Testing should be considered when you suspect that a patient has a primary herpes infection, as HSV-1 is a lifelong diagnosis. Viral culture is technique dependent and limited by 50% sensitivity, as cultures can take from 2 to 4 days to grow.35 The Tzanck test (direct microscopic examination of skin scrapings) has fallen out of favor, and PCR is now the gold standard.
Compared with viral culture, PCR has been shown to detect 80% of positive cases.35 However, PCR—using swab specimens taken from the lesions—is expensive and must be sent to a lab for analysis. One study suggests that while less sensitive than PCR, the Tzanck test can still be a reliably sensitive method of diagnosis when done properly, at less cost and with quicker
results.37
Serologic tests of HSV-1 IgM and IgG antibodies are also available. Serum IgG levels remain elevated in patients with previous infections. In primary infections, IgM is most useful as it can detect recent or active infection, but results may be falsely negative for several days after infection.38
Once diagnosed, management of HSV-1 in athletes is based on whether the infection is primary or recurrent. In both cases, oral antivirals are needed. Acyclovir is the gold standard, but famciclovir and valacyclovir have been proven to be equally effective.39 Both the NCAA and NFHS have published guidelines addressing the question of return to play (TABLE 2).22,23
In addition to the management of primary and recurrent infections of HSV-1, it is recommended that athletes and coaches known to be HSV-1 seropositive be treated with prophylactic suppressive therapy.40
The Centers for Disease Control and Prevention recommends acyclovir 400 mg bid or valacyclovir 500 mg/d as prophylaxis for anyone with ≤10 recurrences per year. For those with >10 recurrences annually, valacyclovir 1000 mg/d is recommended for the rest of the season.40 This has been shown to be effective in the reduction of outbreaks among wrestlers after a large outbreak occurred in 2007 in Minnesota,40,41 and NCAA and NFHS guidelines now support prophylactic therapy during competitive season.22,23 Before prescribing it, clinicians need to consider both the benefits of prophylactic antiviral therapy and the risks of promoting HSV-1 resistance.
Focus on prevention and squelching outbreaks
For cutaneous infections, as with so many medical conditions, prevention is paramount. With good preventive practices, many, if not all, of the skin infections common among athletes can be eliminated and outbreaks can be squelched.
Good hygienic practice is the cornerstone of prevention. Patients who participate in team sports should be advised to:
- shower immediately after practice
- refrain from sharing personal equipment like uniforms, towels, razors, and headgear
- launder workout clothes and towels after each use
- immediately cleanse and cover any abrasions that occur during practice.
Athletes should also be advised to ask their trainer or coach to check their skin for lesions on a regular basis. Surveillance should be instituted to prohibit athletes with cutaneous lesions from participating until they are sufficiently treated.
Although the role that environmental contamination plays in transmission of infection is uncertain, it is recommended that all sports equipment, playing surfaces, and locker rooms be disinfected daily with either a freshly made bactericidal (1/100 bleach/water solution)23,24 or an appropriate product. The Environmental Protection Agency provides a list of commercial products that have been proven to prevent the spread of MRSA on such surfaces (http://epa.gov/oppad001/chemregindex.htm) on its Web site.42
CASE When Shane returned 3 days later, the erythema had resolved, and minimal scaling remained. You tell him to continue to use the topical terbinafine twice a day for 10 days. You also show him how to apply a bio-occlusive dressing and clear him for practice, provided the lesions are fully covered.
You also talk to Shane about prevention, recommending that he immediately clean and cover any abrasion or other skin trauma that occurs during practice and suggesting that he ask his trainer to regularly check team members for skin lesions.
At Day 7, the DTM culture is positive, confirming a dermatophyte infection.
CORRESPONDENCE
Nilesh Shah, MD, 20 Olive Street, Suite 201, Akron, OH 44310;
shahn@summahealth.org
ACKNOWLEDGEMENT
The authors would like to thank Tom Bartsokas, MD, for his help with this manuscript.