Sports Dermatology Robert Kiningham, MD, FACSM Department of Family Medicine University of Michigan Health System Disclosures/Conflicts of Interest ◼ None Goals and Objectives ◼ Review skin infections 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 pain 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 lesions on chin. Started as a single lesion, 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 ◼ Cellulitis ◼ Erysipelas ◼ Impetigo ◼ Furunculosis ◼ Folliculitis ◼ Paronychea Cellulitis Cellulitis ◼ Diffuse infection of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin – Triad of erythema, edema, and warmth in the absence of underlying foci ◼ S. aureus or S. pyogenes Erysipelas Erysipelas ◼ Superficial infection of the dermis ◼ 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 honey – colored crusting of the overlying skin – Bullous, non-bullous, ecthyma ◼ Staphylococcus aureus or Streptococcus pyogenes (group A streptococci) Folliculitis Folliculitis ◼ Infection of the hair follicle that remains superficial - localized to the epidermis ◼ S. aureus, Candida species, Pseudomonas aeruginosa (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 subcutaneous tissue ◼ Forms a perifollicular abscess ◼ Almost always caused by S. aureus Furuncle/Carbuncle ◼ Carbuncle: deeper and wider lesions with interconnecting subcutaneous abscesses arising from infection of several neighboring hair follicles – May have systemic symptoms Great Toe Paronychia Paronychia ◼ Soft tissue infection around a nail ◼ Acute paronychia is usually due to S. aureus or S. pyogenes ◼ Chronic can be due to Candida species ◼ Herpes simplex causes herpetic whitlow Herpetic Whitlow Skin Infections Herpes Simplex (Herpes Gladiatorum) ◼ 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 transmission 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 “spider bite” 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 penicillin, but susceptible to cephalosporins and the penicillinase-resistant penicillins (nafcillin, oxacillin, dicloxicillin), or B- lactam-B-lactamase inhibitor combinations (e.g., amoxicillin- 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 – Sepsis syndrome of life-threatening infection (necrotizing fasciitis) 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 ◼ Incision and drainage alone without antibiotics 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 cephalosporin, semi- synthetic penicillin, macrolide, or clindamycin – 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 surgery for aggressive debridement – 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 antibiotic 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 rash in his inguinal region ◼ He describes it as “itchy” and it exacerbates when he sweats Cutaneous Fungal Infections “Tinea” ◼ Dermatophytes survive on keratin in the stratum corneum ◼ Warm, moist environments promote fungal growth ◼ Tinea corporis 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 – Fluconazole 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 blisters 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