sports dermatology
TRANSCRIPT
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