Winter Sports Dermatology: A Review Sumedha Lamba Englund, MD; Brian B. Adams, MD, MPH As more individuals choose to maintain their fit- Penile frostnip was reported in a winter jogger ness level year-round, they inevitably encounter after running in below-freezing, windy weather skin problems. During these athletic pursuits, the while wearing polyester trousers and cotton under- skin must endure ongoing insult, serving as the wear with an anterior opening.5 To prevent frost- interface between the athlete and environmental nip, athletes should dress in multiple layers and factors unique to the sport and season. Therefore, wear insulated clothing that withstands the outside primary care physicians and dermatologists must temperature.1,2 By adopting a layering effect when understand how athletic activity and weather dressing, air is effectively trapped and serves as contribute to the development of dermatoses. By insulation.6,7 Synthetic clothes wick away moisture appropriately recognizing winter sport derma- compared to natural fibers that become damp with toses, the practitioner can best provide tailored perspiration. Wet clothing reduces its insulation effective treatment that enables the patient to value to 10% of its effectiveness when dry.4,8 Ski quickly return to the winter sport. masks provide protection for the face, though they Cutis. 2009;83:42-48. may be cumbersome.6 Petrolatum-based emollients keep the skin at a higher temperature compared to untreated skin.9,10 Natural sebum enhances this roper diagnosis and treatment of winter sport effect; therefore, delaying washing and shaving until dermatoses requires an awareness of both the after participation in outdoor activities are complete P activity and the effect of cold exposure on the preserves this effect.6 skin. Cold injuries include freezing and nonfreez- Frostbite—Frostbite refers to the freezing of tissue ing injuries. We first discuss cold injuries that may caused by severe cold exposure that damages skin, develop in any winter athlete because of exposure subcutaneous tissue, muscle, and even bone. Ath- to the environment and then describe the specific letes experience a higher risk for developing frost- dermatologic conditions resulting from participation bite resulting from cold exposure at high altitudes. in various winter sports. The combined effects of decreased oxygen tension and increased oxygen demand secondary to exercise CUTANEOUS EFFECTS OF COLD EXPOSURE worsen the cutaneous anoxia caused by compensa- Cold Injuries: Freezing tory peripheral vasoconstriction.11,12 In addition, the Frostnip—Frostnip is the most common skin injury evaporation of sweat increases cutaneous heat loss caused by cold weather.1-4 The term frostnip denotes and hastens hypothermic injury.13 Lastly, athletes a hypothermic injury that involves only the superfi- engaged in high-velocity sports such as downhill cial skin. The most commonly affected areas include skiing, snowmobiling, snowboarding, or luge have the face, nose, cheeks, chin, and ears. Affected amplified rates of heat loss. The skin loses more areas feel numb and have a blue to purple hue. heat at 108C in 20-mph wind than at 2108C in A throbbing or burning sensation may persist still air.14,15 for weeks. With sustained heat loss, blood flow to the skin diminishes, thermal heat loss ensues, and the early Accepted for publication October 1, 2007. symptoms of pain and burning progress to numbness. Dr. Englund is from the University of Louisville School of Medicine, Frostbite initially causes sudden blanching of a nose Kentucky. Dr. Adams is from the Department of Dermatology, or ear with subsequent anesthesia.16 Rapid rewarm- University of Cincinnati School of Medicine, Ohio, and Veterans ing in a circulating warm water bath of 388C to 448C Administration Medical Center, Cincinnati. treats frostbite, but one must only implement treat- The authors report no conflict of interest. Correspondence: Brian B. Adams, MD, MPH, Department of ment after the possibility of further freezing has been Dermatology, University of Cincinnati, PO Box 670592, Cincinnati, eliminated because subsequent refreezing causes a 6 OH 45267-0523 ([email protected]). greater degree of tissue necrosis. 42 CUTIS® Winter Sports Dermatology Cold Sensitivity Disorders: Nonfreezing warmth, pruritus, erythema, urticaria, angioedema, Perniosis (Chilblain)—Perniosis (chilblain) most com- respiratory distress, gastrointestinal symptoms (nau- monly involves the hands and feet and occurs after sea, diarrhea, colic), and vascular collapse occurring prolonged exposure to a cold wet environment. in varying frequencies.26-28 The symptoms of EIA Indurated, edematous, pruritic, red to violaceous usually occur within 5 minutes of exercise.29,30 plaques develop within several hours following cold Two possible mechanisms have been proposed exposure.17,18 Perniosis can occur at other sites and for EIA. The first mechanism involves the acti- location varies according to activity. Cutaneous vation of the complement pathway; the second vasoconstriction with subsequent hypoxemia causes theory implicates mast cell degranulation medi- perniosis. The relatively thicker layer of subcutane- ated via IgE, lactate, or creatine kinase resulting in ous fat found on most women predisposes them to the widespread release of histamine.30-33 The resul- developing perniosis.19 tant histaminemia causes the symptoms occurring A type of nodular pernio called shoe boot pernio with EIA.34 occurs after wearing waterproof boots with wet inner Exercise-induced anaphylaxis, a misnomer, rarely linings.20 Four cases of perniosis have been reported results in respiratory or vascular collapse.35-38 Many in men who waded through extremely cold moun- factors, such as food ingestion (most common), tain rivers.21 Within 2 days, the men developed medications (nonsteroidal anti-inflammatory drugs tender bruising on their thighs. A biopsy specimen or aspirin), the menstrual cycle, and cold exposure, showed edema of the papillary dermis with promi- can exacerbate EIA.39 nent perivascular and perifollicular lymphocytic There is one reported case of cold-dependent infiltration and fat necrosis with foamy macrophages EIA in a runner.40 A 16-year-old adolescent boy had in the upper subcutaneous tissue consistent with a 4-year history of recurrent urticaria and dyspnea deep perniosis and panniculitis. The lesions resolved after winter physical exercise such as jogging, playing within a week with rest and conservative manage- handball, or riding a bicycle. Ingesting food, includ- ment.21 Wearing insulated, water-resistant clothing ing wheat, did not cause the episode. A provocation prevents perniosis in these athletes. test with 15 minutes of exercise and 2 minutes of Raynaud Phenomenon—Transient benign vaso- cold stimulation immediately before or immediately spasm of the fingers occurs commonly, especially in after the exercise, however, did elicit localized wheals. young women. Raynaud phenomenon (RP) describes The authors emphasized that although a variant of a dull pain with sudden blanching of the fingers EIA, cold-dependent EIA is a distinct entity not to linked to cold exposure and not associated with be confused with cold urticaria, food-dependent EIA, an underlying connective tissue disease. Patients cholinergic urticaria, or cold-induced cholinergic with RP have more severe symptoms and more fre- urticaria.40 Cold exposure may serve as an additional quent episodes during the winter.22 The etiology of factor in all forms of EIA. A report of cold-dependant, the seasonal variation of RP cannot be explained food-dependent EIA exists.41 In addition, in a study of simply by an increased vasoconstrictive response. 199 participants with EIA, cold was a factor for EIA This seasonal influence on finger skin temperature in 23% of participants.42 Indeed, another study of and microvascular blood flow that persists during 279 participants with EIA demonstrated that avoidance the winter occurs irrespective of temperature.23 of exercise in extremely cold or hot weather reduced the During exposure to cold, athletes may feel a dull incidence of attacks in 44% of participants.31 pain and typically only part of the hands sud- The immediate treatment of all forms of EIA denly becomes unevenly ivory white then blue and (cold-dependent, food-dependent, and others) slightly swollen. Warming the hands fully relieves focuses on maintaining airway patency and provid- the athlete. ing vascular support as needed. A long-acting, nonse- Athletes can prevent RP by wearing layers of dating antihistamine taken 1 hour before exercising thin, acrylic, moisture-wicking gloves with an outer helps prevent EIA.34,35,43 If antihistamine therapy waterproof layer; many commercially available vari- alone fails, prednisone 40 mg 12 hours prior to exer- eties exist. Athletes with RP also must avoid uncov- cise may prove helpful.44 Cromolyn sodium prevents ered contact with metal objects such as ski poles, the respiratory symptoms while ketoprofen relieves which can quickly trigger an attack. For recalcitrant the dermatologic symptoms of EIA.38,41 Exercise- cases, extended-release nifedipine 30 mg at bedtime induced anaphylaxis does not necessarily occur each reduces the number of attacks.24 Fish oil supplemen- time the athlete exercises; however, athletes with tation provides some added benefit.25 the disorder should carry injectable epinephrine Cold-Dependent Exercise-Induced Anaphylaxis— (0.3–0.5 mL of 1:1000 solution) and exercise with a