Dermatological Issues in Athletes

Daniel A. Clearfield, DO, MS, CAQSM Primary Care Sports Medicine & Concussion Management Assistant Professor – Department of Orthopaedic Surgery Program Director – Sports Medicine Fellowship UNTHSC – Texas College of Osteopathic Medicine UNT Health Bone & Joint Institute Presented at the 2015 AOASM Annual Conference Modified from presentation prepared by Kevin deWeber, MD Objectives Understand mechanical conditions that can affect the athlete’s skin Recognize and understand the management of skin in the athlete – Bacterial skin infections – Viral skin infections – Fungal skin infections – Skin infestations Identify physical & environmental-related skin problems Real Objectives What the hell is that? – Infectious vs. non-infectious Can I play with it? – Yes – No – Yea…but What is the management/Tx? Is there prevention/prophylaxis? OP&P 4 Principles of Osteopathic Medicine

I. The body is a unit; the person is a unit of body, mind, and spirit – Stress, immunocompromise/malnutrition II. The body is capable of self-regulation, self-healing, and health maintenance – Need for /antivirals vs. father time and mother nature III. Structure and function are reciprocally interrelated – Lymphatic obstruction? IV. Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function – Whole patient considerations, is there a reason for the lesion (ie: from injecting anabolic steroids) Case You are working a high school wrestling tournament and while performing a pre- competition skin check you see a sharply demarcated erythematous plaque on the lower leg of one of the wrestlers. The athlete states “oh, that has been there for like 3 weeks”

Case (cont’d) What the hell is that? – Infectious vs. non-infectious Can he compete with it? – Yes – No – Yea…but Case (cont’d) The athlete’s coach gives you a note from the patient’s PCP stating that the patient has been seen and evaluated for this condition 2 days ago. The athlete has been put on oral antibiotics that were initiated on that day, he is currently taking them, last dose this AM. The lesion is dry and not draining. Per the athlete and the coach there has been no spread or new lesions over the past week. Case (cont’d) Can he compete with it? – Yes – No – Yea…but What is the management/Tx? Is there prevention/prophylaxis? OP&P

GUIDELINES FOR RETURN TO COMPETITION FOR CUTANEOUS INFECTIONS IN WRESTLERS

No new lesions for 72 hours before the No new vesicle formation and no swollen lymph examination nodes near the affected area Resolution of all systemic symptoms in Lesions must be well healed with well-adherent primary cases scabs All lesions must be dry and covered by a If antiviral therapy used, withhold from wrestling firm adherent crust; moist, active lesions for 5 days cannot be covered to allow participation Treatment with appropriate systemic National Collegiate Athletic antiviral therapy for at least 120 hours before and at the time of competition Completed 72 hours of therapy Completed 72 hours of antibiotic therapy Association. Wrestling 2010 and No moist or draining lesions No moist or draining lesions, and lesion should No new skin lesions for 48 hours before have a well-adherent scab competition Lesions should be covered with a bio-occlusive 2011 rules and interpretations. Moist or draining lesions cannot be dressing until completely healed covered for participation Appendix B: Skin infections in A minimum of 72 hours of topical A minimum of 72 hours of systemic or topical antifungal therapy for antifungal therapy for tinea corporis A minimum of 2 weeks of systemic No specific recommendation for wrestling. antifungal therapy for tinea capitis Lesions can be covered with a bio-occlusive Lesions can be covered with a bio- dressing for return to competition after a period of occlusive dressing for return to adequate pharmacotherapy competition after a period of adequate pharmacotherapy National Federation of State High Lesions must be covered with a firm Primary outbreaks require 10-14 days of systemic adherent crust antiviral medication No evidence of secondary bacterial Secondary outbreaks require 5 days of systemic School Association, Sports antiviral medication Lesions must be scabbed over with no discharge No new lesions in preceding 48 hours Medicine Advisory Committee.

Lesions must be curetted or removed Lesions should be covered if prone to bleeding Solitary or locally clustered lesions can Sports related skin infections be covered with a gas-permeable membrane and tape position statement and guidelines. Lesions must be “adequately covered” or Lesions should be covered if prone to bleeding curetted Facial lesions can be covered with a mask

A negative microscopic skin prep before return to competition Appropriate pharmacotherapy and completeness of response confirmed by examination Impact of skin infections in NCAA wrestlers 20% of practice time-loss injuries National Federation of High Schools Communicable Disease Procedures

HCP must evaluate skin lesions before returning to competition Consider evaluating other team members Follow state/local “return to competition” rules Skin Checks Stand with feet spread to shoulder width Arms abducted to 90° with thumbs pointed to ceiling – So as not to conceal lesions Special attention to scalp – Tinea Long briefs raised above mid-thigh BACTERIAL Bacterial Infections: NCAA participation criteria No new lesions for 48 hours ≥72 hours of antibiotics completed No moist, exudative or draining lesions Active bacterial infections shall NOT be covered to allow participation if above criteria not met 72/48 rule

Infection of deeper and subcutaneous tissue Erythematous patches w/o discrete borders and underlying subcutaneous edema TX: rest, elevation, oral abx; IV abx if severe or on face NCAA: see Bacterial Infections Erysipelas

Usually Gp A Strep Superficial infection extending into the lymphatics; systemic sxs common More red, swollen than cellulitis, some streaking TX: penicillins, Azithro NCAA: see Bacterial Infections OP&P: address lymphatics superficial with Strep, Staph yellow crusted lesions on red base TX: remove crust; topical mupirocin or oral abx NCAA – see Bacterial Infections

Mild hair follicle or infection, usually Staph – Pseudomonas in hot tubs , pustules around follicles TX: wash with soap, topical mupirocin, oral abx Prevention: – don’t share razors, shave with the hair NCAA: see Bacterial Infections Furuncles

More severe hair follicle abscess with Staph acute, tender, erythematous nodule TX: warm compresses, abx, I&D NCAA – see Bacterial Infections Carbuncle

More extensive abscess than furuncle; Staph TX: I&D, oral or IV abx NCAA: see Bacterial Infections Methicillin-Resistant Staph Aureus “MRSA” Staph strains resistant to ß-lactam abx (e.g. dicloxacillin, methicillin) May be resistant to other abx Cause skin infections usually – Cellulitis, folliculitis, furuncles, Cause significant morbidity – 70% of athletes required IV abx Spread directly person-to-person – Football linemen, rugby, fencing, wrestling – Through injured skin Methicillin-Resistant Staph Aureus “MRSA” When to suspect – Skin abscesses – Infections resistant to initial abx Proper treatment – Culture all abscesses before tx – Susceptibility should guide abx choice Community-acquired strains usually sensitive to TMP/SMX, doxycycline, linezolid, clindamycin, mupirocin 2% cream Check susceptibilities in your area Methicillin-Resistant Staph Aureus “MRSA” Prevention – No participation of infected athletes until cured – Protect exposed skin if high-risk sport – Properly clean/protect injured skin – Proper general hygiene HAND WASHING!!! – Report MRSA to PrevMed and CDC Erythrasma

Corynebacterium infection Uniformly brown and scaly w/o advancing border; coral-red under Wood’s lamp TX: oral or topical erythromycin NCAA: see Bacterial Infections Suppuritiva

Blockage of sweat glands with secondary infection; chronic sinus tracts can form Erythematous papules, nodules, drainage TX: – topical +/- oral abx – I&D – Surgical excision Athletic clearance: – NCAA guidelines bacterial infection tender inflammation of fold – differentiate from ingrown nail TX: warm soaks, I&D, +/- oral abx NCAA: see Bacterial Infections Vulgaris

Propionibacterium acnes colonization TX: topical Retin-A, benzoyl peroxide, abx; oral abx Not a contraindication to sports

“football acne” TX: topical Retin-A, benzoyl peroxide, abx; oral abx Mgmt: sweat wicking clothing, clean equipment Not a contraindication to sports Prevention / Prophylaxis Handwashing Adequate cleaning of clothes/equipment Decolonization practices • Daily chlorhexidine body wash (2-4% solution) • Bleach baths (¼-½ cup bleach to 40 gallons water) 2-3x/wk • Treat the home, training facilities, teammates, family members, etc VIRAL Herpes infections: NCAA participation criteria Primary infection – no systemic sxs – no new lesions x 3 days – all lesions crusted – on oral meds >120 hours (5 days) – Crusts covered Recurrent infection – Ulcers dry, covered by FIRM ADHERENT CRUST – On oral meds for >120 hours – Crusts covered 120/72 rule Genital

Condyloma acuminata HPV, smooth or verrucous papules genital and perianal regions, cluster TX: cryotherapy; topical podophyllox, imiquimod 5% cream Clearance: no restriction in NCAA/NFHS Herpes Gladiatorum

“Mat herpes” HSV1>HSV2 HSV on area of friction/trauma TX: oral antivirals NCAA – see Herpes Infections Genital Herpes

Small, grouped vesicles painful ulcers DX: Tzanck prep TX: acyclovir, valacyclovir NCAA: see Herpes Infections Herpes Labialis

“cold sore” virus Vesicles ulcers near lip; painful TX: topical or oral antivirals, sunscreen to prevent; consider prophylactic valacyclovir NCAA: see Herpes Infections

“wrestler’s warts” poxvirus firm, skin colored, umbilicated papules TX: spontaneous resolution (months), curettage, topicals, cryotherapy NCAA: – curette or remove lesions & – cover with gas-perm membrane AND tape Varicella ()

Varicella zoster virus Lesions in various stages— papules, vesicles, ulcers, crusts on red bases TX: oral antivirals if early; supportive measures; itch creams NCAA: no participation until ALL lesions crusted firmly, no secondary bacterial infection Varicella ()

Varicella zoster virus Lesions in various stages— papules, vesicles, ulcers, crusts on red bases TX: oral antivirals if early; supportive measures; itch creams NCAA: no participation until ALL lesions crusted firmly, no secondary bacterial infection Herpetic

Tender erythematous vesicles near fingertip TX: oral antivirals NCAA – See Herpes Infections, recurrent Warts, Verruca Vulgaris

HPV; unsightly and painful “black dots” after shave-down TX: salicylic acid patch, cryotherapy, occlusion NCAA: cover prior to competition Plantar Warts

HPV thickened plantar papules, shave reveals “black dots” TX: keratolytic solutions, podophyllin, cryotherapy Clearance: cover prior to competition (if barefoot) Prevention / Prophylaxis Handwashing Adequate cleaning of clothes/equipment Herpes Gladiatorum prevention (LOE 2) – Valacyclovir 500 to 1000 mg daily is effective Anderson BJ, Clin J Sports Med 1999 Anderson BJ, Jpn J Inf Dis 2006 – Acylcovir 400 mg bid – Famicylcovir 250 mg bid – Only studied in athletes ≥ 12yo FUNGAL Tinea Infections: NCAA participation criteria

>72 hours treatment for tinea corporis >2 weeks treatment for tinea capitis DQ if extensive lesions Cover lesions with bioocclusive dressing and tape after period of adequate antifungal therapy as discussed above Tinea Corporis (Gladiatorum)

AKA: “Ringworm” or “the worm” infection Erythematous w/ advancing border, pruritic; DX: KOH prep TX: topical antifungals NCAA: see Tinea Infections Tinea Capitis (Gladiatorum)

Dermatophyte infection Erythematous w/ advancing border, pruritic; DX: KOH prep TX: oral antifungals NCAA: see Tinea Infections

“jock itch” Dermatophyte infection Erythematous w/ advancing border, pruritic; DX: KOH prep TX: topical antifungals NCAA: see Tinea Infections Tinea Pedis

“athlete’s foot” Dermatophyte infection Inflamed, flaky, red and white skin with tiny and/or pimples; pruritic DX: KOH prep TX: topical antifungals; oral with more severe cases Mgmt: keep feet dry, treat all shoes & socks Clearance: keep covered Pityrosporum ovale, asymptomatic Hypo- or hyper-pigmented macules; DX: Wood’s lamp, KOH scrape TX: Selenium sulfide shampoo, -azole creams, terbinafine cream; itraconazole oral NCAA: see Tinea Infections fungal infection of nail discoloration, scaling, thickening culture before tx TX: – : Systemic itraconazole or terbinafine 2-4 mos – Mold: topicals – Candida: topical or systemic Clearance: keep covered Dermatophytid Reaction

distant site fungal infection vesicular treat distant site, consider prednisone NCAA: see tineas Prevention / Prophylaxis Handwashing Adequate cleaning of clothes/equipment Tinea prevention (LOE 1): – Fluconazole 100 mg 1x/week INFESTATIONS mite Sarcopetes scabiei exquisitely pruritic papules, excoriations; DX: scraping TX: topical permethrin or oral ivermectin; oral antihistamines for itching NCAA - verification of treatment and negative scrapings Pediculosis (Lice)

Pediculosis humanaus capitis (head lice); Pediculosis humanus humanus (body lice) Small inflammatory papules or punctate hemmorhages from bites DX: nit comb visual identification TX: topical permethrin, mechanical/combing removal from areas, laundering and hot-air drying of clothing and linens – Repeat 1 week later NCAA - verification of treatment and negative comb exam Prevention / Prophylaxis Handwashing/hygiene Adequate cleaning of clothes/equipment Decolonization practices • Treat the home, training facilities, teammates, family members, etc NON-INFECTIOUS Bleeding/Lacerations

Need rapid hemostasis Allow athlete to keep competing safely Concern for scar? Clean the wound – Achieve hemostasis – Steri-strip – Cover/wrap – PRAY it doesn’t come off/reopen Suture/staple after Corns

Hyperkeratotic pressure area hard conical with translucent center TX: modify foot wear to change pressure, soften lesion, remove “Black Heel”

Traumatic micro- hemorrhages small asymptomatic black macules no treatment needed Proper fitting heel cup on shoes Blisters excessive friction vesicles and bullae TX: – Prevention Moisture wicking socks – drainage (leave the roof), – hydrocolloid dressing (duoderm) – 2nd skin, moleskin Ingrown Toenail

From improperly fitting footwear usually great TX: – pressure relief (go shoeless, wider shoes) – cotton under nail – Antibiotics if infected – Surgical excision – Chemical ablation Black Toenails

AKA “joggers toe”, “skiers toe”, “tennis toe” From trauma or pressure Differentiate from TX: – acute : pierce nail – Mild cases: no tx – Prevention: proper shoes, metatarsal pad Jogger’s Nipples irritation and friction, long distance runners painful, fissured, eroded nipples TX: soft fiber shirts, adhesive bandages, petroleum jelly Dyshydrotic Eczema unknown etiology, not infectious eczematous eruption of pruritic vesicles on fingers TX: keep hands dry, lotions, topical steroids Rubra “prickly heat” sweat duct occlusion fine erythematous papules TX: dry clothing, hydrophilic ointments direct chemical irritant or allergic delayed rxn pruritic patches of vesicles on weeping base TX: calamine lotion, benadryl, topical steroids; Zanfel cream dry easily irritated skin, worsened by heat and sweat pruritic erythematous macules and patches, flexor surfaces TX: moisturizers, topical steroids, soap- free cleansing Sunburn

UV radiation mild to intense analgesics, cool compresses, topical steroids or lotions Prevention: SUNTAN LOTION Photosensitivity Reactions reaction to sun or Rx eczema-like in sun- exposed areas TX: – stop offending med – protect skin from sun – topical &/or oral steroids Striae Distensae

Stretch marks rupture of elastic fibers from rapid growth; steroids? perpendicular to lines of tension; shoulders, back, thigh no good treatment proven Back to our Case High school wrestler with erysipelas infectious rash x ~3 weeks Seen PCP 2 days ago, started on abx that day – PCP note provided No new lesions x 1 week, its dry and not draining Case (cont’d) Can he compete with it? – Yes – No – Yea…but hasn’t been on abx long enough What is the management/Tx? – NCAA 72/48 rule; oral/topical abx; I&D prn – Culture prn Is there prevention/prophylaxis? – Handwashing, adequate cleaning of clothes/equipment, decolonization practices (home, training facilities, teammates, family members, etc) OP&P? – The body is capable of self-healing, self-regulation, and health maintenance – Rational treatment is based upon an understanding and practice of the other principles Infection Prevention in Sports Medicine

Appropriate immunizations for the team – Hepatitis B – Age-appropriate vaccines – Appropriate travel vaccines Avoid sharing personal items Proper equipment & facility cleaning Temporary suspension of ill athletes – +/- isolation +/- Probiotic supplements in winter Consider prophylaxis for HSV and Tinea Conclusion Skin diseases in athletes can be sport and regionally specific Recognize and treat early Know the rules for participation Know of prophylactic and preventative measures Utilize OP&P as part of your management Any questions?

Contact me: [email protected] (614) 735-1100 – cell (817) 735-2900 – UNT Health Bone & Joint Institute References

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