The Physician and Sportsmedicine
Menubar Home Journal Personal Health Resource Center CME Advertiser Services About Us

Acing Common Skin Problems in Tennis Players

Rodney S. W. Basler, MD; Michael A. Garcia


In Brief: The following measures can help prevent skin disorders in tennis players: wearing properly fitted shoes to avoid tennis toe, talon noir, and calluses; applying lubricants to protect against blisters and chafing; washing skin thoroughly to reduce the risk of acne mechanica; and wearing a hat and sunscreen to guard against photoinjury. 'Stringer's fingers' can be prevented by breaking the habit of adjusting the racket strings after each point. Should these disorders become troublesome, conservative treatments are usually effective. For example, calluses may be carefully pared, and pain from a subungual hemorrhage can be relieved by piercing the toenail with a hot paper clip.

While the number of athletes active in competitive and recreational tennis has stayed fairly constant, improvements in equipment, playing surfaces, and facilities have introduced a competitive intensity that can result in more aggressive play and longer matches. This style of play may benefit participants' physical conditioning, but it can also lead to more injuries such as stress conditions from overuse. Since the skin is the interface between the tennis player and the athletic environment, it is particularly vulnerable to a variety of overuse injuries and other conditions. Some of these are common to many sports, while others are unique to tennis and other racket sports (1). Physicians who are familiar with the prevention and treatment of these disorders can teach tennis players how to avoid them or intervene when necessary to keep patients on the court.

'Stringer's Fingers'

A condition specific to tennis players is the asymptomatic development of hypertrophic papules over the fingertips, which we call "stringer's fingers." Stringer's fingers occur at the tips of the fingers, usually the middle three, in response to the habitual adjustment of the racket strings. On impact with a tennis ball, strings often move slightly. Many players straighten the strings to ensure a truer shot for the next point. When they do so, however, the skin at the tips of the fingers is exposed to friction that causes the development of a thick, hypertrophied stratum corneum, similar to a callus.

Stringer's fingers may not be seen in all tennis players. The condition is more prevalent in players who hit heavy spin shots and use tight strings. The increased spin causes greater string movement and need for adjustment. The tighter the strings, the greater the friction on the fingers during adjustment.

Treating this condition is often unnecessary. In fact, some players consider it a benefit, because it can facilitate string rearrangement. However, players need to be careful to avoid blisters. If the condition causes functional or cosmetic problems, palliative measures include regular paring of hyperkeratotic skin and the application of salicylic acid plasters.

Preventing stringer's fingers is often impossible unless the activity is stopped. However, more and more of today's tennis rackets are made with string aligns inserted to reduce string movement.

Tennis Toe

Many tennis players are familiar with this malady, a subungual hemorrhage that usually occurs under the great toenails. As a result of the quick start-and-stop action of the game, the toes, especially the great toe, are repeatedly jammed into the front of the toe box of the tennis shoe, resulting in bleeding under the nail plate (2). Hemorrhaging produces a dark discoloration under the nail, referred to as "black toenail" (figure 1), though the color may vary from bright red to dark brown, depending on the acuteness. Fortunately, the symptoms are usually minimal.

Treatment usually starts with rest and warm water soaks, two or three times daily for a week. The great toenail should be trimmed straight across and as short as is possible without causing discomfort. If the hemorrhage is recent, the blood may be drained by burning through the nail plate with a flame-heated paper clip or by using Geiger cautery (3). Wearing shoes that are fitted properly in length and toe box height can help prevent this injury (4).

Talon Noir

This lesion results from the repeated lateral shearing force generated when the epidermis slides over the rete pegs of the papillary dermis, causing intra-epidermal and, ultimately, intracorneal hemorrhage (1). Talon noir, also less romantically termed "black heel," is associated with any sport, including tennis, that involves frequent, quick starts and stops.

The condition appears as a bluish-black plaque composed of multiple pigmented puncta, usually on the posterior or posterolateral aspect of the heel (figure 2). Occasionally, the asymptomatic punctate petechiae can also occur on the palm of the hand ("black palm") in those who play tennis and racquetball (5). For reasons not yet understood, talon noir is seen almost exclusively in teenagers and young adults (1).

Black heel is asymptomatic, causes no disability, does not affect performance, and spontaneously resolves over time without treatment. However, patients often present with the condition because they think it looks like melanoma. To allay this fear, gentle paring of the horny layer of the affected skin with a scalpel will reveal the black color to be merely surface pigment (2).

Preventive measures include wearing properly fitted shoes and gloves.


Blisters occur when a small area of skin is repeatedly rubbed. They are usually a minor annoyance for most athletes, but they can impair a competitive tennis player's performance. In fact, blisters have been reported (6) as the most common injury for which tennis players seek medical attention during the US Open. Although they are often viewed as an unavoidable result of vigorous training, they are usually preventable.

Friction blisters most often appear on the extremities, especially the tips of toes, heels, and palms of the hands. They are tender vesicles filled with clear fluid or blood that often break to form painful erosions (figure 3). Although friction blisters are certainly not sport-specific, our experience suggests that they occur more frequently and are larger in tennis players than in many other athletes, probably because of the start-and-stop nature of the sport.

Whatever the sport, treatment and prevention are the same. Treatment depends on the size and location of the blister. Small blisters are usually self-limiting and heal with conservative treatment. Although the epidermal roof should be left intact to act as a natural barrier, this may prove difficult unless the patient stops playing. Larger blisters—more than 1 cm in diameter—are best drained initially by puncturing them with a needle or scalpel, making sure the wound is small enough to minimize the risk of secondary infection (5). Drained blisters should be covered with a membrane dressing such as DuoDerm (Parkview Pharmacy and Home Health Care Supplies, Inc, Rancho Cucamonga, California), which also offers protection from further friction injury. This can be left in place for 5 to 7 days, allowing for early epithelialization.

To prevent blisters, athletes should increase the intensity of exercise gradually, especially when using new shoes or rackets. Keeping the skin well lubricated helps to reduce friction and the chance of blister formation; for example, tennis players often use petroleum jelly or Aquaphor (Beiersdorf Aktiengesellschaft, Hamburg, Germany) on their feet. Proper clothing can also be protective; acrylic socks, for example, are better than cotton ones because they are designed to diminish friction (2) and wick perspiration from the skin, thus keeping the skin as dry as possible.


Tennis players commonly develop calluses at points of continuous friction on the feet, including the ball of the foot and areas of anatomic or functional deformity. In addition, calluses are almost universally seen on the hands of serious tennis players where the racket handle rubs the skin over the distal metacarpal heads.

Callus formation is the skin's attempt to compensate for persistent friction by increasing its thickness at points of continuous contact. When calluses become too thick, discomfort may occur. Because calluses are a natural reinforcement at sites of cutaneous stress, intervention may not always be advisable. However, if the callus is functionally detrimental or if blisters form under the callus (figure 4), regular, careful paring of the hyperkeratotic skin, abrasive reduction following soaking, or the application of salicylic acid plasters may relieve symptoms.

The apparent increased incidence of corns and calluses among tennis players (6) may be a response to the firmer playing surfaces of recently constructed tennis courts. However, properly fitted shoes that minimize back-and-forth foot movement can help prevent foot calluses. The use of cushioned grips can minimize callus formation on the hand.


A skin problem familiar to all sports participants, chafing is caused by mechanical friction between parts of the body or between the body and clothing. Frequently affected areas include the neck, axilla, and particularly the upper inner thighs. Excess fat or muscle, sweat, and friction with fabric can exacerbate the chafing in the thigh region. The problem may be particularly acute in tennis players because the sport naturally develops the thigh muscles, which may bring the upper inner thighs closer together.

The irritation usually develops after a tennis match is well underway. The skin appears to be abraded, bright red, and inflamed, and it is sensitive to the touch. Fortunately, the condition usually only causes discomfort and is not painful enough to stop play.

Application of a lubricating ointment such as petrolatum or Aquaphor will relieve the symptoms and also help prevent further chafing by reducing friction. Chafing can often be avoided by wearing proper attire. "Bun huggers," which are made of elasticized fabric and extend from the waist to midthigh, are an excellent option, as are sport shorts with longer legs made of low- resistance fabric such as nylon. Friction-reducing powder, such as Zeasorb (Stiefel Laboratories, Inc, Oak Hill, New York), and weight loss are also helpful.

Acne Mechanica

This disorder (figure 5) is a papulopustular eruption, usually on the face and upper trunk, that is caused by pressure, friction, occlusion, and heat (7). A preexisting acne condition may or may not be present.

Acne mechanica typically affects athletes who wear heavy protective equipment (mainly football and hockey players) (8), but it has been seen beneath synthetic leotards that pressure the skin of women who do aerobics (5), on the midback of weight lifters where the skin contacts the plastic-covered weight bench; and on the lateral back of golfers from the pressure of a golf bag. Acne mechanica in tennis players is common on the upper back and chest, shoulders, and lower neck, especially when they wear heavier garments in chilly playing conditions.

Prevention and treatment include obvious measures such as wearing a clean T-shirt made of cotton or a wicking material next to the skin. After a workout, a player should immediately and aggressively wash the affected areas with a mildly abrasive cleanser and back brush or scrub (8). He or she may then apply a keratolytic solution, such as one containing salicylic acid and resorcinol. Applying tretinoin cream at bedtime can further reduce follicular keratinization (9).

Systemic antibiotics such as tetracycline and erythromycin appear to be less effective in acne mechanica than in acne vulgaris. Special caution must be used if systemic isotretinoin is considered in treating severe pustulocystic acne in any competitive athlete; the joint and muscle pain, lethargy, and general decrease in energy that often accompany its use may significantly diminish performance. In our experience, however, this drug seems more detrimental to endurance athletes, such as distance swimmers and cross-country runners, than to those who play racket sports.


Though skin injury from sunlight was once a novel idea (10), it is now generally understood though frequently ignored by the public. Tennis players can be especially vulnerable to long-term skin damage because they often play under the midday summer sun. To combat this risk, tennis enthusiasts need to protect themselves from ultraviolet (UV) exposure by following some simple recommendations.

Time of day. Outdoor matches should be played when the sun's rays are least intense, preferably before 10 am or, as a second choice, after 4 pm. For nonprofessional players, these times will usually suit their work schedules as well.

Clothing. Wearing a cap or, better yet, a hat with a floppy brim is especially important for protecting the face, ears, and top of the scalp. Players should remember, however, that a cap, since it does not block reflected rays from the playing surface, provides protection equivalent to a sunscreen with a sun protection factor (SPF) of only 2, so sunscreen should still be applied. Dark fabric has been reported (2) to be more protective in full sun than white fabric, because it absorbs more of the sun's rays and allows fewer to reach the skin. Unfortunately, many players feel that this absorptive effect increases body heat during matches.

Sunscreen. Although some controversy persists concerning the optimum SPF level for outdoor protection, most dermatologists agree that SPF 15 with combined UVA and UVB protection is adequate. People who play tennis outside should choose a sunscreen with high substantivity (water resistance) (11) and apply it to all exposed skin at least 20 minutes before going into the sun and every 4 hours thereafter, even on cloudy days or when they are in the shade.

Preserving Performance

Competitive and recreational tennis players are susceptible to a variety of skin disorders, most of which can be prevented through thoughtful planning and playing. Conservative treatment of disorders that become troublesome usually allows players to stay on the court with minimal impairment of performance.


  1. Basler RSW: Skin lesions related to sports activity. Prim Care 1983;10(3):479-494

  2. Basler RSW: Managing skin problems in athletes, in Mellion MB, Walsh W, Shelton GL (eds): The Team Physician's Handbook, ed 2. Philadelphia, Hanley & Belfus, Inc, 1997, pp 341-359

  3. Basler RSW: Skin problems encountered in winter sports, in Casey MJ, Foster C, Hixson EG (eds): Winter Sports Medicine. Philadelphia, FA Davis Co, 1990, pp 142-147

  4. Basler RSW: Skin injury in sports medicine. J Am Acad Dermatol 1989;21(6):1257-1262

  5. Basler RSW, Basler DL, Basler GC, et al: Cutaneous injuries in women athletes. Derm Nurs 1998;10(1):9-18

  6. Montgomery RM: Tennis and its skin problems. Cutis 1977; 19(4):480-482

  7. Mills OH, Kligman A: Acne mechanica. Arch Dermatol 1975;111(4):481-483

  8. Basler RSW: Acne mechanica in athletes. Cutis 1992;50(2):125-128

  9. Bergfeld WF: Dermatologic problems in athletes. Clin Sports Med 1982;1(3):419-430

  10. Basler RSW: Damaging effects of sunlight on human skin. Nebr Med J 1978;63(10):337-340

  11. Basler RSW, Rheim JE: Sunlight and skin. J Dermatol Allergy 1982;5:23-27

Dr Basler practices at South Lincoln Dermatology Clinic and is a clinical assistant professor of internal medicine and dermatology at the University of Nebraska in Lincoln. He is a former chair of the Task Force on Sportsmedicine in the American Academy of Dermatology and is a team physician for the University of Nebraska athletic teams. Mr Garcia is a three-time Nebraska Open tennis champion and the No. 1-ranked men's player in the state. Address correspondence to Rodney S. W. Basler, MD, South Lincoln Dermatology Clinic, 2625 Stockwell St, Lincoln, NE 68502.



The McGraw-Hill Companies Gradient

Copyright (C) 1998. The McGraw-Hill Companies. All Rights Reserved
Privacy Policy.   Privacy Notice.