Sports Dermatology

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Sports Dermatology
Military Sports Medicine Fellowship

• Kevin deWeber, MD, FAAFP
• Director
• Primary Care Sports Medicine Fellowship

Every Warrior an Athlete
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Objectives

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

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Introduction

• Definitions
• Feet
• Groin
• Buttocks

• Hands
• Face
• General
• Chest and Back

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Definitions

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

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Definitions

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

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Definitions

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

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Impact of skin infections in NCAA wrestlers

• 15 of practice time-loss injuries

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National Federation of High SchoolsCommunicable
Disease Procedures

• HCP must evaluate skin lesions before returning
  to competition
• Consider evaluating other team members
• Follow state/local return to competition rules

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Corns

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

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Plantar Warts

• HPV
• thickened plantar papules, shave reveals black
  dots
• TX keratolytic solutions, podophyllin,
  cryotherapy

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Black Heel

• Traumatic micro-hemorrhages
• small asymptomatic black macules
• no treatment needed

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Blisters

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

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Ingrown Toenail

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

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Black Toenails

• AKA joggers toe, skiers toe, tennis toe
• From trauma or pressure
• TX
• acute subungual hematoma pierce nail
• Mild cases no tx
• Prevention proper shoes, metatarsal pad

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Onychomycosis

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

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Molluscum Contagiosum

• wrestlers warts
• poxvirus
• firm, skin colored, umbilicated papules
• TX spontaneous resolution (months), curettage,
  topicals, cryotherapy
• NCAA
• curette or remove lesions
• cover with gas-perm membrane AND tape

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Scabies

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

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Genital Warts

• Condyloma acuminata
• HPV, smooth or verrucous papules
• genital and perianal regions, cluster
• TX cryotherapy topical podophyllox, imiquimod
  5 cream

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Genital Herpes

• Small, grouped vesicles?painful ulcers
• DX Tzanck prep
• TX acyclovir, valacyclovir
• NCAA see Herpes Infections

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Herpes infectionsNCAA participation criteria

• Primary infection
• no systemic sxs
• no new lesions x 3 days
• all lesions crusted
• on oral meds gt120 hours ( 5 days)
• Crusts covered
• Recurrent infection
• Ulcers dry, covered by FIRM ADHERENT CRUST
• On oral meds for gt120 hours
• Crusts covered

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Tinea Cruris

• AKA jock itch
• Dermatophyte infection
• Erythematous w/ advancing border, pruritic DX
  KOH prep
• TX topical antifungals
• NCAA see Tinea Infections

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Tinea InfectionsNCAA participation criteria

• gt72 hours treatment
• DQ if extensive lesions
• Cover lesions with OpSite and tape after washing
  with Ketoconazole shampoo and applying antifungal
  cream

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Erythrasma

• Corynebacterium infection
• Uniformly brown and scaly w/o advancing border
  coral-red under Woods lamp
• TX oral or topical erythromycin
• NCAA see Bacterial Infections

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Hidradenitis Suppuritiva

• blockage of sweat glands with secondary
  infection chronic sinus tracts can form
• Erythematous papules, nodules, drainage
• TX
• topical /- oral abx
• ID
• Surgical excision

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Tinea Versicolor

• Pityrosporum ovale, asymptomatic
• Hypo- or hyper-pigmented macules DX Woods
  lamp, KOH scrape
• TX Selenium sulfide shampoo, -azole creams,
  terbinafine cream itraconazole oral
• NCAA see Tinea Infections

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Joggers Nipples

• irritation and friction, long distance runners
• painful, fissured, eroded nipples
• TX soft fiber shirts, adhesive bandages,
  petroleum jelly

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Warts, Verruca Vulgaris

• HPV unsightly and painful
• black dots after shave-down
• TX salicylic acid patch, cryotherapy, occlusion
• NCAA cover prior to competition

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Herpetic Whitlow

• Tender erythematous vesicles near fingertip
• TX oral antivirals
• NCAA
• See Herpes Infections, recurrent

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Dyshydrotic Eczema

• unknown etiology, not infectious
• eczematous eruption of pruritic vesicles on
  fingers
• TX keep hands dry, lotions, topical steroids

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Dermatophytid Reaction

• distant site fungal infection
• vesicular
• treat distant site, consider prednisone
• NCAA see tineas

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Paronychia

• bacterial infection
• tender inflammation of nail fold
• TX warm soaks, ID, /- oral abx
• NCAA see Bacterial Infections

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Bacterial InfectionsNCAA participation criteria

• No new lesions for 48 hours
• gt72 hours of antibiotics completed
• No moist, exudative or draining lesions
• Active bacterial infections shall NOT be covered
  to allow participation if above criteria not met

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Herpes Labialis

• cold sore
• Herpes simplex virus
• Vesicles?ulcers near lip painful
• TX topical or oral antivirals, sunscreen to
  prevent consider prophylactic valacyclovir
• NCAA see Herpes Infections

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Acne Vulgaris

• Acne Mechanica, football acne
• TX topical Retin-A, benzoyl peroxide, abx oral
  abx
• Not a contraindication to sports

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Herpes Gladiatorum

• HSV on area of friction/trauma
• TX oral antivirals
• NCAA see Herpes Infections

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Cellulitis

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

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Erysipelas

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

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Impetigo

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

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Folliculitis

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

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Furuncles

• More severe hair follicle abscess with Staph
• acute, tender, erythematous nodule
• TX warm compresses, abx, ID
• NCAA see Bacterial Infections

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Carbuncle

• More extensive abscess than furuncle Staph
• TX ID, oral or IV abx
• NCAA see Bacterial Infections

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Methicillin-Resistant Staph AureusMRSA

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

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Methicillin-Resistant Staph AureusMRSA

• When to suspect
• Skin abscesses
• Infections resistant to initial abx
• Proper treatment
• Culture all abscesses before tx
• Susceptibility should guide abx choice
• Community-acquired strains usually sensitive to
  SMX-TMP, fluoroquinolones, clindamycin, e-mycin

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Methicillin-Resistant Staph AureusMRSA

• 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

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Varicella (chickenpox)

• Varicella zoster virus
• Lesions in various stagespapules, vesicles,
  ulcers, crusts on red bases
• TX oral antivirals if early supportive
  measures itch creams
• NCAA no participation until ALL lesions crusted
  firmly, no secondary bacterial infection

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Miliaria Rubra prickly heat

• sweat duct occlusion
• fine erythematous papules
• TX dry clothing, hydrophilic ointments

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Contact Dermatitis

• direct chemical irritant or allergic delayed rxn
• pruritic patches of vesicles on weeping base
• TX calamine lotion, benadryl, topical steroids
  Zanfel cream

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Atopic Dermatitis

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

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Sunburn

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

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Photosensitivity Reactions

• reaction to sun or Rx
• eczema-like rash in sun-exposed areas
• TX
• stop offending med
• protect skin from sun
• topical /or oral steroids

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Striae Distensae

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

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Conclusion

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

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Questions?