C l i n i c a l I n s i g h t s Part 1 Sports Dermatoses: Perils of Occlusion for the Athlete

1,2 By Brian B. Adams, MD, MPH universally have a history of acne vulgaris. Various types of Associate Professor, Department of Dermatology, University of athletes develop acne mechanica; the distribution of the ery- Cincinnati School of Medicine; Chief, Dermatology Section, thematous papules and pustules (Fig. 1) relates specifically to Veterans Affairs Medical Center; Author Sports Dermatology the causative sporting equipment (Table*).1,3,4 Dermatologists (Springer); Dermatologist to Sony-Ericsson Women’s Tennis should suspect acne mechanica when an acneiform eruption Association; Cincinnati. worsens during athletic activity or demonstrates an atypical or well-defined distribution. Additionally, acne mechanica does o matter one’s competitive level, sports dermatoses not generally respond as well to typical therapy for acne vul- represent the most common ailment of athletes. The garis. Topical treatment includes retinoids (tazarotene cream Nfield of sports dermatology encompasses a wide variety seems particularly effective), topical (such as clin- of skin conditions. Broadly, these cutaneous diseases include damycin gel, lotion, or solution), and benzoyl peroxide in cream infections, neoplasms, inflammatory and traumatic conditions or wash preparations. Some authors have successfully used 3% as well as encounters with the sporting environment. Many salicylate and 8% resorcinol in 70% ethanol.1,2 Because treat- sports-related dermatoses are not specific to athletes; howev- ment remains challenging, prevention is paramount. Wearing er, they develop these conditions more frequently and more synthetic, moisture-wicking clothing (most sports retail stores severely than non-athletes. The nature of athletic participation, carry these commercially available garments) beneath equip- especially with its close skin-to-skin contact and occlusive tight ment decreases heat, moisture, and friction.1 Athletes or athlet- fitting equipment, results in the development of sports der- ic trainers can also fashion a small barrier from this material for matoses that can cause significant disruption in practice and focal use, such as under chinstraps or elbow/knee pads. competition. Dermatologists can assuage or avert athlete mor- Sports-related contact dermatitis most commonly occurs bidity and league epidemics by recognizing the risk factors as a result of allergy to equipment, but some athletes develop responsible for these skin conditions, instituting rapid targeted irritant contact dermatitis. As equipment can directly cause der- therapy and communicating preventative techniques. matitis, the distribution of the eruption relates to the area on This non-exhaustive, short review will examine some of the which the equipment contacts.1,5 The eruption classically mani- sports-related skin disorders resulting from occlusive athletic fests as well-defined, erythematous, scaling plaques. Affected equipment. Specifically, the review will discuss acne mechanica, athletes should use potent topical steroids for moderate to contact dermatitis, and cutaneous infections. severe disease, while more mild disease will respond to combi- Acne mechanica, the prototypic occlusive skin disorder of nation hydrocortisone acetate/pramoxine HCl (Pramosone®) to athletes, results from a combination of heat, moisture, occlu- address itch and inflammation. Many alternatives exist for sion, and friction.1 Athletes who develop this condition do not equipment that otherwise may cause allergic contact dermati- tis.5 When alternative equipment with different constituents does not exist, athletes can place a barrier between their skin and the offending equipment. Sports-related skin infections represent the most common cause of individual disqualification and ultimately, team disrup- tion. Some skin infections that athletes include tinea corporis gladiatorum, tinea pedis, tinea cruris, herpes gladiato- rum, pitted keratolysis, and Staphylococcal-related , , furunculosis, and . Of these infections, occlu- Fig. 1. This football player developed acne mechanica on his sion most relates to tinea pedis, tinea cruris, pitted keratolysis, chin as a result of his chinstrap. Fig. 2. Dermatophytes thrive in and many of the bacterial infections. While neither tinea pedis the warm, dark, and moist groin of the athlete, in this case creat- nor tinea cruris will cause disqualification, severe or secondari- ing tinea cruris. ly impetiginized outbreaks can sideline athletes. Many studies

Supported by an educational grant from Ferndale Laboratories Sport* Acne location Etiology Dancers Trunk Beneath tight leotard Football Chin Chin strap Hockey Shoulder Shoulder pads Upper inner arm Shoulder pad straps Forehead, cheeks Helmet Golfers Lower lateral back Golf bag carrying Fig. 3.a. Discrete, well-defined small pits characterize pitted Shot putters Neck Shot put before keratolysis. 3b. Pitted keratolysis launch also may affect the plantar sur- Tennis Back Heavy warm clothes face of the toes. Fig. 4. Close skin-to-skin contact between Weightlifters Upper back Plastic/vinyl bench cvr athletes spreads cutaneous Upper central chest Weight bar infections as demonstrated in Wrestlers Chin, Neck Headgear this wrestler with impetigo. Elbows, knees Elbow & kneepads clearly demonstrate a higher prevalence of tinea pedis in ath- letes compared to non-athletes.6-8 One explanation for this pads or athletic tape develop Staphylococcal infections statis- phenomenon includes occlusion by footwear, which creates an tically more often than athletes who do not use pads or ideal environment (warm, dark, moist) for fungi. The same tape.12,13 These infections respond well to both topical and oral physical factors increase the risk of tinea cruris for athletes. antibiotics; rapid institution of this therapy may avert team epi- Tinea pedis presents with one of three main morphologic vari- demics. To decrease transmission to other athletes, infected ants: moccasin-like, interdigital, or plantar vesicular. Typical players should also wear bandages over affected areas if they tinea cruris demonstrates annular red plaques on the medial wish to practice. Specifically for wrestlers, this covering alone aspects of the upper thighs (Fig. 2). does not allow participation in competition.1 Moisture-wick- Topical fungicidal agents clear tinea pedis and tinea cruris, ing, synthetic material placed between the athlete’s skin and but therapy may take several months; moderate to severe dis- the pad or adhesive will decrease the moisture and heat par- ease may also require oral fungicidal medications.1 Athletes tially responsible for the infection. To further prevent transmis- who complain of associated pruritus may use topical steroids. sion of microorganisms, athletes should not share equipment Alcortin A® (Iodoquinol 1.0%, hydrocortisone acetate 2%) may (including towels) or shave body hair.14 represent an ideal treatment option with its antifungal and Occlusion by sporting equipment, such as clothing of sub- anti-inflammatory properties. To help prevent tinea pedis, optimal material and tight-fitting or heavy protective gear, cre- every athlete should wear sandals in the locker room, showers, ates an ideal environment for the development of sports der- and pool decks. No athlete, from weekend warrior to profes- matoses. By recognizing the role of sports in the skin condi- sional, should wear cotton socks, which retain heat and mois- tion, dermatologists can avert or reduce the time athletes ture. Synthetic, moisture-wicking socks, readily available at spend on the sidelines. ● sports specialty stores, keep the soles dry and cool. Wearing * Table reprinted with permission from 2006 Springer Science+Buisness Media synthetic moisture-wicking undergarments and showering 1. Adams, BB. Sports Dermatology. 2006 Springer Science+Buisness Media. 2. Basler RSW. Acne mechanica in athletes. Cutis 1992;50:125-8. immediately after athletic activity decreases the risk of tinea 3. Adams BB. Sports Dermatology. Adolescent Clinics: State of the Art Reviews cruris. Athletes can also use prophylactic topical antifungal 2001;12:305-22. 4. Adams BB. Dermatologic Disorders of the Athlete. Sports Medicine 2002;32:309-21. 1 agents once or twice weekly. 5. Kockentiet B, Adams BB. Contact dermatitis in athletes. J Am Acad Dermatol. Often misdiagnosed as tinea pedis, pitted keratolysis also 2007;56:1048-55. 6. Caputo R, DeBoulle K, DelRosso J, et al. Prevalence of superficial fungal infections will not cause individual disqualification but can disrupt an ath- among sports-active individuals: results from the Achilles survey. J Eur Acad Dermatol lete’s routine. In the literature, tennis players seem particularly Venereol 2001;15:312-6. 7. Pickup TL, Adams BB. Prevalence of tinea pedis in professional and college soccer prone but, in practice, almost any athlete may develop pitted players versus non-athletes. Clin J Sport Med. 2007;17:52-4. keratolysis.1 Occlusive footwear and exertional 8. Field LA, Adams BB. Tinea pedis in athletes. Int J Dermatol. 2008;47:485-92. 9. Anderson BJ. Skin infections in Minnesota high school state tournament wrestlers: provide an ideal microenvironment for Micrococcus and 1997-2006. Clin J Sport Med. 2007;17:478-80. 10. Kazakova SV, Hageman JC, Matava M. et al. A clone of methicillin-resistant Corynebacteria that primarily cause pitted keratolysis (Fig. among professional football players. N Engl J Med. 3a,b).1 Topical antibiotics, such as , clear pitted ker- 2005;352:468-75. 11. Bowers AL, Huffman GR, Sennett BJ. Methicillin-resistant Staphylococcus aureus atolysis; benzoyl peroxide also treats pitted keratolysis but has infections in collegiate football players. Med Sci Sports Exerc. 2008;40:1362-7. the added feature of drying the soles. Synthetic, moisture- 12. Bartlett PC, Martin RJ, Cahill BR. Furunculosis in a high school football team. Am J Sport Med 1982;10:371-4. wicking socks help prevent this condition. 13. Sosin DM, Gunn RA, Ford WL, et al. An outbreak of furunculosis among high Sports-related Staphylococcal infections have generated school athletes. Am J Sport Med 1989;17:828-32. 14. Kirkland EB, Adams BB. Methicillin-resistant Staphylococcus aureus and athletes. significant media attention in the past few years. These infec- J Am Acad Dermatol. 2008;59:494-502. tions often lead to disqualification (among wrestlers) and indi- vidual morbidity and may lead to team and even league epi- demics. Of course, myriad morphologic presentations of Staphylococcal infections exist and most commonly include impetigo, folliculitis, and furunculosis (Fig. 4). Many epidemio- logic studies have examined the risk factors associated with sports-related furunclosis.9-11 Athletes who use elbow/knee Supported by an educational grant from Ferndale Laboratories.

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