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Home , Abscess, Carbuncle, Cellulitis, Ecthyma, Folliculitis, Impetigo

Sports

Robert Kiningham, MD, FACSM Department of Family Medicine University of Michigan Health System Disclosures/Conflicts of Interest

◼ None Goals and Objectives

◼ Review common in athletes ◼ Establish a logical treatment approach to skin infections ◼ Discuss ways to decrease the risk of athlete’s acquiring and spreading skin infections ◼ Discuss disqualification and return-to-play criteria for athletes with skin infections ◼ Recognize and treat non-infectious skin conditions in athletes Skin Infections in Athletes

◼ Bacterial ◼ Herpetic ◼ Fungal Skin Infections in Athletes

◼ Very common – most common cause of practice-loss time in wrestlers ◼ Athletes are susceptible because: – Prone to skin breakdown (abrasions, cuts) – Warm, moist environment – Close contacts Cases 1 -3

◼ 21 year old male football player with 4 day h/o left axillary and tenderness. Two days ago he noticed a tender “bump” that is getting bigger and more tender. ◼ 16 year old football player with 3 day h/o mildly tender on chin. Started as a single , but now has “spread”. Over the past day the lesions have developed a dark yellowish crust. ◼ 19 year old wrestler with a 3 day h/o lesions on right side of face. Noticed “tingling” 4 days ago, small fluid filled lesions then appeared that have now started to crust over. Skin Infections Bacterial Skin Infections

◼ ◼ ◼ ◼ Furunculosis ◼ ◼ Paronychea Cellulitis Cellulitis

◼ Diffuse of connective tissue with severe of dermal and subcutaneous layers of the skin – Triad of , , and warmth in the absence of underlying foci ◼ S. aureus or S. pyogenes Erysipelas Erysipelas

◼ Superficial infection of the ◼ Distinguished from cellulitis by the intracutaneous edema that produces palpable margins of the skin. – May appear thick and dimpled – May have associated systemic symptoms ◼ S. pyogenes (group A strep) Skin Infections Impetigo Impetigo

◼ Superficial dermatologic infection characterized by – colored crusting of the overlying skin – Bullous, non-bullous, ◼ aureus or pyogenes (group A streptococci) Folliculitis Folliculitis

◼ Infection of the that remains superficial - localized to the ◼ S. aureus, species, (whirlpools, hot tubs) enterobacter (rare) ◼ Pseudofolliculitis barbae Pseudofolliculitis Barbae

◼ Inflammation and foreign body reaction from curled-in hair ◼ May get a bacterial superinfection Skin Infections Furuncle Furuncle

◼ Begins as an infection of the hair follicle, but spreads deeper into the dermis and ◼ Forms a perifollicular ◼ Almost always caused by S. aureus Furuncle/

◼ Carbuncle: deeper and wider lesions with interconnecting subcutaneous arising from infection of several neighboring hair follicles – May have systemic symptoms Great Toe Paronychia

◼ Soft tissue infection around a ◼ Acute paronychia is usually due to S. aureus or S. pyogenes ◼ Chronic can be due to Candida species ◼ causes herpetic Skin Infections Herpes Simplex ()

◼ 39% of skin infections in NCAA injury surveillance ◼ Occurs when skin protective barrier is broken ◼ Transmitted primarily by repetitive skin-to-skin contact ◼ Vesicles usually appear within 3-5 days of direct skin-to-skin contact Treatment of Herpes Infections

◼ Self-limiting illness. Anti-viral therapy may reduce duration of illness and limit by inhibiting viral replication ◼ Start anti-viral at very first sign of an outbreak ◼ Acyclovir 400mg tid, valacyclovir 1 gm bid ◼ 7-10 days for initial outbreak, 5 days for recurrent Case #4

◼ 20 y.o. football player presents with a “” on his leg that has been present for 4 days. ◼ It is progressing in size and is uncomfortable ◼ Treated over the weekend in urgent care with Keflex with no improvement. CA - MRSA

◼ Typical presentation is a pustular lesion with central necrosis ◼ Pain is often out of proportion to the size and appearance of the lesion ◼ Patients often c/o of a “spider bite” Treatment of Skin Infections Beware of CA-MRSA

◼ Most S.aureus are beta-lactamase producing, so resistant to , but susceptible to and the penicillinase-resistant (nafcillin, oxacillin, dicloxicillin), or B- lactam-B-lactamase inhibitor combinations (e.g., - clavulanate) Treatment of Skin Infections Beware of CA-MRSA

◼ Increased prevalence of S.aureus that have the mecA gene that produces the penicillin-binding protein PBP2a ◼ Confers resistance to all currently FDA- approved B-lactams Treatment of Skin Infections Beware of CA-MRSA

◼ Study of University affiliated ERs found that 76% of skin/soft tissue infections caused by S. aureus – 59% of total due to MRSA – 77.8% of S. aureus were MRSA – 99% of MRSA were CA-MRSA CA-MRSA Treatment of Skin Infections Beware of CA-MRSA

◼ Class 1 infection – Lesion non-fluctuant – Patient afebrile, otherwise healthy ◼ Class 2 infection – Lesion fluctuant or pustular – Lesion < 5 cm in diameter – Patient afebrile, otherwise healthy Treatment of Skin Infections Beware of CA-MRSA

◼ Class 3 infection – Lesion > 5 cm in diameter – Patient toxic appearing or at least one unstable comorbidity or limb-threatening infection ◼ Class 4 infection – syndrome of life-threatening infection (necrotizing ) Treatment of Skin Infections Beware of CA-MRSA

Key Point Incise and drain the lesion if possible! Treatment of Skin Infections Beware of CA-MRSA

◼ alone without has 90% cure rate ◼ Use 11 blade to create a wide opening ◼ Explore wound for loculations and pack ◼ Frequent follow-up for approximately 2 weeks

Rajendran et al. Antimicrob Agents Chemother 2007;51:4044-4048 Treatment of Skin Infections Beware of CA-MRSA

◼ Class 1 infection – If no drainable abscess, prescribe first or second generation , semi- synthetic penicillin, macrolide, or – Follow-up in 1-2 days to ensure response Treatment of Skin Infections Beware of CA-MRSA

◼ Class 2 infection – I&D the lesion – Frequent follow-up – If not healing within 7 days, empirically treat with TMP-SMX – Clindamycin and tetracycline are alternatives, although higher resistance Treatment of Skin Infections Beware of CA-MRSA

◼ Class 3 and 4 infections – Admit to hospital – Consult for aggressive – Start vancomycin IV – Consult infectious disease specialist Approach to Treatment of Skin Infections in Athletes

◼ Lesions can often not look “typical” because of scratching or rubbing. ◼ If you suspect HSV, un-roof a vesicle for culture (if possible) and treat empirically with oral anti-viral. ◼ I&D, if possible, is the treatment of choice. Send fluid for culture to look for MRSA. Approach to Treatment of Skin Infections

◼ Treat non-fluctuant lesions for MSSA with cephalosporin or amoxicillin- clavulante (augmentin). ◼ Monitor athletes daily for response. If fluctuant lesions appear, I&D them. If not responding, consider switching to oral MRSA based on local sensitivities. Approach to Treatment of Skin Infections

◼ Avoid empiric treatment with oral anti- MRSA antibiotic unless there is a known MRSA outbreak on the team, or lesion has classic MRSA presentation and appearance. ◼ Avoid cephalosporin plus anti-MRSA empiric treatment. Case #5

◼ 19 y.o. Baseball player presents with a lacy in his inguinal region ◼ He describes it as “itchy” and it exacerbates when he sweats Cutaneous Fungal Infections “Tinea”

◼ survive on keratin in the stratum corneum ◼ Warm, moist environments promote fungal growth ◼ in athletes is primarily spread by skin-to-skin contact ◼ Skin scales containing fungal spores can live outside the host on inanimate surfaces Tinea Crura and Pedis Tinea Corporis Treatment of Fungal Infections

◼ Topical treatment usually sufficient – Allyamines (terbinafine, naftifine): fungicidal – Imidazoles (clotrimazole, miconazole): fungistatic – 2-3 times a day for 3-28 days (or longer?) Treatment of Fungal Infections

◼ Oral anti-fungals for widespread lesions, multiple recurrences – 150 mg q wk for 3 weeks – Itraconazole 200 mg qD for 2 weeks – Terbinafine 250 mg qD for 2 weeks Treatment of Fungal Infections

◼ For tinea crura and pedis, keeping the areas as dry as possible are key for successful treatment and prevention of recurrence – Change underwear/socks frequently! Participation and Return to Play Guidelines

◼ Wrestling at all levels (HS, college, international) has specific rules governing criteria for participation and return to play for infectious skin diseases ◼ Other sports do not, but wrestling rules provide a conservative guideline Participation and Return to Play Guidelines

◼ Bacterial infections – Treatment for minimum 72 hrs – No new lesions within 48 hrs – No draining or “wet” lesions ◼ Herpetic infections – Systemic antiviral therapy for at least 120 hrs prior to competition – No new for 72 hrs, no moist lesions Participation and Return to Play Guidelines

◼ Fungal infections – Minimum 72 hrs topical treatment for non-scalp, 2 weeks systemic for scalp, lesions Prevention of Skin Infections in Athletes

◼ Infection acquisition requires skin exposure to infectious agent with breakdown of normal skin barriers ◼ Prevention measures designed to minimize exposure and skin breakdown Prevention of Skin Infections in Athletes

◼ In high contact sports (wrestling, martial arts), transmission is primarily skin-to-skin ◼ Key to prevention: identify infected athletes early and keep them from participating until treated Prevention of Skin Infections in Athletes

◼ Sports with equipment/padding/tight fitting clothes – Proper fit is important to minimize injury to underlying skin – Try and minimize prolonged exposure to hot, moist micro-environments that promote organism growth – Don’t share equipment that directly contacts the skin Prevention of Skin Infections in Athletes

◼ Encourage personal hygiene ◼ Cleaning and disinfecting playing surfaces/mats is a good idea, but has less impact than other measures CDC Measures for Preventing Staph Skin Infections Among Sports Participants

1. Cover all wounds. If a wound cannot be covered adequately, consider excluding players with potentially infectious skin lesions from practice or competitions until the lesions are healed or can be covered adequately. 2. Encourage good hygiene, including showering and washing with soap after all practices and competitions. 3. Ensure availability of adequate soap and hot water. 4. Discourage sharing of towels and personal items (eg, or equipment). 5. Establish routine cleaning schedules for shared equipment. 6. Train athletes and coaches in first aid for wounds and recognition of wounds that are potentially infected. 7. Encourage athletes to report skin lesions to coaches to assess athletes regularly for skin lesions. Prevention of Herpes Gladiatorum

◼ Similar to guidelines to prevent bacterial infections except: ◼ Antiviral prophylaxis has been shown to decrease acquisition and spread of herpes gladiatorum in wrestlers – Continue anti-virals in the athlete after acute outbreak has resolved – Prophylaxis in athletes exposed to an outbreak – Prophylaxis of sero-positive athletes involved in high risk sports (i.e., wrestling) Prevention of Tinea in Athletes

◼ Similar to bacterial infection prevention measures ◼ Role of oral prophylaxis in athletes at high risk is an area of ongoing study Case #6

◼ 51 year old with tender under 1st metatarsal head ◼ Hiked with backpack in rough terrain for 7 miles ◼ Wore wool socks ◼ Generally physically active, but not a habitual backpacker Friction Blisters

◼ Result from friction forces that separate epidermal cells at the level of the stratum spinosum ◼ Potential space fills with fluid and/or blood Friction Blisters

◼ Factors that promote blister formation – Moisture increases frictional forces – Heat – Poorly fitting shoes – New activities – Cotton socks Friction Blisters

◼ Treatment – Decompress large blisters with sterile needle. Leave blister roof intact – “Second skin” or petrolatum and an adhesive bandage should be applied to minimize further friction at the site – Prevention: acrylic or polyester socks Friction Blisters

◼ Prevention – Acrylic or polyester socks changed frequently – Properly fitting shoes – Paring down of thick Contact in Athletes

◼ Allergic

◼ Irritant contact dermatitis Contact Dermatitis in Athletes

◼ Allergic contact dermatitis – Exposure to chemicals, rubber products, athletic tape, dyes, creams – Patch testing if diagnosis not obvious Contact Dermatitis in Athletes

◼ Irritant contact dermatitis – Often due to friction and sweat, or exposure to chemical irritants Contact Dermatitis in Athletes Swimmer’s Resources

◼ Pecci M, Comeau D, Chawla V. Skin conditions in the athlete. Am J Sports Med 2009;37:406-17. ◼ McBride D. Managing community-acquired MRSA lesions: What works? OBG Management 2008;20:28-33. ◼ Cohen P. The skin in the gym. Clinics Derm 2008;26:16-26. ◼ http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html ◼ http://epa.gov/oppad001/chemregindex.htm ◼ http://www.nfhs.org ◼ http://www.mhsaa.com