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Viral Skin Infections

Preventing Outbreaks in Sports Settings

Peggy R. Cyr, MD

Sports Dermatology Series Editor:
William Dexter, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 32 - NO. 7 - JULY 2004


In Brief: Viral skin infections, such as herpes simplex, molluscum contagiosum, and warts, are common in athletes. Visual inspection alone can often provide a diagnosis. The Tzanck test or a direct fluorescent antibody test for herpes simplex virus 1 and 2 can also establish an early diagnosis. If prevention strategies fail, early detection and treatment will help limit the spread of viral infections to other teammates. National Collegiate Athletic Association rules prohibit participation by players who have herpes virus infections unless they are properly treated; lesions of molluscum contagiosum and warts must be treated or securely covered before return to play in contact sports.

Three points underscore the need for clinicians and team physicians to have a thorough knowledge of viral skin infections: (1) the skin is an athlete's largest organ, (2) sports-related skin disorders are among the most common injuries affecting athletes,1 and (3) athletes and other active individuals have skin infections more often than sedentary individuals.2 Herpes simplex and zoster, molluscum contagiosum, and warts (hand, plantar, and other cutaneous areas) will be discussed, but condyloma and genital warts are beyond the scope of this article. Strategies to prevent transmission will also be reviewed.

Sweating, chafing, and occlusive clothing form a perfect environment for viral skin infections. Any breach in the skin from cuts, abrasions, or lacerations increases the risk of infection. Contact sports, such as wrestling or rugby, have a higher rate of viral skin infections than do noncontact sports. Training environments may promote the transmission of some viral infections via fomites, such as weights, mats, weight benches, pool decks, and communal showers.3

The classic appearance of many viral lesions means that a diagnosis can often be made solely by visual inspection. With periodic skin surveillance, the team physician can provide prevention strategies (eg, covering abrasions), early detection, and early treatment of viral skin infections to limit the risk of transmission to other team members.

Herpes

Herpes simplex virus (HSV) includes two closely related viruses that are distinguished as HSV 1 and HSV 2. Both produce primary and recurrent infections that demonstrate a wide range of clinical findings. The more severe primary infection can become latent when HSV remains dormant in neural ganglia. Reactivation of the virus is triggered by events such as sunlight exposure, physical or emotional stress, or neurosurgical manipulation of the ganglia. The recurrent event has a shorter duration and milder clinical findings than the primary infection.

An athlete who has a primary infection may be quite sick with fever, malaise, and lymphadenopathy. These symptoms represent the prodrome, but not every episode of HSV has a prodrome. After an incubation period of 5 to 10 days,4 asymptomatic shedding of viral particles and the development of clinical lesions may occur (figure 1A). The vesicles rupture quickly and crust over (figure 1B) within a few days.5 Crusted lesions last 5 to 7 days and may take 2 to 3 weeks to completely heal.

Two sports with a high degree of close contact have specifically coined terms for HSV infection. Herpes gladiatorum occurs in wrestlers,6 and herpes rugbiorum or scrumpox affects rugby players.7 The lesions of herpes gladiatorum and rugbiorum usually appear on the head and neck and are spread by direct contact. These lesions are highly contagious and can affect multiple members of the same team8 and their opponents. Herpes labialis (cold sores, fever blisters) may affect snow skiers and others who are exposed to cold stress or to increased ultraviolet solar radiation at high altitudes.9

Herpetic whitlow is a primary or recurrent herpes simplex infection of the fingers or hands that occurs by autoinoculation or by direct contact with infected persons. Painful vesicles form along the lateral edge of a fingernail. A primary infection can demonstrate erythematous streaking of the forearm and painful axillary adenopathy.

Herpetic lesions close to the eyes are cause for concern. Ocular HSV is characterized by keratoconjunctivitis with pain, photophobia, chemosis, blurred vision, and tearing. Referral to an ophthalmologist is recommended.

Diagnosis of a herpes infection is made from clinical history and physical exam. A Tzanck test for multinucleated giant cells can provide rapid diagnosis, but considerable experience is needed for accurate interpretation. A direct fluorescent antibody test for HSV 1 and HSV 2 can also establish a rapid, dependable diagnosis.10 A viral culture is the gold standard for diagnosis,11 but the sensitivity is only 70% to 80%, and results may take 4 to 5 days. High clinical suspicion should trigger prompt treatment before the culture results return.

Treatment of primary herpes infections with oral antiviral medication should begin promptly. Options include acyclovir, 200 mg, taken 5 times a day for 10 days or 400 mg bid for 7 to 10 days; famciclovir, 250 mg bid for 7 to 10 days (safety and efficacy in children younger than 18 have not been established); or 1 g of valacyclovir hydrochloride bid for 7 to 10 days. The US Food and Drug Administration recently approved treating herpes labialis with oral administration of 2 g of valacyclovir bid for 1 day. Recurrent herpes infections can be treated by administering lower doses for 5 days: acyclovir 400 mg tid, famciclovir 125 mg tid, or valacyclovir 500 mg bid. Options to prevent recurrence with suppressive therapy include: acyclovir 400 mg bid, famciclovir 250 mg bid, or valacyclovir 500 mg bid.12

Toxicity with oral antivirals is rare, but in patients who are dehydrated or have poor renal function, antiviral drugs can crystallize in the renal tubules and lead to a reversible elevation in creatinine or, rarely, acute tubular necrosis.13 Extra fluid intake should be recommended for anyone taking oral antivirals.

Prevention of cutaneous HSV infections includes avoiding contact with vesicles. Vesicular lesions must be dried scabs before patients return to contact sports. Covering the dried scabs with occlusive dressing may add further protection. Those providing care to athletes who have skin lesions should wear gloves to limit infectious exposure.2

Molluscum Contagiosum

A common benign viral disease of the skin and mucous membranes, molluscum contagiosum predominately affects children. Characterized by discrete, white to skin-colored, umbilicated papules that are 3 to 5 mm in diameter (figure 2), molluscum contagiosum is caused by a virus in the Poxviridae family. The papules are more common in swimmers, gymnasts, and wrestlers but may be seen on athletes in any sport. Lesions are commonly seen on the hands, forearms, and faces of athletes. The lesions are generally asymptomatic, but they may develop pruritus and a localized eczematous reaction. Molluscum contagiosum is spread by skin-to-skin contact and autoinoculation and is moderately contagious. Genital lesions on an adult may be transmitted sexually, hence its classification as a sexually transmitted disease.14

Diagnosis is made based on the characteristic appearance of the lesions.

Treatment is generally recommended, especially if an athlete participates in a contact sport. The infection is self-limited but may take months or even years to resolve without treatment. The three main types of treatments used to eradicate molluscum lesions are:

  • Mechanical, such as curettage, electrotherapy, or cryotherapy with liquid nitrogen or nitrous oxide cyrogun performed by a physician;
  • Chemical, such as physician-applied trichloroacetic acid (25% to 50% solution), 0.7% cantharidin, or Verrusol (1% cantharidin, 30% salicylic acid, 5% podophyllin). These can be mixed by a pharmacist. The chemicals are applied to the lesion and covered for 1 day. A blister forms and then heals.15 Medication effectiveness and side effects depend on how long the medication is left on the skin. Certain areas of the skin are quite sensitive and require less time to be effective. Patient-applied tretinoin gel and tazarotene gel have also been used. These are generally applied daily to the lesions, and areas are monitored for skin redness or irritation and destruction of the lesions; and,
  • Immunologic, such as a topically applied immune enhancer that stimulates cytokines (ie, 5% imiquimod cream). This agent can be used if multiple lesions are present and destructive methods are not well tolerated. The patient applies the cream sparingly to the molluscum lesions 3 times a week, leaves it on the skin for 6 to 10 hours, and then washes it off. The usual treatment course is 4 to 16 weeks.16 This method would not be practical for an athlete who is eager to return to play.

Contact sports can be resumed 48 hours after resolution.17 Caution should still be advised in the treated areas, because some lesions may not yet be clinically apparent.

Warts

Verrucae are epithelial tumors, hyperkeratotic plaques, and cauliflower-shaped papules caused by infection with various forms of the human papillomavirus (HPV). These lesions are commonly seen on the hands and feet, but they may occur on other skin surfaces. Warts are divided into various types by typical appearance and location, including common (figure 3A), periungual (figure 3B), flat (verrucae plana), filiform (frondlike), and deep palmoplantar.7,16 On exposed skin, warts tend to be hard and have a verrucous surface. Infectivity is low, but all types of warts are transmitted by direct skin-to-skin contact and possibly through fomites, such as gymnastic and weight-lifting equipment, swimming pool decks, locker room floors, and shower floors. Calluses, dampness from foot perspiration, and trauma to the skin may increase susceptibility to warts.

After the initial infection, warts frequently are spread by autoinoculation from shaving, scratching, or other skin trauma. Rowing crew members are more likely to have hand warts than track runners, particularly if they do not wear protective gloves for rowing and weight lifting.18 Gymnasts, football players, wrestlers, and swimmers can all develop warts. Plantar warts can be painful and impede performance, and they should be treated.

Diagnosis. Visual inspection is usually sufficient to make a diagnosis. Warts do not retain the normal fingerprint lines on the hands and feet that corns and calluses do. A wart on the surface of the foot can be distinguished from a callus by paring the lesion down with a No. 15 blade (figure 4A). Warts will have 10 to 15 pinpoint black spots that are thrombosed capillaries (figure 4B).16

Treatment. Because warts are confined to the epidermis, they can be removed with little scarring. The treatment options for warts are similar to those for molluscum contagiosum—mechanical, chemical, or immunologic. The most common mechanical methods are freezing with liquid nitrogen, electrocautery, excision, or laser treatment. The wart is frozen until 1 to 2 mm of surrounding skin has turned white, and the treatment is repeated once after the skin thaws. The area should be reexamined in approximately 3 to 4 weeks, because retreatment is commonly needed.

The chemical options range from over-the-counter salicylic acid preparations available in plasters containing 40%, or liquid containing 17% trichloroacetic acid or Verrusol applied by a physician. For plantar warts, soaking the foot, paring down the dead skin, or using a pumice stone before applying the medication will increase the effectiveness of topical preparations. Intralesional injection of the chemotherapy agent bleomycin has been used in recalcitrant plantar warts. Bleomycin causes acute tissue necrosis and must be used with extreme caution.19

The immunologic methods used to induce an immune response to suppress warts include injected agents (eg, candida or mumps antigen), topical agents (eg, imiquimod), or oral agents (eg, 30 to 40 mg/kg/day of cimetidine).16

Recalcitrant warts may require combination treatments to be effective. A mechanical method, such as liquid nitrogen, and a chemical method, such as Verrusol, may be used during the same treatment session.

Athletes can return to competition as soon as warts have been treated, but the warts should remain covered until completely resolved.

General Prevention Pointers

For all of the viral infections discussed, some common strategies that coaches, athletic trainers, and team physicians can use to prevent disease transmission among physically active patients are:

  • Enforcing the practice of good hygiene, such as showering after every athletic event; laundering clothing and uniforms after each use; not sharing towels, soaps, or water bottles; and wearing sandals in communal showers;
  • Examining the athletes' skin routinely for scratches, abrasions, and lacerations and keeping these areas securely covered with bandages;
  • Reminding players to use sunscreen and lip balm with sunscreen during prolonged exposure to the sun;
  • Disqualifying from play any athlete who has active herpes simplex, herpes zoster, or molluscum contagiosum lesions until the conditions have been appropriately treated. Herpes lesions must be completely dry and crusted and should be covered until completely resolved; and
  • Covering all warts until completely resolved.

Return-to-Play Guidelines

The National Collegiate Athletic Association (NCAA) guidelines for wrestling20 outline the proper timing for return to play when an athlete has had a viral skin infection. For a primary herpes infection, the athlete must be free of all systemic symptoms of viral infection (eg, fever, malaise) and have no new blisters (for both primary and recurrent infections) for 72 hours before the exam. All lesions must be dried (no moist lesions) and have a firm adherent crust. The athlete must have taken oral antivirals for at least 120 hours before and be taking them at the time of the athletic event. Covering active herpetic lesions is not allowed. For questionable cases, the player must be excluded from play until a Tzanck test or direct fluorescent antibodies test result is negative. For wrestlers with a history of recurrent herpes, season-long prophylaxis with acyclovir or valacyclovir may be advisable.

Disqualification from play is not required for players who have molluscum lesions or warts as long as the lesions are removed before play or covered with an occlusive dressing.

Take-Home Message

Viral skin infections are common in athletes and other active patients. Team physicians are well suited to provide early detection and treatment of herpes simplex, molluscum contagiosum, and warts. Educating players about prevention strategies is an important task for sports physicians and coaches. Strict adherence to the NCAA return-to-play guidelines is imperative to prevent the spread of viral skin infections.

References

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  3. Rush S: Sports dermatology. ACSM Health Fitness J 2002;6(4):24-26
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  10. Fitzpatrick TB, Freedberg IM: Fitzpatrick's Dermatology in General Medicine, ed 6. New York City, McGraw-Hill, 2003;2:2065
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  12. Drugs for non-HIV viral infections. Med Lett Drugs Ther 1999;41(1067):113-120
  13. Emmert DH: Treatment of common cutaneous herpes simplex virus infections. Am Fam Physician 2000;61(6):1697-1706, 1708
  14. Powell FC: Sports dermatology. J Eur Acad Dermatol Venereol 1994;3(1):1-15
  15. Habif TP: Clinical Dermatology: A Color Guide to Diagnosis and Therapy, ed 3. St Louis, Mosby, 1996, p 305
  16. Stulberg DL, Hutchinson AG: Molluscum contagiosum and warts. Am Fam Physician 2003;67(6):1233-1240
  17. Levandowski R, Keogh G, Mullane JP: Sports dermatology, in Mellion MB (ed): Sports Medicine Secrets, ed 2. Philadelphia, Hanley & Belfus, 1999, pp 192-196
  18. Roach MC, Chretien JH: Common hand warts in athletes: association with trauma to the hand. J Am Coll Health 1995;44(3):125-126
  19. Habif TP: Clinical Dermatology: A Color Guide to Diagnosis and Therapy, ed 3. St Louis, Mosby, 1996, p 333
  20. Bubb RG: NCAA 2003 Wrestling Rules and Interpretations. Indianapolis, The National Collegiate Athletic Association, 2002, pp WA11-WA14. Available at https://www.ncaa.org/library/rules/2003/wrestling_rules.pdf. Accessed June 14, 2004


The author would like to acknowledge Brian O'Donnell, MD, for his help in the preparation of this manuscript.

Dr Cyr is a family practice physician at the Family Practice Center at Maine Medical Center in Portland, Maine. Address correspondence to Peggy R. Cyr, MD, Maine Medical Center, 272 Congress St, Portland, ME 04101-3637; e-mail to [email protected].

Disclosure information: Dr Cyr discloses no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.


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