Sports DermatologySports Dermatology

Kevin deWeber, MD, FAAFPKevin deWeber, MD, FAAFP

DirectorDirector

Primary Care Sports Medicine Primary Care Sports Medicine FellowshipFellowship

Military Sports Medicine

Fellowship

“Every Warrior an Athlete”

ObjectivesObjectives Review common dermatologic Review common dermatologic

problems and how they affect problems and how they affect athletesathletes

Discuss skin disorders specific to Discuss skin disorders specific to athletesathletes

Review diagnostic keys and Review diagnostic keys and treatments of athletic treatments of athletic dermatologic concernsdermatologic concerns

IntroductionIntroduction DefinitionsDefinitions FeetFeet GroinGroin ButtocksButtocks

HandsHands FaceFace GeneralGeneral Chest and Back Chest and Back

DefinitionsDefinitions Macule – not raised, 1 cm or lessMacule – not raised, 1 cm or less Patch – not raised, greater than 1 cmPatch – not raised, greater than 1 cm Papule - raised, 1 cm or lessPapule - raised, 1 cm or less Plaque - flat elevation, greater than 1 Plaque - flat elevation, greater than 1

cmcm Nodule – rounded elevation, greater Nodule – rounded elevation, greater

than 1 cmthan 1 cm Tumor – large noduleTumor – large nodule

DefinitionsDefinitions Vesicle - fluid filled, 1 cm or lessVesicle - fluid filled, 1 cm or less Bulla - fluid filled, greater than 1 Bulla - fluid filled, greater than 1

cm cm Pustule - elevated, pus filledPustule - elevated, pus filled Wheal – firm edematous plaque, Wheal – firm edematous plaque,

transienttransient

DefinitionsDefinitions Crust - dried fluid, e.g. scabCrust - dried fluid, e.g. scab Comedones -plugged sebaceous Comedones -plugged sebaceous

folliclesfollicles Scale - excess keratinScale - excess keratin Excoriation - erosion from scratchingExcoriation - erosion from scratching Erosion - partial thickness lossErosion - partial thickness loss Ulcer - erosion into dermisUlcer - erosion into dermis Fissure - crack-like break into dermisFissure - crack-like break into dermis

Impact of skin infections in Impact of skin infections in NCAA wrestlersNCAA wrestlers

15% of practice time-loss injuries15% of practice time-loss injuries

National Federation of High National Federation of High SchoolsSchools

Communicable Disease ProceduresCommunicable Disease Procedures

HCP must evaluate skin lesions HCP must evaluate skin lesions before returning to competitionbefore returning to competition

Consider evaluating other team Consider evaluating other team membersmembers

Follow state/local “return to Follow state/local “return to competition” rulescompetition” rules

CornsCorns Hyperkeratotic Hyperkeratotic

pressure areapressure area hard conical hard conical

papule with papule with translucent centertranslucent center

TX: modify foot TX: modify foot wear to change wear to change pressure, soften pressure, soften lesion, removelesion, remove

Plantar WartsPlantar Warts HPVHPV thickened plantar thickened plantar

papules, shave papules, shave reveals “black reveals “black dots”dots”

TX: keratolytic TX: keratolytic solutions, solutions, podophyllin, podophyllin, cryotherapycryotherapy

““Black Heel”Black Heel” Traumatic micro-Traumatic micro-

hemorrhageshemorrhages small small

asymptomatic asymptomatic black maculesblack macules

no treatment no treatment neededneeded

BlistersBlisters excessive friction excessive friction vesicles and vesicles and

bullaebullae TX: prevention, TX: prevention,

drainage (leave drainage (leave the roof), the roof), hydrocolloid hydrocolloid dressing dressing (duoderm)(duoderm)

Ingrown ToenailIngrown Toenail From improperly From improperly

fitting footwearfitting footwear usually great toeusually great toe TX: TX:

– pressure relief (go pressure relief (go shoeless, wider shoeless, wider shoes)shoes)

– cotton under nailcotton under nail– Antibiotics if Antibiotics if

infectedinfected– surgical excisionsurgical excision

Black ToenailsBlack Toenails AKA “joggers toe”, AKA “joggers toe”,

“skiers toe”, “tennis “skiers toe”, “tennis toe”toe”

From trauma or From trauma or pressurepressure

TX: TX: – acute subungual acute subungual

hematoma: pierce nailhematoma: pierce nail– Mild cases: no tx Mild cases: no tx – Prevention: proper Prevention: proper

shoes, metatarsal padshoes, metatarsal pad

OnychomycosisOnychomycosis fungal infection of fungal infection of

nailnail discoloration, scaling, discoloration, scaling,

thickeningthickening culture before txculture before tx TX: TX:

– Dermatophytes: Dermatophytes: Systemic itraconazole Systemic itraconazole or terbinafine 2-4 mosor terbinafine 2-4 mos

– Mold: topicalsMold: topicals– Candida: topical or Candida: topical or

systemicsystemic

Molluscum Molluscum ContagiosumContagiosum

““wrestler’s warts”wrestler’s warts” poxviruspoxvirus firm, skin colored, firm, skin colored,

umbilicatedumbilicated papules papules TX: spontaneous resolution TX: spontaneous resolution

(months), curettage, topicals, (months), curettage, topicals, cryotherapycryotherapy

NCAA:NCAA:– curette or remove lesions &curette or remove lesions &– cover with gas-perm cover with gas-perm

membrane AND tapemembrane AND tape

ScabiesScabies mite mite Sarcopetes Sarcopetes

scabieiscabiei exquisitely pruritic exquisitely pruritic

papules, excoriations; papules, excoriations; DX: scrapingDX: scraping

TX: topical permethrin TX: topical permethrin or crotamiton or crotamiton overnightovernight

NCAA - verification of NCAA - verification of treatment and negative treatment and negative scrapingsscrapings

Genital WartsGenital Warts Condyloma Condyloma

acuminataacuminata HPV, smooth or HPV, smooth or

verrucous papulesverrucous papules genital and perianal genital and perianal

regions, clusterregions, cluster TX: cryotherapy; TX: cryotherapy;

topical podophyllox, topical podophyllox, imiquimod 5% creamimiquimod 5% cream

Genital HerpesGenital Herpes Small, grouped Small, grouped

vesiclesvesiclespainful ulcers; painful ulcers; DX: Tzanck prepDX: Tzanck prep TX: acyclovir, TX: acyclovir,

valacyclovirvalacyclovir NCAA: see Herpes NCAA: see Herpes

InfectionsInfections

Herpes infections:Herpes infections:NCAA participation criteriaNCAA participation criteria

Primary infectionPrimary infection– no systemic sxsno systemic sxs– no new lesions x 3 daysno new lesions x 3 days– all lesions crustedall lesions crusted– on oral meds >120 hours ( 5 days)on oral meds >120 hours ( 5 days)– Crusts coveredCrusts covered

Recurrent infectionRecurrent infection– Ulcers dry, covered by FIRM ADHERENT Ulcers dry, covered by FIRM ADHERENT

CRUSTCRUST– On oral meds for >120 hoursOn oral meds for >120 hours– Crusts coveredCrusts covered

Tinea CrurisTinea Cruris AKA “jock itch”AKA “jock itch” Dermatophyte Dermatophyte

infectioninfection Erythematous w/ Erythematous w/

advancing border, advancing border, pruritic; DX: KOH pruritic; DX: KOH prepprep

TX: topical TX: topical antifungalsantifungals

NCAA: see Tinea NCAA: see Tinea InfectionsInfections

Tinea Infections:Tinea Infections:NCAA participation criteriaNCAA participation criteria

>72 hours treatment>72 hours treatment DQ if extensive lesionsDQ if extensive lesions Cover lesions with OpSite and tape Cover lesions with OpSite and tape

after washing with Ketoconazole after washing with Ketoconazole shampoo and applying antifungal shampoo and applying antifungal creamcream

ErythrasmaErythrasma

Corynebacterium Corynebacterium infectioninfection

Uniformly brown and Uniformly brown and scaly w/o advancing scaly w/o advancing border; coral-red border; coral-red under Wood’s lampunder Wood’s lamp

TX: oral or topical TX: oral or topical erythromycinerythromycin

NCAA: see Bacterial NCAA: see Bacterial InfectionsInfections

Hidradenitis SuppuritivaHidradenitis Suppuritiva

blockage of sweat blockage of sweat glands with secondary glands with secondary infection; chronic sinus infection; chronic sinus tracts can formtracts can form

Erythematous papules, Erythematous papules, nodules, drainagenodules, drainage

TX: TX: topical +/- oral abxtopical +/- oral abx I&DI&D Surgical excisionSurgical excision

Tinea VersicolorTinea Versicolor

Pityrosporum ovalePityrosporum ovale, , asymptomaticasymptomatic

Hypo- or hyper-Hypo- or hyper-pigmented macules; pigmented macules; DX: Wood’s lamp, KOH DX: Wood’s lamp, KOH scrapescrape

TX: Selenium sulfide TX: Selenium sulfide shampoo, -azole shampoo, -azole creams, terbinafine creams, terbinafine cream; itraconazole oralcream; itraconazole oral

NCAA: see Tinea NCAA: see Tinea InfectionsInfections

Jogger’s Jogger’s NipplesNipples

irritation and irritation and friction, long friction, long distance runnersdistance runners

painful, fissured, painful, fissured, eroded nippleseroded nipples

TX: soft fiber TX: soft fiber shirts, adhesive shirts, adhesive bandages, bandages, petroleum jellypetroleum jelly

Warts, Verruca Warts, Verruca VulgarisVulgaris

HPV; unsightly HPV; unsightly and painfuland painful

““black dots” after black dots” after shave-downshave-down

TX: salicylic acid TX: salicylic acid patch, patch, cryotherapy, cryotherapy, occlusionocclusion

NCAA: cover prior NCAA: cover prior to competitionto competition

Herpetic WhitlowHerpetic Whitlow Tender Tender

erythematous erythematous vesicles near vesicles near fingertipfingertip

TX: oral antiviralsTX: oral antivirals NCAANCAA

– See Herpes See Herpes Infections, recurrentInfections, recurrent

Dyshydrotic EczemaDyshydrotic Eczema

unknown etiology, unknown etiology, not infectiousnot infectious

eczematous eczematous eruption of eruption of pruritic vesicles pruritic vesicles on fingers on fingers

TX: keep hands TX: keep hands dry, lotions, dry, lotions, topical steroidstopical steroids

Dermatophytid Dermatophytid ReactionReaction

distant site fungal distant site fungal infectioninfection

vesicularvesicular treat distant site, treat distant site,

consider consider prednisoneprednisone

NCAA: see tineasNCAA: see tineas

ParonychiaParonychia bacterial infectionbacterial infection tender tender

inflammation of inflammation of nail foldnail fold

TX: warm soaks, TX: warm soaks, I&D, +/- oral abxI&D, +/- oral abx

NCAA: see NCAA: see Bacterial Bacterial InfectionsInfections

Bacterial Infections:Bacterial Infections:NCAA participation criteriaNCAA participation criteria

No new lesions for 48 hoursNo new lesions for 48 hours >72 hours of antibiotics completed>72 hours of antibiotics completed No moist, exudative or draining No moist, exudative or draining

lesionslesions Active bacterial infections shall NOT Active bacterial infections shall NOT

be covered to allow participation if be covered to allow participation if above criteria not metabove criteria not met

Herpes LabialisHerpes Labialis ““cold sore”cold sore” Herpes simplex virusHerpes simplex virus VesiclesVesiclesulcers near ulcers near

lip; painfullip; painful TX: topical or oral TX: topical or oral

antivirals, sunscreen antivirals, sunscreen to prevent; consider to prevent; consider prophylactic prophylactic valacyclovirvalacyclovir

NCAA: see Herpes NCAA: see Herpes InfectionsInfections

Acne VulgarisAcne Vulgaris Acne Mechanica, Acne Mechanica,

“football acne”“football acne” TX: topical Retin-TX: topical Retin-

A, benzoyl A, benzoyl peroxide, abx; peroxide, abx; oral abxoral abx

Not a Not a contraindication contraindication to sportsto sports

Herpes GladiatorumHerpes Gladiatorum HSV on area of HSV on area of

friction/traumafriction/trauma TX: oral antiviralsTX: oral antivirals NCAA – see NCAA – see

Herpes InfectionsHerpes Infections

CellulitisCellulitis

Infection of dermis Infection of dermis and sub-cu tissueand sub-cu tissue

Expanding erythema, Expanding erythema, swelling, tendernessswelling, tenderness

TX: rest, elevation, TX: rest, elevation, oral abx; IV abx if oral abx; IV abx if severe or on facesevere or on face

NCAA: see Bacterial NCAA: see Bacterial InfectionsInfections

ErysipelasErysipelas Usually Gp A StrepUsually Gp A Strep Superficial infection Superficial infection

extending into the extending into the lymphatics; systemic lymphatics; systemic sxs commonsxs common

More red, swollen More red, swollen than cellulitis, some than cellulitis, some streakingstreaking

TX: penicillins, TX: penicillins, AzithroAzithro

NCAA: see Bacterial NCAA: see Bacterial InfectionsInfections

ImpetigoImpetigo superficial skin superficial skin

infection with Strep, infection with Strep, StaphStaph

yellow crusted yellow crusted lesions on red baselesions on red base

TX: remove crust; TX: remove crust; topical mupirocin or topical mupirocin or oral abxoral abx

NCAA – see Bacterial NCAA – see Bacterial InfectionsInfections

FolliculitisFolliculitis Mild hair follicle Mild hair follicle

inflammation or inflammation or infection, usually Staphinfection, usually Staph– Pseudomonas in hot tubsPseudomonas in hot tubs

Papules, pustules Papules, pustules around folliclesaround follicles

TX: wash with soap, TX: wash with soap, topical mupirocin, oral topical mupirocin, oral abxabx

NCAA: see Bacterial NCAA: see Bacterial InfectionsInfections

FurunclesFuruncles More severe hair More severe hair

follicle abscess with follicle abscess with StaphStaph

acute, tender, acute, tender, erythematous noduleerythematous nodule

TX: warm TX: warm compresses, abx, I&Dcompresses, abx, I&D

NCAA – see Bacterial NCAA – see Bacterial InfectionsInfections

CarbuncleCarbuncle

More extensive More extensive abscess than abscess than furuncle; Staphfuruncle; Staph

TX: I&D, oral or IV TX: I&D, oral or IV abxabx

NCAA: see NCAA: see Bacterial Bacterial InfectionsInfections

Methicillin-Resistant Staph Methicillin-Resistant Staph AureusAureus“MRSA”“MRSA”

Staph strains resistant to Staph strains resistant to ß-lactam abx ß-lactam abx (e.g. dicloxacillin, methicillin)(e.g. dicloxacillin, methicillin)

May be resistant to other abxMay be resistant to other abx Cause skin infections usuallyCause skin infections usually

– Cellulitis, folliculitis, furuncles, abscessesCellulitis, folliculitis, furuncles, abscesses Cause significant morbidityCause significant morbidity

– 70% of athletes required IV abx70% of athletes required IV abx Spread directly person-to-personSpread directly person-to-person

– Football linemen, rugby, fencing, wrestlingFootball linemen, rugby, fencing, wrestling– Through injured skinThrough injured skin

Methicillin-Resistant Staph Methicillin-Resistant Staph AureusAureus“MRSA”“MRSA”

When to suspectWhen to suspect– Skin abscessesSkin abscesses– Infections resistant to initial abxInfections resistant to initial abx

Proper treatmentProper treatment– Culture all abscesses before txCulture all abscesses before tx– Susceptibility should guide abx choiceSusceptibility should guide abx choice

Community-acquired strains usually Community-acquired strains usually sensitive to SMX-TMP, fluoroquinolones, sensitive to SMX-TMP, fluoroquinolones, clindamycin, e-mycinclindamycin, e-mycin

Methicillin-Resistant Staph Methicillin-Resistant Staph AureusAureus“MRSA”“MRSA”

PreventionPrevention– No participation of infected athletes No participation of infected athletes

until cureduntil cured– Protect exposed skin if high-risk sportProtect exposed skin if high-risk sport– Properly clean/protect injured skinProperly clean/protect injured skin– Proper general hygieneProper general hygiene– Report MRSA to PrevMed and CDCReport MRSA to PrevMed and CDC

Varicella (chickenpox)Varicella (chickenpox)

Varicella zoster virusVaricella zoster virus Lesions in various Lesions in various

stages—papules, stages—papules, vesicles, ulcers, crusts vesicles, ulcers, crusts on red baseson red bases

TX: oral antivirals if TX: oral antivirals if early; supportive early; supportive measures; itch creamsmeasures; itch creams

NCAA: no participation NCAA: no participation until ALL lesions crusted until ALL lesions crusted firmly, no secondary firmly, no secondary bacterial infectionbacterial infection

Miliaria Rubra Miliaria Rubra “prickly heat”“prickly heat”

sweat duct sweat duct occlusionocclusion

fine erythematous fine erythematous papulespapules

TX: dry clothing, TX: dry clothing, hydrophilic hydrophilic ointmentsointments

Contact DermatitisContact Dermatitis direct chemical irritant direct chemical irritant

or allergic delayed rxnor allergic delayed rxn pruritic patches of pruritic patches of

vesicles on weeping vesicles on weeping basebase

TX: calamine lotion, TX: calamine lotion, benadryl, topical benadryl, topical steroids; Zanfel creamsteroids; Zanfel cream

Atopic DermatitisAtopic Dermatitis

dry easily irritated dry easily irritated skin, worsened by skin, worsened by heat and sweatheat and sweat

pruritic pruritic erythematous erythematous macules and macules and patches, flexor patches, flexor surfacessurfaces

TX: moisturizers, TX: moisturizers, topical steroids, topical steroids, soap-free cleansingsoap-free cleansing

SunburnSunburn UV radiationUV radiation mild to intense mild to intense

erythema erythema analgesics, cool analgesics, cool

compresses, compresses, topical steroids or topical steroids or lotionslotions

Photosensitivity Photosensitivity ReactionsReactions

reaction to sun or reaction to sun or RxRx

eczema-like rash in eczema-like rash in sun-exposed areassun-exposed areas

TX: TX: – stop offending medstop offending med– protect skin from sunprotect skin from sun– topical &/or oral topical &/or oral

steroidssteroids

Striae DistensaeStriae Distensae rupture of elastic rupture of elastic

fibers from rapid fibers from rapid growth; steroids?growth; steroids?

perpendicular to perpendicular to lines of tension; lines of tension; shoulders, back, shoulders, back, thighthigh

no good no good treatment proventreatment proven

ConclusionConclusion Skin diseases in athletes can be Skin diseases in athletes can be

sports and regionally specificsports and regionally specific Recognize and treat earlyRecognize and treat early Know the rules for participationKnow the rules for participation