 2012:1-7 Preventing MRSA infections in Athletic Facilities. Centers for Disease Control and Prevention. ww.cdc.gov/mrsa/prevent/athletic.html, Accessed 2/25/2013. Brickman K et al. Fluconazole As a Prophylactic Measure for Tinea Gladiatorum in High School Wrestlers. Clin J Sport Med. 2009;19: ) De Luca JF et al. Skin Manifestations of Athletes Competing in the Summer Olympics: What a Sports Medicine Physician Should Know. Sports Med 2012; 42: Daniel M. Rackham DM et al. Community-Associated Methicillin-Resistant Staphylococcus aureus Nasal Carriage in a College Student Athlete Population. Clin J Sport Med 2010;20: Thompson P and Houston S. Decreasing methicillin-resistant Staphylococcus aureus surgical site infections with chlorhexidine and mupirocin. Am J of Infection Control. 2013, In press. Accessed online Garza D. Ineffectiveness of Surveillance to Control Community-Acquired Methicillin-Resistant Staphylococcus aureus in a Professional Football Team. Clin J Sport Med 2009;19: Bowers AL et al. Methicillin-Resistant Staphylococcus aureus Infections in Collegiate Football Players. Med Sci Sports Exerc 2008;40: Creech CB et al. One-Year Surveillance of Methicillin-Resistant Staphylococcus aureus Nasal Colonization and Skin and Soft Tissue Infections in Collegiate Athletes. Arch Pediatr Adolesc Med. 2010;164: Athletes: Implementation of a Prevention Program. Journal of Community Health Nursing, 2009;26:

26 Resources Oller AR. Staphylococcus aureus Recovery From Environmental and Human Locations in 2 Collegiate Athletic Teams. Journal of Athletic Training 2010;45: Cohen PR. The skin in the gym: a comprehensive review of the cutaneous manifestations of community-acquired methicillin-resistant Staphylococcus aureus infection in athletes. Clinics in Dermatology. 2008;26:16 26 Wendt C et al. Value of Whole Body Washing With Chlorhexidine for the Eradication of Methicillin Resistant Staphylococcus aureus: A Randomized, placebo Controlled, Double Blind Clinical Trial. Infection Control and Hospital Epidemiology. 2007;28: Anderson BJ. The Effectiveness of Valacyclovir in Preventing Reactivation of Herpes Gladiatorum in Wrestlers. Clin J Sports Med 1999;9: Anderson BJ. The Epidemiology and Clinical Analysis of Several Outbreaks of Herpes Gladiatorum. Anderson BJ. Valacyclovir to Expedite the Clearance of Recurrent Herpes Gladiatorum. Clin J Sport Med 2008;15: Stanforth B et al. Prevalence of Community-Associated Methicillin-Resistant Staphylococcus Aureus in High School Wrestling Environments. J of Environmental Health 2010;72: J. Chad Sanders DNP and FNP-BC (2009): Reducing MRSA Infections in College Student Thank You!! 26