Understanding and Identifying Skin Infections: Causes, Symptoms, and Treatment

Athletic activities, particularly contact sports, can put athletes at risk of various skin infections that can lead to severe health consequences and hinder their performance. Herpes gladiatorum, molluscum contagiosum, and verrucous warts are just a few examples of common skin infections that athletes may encounter.

It is crucial to identify these infections early on, take appropriate preventive measures, and promptly treat them to avoid further complications and transmission to other athletes. In this text, we will discuss the causes, symptoms, treatments, and preventive measures for some of the most prevalent skin infections in athletes, providing important information to help athletes maintain their skin health and overall well-being.

Engaging in physical sports, such as wrestling, martial arts, and football, inherently puts participants in danger of contracting skin infections. These sports involve close physical contact, often resulting in sweating, skin abrasions, and repeated skin rubbing, all of which contribute to transmitting infectious agents, including bacteria, fungi, and viruses.

Skin infections have become increasingly prevalent in contact sports over the years. For instance, in January 1999, an outbreak of herpes gladiatorum affected 64 wrestlers and coaches in 19 Minnesota high schools, and similar epidemics occurred in other high school wrestling teams across the United States.

Furthermore, community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) epidemics were in multiple collegiate and professional football teams in 2003. In contrast, nonphysical sports like golf or tennis have practically no cases of skin infections.

The popularity of contact sports raises the possibility of more outbreaks in the future. The risks increase by a lack of awareness among medical practitioners on preventing the spread of infections and by athletes who seek medical approval to compete despite having an active infection, disregarding the potential for transmitting it to their opponents.

Proper Hygiene Practices for Combat Sports:

• Wash your practice clothes, bags, and gear after every practice.
• Take a shower right after every practice or match.
• Avoid shaving your chest, arms, legs, or pubic areas for cosmetic reasons.
• Use liquid soap dispensers instead of bar soap.
• Don’t share your hygiene products.
• Use your towels and take a shower before using whirlpools.
• Make sure to clean all mats before each practice and competition.
• During tournaments, clean the mat surfaces multiple times.
• Don’t walk on the mats with your street shoes.
• Consider cleaning your shoes before you step on the mat.
• Check your skin every day and before any competitions.
• Skin problems should be checked and treated by your doctor before you compete.
• Wear clothing that covers your arms and legs. Leggings can be worn as part of your competition uniform to reduce skin exposure.
• Have continuity in medical care, which means sticking with the same doctor. Studies show that this helps control skin infections better than having access to medical care.

Here are two examples that highlight how serious the issue of skin infections in physical sports can be.

The first is community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA), which surprised the sports community and has resulted in several deaths and severe illnesses among collegiate and professional players who contracted the infection during public epidemics.

The second is herpes gladiatorum, which has caused wrestlers to develop a viral infection on the surface of their corneas, known as herpes keratitis. With viral reactivation continuing for 20 or more years, there is a 63% chance of the athlete experiencing continued corneal involvement, leading to scarring and possibly even blindness.

These incidents could have catastrophic legal implications, potentially causing society to question whether these sports should be allowed to continue. Skin and soft tissue infections (SSTI) can arise from many infectious agents, including bacteria, fungi, and viruses, and any open wound can serve as a portal for these agents to invade the skin.

Follow hygienic principles, such as cleansing and bandaging wounds, to help prevent or minimize the spread of infections. Failing to do so can increase the risk of these infections spreading and requiring medical treatment.

Prevalence of Bacterial Infections in Athletes

The National Collegiate Athletic Association Injury Surveillance System reports that bacterial infections are the second most common type of skin infection experienced by athletes falling behind herpes infections but come before tinea in terms of causing athletes to miss practice or competition.

Overview of Common Bacterial Skin Infections in Athletes

Bacterial skin infections are common in athletes, with several types presenting distinct clinical features. Cellulitis is a reaction to bacterial invasion and can be caused by staph or strep.

Impetigo is a skin infection caused by bacteria. It typically presents as pustules that eventually rupture and form crusts. This infection often occurs in areas where the skin has opened due to cuts or abrasions.

Folliculitis is an inflammation of the hair follicles and can expand to cause cellulitis in the surrounding tissues. Furuncles and carbuncles are deep-seated follicular infections that involve apocrine glands and surrounding adipose tissue.

Infections caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) have increased in prevalence, accounting for 59% of SSTIs in emergency rooms and more commonly found in contact sports. CA-MRSA infections may present as a “spider bite,” rapidly progressing to abscess formation and invasion of deeper tissues.

Treating Bacterial Infections in Athletes

In respect of bacterial infections, treatment is usually by oral antibiotics. However, deep tissue infections like furuncles or carbuncles may require local debridement.

Controlling these infections as a primary way of treatment is local incision and drainage accompanied by antibiotics to speed up the clearance and prevent spreading to other athletes. Abscesses should be cultured to ensure appropriate antibiotic prescriptions.

When an abscess has been cultured, a sample of the pus or tissue is taken and sent to a laboratory to identify the specific type of bacteria causing the infection.

Making cultures helps the healthcare provider determine which antibiotics are most effective against the bacteria causing the infection, ensuring that the patient receives the appropriate antibiotic prescription and is treated effectively.

Balancing treatment and allowing the athlete to return to competition as soon as possible requires proper medical judgment. Generally, a 7-10 day antibiotic regimen is necessary for eradication.

An athlete can return to competition after 72 hours of treatment if the infection improves and the affected areas are covered with inclusive agents like Tegaderm.

If CA-MRSA is discovered, the athlete must wait ten days to ensure complete eradication of the infection. Consider attempts to eradicate any carrier state of this organism due to its severity and consequences.

During treatment, applying mupirocin 2% cream twice a day in the nose and daily scrubbing of the body with chlorhexidine gluconate 4% for the last five days of treatment can help reduce the colonization of the infection. If CA-MRSA persists or recurs, contact the local public health department for further assistance.

Fungal Infections

The incidence of fungal skin infections has risen significantly over the past two decades in the general public. Trichophyton tonsurans, a dermatophyte, is the primary cause of cutaneous mycoses and is responsible for 90% of tinea capitis cases in urban areas.

In the context of wrestling, tinea accounted for more than 70% of skin infections at the Minnesota State High School wrestling tournament over ten years from 1997 to 2006. A study conducted in 2001 showed that 35-40% of participants in Japanese Judo Clubs displayed symptoms of this infection during screening examinations.

Tinea corporis gladiatorum (TCG) is often regarded as a minor issue but can be challenging to treat, and the cost of eradicating the infection can be as high as US$525. TCG typically develops within 3-5 days after direct skin-to-skin contact with an infected opponent or through fomite contact. The infection looks like a small, erythematous, vesiculobullous lesion that spreads in a circular pattern, with a flaky outer border and a central clearing.

Although single lesions can grow 8-10 cm in diameter, athletes usually seek treatment before the infection reaches that size.

TCG infection typically affects only superficial skin structures without involving deeper layers.

When the infection becomes more severe, it may affect the scalp and lead to granulomatous lesions, particularly around hair follicles, resulting in alopecia and classic kerion formation. The presence of pustules with serosanguinous discharge may also be observed, and regional lymphadenopathy may develop.

T. tonsurans is typically an anthropophilic species, meaning it is specific to humans. However, outbreaks of TCG have been reported, where the dermatophyte was transmitted through close contact with infected animals, which is particularly relevant for athletes who work in farming communities and may contract the agent from bovine or swine sources.

TCG primarily develops on exposed areas of the skin, with a predilection for the extremities. While most infections can be treated effectively with topical agents, oral medications are necessary when lesions occur on the scalp or when multiple skin lesions are present.

The appropriate duration of treatment for TCG in physical sports has always been a matter of debate, as there is a need to balance the athlete’s return to competition with the requirement to treat long enough to eradicate the fungus.

In a previous study, Kohl found that culturable fungus could be present up to 21 days after starting oral antifungal medication.

Before athletes infected with TCG return to competition, the National Collegiate Athletic Association (NCAA) and the National Federation of State High Schools Association (NFHS) recommend the following precautions:

• Athletes with TCG should receive 14 days of oral antifungal medication for scalp lesions, and topical or oral medications for all other lesions should be administered for 72 hours.
• Athletes without scalp lesions can return to competition if their lesions are covered with a bioclusive agent for the remaining 2-4 weeks of the treatment regimen.
• Athletes with scalp lesions can return to competition after 14 days of oral medication, provided that they wash their scalp with selenium sulfide shampoo before each competition to minimize the shedding of fungal spores and limit their spread.

It is essential to follow proper hygiene practices, conduct skin checks before competitions, and adhere to appropriate treatment regimens to prevent the spread and contraction of tinea infections. Additional preventative measures may be necessary if outbreaks still occur despite these precautions.

Skin barriers like Kenshield or Clear Shield can help reduce the transmission of infections but may not be more effective than daily skin checks. Wrestlers can also use oral antifungal medications to prevent fungal infections, and studies have shown they are effective and safe.

Hazen and Weil conducted a study with 37 subjects using itraconazole 200 mg twice daily for one day every two weeks and observed no occurrences of tinea over eight weeks.

Similarly, Kohl conducted a placebo-controlled study with 131 participants using fluconazole 100 mg daily and found that tinea developed in only 6% of subjects on fluconazole compared to 22% of subjects on placebo (P < 0.05).

Viral Infections

Herpes simplex virus is highly prevalent among humans, with types 1 and 2 being the usual agents transmitted in contact sports, with HSV-1 accounting for 94-97% of infections.

Ocular involvement can lead to significant morbidity, with recurrent outbreaks increasing the risk of developing herpes keratitis, which can cause corneal scarring, decreased vision, and potentially require a corneal transplant. Although rare, more severe complications include retinal necrosis and blindness in the affected eye.

Direct skin-to-skin contact is the primary mode of transmission for herpes infection. The prevalence of herpes infection is estimated to be similar among athletes and non-athletes, but the location of epidemics may differ. In non-athletes, primary outbreaks usually occur around the oro-nasal region, resulting in herpes labialis.

In physical sports, herpes outbreaks commonly occur in areas with the most skin-to-skin contact with an opponent. The infection that develops in wrestling is called herpes gladiatorum, with over two-thirds of cases occurring on the head, face, and neck.

The primary symptoms of herpes gladiatorum include systemic involvement and groups of 2 mm vesicles that merge to form clusters of 3-10 lesions. There may also be redness and warmth around the lesions that typically last 10-14 days.

The virus can affect multiple sites and dermatomes as it progresses along the sensory neuron and infects ganglions. As the virus establishes latency in one ganglion, significant regional lymphadenopathy and multiple site involvements are common.

Recurrent herpes outbreaks involve fewer and smaller vesicles, and they tend to resolve more quickly than primary outbreaks. Reactivation of the virus occurs in only one ganglion, leading to recurrences that always appear along the same dermatomal pattern.

Treatment can help speed up healing, but it cannot eliminate the virus from the nerve ganglion. Outbreaks are often triggered by weight cutting, rubbing, or stress. Athletes can return to competition once they meet certain criteria, such as the absence of new vesicles or eschar formation, and no regional lymphadenopathy. Treatment can reduce the time until clearance, but it is important to meet these criteria to prevent transmission to other athletes.

Recurrent outbreaks may require a lower dosage and shorter duration of treatment compared to a primary outbreak. Typically after 120 hours of treatment, the outbreak has cleared, and the risk of transmission is significantly reduced.

Athletes may not be aware of the high prevalence of HSV-1 infection. Studies show that a large number of high school wrestlers are infected with the virus, even though only a small percentage are aware of their infection. For example, while only 3.3% of wrestlers may know they have the virus, up to 29.8% could be carrying it.

It is important to note that the virus can be transmitted even before the appearance of visible lesions, so infected athletes should take appropriate precautions to avoid spreading the infection to their opponents.

Asymptomatic shedding of HSV-1 is a significant source of transmission, with approximately 1-5% of seropositive individuals shedding the virus without any symptoms. This means that they can unknowingly transmit the virus to others even when they are not experiencing an outbreak. However, once an outbreak does occur in a competitor, the risk of transmission to an opponent can be as high as 30%.

It is important to note that 90% of people with herpes simplex virus (HSV) are unaware that they are infected. Therefore, athletes without a history of herpes gladiatorum should consider getting yearly antibody testing for HSV.

This can help identify individuals who may be carrying the virus and can be placed on antiviral prophylaxis to reduce the risk of transmission. Athletes with a history of herpes gladiatorum should take prophylactic antiviral medication throughout the competitive season. Valacyclovir 1 gm once daily has been found to reduce recurrent outbreaks in wrestlers to 7.7%, compared to 24.1% with a placebo.

Molluscum contagiosum is a skin infection caused by a virus from the Poxviridae family, usually spread through direct skin-to-skin contact. It appears as small, dome-shaped papules with a central depression, often found on the chest, neck, arms, and axillary regions.

Treatment involves curette and hyfrecator for quick removal or topical application of Imiquimod 5% cream for up to 12–16 weeks. For facial involvement, treatment requires caution to avoid scarring. After treatment, athletes can return to competition immediately if the area is covered with a bioclusive agent. Verrucous warts, caused by papillomavirus, are another harmless skin infection.

Verrucous warts are a common childhood infection that typically affects the hands, feet, elbows, or knees. They appear as firm, raised bumps that can be 1-10 mm in size and may cluster together. Although they often go away on their own, treatment can speed up their resolution. If the warts are on the fingers, they can crack and bleed, making the skin vulnerable to injury and infection during contact sports.

Therefore, treatment is important to reduce the risk of bleeding and transmission to others.

Cryotherapy takes a long time to work, and using imiquimod cream is another option but also takes a while. Cover the affected area with bioclusive to prevent the virus from spreading through blood exposure. These infections have been studied in wrestling, and the same principles for control and treatment apply also.

Practice good hygiene, seek help from a healthcare provider, and avoid competing until it’s safe to prevent spreading the infection to others. In some cases, medication can be used to prevent the spread of fungal or viral infections.

Carbuncles and furuncles should be routinely cultured to detect CA-MRSA. Herpes gladiatorum is often mistaken for recurrent bacterial folliculitis due to a lack of recognition and understanding in medical and athletic communities. Failure in treating fungal infections is often due to a lack of compliance with treatment.