1. Case Studies in Sports Dermatology
Kent Scheff MD
University of Michigan Primary Care Sports Medicine Fellow

2. Disclosures
None

3. Objectives
Be able diagnose common infections encountered in the training room.
Choose appropriate therapy for the above infections
Be able to propose an appropriate time for athletes to return to competition following infection
Propose methods for reducing further infection and recurrence.

4. Case #1
Too Close for Comfort

5. Case #1 19 y.o. Wrestler 2 day history of rash on face
Initially started with tingling/burning sensation
Vesicular rash appeared on day 2, some lesions have started to scab/crust
Presents for evaluation
Holiday Tournament scheduled in 3 days

6. Case #1

7. Herpes Gladiatorum Caused by Herpes Simplex Virus 1
Prominent among wrestlers and in other sports with skin to skin contact
Accounts for 39% of skin infections in the NCAA injury surveillance of wrestlers
Incubation is 2-20 days however, most lesions appear after 3-5 days of exposure

8. Herpes Gladiatorum
Initial presentation is seen on head, neck, face (right side) ears, torso or upper extremities
Primary infections may present with constitutional symptoms along with burning, tingling or stinging at the site
Vesicles then form on an erythematous base
Vesicles ulcers plaques

9. Herpes Gladiatorum vesicles

10. Herpes Gladiatorum ulcers

11. Herpes Gladiatorum Crust

12. Diagnostic Methods
Gold standard is Viral Culture remembering that maximum sensitivity is achieved in 2-7 days.
Sample base of a disrupted vesicle during active lesion
HSV PCR test is more sensitive and faster though more expensive
Serology IgM days, IgG 6-8 weeks after exposure

13. Treatment
Early treatment is key; virus exponentially replicates within the first 48 hours
Acyclovir 400 mg TID
Valacyclovir 1 gm BID days
Famciclovir 500 mg Bid
Recurrence: identical dosing for 5 days

14. Return to Play Free of systemic symptoms No new lesions for 72 hours
All lesions must be dry with a firm adherent crust
Appropriate treatment with a systemic antiviral for 120 hours prior to competition
Active lesions are not to be covered to allow competition

15. Prevention Early diagnosis and quarantine of affected athletes
Athlete education “no sharing” of towels
Disinfection of commonly used items, mats, exercise equipment
Antiviral prophylaxis has been shown to decrease acquisition and spread of Herpes Gladiatorum in wrestlers
Valacyclovir 500 mg to 1 gm daily
Consider continuing antiviral after acute episode, in seropositive individuals

16. Training Room Challenge
Case #2
Training Room Challenge

17. Case #2
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.

18. Community Acquired MRSA
Most S.aureus are beta-lactamase producing, 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)

19. 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

20. 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

21. CA-MRSA Median age of HA-MRSA: 68 yrs Median age of CA-MRSA: 23 yrs
2006 survey of Texas Athletic Trainers found that 32% had treated MRSA infections in their athletes

22. 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”

23. CA-MRSA

24. CA-MRSA Class 1 infection Lesion non-fluctuant
Patient afebrile, otherwise healthy

25. CA-MRSA Class 2 infection Lesion fluctuant or pustular
Lesion < 5 cm in diameter
Patient afebrile, otherwise healthy

26. CA-MRSA Lesion > 5 cm in diameter
Class 3 infection
Lesion > 5 cm in diameter
Patient toxic appearing or at least one unstable comorbidity or limb-threatening infection

27. CA-MRSA Class 4 infection
Sepsis syndrome of life-threatening infection (necrotizing fasciitis)

28. Key Point Incision and Drainage of the Lesion! (if possible)
CA-MRSA
Key Point Incision and Drainage of the Lesion! (if possible)

29. 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 Chemotherapy 2007;51:

30. CA-MRSA treatment 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

31. CA-MRSA Class 2 infection I&D the lesion Frequent follow-up
If not healing within 7 days, empirically treat with TMP-SMX DS 2 tabs BID
Clindamycin and tetracycline are alternatives, but have slightly less efficacy

32. CA-MRSA treatment Class 3 and 4 infections Admit to hospital
Consult surgery for aggressive debridement
Start vancomycin IV
Consult infectious disease specialist

33. CA-MRSA Return to Play Bacterial infections
Treatment for minimum 72 hrs
No new lesions within 48 hrs
No draining or “wet” lesions

34. CA-MRSA Prevention
Washing/Showering with soap and warm water as soon as possible after competition/practice
Not Sharing soap bars, towels, razors or clothing
Prompt treatment of abrasions, cuts

35. Case #3
Moisture is the Enemy

36. Case #3
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

37. Tinea Infections
Dermatophytes survive on keratin in the stratum corneum layer of the skin
Warm, moist environments promote fungal growth
Tinea corpora in athletes is primarily spread by skin-to-skin contact
Skin scales containing fungal spores can live outside the host on inanimate surfaces

38. Tinea Corporis and Pedis

39. Tinea Diagnosis Diagnosis can often be made by inspection
Scraping the edge of the lesion and examining with heated KOH prep heated under microscopy yields hyphae

40. Tinea Treatment Allylamines Terbinafine Naftifine
May have shorter treatment periods than imidazoles
Fungicidal
Decreased liver toxicity
Imidazoles
Clotrimazole
Ketoconazole
Miconazole
Effective for most fungal infections, but may employ a longer treatment period
Fungistatic

41. Tinea Treatment
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

42. Tinea Return to Play NCAA and NFHS guidelines
Minimum of 72 hours of topical therapy needed for non-scalp infections
Minimum of 2 weeks of systemic antifungal for scalp infection before participation is allowed.
Lesions should be washed with selenium sulfide or ketoconazole shampoo, coated with naftifine or terbinafine cream then covered with pre-wrap and tape prior to competition

43. Tinea Prevention Similar to CA-MRSA recommendations
Athlete cleanliness
No sharing equipment such as helmets or towels
Reduce time practicing in hot/damp environments
Cleaning Mats helps, but major risk is skin to skin contact

44. Case #4
My Achin’ Feet!

45. Case #4 51 y.o. backpacker Presents with a blister on his foot
Hiked in rough terrain for 7 miles with a 50 pound pack
Wore wool socks
A recreational runner, but not accustomed to
Weight/terrain, etc

46. Friction Blister

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

48. Friction Blisters Factors promoting blister formation
Moisture increases frictional forces
Heat
Poorly fitting shoes
New activities
Cotton socks

49. Friction Blisters Treatment
Decompress large blisters with a sterile needle.
Leave blister roof intact
“Second Skin” or petrolatum, donut pad, should be
applied to minimize further friction at the site.
Prevention: acrylic or polyester socks

50. Friction Blister

51. Case #5

52. Case #5
20 y.o. soccer player presents with a pruritic rash for 2 days between the fingers and in beltline.
21 y.o. football player presented later that day with similar symptoms and rash distribution
Yet another 21 y.o. soccer player presented with similar rash in the beltline.
What’s going on?

53. Case #5

54. Scabies Caused by mite Sarcoptes scabiei (0.4 mm)
Female mite attracted to warmth (intertriginous, beltline, groin, axillary regions)

55. Scabies Female mite makes a burrow, lays eggs 1-3 daily
Produces secretions that cause allergic rxn.
Larvae hatch from eggs travel to skin surface and also produce secretions.

56. Scabies Treatment
Topical application of Permethrin (Elimite cream) from neck to toes at night.
Wash all bedclothing and suspected contaminated clothing in hot water.
Avoid sleeping on roomate’s couch that is infested.

57. Summary
Reviewed examples of infections and blisters encountered in athletes
Reviewed Diagnosis and treatment
Plans for return to play
Reviewed suggested methods of prevention of infection and re-infection

58. Bibliography
Pecci M, Comeau D, Chawla V. Skin conditions in the athlete. Am J Sports Med 2009;37:
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.