Download Skin Problems in Athletes

Case Studies in Sports
Dermatology
Kent Scheff MD
University of Michigan Primary Care
Sports Medicine Fellow
Disclosures
• None
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.
Case #1
Too Close for Comfort
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
Case #1
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
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
Herpes Gladiatorum vesicles
Herpes Gladiatorum ulcers
Herpes Gladiatorum Crust
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 20-25 days, IgG 6-8 weeks after
exposure
Treatment
• Early treatment is key; virus exponentially
replicates within the first 48 hours
• Acyclovir 400 mg TID
• Valacyclovir 1 gm BID
7-10 days
• Famciclovir 500 mg Bid
• Recurrence: identical dosing for 5 days
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
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
Case #2
Training Room Challenge
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.
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 Blactam-B-lactamase inhibitor
combinations (e.g., amoxicillinclavulanate)
CA-MRSA
• Increased prevalence of S.aureus that
have the mecA gene that produces the
penicillin-binding protein PBP2a
• Confers resistance to all currently FDAapproved B-lactams
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
• 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
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”
CA-MRSA
CA-MRSA
• Class 1 infection
–Lesion nonfluctuant
–Patient afebrile,
otherwise
healthy
CA-MRSA
• Class 2 infection
–Lesion fluctuant
or pustular
–Lesion < 5 cm in
diameter
–Patient afebrile,
otherwise
healthy
CA-MRSA
• Class 3 infection
– Lesion > 5 cm in
diameter
– Patient toxic
appearing or at
least one unstable
comorbidity or
limb-threatening
infection
CA-MRSA
• Class 4 infection
– Sepsis syndrome
of life-threatening
infection
(necrotizing
fasciitis)
CA-MRSA
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;51:4044-48
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
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
CA-MRSA treatment
• Class 3 and 4 infections
–Admit to hospital
–Consult surgery for aggressive
debridement
–Start vancomycin IV
–Consult infectious disease specialist
CA-MRSA
Return to Play
• Bacterial infections
–Treatment for minimum 72 hrs
–No new lesions within 48 hrs
–No draining or “wet” lesions
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
Case #3
Moisture is the Enemy
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
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
Tinea Corporis and Pedis
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
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
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
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
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
Case #4
My Achin’ Feet!
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
Friction Blister
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
Friction Blisters
• Factors promoting blister formation
– Moisture increases frictional forces
– Heat
– Poorly fitting shoes
– New activities
– Cotton socks
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
Friction Blister
Case #5
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?
Case #5
Scabies
• Caused by mite
Sarcoptes scabiei (0.4
mm)
• Female mite attracted
to warmth
(intertriginous, beltline,
groin, axillary regions)
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.
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.
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
Bibliography
• 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;20:2833.
• Cohen P. The skin in the gym. Clinics Derm 2008;26:1626.
• http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html
• http://epa.gov/oppad001/chemregindex.htm
• http://nfhs.org
• http://www.mhsaa.com