Sports Dermatology Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship “Every Warrior an Athlete”

Objectives l Review common dermatologic problems and how they affect athletes l Discuss skin disorders specific to athletes l Review diagnostic keys and treatments of athletic dermatologic concerns

Introduction l Definitions l Feet l Groin l Buttocks l Hands l Face l General l Chest and Back

Definitions l Macule – not raised, 1 cm or less l Patch – not raised, greater than 1 cm l Papule - raised, 1 cm or less l Plaque - flat elevation, greater than 1 cm l Nodule – rounded elevation, greater than 1 cm l Tumor – large nodule

Definitions l Vesicle - fluid filled, 1 cm or less l Bulla - fluid filled, greater than 1 cm l Pustule - elevated, pus filled l Wheal – firm edematous plaque, transient

Definitions l Crust - dried fluid, e.g. scab l Comedones -plugged sebaceous follicles l Scale - excess keratin l Excoriation - erosion from scratching l Erosion - partial thickness loss l Ulcer - erosion into dermis l Fissure - crack-like break into dermis

Impact of skin infections in NCAA wrestlers l 15% of practice time-loss injuries

National Federation of High Schools Communicable Disease Procedures l HCP must evaluate skin lesions before returning to competition l Consider evaluating other team members l Follow state/local “return to competition” rules

Corns l Hyperkeratotic pressure area l hard conical papule with translucent center l TX: modify foot wear to change pressure, soften lesion, remove

Plantar Warts l HPV l thickened plantar papules, shave reveals “black dots” l TX: keratolytic solutions, podophyllin, cryotherapy

“Black Heel” l Traumatic micro- hemorrhages l small asymptomatic black macules l no treatment needed

Blisters l excessive friction l vesicles and bullae l TX: prevention, drainage (leave the roof), hydrocolloid dressing (duoderm)

Ingrown Toenail l From improperly fitting footwear l usually great toe l TX: –pressure relief (go shoeless, wider shoes) –cotton under nail –Antibiotics if infected –surgical excision

Black Toenails l AKA “joggers toe”, “skiers toe”, “tennis toe” l From trauma or pressure l TX: –acute subungual hematoma: pierce nail –Mild cases: no tx –Prevention: proper shoes, metatarsal pad

Onychomycosis l fungal infection of nail l discoloration, scaling, thickening l culture before tx l TX: –Dermatophytes: Systemic itraconazole or terbinafine 2-4 mos –Mold: topicals –Candida: topical or systemic

Molluscum Contagiosum l “wrestler’s warts” l poxvirus l firm, skin colored, umbilicated papules l TX: spontaneous resolution (months), curettage, topicals, cryotherapy l NCAA: –curette or remove lesions & –cover with gas-perm membrane AND tape

Scabies l mite Sarcopetes scabiei l exquisitely pruritic papules, excoriations; DX: scraping l TX: topical permethrin or crotamiton overnight l NCAA - verification of treatment and negative scrapings

Genital Warts l Condyloma acuminata l HPV, smooth or verrucous papules l genital and perianal regions, cluster l TX: cryotherapy; topical podophyllox, imiquimod 5% cream

Genital Herpes l Small, grouped vesicles  painful ulcers; l DX: Tzanck prep l TX: acyclovir, valacyclovir l NCAA: see Herpes Infections

Herpes infections: NCAA participation criteria l Primary infection –no systemic sxs –no new lesions x 3 days –all lesions crusted –on oral meds >120 hours ( 5 days) –Crusts covered l Recurrent infection –Ulcers dry, covered by FIRM ADHERENT CRUST –On oral meds for >120 hours –Crusts covered

Tinea Cruris l AKA “jock itch” l Dermatophyte infection l Erythematous w/ advancing border, pruritic; DX: KOH prep l TX: topical antifungals l NCAA: see Tinea Infections

Tinea Infections: NCAA participation criteria l >72 hours treatment l DQ if extensive lesions l Cover lesions with OpSite and tape after washing with Ketoconazole shampoo and applying antifungal cream

Erythrasma l Corynebacterium infection l Uniformly brown and scaly w/o advancing border; coral-red under Wood’s lamp l TX: oral or topical erythromycin l NCAA: see Bacterial Infections

Hidradenitis Suppuritiva l blockage of sweat glands with secondary infection; chronic sinus tracts can form l Erythematous papules, nodules, drainage l TX: n topical +/- oral abx n I&D n Surgical excision

Tinea Versicolor l Pityrosporum ovale, asymptomatic l Hypo- or hyper-pigmented macules; DX: Wood’s lamp, KOH scrape l TX: Selenium sulfide shampoo, -azole creams, terbinafine cream; itraconazole oral l NCAA: see Tinea Infections

Jogger’s Nipples l irritation and friction, long distance runners l painful, fissured, eroded nipples l TX: soft fiber shirts, adhesive bandages, petroleum jelly

Warts, Verruca Vulgaris l HPV; unsightly and painful l “black dots” after shave-down l TX: salicylic acid patch, cryotherapy, occlusion l NCAA: cover prior to competition

Herpetic Whitlow l Tender erythematous vesicles near fingertip l TX: oral antivirals l NCAA –See Herpes Infections, recurrent

Dyshydrotic Eczema l unknown etiology, not infectious l eczematous eruption of pruritic vesicles on fingers l TX: keep hands dry, lotions, topical steroids

Dermatophytid Reaction l distant site fungal infection l vesicular l treat distant site, consider prednisone l NCAA: see tineas

Paronychia l bacterial infection l tender inflammation of nail fold l TX: warm soaks, I&D, +/- oral abx l NCAA: see Bacterial Infections

Bacterial Infections: NCAA participation criteria l No new lesions for 48 hours l >72 hours of antibiotics completed l No moist, exudative or draining lesions l Active bacterial infections shall NOT be covered to allow participation if above criteria not met

Herpes Labialis l “cold sore” l Herpes simplex virus l Vesicles  ulcers near lip; painful l TX: topical or oral antivirals, sunscreen to prevent; consider prophylactic valacyclovir l NCAA: see Herpes Infections

Acne Vulgaris l Acne Mechanica, “football acne” l TX: topical Retin-A, benzoyl peroxide, abx; oral abx l Not a contraindication to sports

Herpes Gladiatorum l HSV on area of friction/trauma l TX: oral antivirals l NCAA – see Herpes Infections

Cellulitis l Infection of dermis and sub-cu tissue l Expanding erythema, swelling, tenderness l TX: rest, elevation, oral abx; IV abx if severe or on face l NCAA: see Bacterial Infections

Erysipelas l Usually Gp A Strep l Superficial infection extending into the lymphatics; systemic sxs common l More red, swollen than cellulitis, some streaking l TX: penicillins, Azithro l NCAA: see Bacterial Infections

Impetigo l superficial skin infection with Strep, Staph l yellow crusted lesions on red base l TX: remove crust; topical mupirocin or oral abx l NCAA – see Bacterial Infections

Folliculitis l Mild hair follicle inflammation or infection, usually Staph –Pseudomonas in hot tubs l Papules, pustules around follicles l TX: wash with soap, topical mupirocin, oral abx l NCAA: see Bacterial Infections

Furuncles l More severe hair follicle abscess with Staph l acute, tender, erythematous nodule l TX: warm compresses, abx, I&D l NCAA – see Bacterial Infections

Carbuncle l More extensive abscess than furuncle; Staph l TX: I&D, oral or IV abx l NCAA: see Bacterial Infections

Methicillin-Resistant Staph Aureus “MRSA” l Staph strains resistant to ß-lactam abx (e.g. dicloxacillin, methicillin) l May be resistant to other abx l Cause skin infections usually –Cellulitis, folliculitis, furuncles, abscesses l Cause significant morbidity –70% of athletes required IV abx l Spread directly person-to-person –Football linemen, rugby, fencing, wrestling –Through injured skin

Methicillin-Resistant Staph Aureus “MRSA” l When to suspect –Skin abscesses –Infections resistant to initial abx l Proper treatment –Culture all abscesses before tx –Susceptibility should guide abx choice n Community-acquired strains usually sensitive to SMX-TMP, fluoroquinolones, clindamycin, e- mycin

Methicillin-Resistant Staph Aureus “MRSA” l Prevention –No participation of infected athletes until cured –Protect exposed skin if high-risk sport –Properly clean/protect injured skin –Proper general hygiene –Report MRSA to PrevMed and CDC

Varicella (chickenpox) l Varicella zoster virus l Lesions in various stages— papules, vesicles, ulcers, crusts on red bases l TX: oral antivirals if early; supportive measures; itch creams l NCAA: no participation until ALL lesions crusted firmly, no secondary bacterial infection

Miliaria Rubra “prickly heat” l sweat duct occlusion l fine erythematous papules l TX: dry clothing, hydrophilic ointments

Contact Dermatitis l direct chemical irritant or allergic delayed rxn l pruritic patches of vesicles on weeping base l TX: calamine lotion, benadryl, topical steroids; Zanfel cream

Atopic Dermatitis l dry easily irritated skin, worsened by heat and sweat l pruritic erythematous macules and patches, flexor surfaces l TX: moisturizers, topical steroids, soap- free cleansing

Sunburn l UV radiation l mild to intense erythema l analgesics, cool compresses, topical steroids or lotions

Photosensitivity Reactions l reaction to sun or Rx l eczema-like rash in sun-exposed areas l TX: –stop offending med –protect skin from sun –topical &/or oral steroids

Striae Distensae l rupture of elastic fibers from rapid growth; steroids? l perpendicular to lines of tension; shoulders, back, thigh l no good treatment proven

Conclusion l Skin diseases in athletes can be sports and regionally specific l Recognize and treat early l Know the rules for participation