Skin Infections in Athletes

Brian B Adams

Disclosures

Expert Rev Dermatol. 2010;5(5):567-577. 

In This Article

Fungi

Fungal infections predominate in the total number of sports-related skin infections. Dermatophytes may infect the foot (tinea pedis), nails (onychomycosis), any exposed skin surface (tinea corporis gladiatorum) or predominantly the trunk (tinea versicolor). Occasionally, athletes contemporaneously suffer from several types of infection with dermatophytes.

Tinea Pedis

Tinea pedis (athlete's foot) represents the most common cutaneous fungal infection in athletes. Myriad epidemiologic studies document the greater prevalence of tinea pedis among athletes compared with nonathletes.[2–6] Soccer players, swimmers, runners and basketball players appear to be particularly susceptible (Table 1). The warm, dark and moist feet of the athlete provide an optimal environment for fungal growth.

The three variants of tinea pedis (interdigital, moccasin and vesicular) affect various locations of the foot. Trichophyton rubrum most commonly causes both the interdigital and moccasin variants, which occur between the toes and on the soles, respectively (Figure 1). Trichophyton mentagrophytes most often causes the vesicular variant on the instep of the foot.[1,6] Occasionally, sports-related contact dermatitis may mimic the inflammatory variant of tinea pedis. A positive potassium hydroxide examination of foot scrapings confirms the diagnosis. Mild or limited disease may resolve with topical fungicidal agents such as the allylamines, but more extensive or severe tinea pedis may require oral antifungal agents such as terbinafine or itraconazole.[1]

Figure 1.

Tinea pedis.

To prevent acquisition and spread of the fungal organisms, athletes should always wear sandals in the locker room, showers and pool decks. Multiple studies have documented the high prevalence of these organisms in these locations.[7–10] No athlete of any level should wear cotton socks; this material promotes an ideal environment for microorganism growth. Synthetic, moisture-wicking socks that keep the feet cool and dry, deter dermatophyte growth.[1] While no evidence-based studies have confirmed this practice, applying topical antifungal agents to the feet after athletic activity may decrease one's propensity for developing tinea pedis.

Onychomycosis

Onychomycosis represents a fungal infection of the nail. As athletes experience a far greater risk for fungal infection of the feet, not surprisingly, they also frequently develop onychomycosis. Infected nails appear yellow and thick and possess subungual debris. Infection with Pseudomonas or mold may result in a greenish discoloration in the nail. Athletes, not uncommonly, develop noninfectious nail abnormalities as a result of their sports activity. Termed athlete's toe, these nail changes may mimic those seen in onychomycosis (Figure 2). In practice, athlete's toe often gets misdiagnosed and treated as onychomycosis. Athlete's toe results from constant collision of the nail with the athlete's footwear. The mechanism of trauma and clinical presentation vary slightly depending on the sport. Differential effects on various parts of the nail unit represent the reason for the somewhat variable clinical presentation of athlete's toe.

Figure 2.

Athlete's toe.

Further complicating the accurate diagnosis of nail disease in athletes, athlete's toe significantly disrupts the integrity of the nail and facilitates fungal infection. Oral agents such as terbinafine or itraconazole, in combination with topical antifungal agents, can clear onychomycosis, but recurrences are common. As such, athletes must employ attentive prevention techniques. Firstly, no athletes should go barefoot in the locker room, shower floors or hotel floors; furthermore, swimmers should not allow their feet to touch the pool decks. Investigators have demonstrated the presence of dermatophytes on these locations.[7–10] To further prevent onychomycosis, athletes should apply topical antifungal agents to their soles once weekly and can consider applying topical antifungal nail polish.[1]

Tinea Versicolor

No studies exist that examine the epidemiology of tinea versicolor in athletes. The warm and moist microenvironment of athletes' skin promotes the overgrowth of the causative organisms: Malassezia globosa and Malassezia furfur. Tinea versicolor presents with either hypo- or hyper-pigmented, discrete and confluent macules and patches typically distributed on the trunk and neck (Figure 3). To confirm the diagnosis, the sports medicine clinician should scrape the affected area and examine the scrapings microscopically after adding potassium hydroxide. A positive preparation will demonstrate short hyphae and spores.

Figure 3.

Tinea versicolor.

Confluent and reticulated papillomatosus of Gougerot and Carteaud and progressive macular hypomelanosis can mimic the clinical presentation of tinea versicolor.[1] Confluent and reticulated papillomatosus of Gougerot and Carteaud also affects the trunk and upper extremities and presents with hyperpigmented patches in a lace-like pattern, but lacks a positive potassium hydroxide examination (Figure 4). While the cause of this rare cutaneous condition is not known, daily minocycline clears the eruption in just a few weeks. Progressive macular hypomelanosis presents with hypopigmented, nonscaling macules on the trunk, especially the abdomen and lower back of young adults (Figure 5).[11]

Figure 4.

Confluent and reticulated papillomatosis of Gougerot and Carteaud.

Figure 5.

Progressive macular hypomelanosis.

Both topical and systemic treatments for tinea versicolor exist. Affected athletes can apply selenium sulfide lotion to the affected areas once-daily for 1 week; once applied, the athlete should wash it off 15-min later.[1] To enhance remission, susceptible athletes should prophylactically apply this lotion once-weekly whether or not they exhibit the disease. Unlike the complete disappearance of the hyperpigmentation of confluent and reticulated papillomatosus of Gougerot and Carteaud after therapy, the discoloration of tinea versicolor may take several weeks to months to normalize. In athletes exhibiting the hypopigmented variety of tinea versicolor, if the discoloration has not normalized after several months, clinicians should suspect progressive macular hypomelanosis.

Tinea Corporis Gladiatorum

Otherwise known as ringworm, tinea corporis gladiatorum occurs in epidemics in wrestlers. Many authors have reported tinea corporis gladiatorum epidemics in the literature with as many as 77% of the team infected;[12–17] one review of reported epidemics calculated the median prevalence to be 31%.[18] One study even documented a tinea corporis gladiatorum prevalence of 24% in a team without a known epidemic.[16] Wrestlers experience this infection at such a high prevalence primarily owing to the intense skin-to-skin contact inherent to the sport. In nonwrestlers, the most common causative organism of tinea corporis is Trichophyton rubrum; interestingly, most cases of tinea corporis gladiatorum result from infection by Trichophyton tonsurans, which typically causes tinea capitis (scalp ringworm).

As T. tonsurans represents the most common organism of tinea corporis gladiatorum, investigators have speculated that some wrestlers possess and transmit the organism from their scalp. Some wrestlers even carry T. tonsurans in their scalp without demonstrating any clinical lesions. Variable prevalence of asymptomatic carriers exists in the literature. One group physically examined the scalp of 31 judo members and discovered that nine (29%) had positive scalp cultures despite not having any clinical lesions.[19] Other authors have documented a lower prevalence (10–11%) of culture-positive tinea capitis in judo athletes.[20,21] Other investigators discovered that 76% of wrestlers infected with tinea corporis gladiatorum had concomitant culture-positive tinea capitis.[22] Interestingly, very few studies have documented the causative organism on the wrestling mats.[23,24]

The clinical appearance of tinea corporis gladiatorum varies with the age of the lesion. Mature lesions appear as annular, erythematous, scaling plaques. Very early lesions present diagnostic challenges as tinea corporis gladiatorum begins as relatively nonspecific erythematous papules (Figure 6).[1,18] Other cutaneous infections of athletes and inflammatory conditions begin similarly. Early lesions of herpes gladiatorum, impetigo, acne, dermatitis and lupus erythematosus are often indistinguishable clinically.[1,18] Since athletes and athletic trainers recognize the impact of infection on the athlete's training and competition, they seek medical attention early in the course of their disease, when the infection has not had time to attain the annular morphology typical of tinea corporis.

Figure 6.

Tinea corporis gladiatorum.

To confirm the diagnosis, the clinician should scrape the lesion to demonstrate the hyphae on microscopic examination. Clinicians should examine the scalp of infected wrestlers and culture it to determine carrier status. Studies have supported the use of oral antifungal agents in a more rapid clearance of tinea corporis gladiatorum.[15,17,18] In practice, a combination of both topical and oral agents represents an ideal treatment regime to return the athlete safely to practice and competition. No studies exist that examine the optimal type and duration of therapy for tinea corporis gladiatorum.

Prevention remains the key to thwarting epidemics. Athletes (especially wrestlers) need to perform daily skin examinations. Athletic trainers can facilitate this process and may also participate especially for previous infected athletes and during periods of high prevalence. By detecting lesions early in the progression of disease, clinicians can minimize the disruption of daily activities for the athlete and team.

Athletes should limit the amount of exposed skin. Fortunately, fabric technology has advanced considerably and athletes can wear long-sleeved clothing that places a barrier between them and their competitors, wicks away the moisture and sweat, and still allows the athlete to regulate their temperature.[1] Infected athletes must meticulously cover their injured skin. During periods of low prevalence of infections in the team and only during practice, trainers may use bandaging techniques on the infected athlete; bandaging alone does not allow one to compete. During time periods of high prevalence of tinea corporis gladiatorum, trainers should restrict activity. No athlete should share towels, pads, clothing, razors or protective headgear. After practice and competition, although no supportive evidence exists, athletes should take showers with antibacterial soaps. Furthermore, all clothing and undergarments require daily laundering.

Pharmacologic preventative techniques also exist. One prospective trial of weekly fluconazole (100 mg) demonstrated a decrease in prevalence of tinea corporis gladiatorum.[17] A randomized double-blind trial using once, every-other-week itraconazole (400 mg) also decreased the prevalence of this fungal infection in wrestlers.[13] These medications, however, have significant drug interactions and potential hepatic side effects. As such, sports medicine physicians should use caution in prescribing these antifungal agents for the duration of the season; furthermore, not every wrestler should take systemic prophylaxis. Sports medicine clinicians should target athletes with a history of tinea corporis gladiatorum and those who compete at elite, national and international levels. Clinicians should carefully assess the athlete's medication use and their personal and family history of liver disease. Baseline and mid-season liver function tests may detect pre-existing liver disease or medication-induced hepatic side effects, respectively.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....