Practice recommendations
• Do not permit athletes with wet, weeping lesions to return to play. C
• Familiarize yourself with the rules governing the team sports your patients participate in and use them to guide return-to-play decisions. C
• Explain to athletes with herpes or bacterial infections that they cannot participate while the lesions are active, even if they are covered with occlusive dressings. C
Strength of recommendation (SOR)
A: Good-quality patient-oriented evidence
B: Inconsistent or limited-quality patient-oriented evidence
C: Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE Shane O, a 16-year-old on his high school wrestling team, presents with red, scaly, well-defined plaques on his forehead. The coach spotted the lesions and removed him from play. The patient reports that he’s training for a competitive event and is anxious to return to practice.
You take skin scrapings for a potassium chloride (KOH) test, which is negative, and for a dermatophyte culture. The culture will take 7 to 14 days, however. What should you do in the meantime?
Chances are you’ve cared for countless patients with cutaneous infections. But when the individual who’s infected participates in a team sport, it’s a game changer. In addition to treating the infection, it is necessary to take steps to prevent an outbreak among other players.
More than half of the infections incurred by athletes are cutaneous lesions1—not surprising considering the numerous opportunities sports play provides for common skin conditions to spread. Predisposing factors, in addition to skin-to-skin contact and abrasions, include shared close quarters (eg, locker rooms and showers), shared sports equipment, and poor hygiene.2-5
For a competitive athlete like Shane, the loss of practice may be the most worrisome aspect of a cutaneous infection. From a medical perspective, there are far more pressing concerns. Contact with a teammate’s active herpes simplex lesion (HSV-1), for example, could result in a lifelong infection, and a methicillin-resistant Staphylococcus aureus (MRSA) infection can be a source of significant morbidity for anyone who is infected. There is also the potential for a public health hazard. In addition to prompt, accurate diagnosis, a treatment approach that considers both the need to protect others and the importance of getting the player back in the game as soon as it is safe to do so is critical.
Athlete’s foot, ringworm, jock itch—fungal infections are easily spread
Fungal infections are a common cause of skin disease in athletes. Dermatophytes can spread from fomites such as mats, floors, laundry items, and shared clothing, combs, and brushes, as well as in swimming pools and from direct contact with carriers.2
National Collegiate Athletic Association (NCAA) data show that fungi account for 22% of the skin infections that athletes involved in competitive wrestling develop.6 Sports with skin-to-skin contact, such as wrestling, pose the greatest risk. Fungal infection is the No. 1 reason cited for missing wrestling practice, according to the NCAA.6
Fungal infections are not just a wrestler’s problem, however. Tinea pedis (athlete’s foot) is common among runners and swimmers, and tinea corporis (ringworm), in prepubertal athletes.5
Fungal skin infections are caused by 3 dermatophyte genera: Trichophyton, Epidermophyton, and Microsporum. In the United States, T rubrum is responsible for most cutaneous fungal infections, including tinea corporis, tinea unguium (nail), tinea pedis, and tinea cruris (commonly called jock itch).5
Tinea corporis (Figure 1) may present with areas of central hypopigmentation that give it a ring-like appearance. This type of fungal infection also includes tinea gladiatorum, so named for its high prevalence among wrestlers and characterized by well-defined, red scaling plaques on the head, neck, and upper extremities, often with an irregular border.7
Tinea pedis typically develops in the web spaces of the toes, with skin maceration often accompanied by thick scaling or desquamation. Tinea cruris presents as erythematous plaques in the pubic and inguinal areas.8
Onychomycosis can affect the nail plate, resulting in thickening, change in color, and alteration of nail texture.9
T tonsurans is the dominant pathogen for tinea capitis—fungal infection of the scalp,5 which can be inflammatory or noninflammatory. The noninflammatory form may present with gray-patch scaling, seborrheic dermatitis-like scale, hair thinning without significant scaling, or patches of “black-dot” alopecia. Inflammatory forms of tinea capitis may present as anything from localized pustules to widespread abscesses, or may remain in an asymptomatic carrier state.10
When to confirm a clinical diagnosis
Fungal infections can often be diagnosed based on clinical presentation, but confirmation is important when systemic therapy is required—for tinea capitis, in particular. The traditional method is an examination of skin scraped from the edge of a lesion and treated with 10% to 20% KOH, gently heated, and viewed under light microscopy.8