CME #116 September 2003 S kin & Aging is proud to bring you this latest installment in its CME series. This series consists of regular CME activities that qualify you for two category 1 physician credit hours. As a reader of Skin & Aging, this course is brought to you free of charge — you aren’t required to pay a processing fee. Athletes prove to be a unique patient group. Their participation in a variety of sports puts them at risk for many skin, hair and nail disorders. And treatment is of great importance, as most can’t afford to be out of commission for long. This article reviews the diagnosis, treatment and prevention of many of the conditions that commonly affect athletes. At the end of this article, you’ll find a 10-question exam. Mark your responses in the designated area and fax page to HMP Communications at (610) 560-0501. About 1 month after the publication date, we’ll post this course on our Web site — www.skinandaging.com. I hope this CME contributes to your clinical skills. Steven R. Feldman, M.D., Ph.D., CME Editor Dr. Feldman is Professor of Dermatology, Pathology and Public Health Sciences at Wake Forest University Medical Center in Winston-Salem, NC. He’s also Director of the Center for Dermatology Research (funded by a grant from Galderma). Skin and Sports F rom the casual sportsman to the professional athlete, myriad sports related skin problems abound. The athlete presents a challenge for the clinician, as the diagnosis and treatment must be uniquely tailored to the individual sport. Many sports-related dermatoses seem trivial such as blisters, calluses and nail deformities; but for the competing athlete, they can be devastating. Serious dermatoses related to athletic participation include herpes simplex infection, exercise-induced anaphylaxis and skin cancer. Common Infections Skin infections are among the most common of all sports-related dermatoses and are caused by viruses, fungi, bacteria, atypical mycobacteria and parasites. Warts can plague recreational and professional athletes. Human papilloma virus, causing plantar warts, can be spread in showers, in the locker room or at poolside.1 Warts may be clinically confused with calluses and corns. You need to carefully pare the area to reveal pinpoint hemorrhages, characteristic of warts. Warts are very problematic because they pose an infectious hazard for other athletes in the locker room, and can cause pain and hinder an athlete’s performance. While destructive methods can often be quite effective, they may result in loss of training time. Topical imiquimod (Aldara), under occlusion with adhesive tape, is effective and may allow the athlete to quickly return to activity. To prevent infection, athletes must wear sandals in the showers and locker room. The pox virus can also cause problems for athletes. Molluscum contagiosum, which is caused by a pox virus, occurs in athletes with extensive skin-to-skin contact, such as wrestlers and rugby players. Swimmers seem to also be particularly prone to develop molluscum contagiosum. Clinically, these lesions present as well-defined, dome-shaped, white papules with an umbilicated center. Prompt treatment of molluscum, generally by destructive methods, can avert epidemics.1 Herpes simplex virus can occur in two different sporting arenas. First, skiers seem particularly prone to develop herpes labialis that can be initiated by intense and frequent exposure to the sun. A recent study showed that the intensity of ultraviolet B radiation in Vail, CO, at 11,000 feet is the same as in Orlando, FL.2 Remind any skiers among your patients to wear sunscreen on their lips; and young ski enthusiasts should also be warned that several oral acne medications may make them more likely to burn while on the slopes. Herpes viruses can also be transmitted among wrestlers (herpes gladiatorum)3-5 and rugby players (herpes rugbieorum).6 There have been reports of epidemics of herpes gladiatorum, infecting up to 30% to 40% of a team.3-5 The incidence of herpes gladiatorum during the season varies with different study methodologies. The nature of wrestling and rugby places participants at increased risk because frequent abrasions and macerated skin from sweating allows the organism to penetrate easier. Close and persistent skin-to-skin contact and sharing equipment also are clearly important risk factors. Wrestling mats probably do not play a role in the transmission of the virus, though.1 Typically herpes gladiatorum is located on the arms, upper trunk, and head and neck (areas of close skin contact with competitors). Typical lesions are discrete grouped vesicles upon an erythematous base. Early lesions may not display the classic vesicles and are, therefore, sometimes confused with early lesions of tinea corporis gladiatorum, impetigo, atopic dermatitis and acne. Tzanck smear, culture, and direct immunofluorescence may assist in confirming diagnosis. Institute treatment immediately with oral antiviral medications. Acyclovir (Zovirax, Acyclovir) was the original medication used, but the newer antiviral medications, such as valacyclovir (Valtrex) are now more frequently prescribed.7 Infected athletes cannot compete and are disqualified during pre-match skin inspections. Although, in some cases individuals have been allowed to practice as long as the lesions are localized and adequately bandaged. The length of time that infected athletes should be benched is quite controversial. After 10 days of oral therapy, the athlete most likely no longer poses an infectious threat and may safely return to wrestling. Prevention of herpes is a critical goal for wrestling teams. Sharing of equipment should be strongly discouraged, and the coaching and medical staff must encourage daily self-skin checks. One recent double-blind trial suggested that valacyclovir 500 mg during the season significantly decreases a team’s incidence of herpes gladiatorum.8 Tinea corporis gladiatorum is another disease that can reach epidemic proportions for wrestling teams. The prevalence has been reported to range between 24% to 77% and varies with study methodology..9-11 Lesions are typically distributed over the head and neck, upper trunk and arms.12 The most common location is on the upper extremities. Diagnosis of early lesions is quite challenging, as often the typical annular shape isn’t apparent.12 (See photo above.) Consider herpes gladiatorum, impetigo, atopic dermatitis and acne in the differential diagnosis. If the diagnosis isn’t clear, a potassium hydroxide examination of skin scraping is warranted. The most likely organism to be cultured is Trichophyton tonsurans, which is an unusual cause of tinea corporis.13 For this reason, many authors have proposed that asymptomatic carriers of Trichophyton tonsurans (found in the scalp, which is the typical location) may play a role in epidemics.13 Isolate and treat infected athletes immediately. If the lesion can be bandaged, the athlete may continue to practice, but many states won’t allow participation in competitions. The mode and duration of therapy has been controversial. Some authors have suggested topical antifungal agents, but there is some evidence-based medicine that oral fluconazole (Diflucan), 100 mg, once weekly, is most effective and allows the patients to rapidly return to competition.14 With this therapy, all cultures were negative at 3 weeks. Most athletes return to competition in 7 to 10 days, but there is no evidence-based medicine to support this period of disqualification. Prevention of epidemics is critical; equipment should not be shared. Most evidence suggests that wrestling mats do not transmit the fungal organism, but one study reported positive cultures taken from the mat.15 Recent research revealed that pharmacological prevention (weekly fluconazole, 200 mg or bimonthly itraconazole (Sporanox), 400 mg), appears to significantly reduce the transmission of the fungus.10 Impetigo contagiosum, caused by Staphylococcus aureus or Streptococcus aureus, is also common in various athletes.16,17 Sports with close skin-to-skin contact, such as rugby, football and wrestling, have experienced outbreaks. The typical lesions are well-defined erythematous plaques found distributed on the head and neck regions. It’s possible to confuse the differential of early lesions with herpes gladiatorum, tinea corporis gladiatorum, acne and atopic dermatitis. Again, athletes with this infection should be isolated from the team and promptly treated with topical mupirocin (Bactroban) (b.i.d.) and dicloxacillin (Dycill, Dynapen) or cephalexin (Keflex, Cephalexin) (500 mg t.i.d.). The duration of therapy before an athlete may return to competition is controversial, although 5 to 7 days of therapy seems prudent. As with other sports-related skin infections, daily skin checks are required to minimize loss of training and to thwart epidemics. Furunculosis, like impetigo, is caused by Staphylococcus aureus.18-20 Rarely, the methicillin-resistant type has been cultured.20 Epidemics have occurred in wrestlers and football and basketball players.18 Risk factors in the development of furunculosis include exposure to other athlete’s furuncles and prior skin injury.18 Typical lesions are erythematous, well-defined papules or nodules distributed on the upper extremities. Treatment includes both topical and oral antibiotics, such as mupirocin and dicloxacillin, respectively. If recurrent outbreaks are observed, staphylococcal infestation of the nasal carriage should be considered. Mupirocin ointment or cream applied twice daily to both nares for 1 week can significantly decrease carriage for up to 6 months. Complications of furunculosis are rare; but, post-streptococcal nephritis has been reported in previous infected rugby players and is aptly named, “scrum kidney.”19 Recommendations for disqualification are similar to that for impetigo. Mycobacterium marinum is another cutaneous infection that may affect athletes.21 This atypical mycobacterium causes swimming pool granuloma and has occurred at alarming rates in some swimmers.21 The lesion is often non-specific, making the diagnosis challenging. Perform a biopsy and culture to confirm the diagnosis. Several weeks of clarithromycin (Biaxin) or another macrolide antibiotic are needed to clear this infection. To help prevent swimming pool granuloma, care should be taken to protect abraded skin surfaces while swimming. Cutaneous larva migrans may affect athletes, particularly those who play beach sports.22 (See photo at above). Typically linear erythematous burrows develop on the lower extremities as the parasite migrates through the stratum corneum. Oral ivermectin (Stromectol) or topical thiabendazole (Mintezol) are effective treatments. Tell patients to wear protective footwear while competing on the beach in endemic areas is recommended. Inflammatory Conditions Several inflammatory dermatoses affect athletes much more frequently than nonathletes. Let’s review some of the most common of these dermatoses. Exercise-induced anaphylaxis is perhaps the most serious of these conditions.23,24 While the term is somewhat misleading, in that respiratory and vascular collapse is not universal, this dermatosis can be life threatening. Exercise-induced anaphylaxis occurs most commonly in runners, but affects myriad athletes. The affected patient may present with pruritus, angioedema and urticaria. Other potential associated symptoms include respiratory and gastrointestinal symptoms such as diarrhea and nausea. Immediate therapy includes airway and vascular support, if necessary. Antihistamines and epinephrine (EpiPen [epinephrine for injection]) are effective, but steroids probably don’t offer any benefit.12 Behavioral modifications by predisposed athletes may reduce the likelihood of developing the condition. Advise at-risk patients to avoid eating before exercising and to avoid exercising in extreme temperatures — this will help these athletes avert nearly one-third of episodes.23 Aspirin and non-steroidal anti-inflammatory agents have also been associated with increased risk for development of disease.23 Allergic contact dermatitis is much more common than exercise-induced, as nearly every athlete is at risk to develop this. Allergic reactions to sports equipment are the most likely cause of contact dermatitis in athletes. Most equipment possesses the ability to sensitize the sensitive athlete.25,26 Ethyl butylthiourea is found in shoe insoles, wet suits, and goggles, and mercaptobenzothiazole is present in shoe insoles, underwater masks, and swim caps.26 The diagnosis is straightforward as long as you obtain proper history. A topical corticosteroid is generally all that’s required; in rare cases of extensive disease, brief courses of oral corticosteroids are needed. Fortunately for the athlete, manufactured alternatives exist for the allergens aforementioned. Neoprene goggles can be substituted for ethyl butylthiourea containing goggles. Underwater masks and swim caps can be made with silicone; polyurethane can be substituted in the construction of shoe insoles.26 Contact irritant dermatitis differs from contact allergic dermatitis, as the latter requires antigen presentation by the athlete’s immune system. The line markings of soccer fields when mixed with water or sweat can cause severe skin irritation.27 Hockey players have also developed irritant dermatitis from the fiberglass in their hockey sticks.28 Topical steroids are effective therapy. Urticaria is another risk for athletes. Several types of urticaria can be related to sports, including cold, solar, aquagenic, and cholinergic.29 Cholinergic urticaria is the most common and is related to elevated core body temperatures. For unknown reasons, this type of urticaria disproportionately affects runners. Cold urticaria occurs in winter enthusiasts, aquagenic urticaria affects swimmers, and nearly every predisposed outdoor athlete may develop solar urticaria. Antihistamines and steroids are not universally effective.12 Sometimes nothing completely relieves this condition. Traumatic Conditions Calluses are perhaps the most common of all skin lesions of the athlete, but they can often offer a protective advantage. Calluses can easily be confused with warts. If your diagnosis is in doubt, the area should be pared. While many athletes choose not to treat calluses, synthetic socks and petroleum jelly may aid in their prevention. Blisters, conversely, can cause a great deal of pain for the athletes. Acute friction causes an intraepidermal split leading to fluid filled blisters. The blister roof should be kept intact and only a small incision made at the periphery to allow fluid to be removed.7 You can apply synthetic dressings to a blister, but the cost may be prohibitive. Prevention of blisters is paramount — moisture wicking synthetic socks, petroleum jelly, and appropriately fitted shoes decrease frictional forces and inhibit blister formation.7 “Jogger’s nipples” is another condition that runners may experience as a result of frictional forces.7,30 (See photo above.) Repetitive rubbing of an athlete’s shirt on the nipples causes a painful erosion. Often these lesions bleed, creating a dramatic display on a runner’s shirt. Treatment is supportive and may include topical antibiotic ointment or petroleum jelly. Recent advances in moisture wicking synthetic clothing significantly decrease the forces that create jogger’s nipples. A runner may also apply petroleum jelly to the nipples before long runs; commercially available pads also exist that cover the nipple for the duration of the run.7 Athletes’ skin, hair, and nails also experience nonfrictional forces that create unique conditions. Talon noire, manifested by well-defined black macules on the soles, can be clinically confused with melanoma.31 Young basketball players frequently develop this condition because the abrupt stops inherent in the game lead to intraepidermal hemorrhages. Black palm (or Mogul’s palm), caused by similar forces on the palm, predominantly affects mogul skiers.32 These condition doesn’t require treatment, and simple paring removes the hemorrhage. If you do suspect melanoma (though melanoma on the sole is rare), biopsy or consultation is recommended. Heel pads ameliorate the condition. Piezogenic pedal papules occur on posterolateral heels of athletes.33 These herniations of fat create intense pain that thwart athletic activity. It may be confused with many orthopedic conditions; however, by having the athlete stand solely on the affected limb, you’ll easily observe the herniations of fat. Treatment is difficult, though heel pads have been suggested.12 Nail disorders, unlike the above conditions, are common. The general term “tennis toe” refers to nail abnormalities caused by participation in many different sporting events, including tennis and basketball.34,35 These nail changes are caused by abrupt stops typical in these sports. In “tennis toe,” the longest toenail displays nail discoloration, nail thickening, and transverse ridging; a callus may develop in the hyponychium. Jogger’s toe, conversely, develops from the chronic slamming of the toe into the toebox; downhill courses can be particularly damaging.36 (See photo below.) Soccer players sometimes lose their nail plate (avulsion) with forceful kicks.37 If you don’t take a careful history, you may confuse these nail disorders with onychomycosis or melanoma. Onychomycosis differs from sports-related nail changes by the presence of subungual debris. Note, however, that the two conditions might co-exist. Potassium hydroxide examination and culture are necessary to confirm fungal infection. Ungual melanoma may also reveal pigmentation of the proximal nail fold (Hutchinson’s sign). If melanoma is suspected, take a biopsy of the nail matrix. Nail disorders related to sports are preventable; athletes must have properly fitted shoes with an adequate toebox. Athletes should not trim their nails with curved edges. The straight cut ensures equal distribution of the forces from the toebox. Hair disorders can also be a problem for athletes as a result of their participation in sports. Well-defined alopecic patches on the scalps of gymnasts characterize balance beam alopecia.38 This alopecia results from the constant rubbing between the scalp and the balance beam. The areas are asymptomatic and regrow on discontinuation of gymnastics. Water slide enthusiasts may develop well-circumscribed alopecic patches on their legs as a result of repeated friction.39 These patches may be confused with alopecia areata; but a careful history clearly elucidates the issue. (See photo below.) Acne mechanica can result from a combination of forces on an athlete’s skin. Caused by heat, friction and occlusion, acne mechanica occurs under heavy protective equipment, such as uniforms worn by hockey and football players.40 Protective padding, such as that worn by wrestlers, may also cause acne mechanica. This skin disorder does not respond well to typical acne therapy. Keratolytic agents (3% salicylate and 8% resorcinol in 70% ethanol) have been useful. Some authors also add topical antibiotics (0.5% clindamycin). Athletes can also prevent this condition by wearing moisture-wicking synthetic clothing under protective equipment. Encounters with the Environment Sports enthusiasts must interact with the outdoor environment. Several skin conditions result from this interaction. Green hair is common in swimmers, especially those with light hair, after exposure to pools.41 Though it’s commonly believed that chlorine is responsible, copper deposition is the actual cause. The copper may either originate from pipes or copper containing algicides. Fortunately, green hair can simply be treated with commercially available copper chelating shampoos or hydrogen peroxide. To prevent green hair, swimmers should immediately wash their hair after swimming in pools. Swimmer’s itch is a condition that swimmers in lakes and oceans are exposed to. It’s caused by cercarial schistosomes, occurs after exposure to fresh water, especially in the Northern United States and Canada.42 Swimmer’s itch is characterized by multiple urticarial papules and plaques distributed on areas covered by the bathing suit. Topical steroids and antihistamines are used for symptomatic relief. Seabather’s eruption, conversely, occurs in those swimming in the ocean.43 Larvae of many sea creatures, including jellyfish and man-of-war, sting the unsuspecting bather on exposed areas; the skin beneath the bathing suit is spared. The treatment is primarily directed to assuage pruritus, and topical steroids and antihistamines may be beneficial. Swimmers should promptly shower after being exposed to potentially infested water. Skin Neoplasms Melanoma and non-melanoma skin cancer are the most concerning of all neoplasms for the athlete. Athletes experience a great deal of sun exposure. Recent studies reveal that cyclists in the Tour de Suisse experience several times the ultraviolet radiation required to cause sunburn.44 As mentioned, another study showed that a skier at 11,000 feet in Vail, CO, received the same intense ultraviolet B radiation as a sunbather in Orlando, FL.2 Several studies have also associated melanoma, squamous cell carcinoma, and basal cell carcinoma with water sports participation.45,46 Treatment of acute sunburn includes supportive measures such oral non-steroidal anti-inflammatories, sarna lotion and warm soaks. Inform patients that it’s imperative to avoid these sunburns to reduce the risk of future skin cancers. Current recommendations suggest that individuals limit their sun exposure between 10 a.m. and 2 p.m. As many games and practices occur during this time period, sunscreen and hats should be worn. Discourage patients from not wearing a shirt during practices. Athletes often fail to use sunscreens because they sting their eyes and skin. Sunscreens in the spray and lotion versions are appealing, as they tend not to cause stinging. It should be noted that while sunscreens may be “sweatproof”or “waterproof,” intense athletic activity may significantly decrease its effectiveness. Repeated applications are required. Athletes’ nodules, less serious neoplasms, can affect a variety of athletes. Boxers develop these on the knuckles, and football and hockey players (“skate bite”) develop lesions on the ankles.47 Surfers may develop “surfers’ nodules” on the knee, tibial prominence, and the dorsal aspects of the feet.47 These nodules develop from chronic friction, but in the particular case of surfers, may also result from a granulomatous reaction to embedded sand in their skin. The differential diagnosis is vast and differs depending on the location of an athlete’s nodule. The diagnosis of athlete’s nodule should be suspected based on a patient’s history. If diagnosis is unclear, take a biopsy. Treatment is not always necessary, but intralesional steroids and surgical excision may be required. A Unique Patient Athletes present a unique challenge to the clinician. Skin disorders, both banal and serious, occur in the sportsperson from the neophyte to the professional. Without considering the activities inherent in your patient’s sport, you may fail to diagnose, treat or prevent effectively the sports-related dermatoses.
CME 116 Skin and Sports
CME #116 September 2003 S kin & Aging is proud to bring you this latest installment in its CME series. This series consists of regular CME activities that qualify you for two category 1 physician credit hours. As a reader of Skin & Aging, this course is brought to you free of charge — you aren’t required to pay a processing fee. Athletes prove to be a unique patient group. Their participation in a variety of sports puts them at risk for many skin, hair and nail disorders. And treatment is of great importance, as most can’t afford to be out of commission for long. This article reviews the diagnosis, treatment and prevention of many of the conditions that commonly affect athletes. At the end of this article, you’ll find a 10-question exam. Mark your responses in the designated area and fax page to HMP Communications at (610) 560-0501. About 1 month after the publication date, we’ll post this course on our Web site — www.skinandaging.com. I hope this CME contributes to your clinical skills. Steven R. Feldman, M.D., Ph.D., CME Editor Dr. Feldman is Professor of Dermatology, Pathology and Public Health Sciences at Wake Forest University Medical Center in Winston-Salem, NC. He’s also Director of the Center for Dermatology Research (funded by a grant from Galderma). Skin and Sports F rom the casual sportsman to the professional athlete, myriad sports related skin problems abound. The athlete presents a challenge for the clinician, as the diagnosis and treatment must be uniquely tailored to the individual sport. Many sports-related dermatoses seem trivial such as blisters, calluses and nail deformities; but for the competing athlete, they can be devastating. Serious dermatoses related to athletic participation include herpes simplex infection, exercise-induced anaphylaxis and skin cancer. Common Infections Skin infections are among the most common of all sports-related dermatoses and are caused by viruses, fungi, bacteria, atypical mycobacteria and parasites. Warts can plague recreational and professional athletes. Human papilloma virus, causing plantar warts, can be spread in showers, in the locker room or at poolside.1 Warts may be clinically confused with calluses and corns. You need to carefully pare the area to reveal pinpoint hemorrhages, characteristic of warts. Warts are very problematic because they pose an infectious hazard for other athletes in the locker room, and can cause pain and hinder an athlete’s performance. While destructive methods can often be quite effective, they may result in loss of training time. Topical imiquimod (Aldara), under occlusion with adhesive tape, is effective and may allow the athlete to quickly return to activity. To prevent infection, athletes must wear sandals in the showers and locker room. The pox virus can also cause problems for athletes. Molluscum contagiosum, which is caused by a pox virus, occurs in athletes with extensive skin-to-skin contact, such as wrestlers and rugby players. Swimmers seem to also be particularly prone to develop molluscum contagiosum. Clinically, these lesions present as well-defined, dome-shaped, white papules with an umbilicated center. Prompt treatment of molluscum, generally by destructive methods, can avert epidemics.1 Herpes simplex virus can occur in two different sporting arenas. First, skiers seem particularly prone to develop herpes labialis that can be initiated by intense and frequent exposure to the sun. A recent study showed that the intensity of ultraviolet B radiation in Vail, CO, at 11,000 feet is the same as in Orlando, FL.2 Remind any skiers among your patients to wear sunscreen on their lips; and young ski enthusiasts should also be warned that several oral acne medications may make them more likely to burn while on the slopes. Herpes viruses can also be transmitted among wrestlers (herpes gladiatorum)3-5 and rugby players (herpes rugbieorum).6 There have been reports of epidemics of herpes gladiatorum, infecting up to 30% to 40% of a team.3-5 The incidence of herpes gladiatorum during the season varies with different study methodologies. The nature of wrestling and rugby places participants at increased risk because frequent abrasions and macerated skin from sweating allows the organism to penetrate easier. Close and persistent skin-to-skin contact and sharing equipment also are clearly important risk factors. Wrestling mats probably do not play a role in the transmission of the virus, though.1 Typically herpes gladiatorum is located on the arms, upper trunk, and head and neck (areas of close skin contact with competitors). Typical lesions are discrete grouped vesicles upon an erythematous base. Early lesions may not display the classic vesicles and are, therefore, sometimes confused with early lesions of tinea corporis gladiatorum, impetigo, atopic dermatitis and acne. Tzanck smear, culture, and direct immunofluorescence may assist in confirming diagnosis. Institute treatment immediately with oral antiviral medications. Acyclovir (Zovirax, Acyclovir) was the original medication used, but the newer antiviral medications, such as valacyclovir (Valtrex) are now more frequently prescribed.7 Infected athletes cannot compete and are disqualified during pre-match skin inspections. Although, in some cases individuals have been allowed to practice as long as the lesions are localized and adequately bandaged. The length of time that infected athletes should be benched is quite controversial. After 10 days of oral therapy, the athlete most likely no longer poses an infectious threat and may safely return to wrestling. Prevention of herpes is a critical goal for wrestling teams. Sharing of equipment should be strongly discouraged, and the coaching and medical staff must encourage daily self-skin checks. One recent double-blind trial suggested that valacyclovir 500 mg during the season significantly decreases a team’s incidence of herpes gladiatorum.8 Tinea corporis gladiatorum is another disease that can reach epidemic proportions for wrestling teams. The prevalence has been reported to range between 24% to 77% and varies with study methodology..9-11 Lesions are typically distributed over the head and neck, upper trunk and arms.12 The most common location is on the upper extremities. Diagnosis of early lesions is quite challenging, as often the typical annular shape isn’t apparent.12 (See photo above.) Consider herpes gladiatorum, impetigo, atopic dermatitis and acne in the differential diagnosis. If the diagnosis isn’t clear, a potassium hydroxide examination of skin scraping is warranted. The most likely organism to be cultured is Trichophyton tonsurans, which is an unusual cause of tinea corporis.13 For this reason, many authors have proposed that asymptomatic carriers of Trichophyton tonsurans (found in the scalp, which is the typical location) may play a role in epidemics.13 Isolate and treat infected athletes immediately. If the lesion can be bandaged, the athlete may continue to practice, but many states won’t allow participation in competitions. The mode and duration of therapy has been controversial. Some authors have suggested topical antifungal agents, but there is some evidence-based medicine that oral fluconazole (Diflucan), 100 mg, once weekly, is most effective and allows the patients to rapidly return to competition.14 With this therapy, all cultures were negative at 3 weeks. Most athletes return to competition in 7 to 10 days, but there is no evidence-based medicine to support this period of disqualification. Prevention of epidemics is critical; equipment should not be shared. Most evidence suggests that wrestling mats do not transmit the fungal organism, but one study reported positive cultures taken from the mat.15 Recent research revealed that pharmacological prevention (weekly fluconazole, 200 mg or bimonthly itraconazole (Sporanox), 400 mg), appears to significantly reduce the transmission of the fungus.10 Impetigo contagiosum, caused by Staphylococcus aureus or Streptococcus aureus, is also common in various athletes.16,17 Sports with close skin-to-skin contact, such as rugby, football and wrestling, have experienced outbreaks. The typical lesions are well-defined erythematous plaques found distributed on the head and neck regions. It’s possible to confuse the differential of early lesions with herpes gladiatorum, tinea corporis gladiatorum, acne and atopic dermatitis. Again, athletes with this infection should be isolated from the team and promptly treated with topical mupirocin (Bactroban) (b.i.d.) and dicloxacillin (Dycill, Dynapen) or cephalexin (Keflex, Cephalexin) (500 mg t.i.d.). The duration of therapy before an athlete may return to competition is controversial, although 5 to 7 days of therapy seems prudent. As with other sports-related skin infections, daily skin checks are required to minimize loss of training and to thwart epidemics. Furunculosis, like impetigo, is caused by Staphylococcus aureus.18-20 Rarely, the methicillin-resistant type has been cultured.20 Epidemics have occurred in wrestlers and football and basketball players.18 Risk factors in the development of furunculosis include exposure to other athlete’s furuncles and prior skin injury.18 Typical lesions are erythematous, well-defined papules or nodules distributed on the upper extremities. Treatment includes both topical and oral antibiotics, such as mupirocin and dicloxacillin, respectively. If recurrent outbreaks are observed, staphylococcal infestation of the nasal carriage should be considered. Mupirocin ointment or cream applied twice daily to both nares for 1 week can significantly decrease carriage for up to 6 months. Complications of furunculosis are rare; but, post-streptococcal nephritis has been reported in previous infected rugby players and is aptly named, “scrum kidney.”19 Recommendations for disqualification are similar to that for impetigo. Mycobacterium marinum is another cutaneous infection that may affect athletes.21 This atypical mycobacterium causes swimming pool granuloma and has occurred at alarming rates in some swimmers.21 The lesion is often non-specific, making the diagnosis challenging. Perform a biopsy and culture to confirm the diagnosis. Several weeks of clarithromycin (Biaxin) or another macrolide antibiotic are needed to clear this infection. To help prevent swimming pool granuloma, care should be taken to protect abraded skin surfaces while swimming. Cutaneous larva migrans may affect athletes, particularly those who play beach sports.22 (See photo at above). Typically linear erythematous burrows develop on the lower extremities as the parasite migrates through the stratum corneum. Oral ivermectin (Stromectol) or topical thiabendazole (Mintezol) are effective treatments. Tell patients to wear protective footwear while competing on the beach in endemic areas is recommended. Inflammatory Conditions Several inflammatory dermatoses affect athletes much more frequently than nonathletes. Let’s review some of the most common of these dermatoses. Exercise-induced anaphylaxis is perhaps the most serious of these conditions.23,24 While the term is somewhat misleading, in that respiratory and vascular collapse is not universal, this dermatosis can be life threatening. Exercise-induced anaphylaxis occurs most commonly in runners, but affects myriad athletes. The affected patient may present with pruritus, angioedema and urticaria. Other potential associated symptoms include respiratory and gastrointestinal symptoms such as diarrhea and nausea. Immediate therapy includes airway and vascular support, if necessary. Antihistamines and epinephrine (EpiPen [epinephrine for injection]) are effective, but steroids probably don’t offer any benefit.12 Behavioral modifications by predisposed athletes may reduce the likelihood of developing the condition. Advise at-risk patients to avoid eating before exercising and to avoid exercising in extreme temperatures — this will help these athletes avert nearly one-third of episodes.23 Aspirin and non-steroidal anti-inflammatory agents have also been associated with increased risk for development of disease.23 Allergic contact dermatitis is much more common than exercise-induced, as nearly every athlete is at risk to develop this. Allergic reactions to sports equipment are the most likely cause of contact dermatitis in athletes. Most equipment possesses the ability to sensitize the sensitive athlete.25,26 Ethyl butylthiourea is found in shoe insoles, wet suits, and goggles, and mercaptobenzothiazole is present in shoe insoles, underwater masks, and swim caps.26 The diagnosis is straightforward as long as you obtain proper history. A topical corticosteroid is generally all that’s required; in rare cases of extensive disease, brief courses of oral corticosteroids are needed. Fortunately for the athlete, manufactured alternatives exist for the allergens aforementioned. Neoprene goggles can be substituted for ethyl butylthiourea containing goggles. Underwater masks and swim caps can be made with silicone; polyurethane can be substituted in the construction of shoe insoles.26 Contact irritant dermatitis differs from contact allergic dermatitis, as the latter requires antigen presentation by the athlete’s immune system. The line markings of soccer fields when mixed with water or sweat can cause severe skin irritation.27 Hockey players have also developed irritant dermatitis from the fiberglass in their hockey sticks.28 Topical steroids are effective therapy. Urticaria is another risk for athletes. Several types of urticaria can be related to sports, including cold, solar, aquagenic, and cholinergic.29 Cholinergic urticaria is the most common and is related to elevated core body temperatures. For unknown reasons, this type of urticaria disproportionately affects runners. Cold urticaria occurs in winter enthusiasts, aquagenic urticaria affects swimmers, and nearly every predisposed outdoor athlete may develop solar urticaria. Antihistamines and steroids are not universally effective.12 Sometimes nothing completely relieves this condition. Traumatic Conditions Calluses are perhaps the most common of all skin lesions of the athlete, but they can often offer a protective advantage. Calluses can easily be confused with warts. If your diagnosis is in doubt, the area should be pared. While many athletes choose not to treat calluses, synthetic socks and petroleum jelly may aid in their prevention. Blisters, conversely, can cause a great deal of pain for the athletes. Acute friction causes an intraepidermal split leading to fluid filled blisters. The blister roof should be kept intact and only a small incision made at the periphery to allow fluid to be removed.7 You can apply synthetic dressings to a blister, but the cost may be prohibitive. Prevention of blisters is paramount — moisture wicking synthetic socks, petroleum jelly, and appropriately fitted shoes decrease frictional forces and inhibit blister formation.7 “Jogger’s nipples” is another condition that runners may experience as a result of frictional forces.7,30 (See photo above.) Repetitive rubbing of an athlete’s shirt on the nipples causes a painful erosion. Often these lesions bleed, creating a dramatic display on a runner’s shirt. Treatment is supportive and may include topical antibiotic ointment or petroleum jelly. Recent advances in moisture wicking synthetic clothing significantly decrease the forces that create jogger’s nipples. A runner may also apply petroleum jelly to the nipples before long runs; commercially available pads also exist that cover the nipple for the duration of the run.7 Athletes’ skin, hair, and nails also experience nonfrictional forces that create unique conditions. Talon noire, manifested by well-defined black macules on the soles, can be clinically confused with melanoma.31 Young basketball players frequently develop this condition because the abrupt stops inherent in the game lead to intraepidermal hemorrhages. Black palm (or Mogul’s palm), caused by similar forces on the palm, predominantly affects mogul skiers.32 These condition doesn’t require treatment, and simple paring removes the hemorrhage. If you do suspect melanoma (though melanoma on the sole is rare), biopsy or consultation is recommended. Heel pads ameliorate the condition. Piezogenic pedal papules occur on posterolateral heels of athletes.33 These herniations of fat create intense pain that thwart athletic activity. It may be confused with many orthopedic conditions; however, by having the athlete stand solely on the affected limb, you’ll easily observe the herniations of fat. Treatment is difficult, though heel pads have been suggested.12 Nail disorders, unlike the above conditions, are common. The general term “tennis toe” refers to nail abnormalities caused by participation in many different sporting events, including tennis and basketball.34,35 These nail changes are caused by abrupt stops typical in these sports. In “tennis toe,” the longest toenail displays nail discoloration, nail thickening, and transverse ridging; a callus may develop in the hyponychium. Jogger’s toe, conversely, develops from the chronic slamming of the toe into the toebox; downhill courses can be particularly damaging.36 (See photo below.) Soccer players sometimes lose their nail plate (avulsion) with forceful kicks.37 If you don’t take a careful history, you may confuse these nail disorders with onychomycosis or melanoma. Onychomycosis differs from sports-related nail changes by the presence of subungual debris. Note, however, that the two conditions might co-exist. Potassium hydroxide examination and culture are necessary to confirm fungal infection. Ungual melanoma may also reveal pigmentation of the proximal nail fold (Hutchinson’s sign). If melanoma is suspected, take a biopsy of the nail matrix. Nail disorders related to sports are preventable; athletes must have properly fitted shoes with an adequate toebox. Athletes should not trim their nails with curved edges. The straight cut ensures equal distribution of the forces from the toebox. Hair disorders can also be a problem for athletes as a result of their participation in sports. Well-defined alopecic patches on the scalps of gymnasts characterize balance beam alopecia.38 This alopecia results from the constant rubbing between the scalp and the balance beam. The areas are asymptomatic and regrow on discontinuation of gymnastics. Water slide enthusiasts may develop well-circumscribed alopecic patches on their legs as a result of repeated friction.39 These patches may be confused with alopecia areata; but a careful history clearly elucidates the issue. (See photo below.) Acne mechanica can result from a combination of forces on an athlete’s skin. Caused by heat, friction and occlusion, acne mechanica occurs under heavy protective equipment, such as uniforms worn by hockey and football players.40 Protective padding, such as that worn by wrestlers, may also cause acne mechanica. This skin disorder does not respond well to typical acne therapy. Keratolytic agents (3% salicylate and 8% resorcinol in 70% ethanol) have been useful. Some authors also add topical antibiotics (0.5% clindamycin). Athletes can also prevent this condition by wearing moisture-wicking synthetic clothing under protective equipment. Encounters with the Environment Sports enthusiasts must interact with the outdoor environment. Several skin conditions result from this interaction. Green hair is common in swimmers, especially those with light hair, after exposure to pools.41 Though it’s commonly believed that chlorine is responsible, copper deposition is the actual cause. The copper may either originate from pipes or copper containing algicides. Fortunately, green hair can simply be treated with commercially available copper chelating shampoos or hydrogen peroxide. To prevent green hair, swimmers should immediately wash their hair after swimming in pools. Swimmer’s itch is a condition that swimmers in lakes and oceans are exposed to. It’s caused by cercarial schistosomes, occurs after exposure to fresh water, especially in the Northern United States and Canada.42 Swimmer’s itch is characterized by multiple urticarial papules and plaques distributed on areas covered by the bathing suit. Topical steroids and antihistamines are used for symptomatic relief. Seabather’s eruption, conversely, occurs in those swimming in the ocean.43 Larvae of many sea creatures, including jellyfish and man-of-war, sting the unsuspecting bather on exposed areas; the skin beneath the bathing suit is spared. The treatment is primarily directed to assuage pruritus, and topical steroids and antihistamines may be beneficial. Swimmers should promptly shower after being exposed to potentially infested water. Skin Neoplasms Melanoma and non-melanoma skin cancer are the most concerning of all neoplasms for the athlete. Athletes experience a great deal of sun exposure. Recent studies reveal that cyclists in the Tour de Suisse experience several times the ultraviolet radiation required to cause sunburn.44 As mentioned, another study showed that a skier at 11,000 feet in Vail, CO, received the same intense ultraviolet B radiation as a sunbather in Orlando, FL.2 Several studies have also associated melanoma, squamous cell carcinoma, and basal cell carcinoma with water sports participation.45,46 Treatment of acute sunburn includes supportive measures such oral non-steroidal anti-inflammatories, sarna lotion and warm soaks. Inform patients that it’s imperative to avoid these sunburns to reduce the risk of future skin cancers. Current recommendations suggest that individuals limit their sun exposure between 10 a.m. and 2 p.m. As many games and practices occur during this time period, sunscreen and hats should be worn. Discourage patients from not wearing a shirt during practices. Athletes often fail to use sunscreens because they sting their eyes and skin. Sunscreens in the spray and lotion versions are appealing, as they tend not to cause stinging. It should be noted that while sunscreens may be “sweatproof”or “waterproof,” intense athletic activity may significantly decrease its effectiveness. Repeated applications are required. Athletes’ nodules, less serious neoplasms, can affect a variety of athletes. Boxers develop these on the knuckles, and football and hockey players (“skate bite”) develop lesions on the ankles.47 Surfers may develop “surfers’ nodules” on the knee, tibial prominence, and the dorsal aspects of the feet.47 These nodules develop from chronic friction, but in the particular case of surfers, may also result from a granulomatous reaction to embedded sand in their skin. The differential diagnosis is vast and differs depending on the location of an athlete’s nodule. The diagnosis of athlete’s nodule should be suspected based on a patient’s history. If diagnosis is unclear, take a biopsy. Treatment is not always necessary, but intralesional steroids and surgical excision may be required. A Unique Patient Athletes present a unique challenge to the clinician. Skin disorders, both banal and serious, occur in the sportsperson from the neophyte to the professional. Without considering the activities inherent in your patient’s sport, you may fail to diagnose, treat or prevent effectively the sports-related dermatoses.
CME #116 September 2003 S kin & Aging is proud to bring you this latest installment in its CME series. This series consists of regular CME activities that qualify you for two category 1 physician credit hours. As a reader of Skin & Aging, this course is brought to you free of charge — you aren’t required to pay a processing fee. Athletes prove to be a unique patient group. Their participation in a variety of sports puts them at risk for many skin, hair and nail disorders. And treatment is of great importance, as most can’t afford to be out of commission for long. This article reviews the diagnosis, treatment and prevention of many of the conditions that commonly affect athletes. At the end of this article, you’ll find a 10-question exam. Mark your responses in the designated area and fax page to HMP Communications at (610) 560-0501. About 1 month after the publication date, we’ll post this course on our Web site — www.skinandaging.com. I hope this CME contributes to your clinical skills. Steven R. Feldman, M.D., Ph.D., CME Editor Dr. Feldman is Professor of Dermatology, Pathology and Public Health Sciences at Wake Forest University Medical Center in Winston-Salem, NC. He’s also Director of the Center for Dermatology Research (funded by a grant from Galderma). Skin and Sports F rom the casual sportsman to the professional athlete, myriad sports related skin problems abound. The athlete presents a challenge for the clinician, as the diagnosis and treatment must be uniquely tailored to the individual sport. Many sports-related dermatoses seem trivial such as blisters, calluses and nail deformities; but for the competing athlete, they can be devastating. Serious dermatoses related to athletic participation include herpes simplex infection, exercise-induced anaphylaxis and skin cancer. Common Infections Skin infections are among the most common of all sports-related dermatoses and are caused by viruses, fungi, bacteria, atypical mycobacteria and parasites. Warts can plague recreational and professional athletes. Human papilloma virus, causing plantar warts, can be spread in showers, in the locker room or at poolside.1 Warts may be clinically confused with calluses and corns. You need to carefully pare the area to reveal pinpoint hemorrhages, characteristic of warts. Warts are very problematic because they pose an infectious hazard for other athletes in the locker room, and can cause pain and hinder an athlete’s performance. While destructive methods can often be quite effective, they may result in loss of training time. Topical imiquimod (Aldara), under occlusion with adhesive tape, is effective and may allow the athlete to quickly return to activity. To prevent infection, athletes must wear sandals in the showers and locker room. The pox virus can also cause problems for athletes. Molluscum contagiosum, which is caused by a pox virus, occurs in athletes with extensive skin-to-skin contact, such as wrestlers and rugby players. Swimmers seem to also be particularly prone to develop molluscum contagiosum. Clinically, these lesions present as well-defined, dome-shaped, white papules with an umbilicated center. Prompt treatment of molluscum, generally by destructive methods, can avert epidemics.1 Herpes simplex virus can occur in two different sporting arenas. First, skiers seem particularly prone to develop herpes labialis that can be initiated by intense and frequent exposure to the sun. A recent study showed that the intensity of ultraviolet B radiation in Vail, CO, at 11,000 feet is the same as in Orlando, FL.2 Remind any skiers among your patients to wear sunscreen on their lips; and young ski enthusiasts should also be warned that several oral acne medications may make them more likely to burn while on the slopes. Herpes viruses can also be transmitted among wrestlers (herpes gladiatorum)3-5 and rugby players (herpes rugbieorum).6 There have been reports of epidemics of herpes gladiatorum, infecting up to 30% to 40% of a team.3-5 The incidence of herpes gladiatorum during the season varies with different study methodologies. The nature of wrestling and rugby places participants at increased risk because frequent abrasions and macerated skin from sweating allows the organism to penetrate easier. Close and persistent skin-to-skin contact and sharing equipment also are clearly important risk factors. Wrestling mats probably do not play a role in the transmission of the virus, though.1 Typically herpes gladiatorum is located on the arms, upper trunk, and head and neck (areas of close skin contact with competitors). Typical lesions are discrete grouped vesicles upon an erythematous base. Early lesions may not display the classic vesicles and are, therefore, sometimes confused with early lesions of tinea corporis gladiatorum, impetigo, atopic dermatitis and acne. Tzanck smear, culture, and direct immunofluorescence may assist in confirming diagnosis. Institute treatment immediately with oral antiviral medications. Acyclovir (Zovirax, Acyclovir) was the original medication used, but the newer antiviral medications, such as valacyclovir (Valtrex) are now more frequently prescribed.7 Infected athletes cannot compete and are disqualified during pre-match skin inspections. Although, in some cases individuals have been allowed to practice as long as the lesions are localized and adequately bandaged. The length of time that infected athletes should be benched is quite controversial. After 10 days of oral therapy, the athlete most likely no longer poses an infectious threat and may safely return to wrestling. Prevention of herpes is a critical goal for wrestling teams. Sharing of equipment should be strongly discouraged, and the coaching and medical staff must encourage daily self-skin checks. One recent double-blind trial suggested that valacyclovir 500 mg during the season significantly decreases a team’s incidence of herpes gladiatorum.8 Tinea corporis gladiatorum is another disease that can reach epidemic proportions for wrestling teams. The prevalence has been reported to range between 24% to 77% and varies with study methodology..9-11 Lesions are typically distributed over the head and neck, upper trunk and arms.12 The most common location is on the upper extremities. Diagnosis of early lesions is quite challenging, as often the typical annular shape isn’t apparent.12 (See photo above.) Consider herpes gladiatorum, impetigo, atopic dermatitis and acne in the differential diagnosis. If the diagnosis isn’t clear, a potassium hydroxide examination of skin scraping is warranted. The most likely organism to be cultured is Trichophyton tonsurans, which is an unusual cause of tinea corporis.13 For this reason, many authors have proposed that asymptomatic carriers of Trichophyton tonsurans (found in the scalp, which is the typical location) may play a role in epidemics.13 Isolate and treat infected athletes immediately. If the lesion can be bandaged, the athlete may continue to practice, but many states won’t allow participation in competitions. The mode and duration of therapy has been controversial. Some authors have suggested topical antifungal agents, but there is some evidence-based medicine that oral fluconazole (Diflucan), 100 mg, once weekly, is most effective and allows the patients to rapidly return to competition.14 With this therapy, all cultures were negative at 3 weeks. Most athletes return to competition in 7 to 10 days, but there is no evidence-based medicine to support this period of disqualification. Prevention of epidemics is critical; equipment should not be shared. Most evidence suggests that wrestling mats do not transmit the fungal organism, but one study reported positive cultures taken from the mat.15 Recent research revealed that pharmacological prevention (weekly fluconazole, 200 mg or bimonthly itraconazole (Sporanox), 400 mg), appears to significantly reduce the transmission of the fungus.10 Impetigo contagiosum, caused by Staphylococcus aureus or Streptococcus aureus, is also common in various athletes.16,17 Sports with close skin-to-skin contact, such as rugby, football and wrestling, have experienced outbreaks. The typical lesions are well-defined erythematous plaques found distributed on the head and neck regions. It’s possible to confuse the differential of early lesions with herpes gladiatorum, tinea corporis gladiatorum, acne and atopic dermatitis. Again, athletes with this infection should be isolated from the team and promptly treated with topical mupirocin (Bactroban) (b.i.d.) and dicloxacillin (Dycill, Dynapen) or cephalexin (Keflex, Cephalexin) (500 mg t.i.d.). The duration of therapy before an athlete may return to competition is controversial, although 5 to 7 days of therapy seems prudent. As with other sports-related skin infections, daily skin checks are required to minimize loss of training and to thwart epidemics. Furunculosis, like impetigo, is caused by Staphylococcus aureus.18-20 Rarely, the methicillin-resistant type has been cultured.20 Epidemics have occurred in wrestlers and football and basketball players.18 Risk factors in the development of furunculosis include exposure to other athlete’s furuncles and prior skin injury.18 Typical lesions are erythematous, well-defined papules or nodules distributed on the upper extremities. Treatment includes both topical and oral antibiotics, such as mupirocin and dicloxacillin, respectively. If recurrent outbreaks are observed, staphylococcal infestation of the nasal carriage should be considered. Mupirocin ointment or cream applied twice daily to both nares for 1 week can significantly decrease carriage for up to 6 months. Complications of furunculosis are rare; but, post-streptococcal nephritis has been reported in previous infected rugby players and is aptly named, “scrum kidney.”19 Recommendations for disqualification are similar to that for impetigo. Mycobacterium marinum is another cutaneous infection that may affect athletes.21 This atypical mycobacterium causes swimming pool granuloma and has occurred at alarming rates in some swimmers.21 The lesion is often non-specific, making the diagnosis challenging. Perform a biopsy and culture to confirm the diagnosis. Several weeks of clarithromycin (Biaxin) or another macrolide antibiotic are needed to clear this infection. To help prevent swimming pool granuloma, care should be taken to protect abraded skin surfaces while swimming. Cutaneous larva migrans may affect athletes, particularly those who play beach sports.22 (See photo at above). Typically linear erythematous burrows develop on the lower extremities as the parasite migrates through the stratum corneum. Oral ivermectin (Stromectol) or topical thiabendazole (Mintezol) are effective treatments. Tell patients to wear protective footwear while competing on the beach in endemic areas is recommended. Inflammatory Conditions Several inflammatory dermatoses affect athletes much more frequently than nonathletes. Let’s review some of the most common of these dermatoses. Exercise-induced anaphylaxis is perhaps the most serious of these conditions.23,24 While the term is somewhat misleading, in that respiratory and vascular collapse is not universal, this dermatosis can be life threatening. Exercise-induced anaphylaxis occurs most commonly in runners, but affects myriad athletes. The affected patient may present with pruritus, angioedema and urticaria. Other potential associated symptoms include respiratory and gastrointestinal symptoms such as diarrhea and nausea. Immediate therapy includes airway and vascular support, if necessary. Antihistamines and epinephrine (EpiPen [epinephrine for injection]) are effective, but steroids probably don’t offer any benefit.12 Behavioral modifications by predisposed athletes may reduce the likelihood of developing the condition. Advise at-risk patients to avoid eating before exercising and to avoid exercising in extreme temperatures — this will help these athletes avert nearly one-third of episodes.23 Aspirin and non-steroidal anti-inflammatory agents have also been associated with increased risk for development of disease.23 Allergic contact dermatitis is much more common than exercise-induced, as nearly every athlete is at risk to develop this. Allergic reactions to sports equipment are the most likely cause of contact dermatitis in athletes. Most equipment possesses the ability to sensitize the sensitive athlete.25,26 Ethyl butylthiourea is found in shoe insoles, wet suits, and goggles, and mercaptobenzothiazole is present in shoe insoles, underwater masks, and swim caps.26 The diagnosis is straightforward as long as you obtain proper history. A topical corticosteroid is generally all that’s required; in rare cases of extensive disease, brief courses of oral corticosteroids are needed. Fortunately for the athlete, manufactured alternatives exist for the allergens aforementioned. Neoprene goggles can be substituted for ethyl butylthiourea containing goggles. Underwater masks and swim caps can be made with silicone; polyurethane can be substituted in the construction of shoe insoles.26 Contact irritant dermatitis differs from contact allergic dermatitis, as the latter requires antigen presentation by the athlete’s immune system. The line markings of soccer fields when mixed with water or sweat can cause severe skin irritation.27 Hockey players have also developed irritant dermatitis from the fiberglass in their hockey sticks.28 Topical steroids are effective therapy. Urticaria is another risk for athletes. Several types of urticaria can be related to sports, including cold, solar, aquagenic, and cholinergic.29 Cholinergic urticaria is the most common and is related to elevated core body temperatures. For unknown reasons, this type of urticaria disproportionately affects runners. Cold urticaria occurs in winter enthusiasts, aquagenic urticaria affects swimmers, and nearly every predisposed outdoor athlete may develop solar urticaria. Antihistamines and steroids are not universally effective.12 Sometimes nothing completely relieves this condition. Traumatic Conditions Calluses are perhaps the most common of all skin lesions of the athlete, but they can often offer a protective advantage. Calluses can easily be confused with warts. If your diagnosis is in doubt, the area should be pared. While many athletes choose not to treat calluses, synthetic socks and petroleum jelly may aid in their prevention. Blisters, conversely, can cause a great deal of pain for the athletes. Acute friction causes an intraepidermal split leading to fluid filled blisters. The blister roof should be kept intact and only a small incision made at the periphery to allow fluid to be removed.7 You can apply synthetic dressings to a blister, but the cost may be prohibitive. Prevention of blisters is paramount — moisture wicking synthetic socks, petroleum jelly, and appropriately fitted shoes decrease frictional forces and inhibit blister formation.7 “Jogger’s nipples” is another condition that runners may experience as a result of frictional forces.7,30 (See photo above.) Repetitive rubbing of an athlete’s shirt on the nipples causes a painful erosion. Often these lesions bleed, creating a dramatic display on a runner’s shirt. Treatment is supportive and may include topical antibiotic ointment or petroleum jelly. Recent advances in moisture wicking synthetic clothing significantly decrease the forces that create jogger’s nipples. A runner may also apply petroleum jelly to the nipples before long runs; commercially available pads also exist that cover the nipple for the duration of the run.7 Athletes’ skin, hair, and nails also experience nonfrictional forces that create unique conditions. Talon noire, manifested by well-defined black macules on the soles, can be clinically confused with melanoma.31 Young basketball players frequently develop this condition because the abrupt stops inherent in the game lead to intraepidermal hemorrhages. Black palm (or Mogul’s palm), caused by similar forces on the palm, predominantly affects mogul skiers.32 These condition doesn’t require treatment, and simple paring removes the hemorrhage. If you do suspect melanoma (though melanoma on the sole is rare), biopsy or consultation is recommended. Heel pads ameliorate the condition. Piezogenic pedal papules occur on posterolateral heels of athletes.33 These herniations of fat create intense pain that thwart athletic activity. It may be confused with many orthopedic conditions; however, by having the athlete stand solely on the affected limb, you’ll easily observe the herniations of fat. Treatment is difficult, though heel pads have been suggested.12 Nail disorders, unlike the above conditions, are common. The general term “tennis toe” refers to nail abnormalities caused by participation in many different sporting events, including tennis and basketball.34,35 These nail changes are caused by abrupt stops typical in these sports. In “tennis toe,” the longest toenail displays nail discoloration, nail thickening, and transverse ridging; a callus may develop in the hyponychium. Jogger’s toe, conversely, develops from the chronic slamming of the toe into the toebox; downhill courses can be particularly damaging.36 (See photo below.) Soccer players sometimes lose their nail plate (avulsion) with forceful kicks.37 If you don’t take a careful history, you may confuse these nail disorders with onychomycosis or melanoma. Onychomycosis differs from sports-related nail changes by the presence of subungual debris. Note, however, that the two conditions might co-exist. Potassium hydroxide examination and culture are necessary to confirm fungal infection. Ungual melanoma may also reveal pigmentation of the proximal nail fold (Hutchinson’s sign). If melanoma is suspected, take a biopsy of the nail matrix. Nail disorders related to sports are preventable; athletes must have properly fitted shoes with an adequate toebox. Athletes should not trim their nails with curved edges. The straight cut ensures equal distribution of the forces from the toebox. Hair disorders can also be a problem for athletes as a result of their participation in sports. Well-defined alopecic patches on the scalps of gymnasts characterize balance beam alopecia.38 This alopecia results from the constant rubbing between the scalp and the balance beam. The areas are asymptomatic and regrow on discontinuation of gymnastics. Water slide enthusiasts may develop well-circumscribed alopecic patches on their legs as a result of repeated friction.39 These patches may be confused with alopecia areata; but a careful history clearly elucidates the issue. (See photo below.) Acne mechanica can result from a combination of forces on an athlete’s skin. Caused by heat, friction and occlusion, acne mechanica occurs under heavy protective equipment, such as uniforms worn by hockey and football players.40 Protective padding, such as that worn by wrestlers, may also cause acne mechanica. This skin disorder does not respond well to typical acne therapy. Keratolytic agents (3% salicylate and 8% resorcinol in 70% ethanol) have been useful. Some authors also add topical antibiotics (0.5% clindamycin). Athletes can also prevent this condition by wearing moisture-wicking synthetic clothing under protective equipment. Encounters with the Environment Sports enthusiasts must interact with the outdoor environment. Several skin conditions result from this interaction. Green hair is common in swimmers, especially those with light hair, after exposure to pools.41 Though it’s commonly believed that chlorine is responsible, copper deposition is the actual cause. The copper may either originate from pipes or copper containing algicides. Fortunately, green hair can simply be treated with commercially available copper chelating shampoos or hydrogen peroxide. To prevent green hair, swimmers should immediately wash their hair after swimming in pools. Swimmer’s itch is a condition that swimmers in lakes and oceans are exposed to. It’s caused by cercarial schistosomes, occurs after exposure to fresh water, especially in the Northern United States and Canada.42 Swimmer’s itch is characterized by multiple urticarial papules and plaques distributed on areas covered by the bathing suit. Topical steroids and antihistamines are used for symptomatic relief. Seabather’s eruption, conversely, occurs in those swimming in the ocean.43 Larvae of many sea creatures, including jellyfish and man-of-war, sting the unsuspecting bather on exposed areas; the skin beneath the bathing suit is spared. The treatment is primarily directed to assuage pruritus, and topical steroids and antihistamines may be beneficial. Swimmers should promptly shower after being exposed to potentially infested water. Skin Neoplasms Melanoma and non-melanoma skin cancer are the most concerning of all neoplasms for the athlete. Athletes experience a great deal of sun exposure. Recent studies reveal that cyclists in the Tour de Suisse experience several times the ultraviolet radiation required to cause sunburn.44 As mentioned, another study showed that a skier at 11,000 feet in Vail, CO, received the same intense ultraviolet B radiation as a sunbather in Orlando, FL.2 Several studies have also associated melanoma, squamous cell carcinoma, and basal cell carcinoma with water sports participation.45,46 Treatment of acute sunburn includes supportive measures such oral non-steroidal anti-inflammatories, sarna lotion and warm soaks. Inform patients that it’s imperative to avoid these sunburns to reduce the risk of future skin cancers. Current recommendations suggest that individuals limit their sun exposure between 10 a.m. and 2 p.m. As many games and practices occur during this time period, sunscreen and hats should be worn. Discourage patients from not wearing a shirt during practices. Athletes often fail to use sunscreens because they sting their eyes and skin. Sunscreens in the spray and lotion versions are appealing, as they tend not to cause stinging. It should be noted that while sunscreens may be “sweatproof”or “waterproof,” intense athletic activity may significantly decrease its effectiveness. Repeated applications are required. Athletes’ nodules, less serious neoplasms, can affect a variety of athletes. Boxers develop these on the knuckles, and football and hockey players (“skate bite”) develop lesions on the ankles.47 Surfers may develop “surfers’ nodules” on the knee, tibial prominence, and the dorsal aspects of the feet.47 These nodules develop from chronic friction, but in the particular case of surfers, may also result from a granulomatous reaction to embedded sand in their skin. The differential diagnosis is vast and differs depending on the location of an athlete’s nodule. The diagnosis of athlete’s nodule should be suspected based on a patient’s history. If diagnosis is unclear, take a biopsy. Treatment is not always necessary, but intralesional steroids and surgical excision may be required. A Unique Patient Athletes present a unique challenge to the clinician. Skin disorders, both banal and serious, occur in the sportsperson from the neophyte to the professional. Without considering the activities inherent in your patient’s sport, you may fail to diagnose, treat or prevent effectively the sports-related dermatoses.
