Sports Dermatology. Kyle Yost, D.O. Primary Care Sports Medicine University of Maryland

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1 Sports Dermatology Kyle Yost, D.O. Primary Care Sports Medicine University of Maryland

2 DISCLOSURES Neither I, Kyle Yost, nor any family member(s), have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation.

3 OBJECTIVES Identify common dermatologic diseases of the athlete. Understand the treatments for common infections of the athlete. Understand the return to play guidelines for common infections of the athlete.

4 EPIDEMIOLOGY The incidence of skin related infections are 8.5% and 20.9% of all sportsrelated conditions and injuries, in high school an college respectively. 4 Skin infections among high school athletes are broken down as follows: bacteria, 30%; herpes viruses, 20%; and tinea fungi, 20%. 4 Among collegiate athletes, the prevalence of skin infections have been reported as follows: herpes viruses, 47%; impetigo, 37%; tinea fungi, 7%; cellulitis, 6%; and methicillin-resistant Staphylococcus aureus (MRSA), 3%. 4 Reported statistics from Minnesota State Wrestling Tournaments between 1997 and 2006 revealed an incidence of skin infections between 2.5 to 3.7%. 7,9 The National Collegiate Athletic Association (NCAA) wrestling injury database statistics from 1988 through 2004 show the incidence of skin infections at an estimated 0.98 of 1000 athlete exposures (with exposure defined as equivalent to 1 practice or game). 10

7 FUNGAL INFECTIONS Tinea Capitis Tinea Corporis Tinea Pedis Tinea Versicolor

8 TINEA CAPITIS Presents with a patchy scale and alopecia Treatment for this is more stringent than other non-scalp fungal infection Treat with oral anti-fungal medication for at least eight weeks Return to play requires 14 days of oral anti-fungal medication plus an optional shampoo

TINEA CORPORIS Scaly erythematous ring shaped raised border with central clearing Treat with topical antifungals for 72 hours Return to play for NCAA is return immediately if area

9 TINEA CORPORIS Scaly erythematous ring shaped raised border with central clearing Treat with topical antifungals for 72 hours Return to play for NCAA is return immediately if area is able to be covered. If it can not be covered must be treated for 72 hours with antifungal medication. Return to play for NFHS is 72 hours of oral or topical antifungal medication

TINEA PEDIS Incidence of 69% in male athletes and 43% in female athletes, compared to age matched control group incidences of 20% in men and 0% in women (Pickup et al.

10 TINEA PEDIS Incidence of 69% in male athletes and 43% in female athletes, compared to age matched control group incidences of 20% in men and 0% in women (Pickup et al.) Seen in the feet with maceration of the skin including peeling, cracking, or pruritis of the interdigits. Increases risk for secondary infections due to the break in the skin No restriction on return to play Treat with topical antifungals or in severe cases oral antifungal therapy may be used

11 TINEA VERSICOLOR Hypopigmentation patches of the skin Caused by Malassezia furfur No restriction on return to play Treat with selenium sulfide 2.5% shampoo, topical or oral antifungal medication, or observation only (as it can be self limiting).

12 ANTIFUNGAL MEDICATIONS Medication Oral Fluconazole Griseofulvin Itraconazole Terbinafine Dosage 150mg Weekly 500mg Daily 100mg Daily 250mg Daily Topical Clotrimazole Ketoconazole Terbinafine 2-3 times daily 2-3 times daily 2-3 times daily

13 FUNGAL INFECTION RETURN TO PLAY Condition NCAA Guidelines NFHS Guidelines Tinea Capitis Oral antifungal >14d Oral antifungal >14d Tinea Corporis Lesions must be covered Antifungal >72h Lesions must be covered Tinea Pedis No restriction No restriction Tinea Versicolor No restriction No restriction

14 VIRAL INFECTIONS Herpes Gladitorum Herpatic Labialis Herpatic Whitlow Herpes Zoster Molluscum Contagiosum

15 HERPES GLADITORUM Clustered vesicles with erythematous borders, creating a Dew drop on a rose pattern Caused by HSV-1 Confirmation with a tzanck smear

16 HERPATIC LABIALIS Also known as cold sores Abreva is OTC and can help shorten the course

HERPATIC WHITLOW Lesion on the fingers caused by HSV-1 Can also be caused by HSV-2 but uncommon Seen in Dentists, people who have hands in mouths Symptoms

17 HERPATIC WHITLOW Lesion on the fingers caused by HSV-1 Can also be caused by HSV-2 but uncommon Seen in Dentists, people who have hands in mouths Symptoms include: Swelling, redness, tenderness, fever, swollen lymph node Vesicles are isolated and clear at first then merge and become more cloudy in appearance

18 HERPES GLADITORUM/LABIALIS/WHITLOW TREATMENT Medication and Dosage Treatment Purpose Acyclovir Famciclovir Valacyclovir Primary (14d of treatment) Recurrent (5d of treatment) 400mg 5x daily 500mg 3x daily 1000mg 2x daily 400mg 3x daily 125mg 2x daily 1000mg 2x daily Chronic 400mg 3x daily 250mg 2x daily <10 episodes: 500mg daily >10 episodes or <2y of recent infection: 1g daily

HERPATIC ZOSTER AKA Shingles reactivation of the varicella zoster virus Appears as a vesicular eruption in a dermatomal pattern Does not cross

19 HERPATIC ZOSTER AKA Shingles reactivation of the varicella zoster virus Appears as a vesicular eruption in a dermatomal pattern Does not cross the midline Typically rash is preceded by hyperesthesia/dysesthesias Treat with valacyclovir 1000mg TID x7d Start treatment within 72hours of onset

20 HERPES (GLADITORUM, LABIALIS, WHITLOW, ZOSTER) RETURN TO PLAY NCAA: Skin lesions must have a firm adherent crust and no new lesions in the past 72 hours. For primary and recurrent episodes: a minimum of 5 days of anti-viral treatment, if no general body signs (Fever, malaise, swollen lymph nodes, etc) are present. NFHS: No new lesions in the last 48 hours and all lesions must be scabbed over with no active discharge. For primary episodes: a minimum of 10 days of anti-viral treatment, if no general body signs (Fever, malaise, swollen lymph nodes, etc) are present. If general body signs present a minimum of 14 days on anti-viral treatment is required. For recurrent outbreaks a minumum of 5 days of anti viral treatment is required with all lesions scabbed over and no new lesions present.

21 MOLLUSCUM CONTAGIOSUM Caused by the poxvirus Flesh colored dome shaped papules with central umbilication Treat with cryotherapy, curettage, KOH Solution, imiquimod solution, or cantharidin solution Return to play NCAA: Immediately after lesions are curetted or removed NFHS: 24 hours after treatment

22 VERRUCAE Also known as warts Caused by HPV Usually non painful On the plantar aspect of the foot it can be painful Treat with cryotherapy, curettage, KOH Solution, imiquimod solution, or cantharidin solution

23 VIRAL INFECTIONS RETURN TO PLAY Condition NCAA Guidelines NFHS Guidelines Primary HSV (Gladitorum, Labialis, Whitlow, Zoster) All lesions crusted No systemic symptoms >72h No new lesions >72h Oral antivirals >120h No active lesions Recurrent HSV Oral antivirals >120h No active lesions Molloscum Contagiosum Lesions curetted or removed Site covered Verrucae Face: Covered with a mask Nonface: Lesions must be covered Oral antivirals >10d No new lesions while on antiviral treatment x48h All lesions scabbed Oral antivirals >120h No new lesions while on antiviral treatment x48h All lesions scabbed 24h post curettage Site covered Face: Covered with a mask Nonface: Lesions must be covered

24 BACTERIAL INFECTIONS Cellulitis Folliculitis Furuncles (boils) & Carbuncles MRSA Impetigo Hidradenitis suppurativa

25 CELLULITIS Infection of the deep dermis and subcutaneous tissue Can be from staph or strep If isolated treat for B-Hemolytic strep with a beta lactam abx

26 FOLLICULITIS Pustules associated with a hair follicle infection Usually staph aureus Think pseudomonas with recent hot tub use Treat with topical clindamycin or mupirocin If wide spread consider using oral antibiotics

27 FURUNCLES (BOILS) & CARBUNCLES Furuncles Infection deep to the dermis of a hair follicle Purulent Carbuncles Infection involving multiple follicles with different areas of drainage Treat with I&D Antibiotics are not needed unless MRSA is suspected

28 FURUNCLES (BOILS) & CARBUNCLES

29 MRSA Infections related to insect bites Rapidly spreading Purulent Infections not responding to 48 hours of cephalosporin therapy Systemic Toxicity Will treat with I&D (If abscess present) + antibiotic (Oral/IV)

IMPETIGO Unique appearance with sterotypical honey crusted lesion Common around the mouth and nose Due to staph or strep Can be misdiagnosed as HSV-1 Diagnosis is

30 IMPETIGO Unique appearance with sterotypical honey crusted lesion Common around the mouth and nose Due to staph or strep Can be misdiagnosed as HSV-1 Diagnosis is clinical and culture is not needed Commonly resistant to OTC medications Can use topical Mupirocin if limited area Most of the time it will require systemic antibiotics

31 BACTERIAL INFECTIONS RETURN TO PLAY Complete >72h of oral antibiotic therapy No new lesions in the past 48 hours No draining lesions Active infections may not be covered to allow for participation Consider MRSA if new lesions or drainage continues after 48 hours of oral antibiotics

HIDRADENITIS SUPPURATIVA Blockage of sweat glands with secondary infection Chronic sinus tracts can form Erythematous nodules, drainage Treatment: Oral or

32 HIDRADENITIS SUPPURATIVA Blockage of sweat glands with secondary infection Chronic sinus tracts can form Erythematous nodules, drainage Treatment: Oral or topical antibiotics I&D Surgical excision Return to play: Athlete is disqualified if extensive or purulent drainage is noted. No covering is allowed to participate.

CONJUNCTIVITIS Also known as pink eye Viruses, bacteria and allergens can cause infection of the conjunctiva Treatment varies based on the cause Viruses: Symptomatic treatment Bacteria:

33 CONJUNCTIVITIS Also known as pink eye Viruses, bacteria and allergens can cause infection of the conjunctiva Treatment varies based on the cause Viruses: Symptomatic treatment Bacteria: Antibiotic eye drops or ointments Azithromycin (Drops), Ciprofloxacin (Drops/Ointment), Erythromycin (Ointment) Allergens: Antihistamines, symptomatic treatment RTP: 24 hours of treatment and no discharge

34 INFESTATIONS Pediculosis Scabies

malathion, along with fomite decontamination.

35 PEDICULOSIS Also known as lice Most commonly affects school aged children 3-10yo It is estimated that about 3% of school children are diagnosed with lice Treatment: permethrin 1%, lindane, or malathion, along with fomite decontamination. Return-to-play guidelines require restriction of activity for 24 hours after completion of treatment and reexamined for complete response of treatment

SCABIES Pruritic infestation of the Sarcoptes scabiei mite occur in the area of the finger webs, feet, ventral wrists, elbows, back, buttocks, and external genitals Trails of the burrowing mites are

36 SCABIES Pruritic infestation of the Sarcoptes scabiei mite occur in the area of the finger webs, feet, ventral wrists, elbows, back, buttocks, and external genitals Trails of the burrowing mites are linear or S-shaped tracks in the skin often accompanied by rows of small, pimplelike mosquito or insect bites. Treatment includes permethrin 5%, lindane, malathion, or ivermectin, in addition to fomite decontamination. Return-to-play guidelines require restriction of activity for 24 hours after completion of treatment, in addition to negative results from a scabies mineral oil preparation under microscopy.

37 CONCLUSION Herpes infections are becoming more common even in the high school population. Recognition and early treatment is key for these. Tinea capitis is the one tinea that requires oral treatment as it needs to penetrate the follicle I&D do not require antibiotics unless MRSA is suspecte You do not want to miss a MRSA infection, so look for systemic signs There are skin forms for the NCAA and NFHS to help guide you for the return to play

38 REFERENCES 1. Ahmadinejad Z, Alijani N, Mansori S, Ziaee V. Common Sports-Related Infections: A Review on Clinical Pictures, Management and Time to Return to Sports. Asian Journal of Sports Medicine. 2014;5(1): Ahmadinejad Z, Razaghi A, Noori A, et al. Prevalence of fungal skin infections in Iranian wrestlers. Asian Journal of Sports Medicine. 2013;4: Lincoln P, Likness DO. Common dermatologic infections in athletes and return-to-play guidelines. Journal of the American Osteopathic Association. 2011;111: Yard EE, Collins CL, Dick RW, Comstock RD. An epidemiologic comparison of high school and college wrestling injuries [published online ahead of print October 11, 2007]. Am J Sports Med. 2008;36(1): Adams BB. Skin infections in athletes [review]. Dermatol Nurs.. (2008). ;20(1): Guideline 2j: Skin infections in athletics. National Collegiate Athletic Association Sports Medicine Handbook; Indianapolis, IN: National Collegiate Athletic Association; Pg Anderson BJ. Managing herpes gladiatorum outbreaks in competitive wrestling: the 2007 Minnesota experience. Curr Sports Med Rep. 2008;7(6): Adams B. Skin infections in athletes [review]. Dermatology Nursing. (2008). ;20(1): Anderson BJ. Skin infections in Minnesota high school state tournament wrestlers: Clin J Sport Med. 2007;17(6): Agel J, Ransone J, Dick R, Oppliger R, Marshall SW. Descriptive epidemiology of collegiate men's wrestling injuries: National Collegiate Athletic Association Injury Surveillance System, through J Athl Train.. (2007). ;42(2): Pickup TL, Adams BB. Prevalence of tinea pedis in professional and college soccer players versus non-athletes. Clin J Sport Med.. (2007). ;17(1): Turbeville SD, Cowan LD, Greenfield RA. Infectious Disease Outbreaks in Competitive Sports: A Review of the Literature. American Journal of Sports Medicine. 2006;34: Winokur RC, Dexter WW. Fungal infections and parasitic infections in sports: expedient identification and treatment. Phys Sportsmed. 2004;32 (10): Anderson BJ. The epidemiology and clinical analysis of several outbreaks of herpes gladiatorum. Med Sci Sports Exerc. 2003;35(11): Adams BB. Sports dermatology [review]. Adolesc Med. 2001;12(2): Adams B. Transmission of cutaneous infections in athletes. British Journal of Sports Medicine. 2000;34: Adams BB. Tinea corporis gladiatorum: A cross-sectional study. Journal of the American Academy Dermatology. 2000;43: Kohl TD, Martin DC, Berger MS. Comparison of topical and oral treatments for tinea gladiatorum. Clinical Journal of Sports Medicine. 1999;9:161 6.

Public participation in sports is popular in many countries,

Public participation in sports is popular in many countries, The Journal of The american osteopathic association Common Dermatologic Infections in Athletes and Return-to-Play Guidelines Lincoln P. Likness, DO Although the usual perspective on return to play for