Skin Manifestations of Athletes Competing
Transcription
Skin Manifestations of Athletes Competing
Sports Med 2012; 42 (5): 399-413 0112-1642/12/0005-0399/$49.95/0 REVIEW ARTICLE Adis ª 2012 Springer International Publishing AG. All rights reserved. Skin Manifestations of Athletes Competing in the Summer Olympics What a Sports Medicine Physician Should Know Jacqueline F. De Luca,1 Brian B. Adams2,3 and Gil Yosipovitch4 1 2 3 4 University of Hawaii Transitional Residency Program, Honolulu, HI, USA Department of Dermatology, University of Cincinnati, Cincinnati, OH, USA Section of Dermatology, Veterans Affairs Medical Center, Cincinnati, OH, USA Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA Contents Abstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. Endurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1 Friction Bullae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 Jogger’s Nipples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.3 Athlete’s Nodules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.4 Urticaria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5 Tinea Pedis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.6 Skin Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 Auricular Haematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2 Calluses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3 Tinea Corporis Gladiatorum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4 Herpes Gladiatorum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Team Sport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1 Talon Noir . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2 Piezogenic Pedal Papules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3 Pitted Keratolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4 Cutaneous Larva Migrans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Performing Arts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1 Green Hair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Abstract 399 400 402 403 403 403 405 405 406 406 406 407 407 408 408 408 409 409 409 410 410 Olympic athletes are vulnerable to traumatic, environmental and infectious skin manifestations. Although dermatological complaints are frequent among Olympians, there is a scarcity of literature that reviews sports-related dermatoses among Olympic athletes. A comprehensive review of PREMEDLINE and MEDLINE searches of all available literature through to January 2011 was conducted, focusing on sports-related dermatological presentations as well as the key words ‘Olympic athletes’ and ‘skin diseases’. Common skin conditions can be harmful and even prohibitive for competition. Common aetiologies of dermatological conditions related to sports include: skin infections with dermatophytes such as tinea pedis and tinea corporis, De Luca et al. 400 bacteria such as pitted keratolysis, and folliculitis and viruses such as herpes gladiatorum. Frictional dermatoses occur commonly and include athlete’s nodules, jogger’s itch, frictional blisters, callosities and talon noir. Trauma can cause haematomas such as auricular haematomas. Due to long training hours in the sun, many endurance athletes experience high levels of UV radiation and a higher risk for both melanoma and non-melanoma skin cancer. Pre-existing dermatoses can also be aggravated with practice and competition; in particular, atopic eczema and physical urticarias. Infrequent dermatoses are susceptible to misdiagnosis, delay in treatment and needless biopsies. This review highlights the diagnosis and management of sports-related dermatoses by the following general categories of Olympic sport: endurance, resistance, team sport, and performing arts. ‘Faster, higher, stronger’ – the most talented and conditioned athletes worldwide live by this creed in order to strive for the opportunity to compete in the Olympic Games. Although these athletes intrinsically represent health and well-being, the extensive training and environmental conditions can result in significant morbidity. Dermatological conditions, in particular, are an increasing cause of medical problems for Olympic athletes. Concordantly, the International Olympic Committee (IOC) Medical Commission specifically surveys dermatological problems in the Periodic Health Assessment of elite athletes; the importance of surveying dermatological problems, according to the IOC Medical Commission, is because these conditions are common, can be transmissible and may prevent clearance to compete.[1] Although most athletes present with many common easily identifiable dermatoses, rarer sportsrelated conditions also exist, this may confound some physicians and create potential for misdiagnosis and unnecessary procedures. Moreover, early correct diagnosis is imperative for the athletes to both participate and compete to their full potential. Common aetiologies of dermatological conditions related to sports include infections, neoplasms, inflammatory conditions, trauma and environmental factors. Pre-existing dermatoses can also be aggravated with practice and competition. This is especially problematic given the fact that prevalence of eczema and atopy are higher in the elite athlete population.[2] Adis ª 2012 Springer International Publishing AG. All rights reserved. A study of Olympians from South Africa reported the use of medical services at the Olympics and demonstrated that dermatological conditions are increasing in their athletes. More importantly, dermatological conditions were the most prevalent amongst the medical (non-injury) complaints comprising 16% of the total consultations in 2004, the last Olympics analysed.[3] We will provide a comprehensive review, using PREMEDLINE and MEDLINE literature through to January 2011, focusing on sports-related dermatological presentations, and also searching under the key words ‘Olympic athletes’ and ‘skin diseases’. The paper will be structured to provide sports-related dermatoses by the general categories of Olympic sport: endurance, resistance, team sport, and performing arts (table I). 1. Endurance Marathon runners, triathletes, long-distance swimmers and open-water marathon swimmers (10 K) in the Olympics serve as a paradigm for endurance sports. The nature of these sports necessitates constant frictional and traumatic forces to numerous areas of the body. Infectious diseases may also be more problematic for endurance athletes, as the constant wet environment in runners and swimmers and resultant maceration also serve as an ideal environment for fungal growth. Moreover, numerous hours of UV exposure in all of these sports presents a risk for the development of skin cancer (tables II and III) Sports Med 2012; 42 (5) Skin Manifestations of Athletes Competing in the Summer Olympics 401 Table I. Potential traumatic, environmental, and infectious aetiologies to dermatological problems in athletes, divided by sport Sport Traumatic Environmental Cycling Frictional alopecia Friction bullae Occlusive acne UVR Marathon running Friction bullae[4] Athlete’s nodules[5] Calluses Jogger’s nipples[6] Piezogenic pedal papules[7] Subungual haematoma Talon noir[8] Physical urticaria[8] UVR Rowing Calluses Friction bullae Rowers rump[11] UVR Infectious Endurance Pitted keratolysis[9] Tinea pedis[10] Aquagenic acne[12] Contact dermatitis[12] Green hair[12] Seabather’s eruption UVR Xerosis Occlusive folliculitis Tinea pedis[13] Verruca vulgaris (warts) Friction bullae Athlete’s nodules Calluses Piezogenic pedal papules Jelly fish stings Seabather’s eruption (in ocean water) Swimmer’s itch (in fresh water) UVR Occlusive folliculitis Tinea pedis Verruca vulgaris (warts) Boxing Auricular haematoma and cauliflower ear Calluses Knuckle pad Contact dermatitis Judo Auricular haematoma and cauliflower ear Calluses Contact dermatitis Tinea pedis Weightlifting Calluses Friction bullae Tache noir Contact dermatitis MRSA[15] Wrestling Auricular haematoma and cauliflower ear[14] Calluses Contact dermatitis Folliculitis, furuncles, carbuncles Herpes gladiatorum Impetigo MRSA[15] Tinea capitis Tinea corporis gladiatorum Verruca vulgaris Calluses Fiction bullae Piezogenic pedal papules[16] Talon noir[17] Contact dermatitis Pitted keratolysis[9] MRSA[15] Tinea pedis UVR Cutaneous larva migrans Friction bullae Calluses[17] Tache noir Talon noir[17] UVR Contact dermatitis Pitted keratolysis[9] Swimming Triathlon Resistance Team Support Basketball Beach volleyball Tennis Continued next page Adis ª 2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (5) De Luca et al. 402 Table I. Contd Sport Traumatic Environmental Infectious Soccer Calluses Friction bullae Talon noir Turf burn[18] UVR Contact dermatitis MRSA[15] Tinea pedis[19] Volleyball Calluses Friction bullae Piezogenic pedal papules[16] MRSA[15] Water polo Performing Arts Diving Aquagenic acne Contact dermatitis Green hair UVR Xerosis Occlusive folliculitis Tinea pedis Verruca vulgaris (warts) Aquagenic acne Contact dermatitis[12] Green hair[12] UVR Xerosis Occlusive folliculitis Tinea pedis Verruca vulgaris (warts) Verruca vulgaris Gymnastics Frictional alopecia[20] Friction bullae Calluses Tache Noir Talon Noir Contact dermatitis Rhythmic gymnastics Calluses Frictional alopecia[20] Contact dermatitis Synchronized swimming Aquagenic acne Contact dermatitis[12] Green hair[12] UVR Xerosis Occlusive folliculitis Tinea pedis Verruca vulgaris (warts) MRSA = Methicillin-resistant Staphylococcus aureus; UVR = UV radiation. 1.1 Friction Bullae Friction bullae occur frequently in endurance athletes. With an incidence of 0.2–39% in marathon runners, it is their most frequent complaint.[6] Repetitive frictional forces, especially when combined with moisture, cause separation of epidermal cells at the level of the stratum spinosum, which may fill with either transudate or blood.[38,39] The likelihood of bullae development is positively correlated with the magnitude of friction and frequency of cycles.[38] Bullae usually occur in areas that have a thick stratum corneum, such as on the palms of the hands and soles of the feet. The most commonly affected sites are on the tips of the toes, the balls of the feet and the posterior heel. Prevention should be aimed, therefore, at both decreasing frictional forces and preventing moisture. Tension can be reduced with proper-fitting Adis ª 2012 Springer International Publishing AG. All rights reserved. shoes that distribute frictional forces and wearing socks with low friction, particularly on the side facing the skin. Moisture reduction can be accomplished with acrylic or polyester socks that work by wicking away sweat. Antiperspirants can also prevent moisture development, but may cause an irritant contact dermatitis. Treatment involves sterile incision and drainage at the edge of painful bullae while carefully maintaining the blister roof. This should be performed early, in the first 24 hours after blister development; the blister roof acts as a dressing that provides for quicker healing and lower infection rates. Moleskin padding may also be used to minimize additional trauma to the blister and to relieve discomfort. Hydrocolloid dressings and silvadene or antibacterial ointments may decrease discomfort, prevent secondary infection and augment healing. Sports Med 2012; 42 (5) Skin Manifestations of Athletes Competing in the Summer Olympics 1.2 Jogger’s Nipples Repetitive friction to the nipples can lead to painful irritation, fissures and bleeding (figure 1). A tight-fitting, course cotton fabric shirt is the usual culprit. Among marathon runners, the prevalence is between 2–16.3%.[6] Jogger’s nipples can be treated with petroleum jelly or topical erythromycin.[8] For refractory cases, tacrolimus 0.1% has been successful.[21] Runners can prevent ‘jogger’s nipple’ by wearing clothes that reduce irritation, such as supportive jogging bras for women, and wearing lycra or silk shirts instead of cotton shirts; cotton absorbs water, keeping the area moist and creating more irritation. Also, men always have the option of going without a shirt, as the weather permits. Other preventative Table II. Treatment: non-systemic therapies Dermatological condition Treatment Friction bullae Hydrocolloid dressings Silvadene Antibacterial ointment Jogger’s nipples Petroleum jelly[8] Topical erythromycin ointment[8] Tacrolimus 0.1% (only for refractory cases)[21] Tinea corporis gladiatorum 1% terbinafine cream applied bid for 1–2 weeks[22] Piezogenic pedal papules Three intralesional injections of betamethasone and bupivacaine (in equal parts)a [23] Pitted keratolysis Topical 20% aluminum chloride solution applied bid Botulinum toxin injections[24] Topical clindamycin 1% (with or without 5% benzoyl peroxide)[25] Topical mupirocin applied bid[26] Topical erythromycin 2% solution applied bid[27] Cutaneous larva migrans Topical 15% thiabendazole at bedtime[28] Green hair Penicillamine containing shampoo[29] Hydrogen peroxide (2–3%)[12] Chelating agents[12] a USADA prohibits systemic corticosteroid use such as IM injections and oral/IV therapy, but has no restrictions on topical or intralesional corticosteroid injections.[30] bid = twice daily; IM = intramuscular; IV = intravenous. Adis ª 2012 Springer International Publishing AG. All rights reserved. 403 strategies include lubrication and nipple protection: surgical tape, bandages or breast shields.[8] 1.3 Athlete’s Nodules Athlete’s nodules (also known as collogenomas, ‘Nike nodule’ in runners, or ‘nuckle pad’ in boxers) are cutaneous nodules that occur after chronic trauma, either frictional or pressure.[4,5] ‘Nike nodules’ occur over the malleolus and dorsal aspect of the foot and are soft skin-coloured nodules that are keratinized on its surface and range in size from 0.5 cm to 4.0 cm (figure 2). A biopsy confirms the diagnosis. Although dermatofibromas appear similar, histologically, athlete’s nodule will have a tumorous proliferation of fibroblasts in the dermis and reactive hypertrophy of the epidermis.[5] Surgical excision assuages symptoms if present.[40] 1.4 Urticaria Athletes, in general, are particularly predisposed to physical urticarias. While physical urticarias represent only 2.4% of urticarial types in the population at large, in athletes they comprise 15%.[41] Although multiple sports appear to hasten physical urticarias, running is the most recognized.[8] The physical urticarias include cholinergic, exercise-induced, cold, solar, pressure, dermatographical, vibratory and aquagenic varieties (figure 3).[42] While all can occur in athletes, this review focuses on cholinergic urticaria and exerciseinduced anaphylaxis; both entities present with pruritus and wheals after initiation of exercise, but the latter form is potentially life-threatening. Cholinergic urticaria is related to the elevation of core body temperature, as occurs during exercise, passive warming and emotional stress. It presents with numerous punctate wheals (2–5 mm) surrounded by erythematous large flares that may coalesce. They usually appear on the trunk and neck and spread distally.[43] Although brochospasm can occur with cholinergic urticaria, only rare cases will progress to anaphylaxis.[44] Initial treatment for athletes should consist of antihistamines.[45] Other treatments consist of avoiding exercise and other triggers and taking b-blockers and Danazol, all of which would be unappealing to the Olympic Sports Med 2012; 42 (5) De Luca et al. 404 Table III. Treatment: systemic therapies Dermatological condition Treatment Dosing USADA regulations Cholinergic urticaria Non-sedating anti-histamines 2nd generation: (1) cetirizine 3rd generation: (2) xyzal (1) 20 mg daily[31] (2) 10 mg daily No restrictions[32] Danazol (17a-ethynyl-17bhydroxyandrost-4-eno[2,3-d] isoxazole) Is an anabolic androgenic steroid; prohibited in all sports, both in and out of competition[32] Propranolol 20 mg bid[33] Prohibited in particular sports while in competition Prohibited while in and out of competition in archery and shooting[32] Exercise-induced anaphylaxis Epinephrine 0.3 mg IM PRN anaphylaxis Prohibited while in competition Not prohibited while out of competition[32] Tinea corporis gladiatorum Terbinafine Treatment: 250 mg daily for 2–4 weeks[22] No restrictions[32] Itraconazole Treatment: 100 mg daily for 15 days[22] Prophylaxis: 200 mg bid, 1 day every other week[34] No restrictions[32] Fluconazole Treatment: 150 mg weekly for 3–4 weeks[22] Prophylaxis: 100 mg weekly[35] No restrictions[32] Herpes gladiatorum Valacyclovir Other alternatives: acyclovir or famciclovir Primary HG: 1 g bid for 10–14 days[36] Recurrent HG: 500 mg bid for 7 days[36] Prophylaxis: 500–1000 mg daily during season[36] No restrictions[32] Cutaneous larva migrans Ivermectin 200 mg/kg, single dose[37] No restrictions[32] Albendazole 400 mg daily for 3 days[37] No restrictions[32] bid = twice daily; IM = intramuscular; PRN = when necessary; USADA = National Anti-Doping Organization of the United States. athlete.[46] The World Anti-Doping Agency classifies Danazol as a prohibited substance in all sports, and b-blockers as prohibited during competition for many Olympic sports.[30] Exercise-induced anaphylaxis relates to food ingestion in some cases. In this food-dependent exercise-induced anaphylaxis, exercise must occur within 4 hours after ingestion of a food for a response to occur.[47] Personal history of atopy, aspirin or NSAID use, exposure to high pollen levels, insect stings, extremes of weather, humidity and menses may also contribute to exerciseinduced anaphylaxis.[48-51] On examination, the wheals are typically larger in size than those of cholinergic urticaria (10–15 mm) and individuals can develop angioedema, laryngeal Adis ª 2012 Springer International Publishing AG. All rights reserved. oedema, bronchospasm, gastrointestinal symptoms, syncope, and/or hypotension.[43,52] Athletes that show a relation with food should be evaluated with prick tests and radioallergosorbent blood tests (RAST).[53] Acute treatment should consist of airway and cardiovascular support, and administration of epinephrine if necessary. Athletes should prevent recurrences by identifying and avoiding any provoking foods and medications. They may even need to wait 6 hours after any food ingestion to exercise. Prophylactic pharmacotherapy is not particularly effective, as antihistamines usually prevent urticaria but not anaphylaxis. Above all else, monitoring is crucial and should consist of either exercising with a medically-trained companion or wearing a medical alert device.[45] Sports Med 2012; 42 (5) Skin Manifestations of Athletes Competing in the Summer Olympics 405 freshwater risk developing swimmer’s itch, which most commonly occurs in non-covered portions of the body. Last, jellyfish stings can cause severe urticarial reactions and even mortality, as has been reported with the Irukandji syndrome.[57] Some Olympic athletes in Sydney, NSW, Australia, experienced jellyfish stings. Detailed analysis of this eruption is beyond the scope of this review. 1.6 Skin Cancer Fig. 1. Painful fissures in a male runner with ‘jogger’s nipple’. 1.5 Tinea Pedis Almost all athletes are at risk for tinea pedis, but a higher prevalence has been specifically exposed in running, swimming, soccer, water polo and basketball.[13] Occlusive footwear is a major culprit as dermatophytes thrive with sweating and maceration. Trichophyton rubrum and Trichophyton mentagrophytes are the species most commonly involved and are relatively equivalent in prevalence amongst runners, 43.8% and 44.9%, respectively. Runners are also likely under diagnosed, since occult athlete’s foot disease has been found in up to 48% of cases.[10] In swimmers, T. mentagrophytes was the more common culprit of occult infection, occurring between 70% and 85%.[13,54] It is also speculated that the floor of swimming pool decks and locker rooms may be a source of these occult infections since T. mentagrophytes has been isolated from these areas.[13,54,55] Prevention of tinea pedis infection in athletes should include wearing moisture-wicking synthetic socks and changing them regularly, keeping the feet dry, wearing well ventilated shoes, using antifungal powder, and always using sandals in the locker room and on the pool deck.[56] Sea water creatures can also affect Olympic athletes, such as triathletes. Sea bather’s eruption, caused by the larval-stage thimble jellyfish, occurs in seawater swims and presents as erythematous papules most commonly beneath the swimsuit. Conversely, triathletes training or competing in Adis ª 2012 Springer International Publishing AG. All rights reserved. Due to long training hours in the sun many endurance athletes experience high levels of UV radiation (UVR), which is thought to be the most important environmental risk factor for both melanoma and nonmelanoma skin cancer development.[58] Extremely high levels of UVR exposure have been documented in tennis players, sailors, cyclists and triathletes. For example, three triathletes were measured during the Ironman competition in Hawaii and were found to have a mean personal UV of 8.3 minimal erythemal dose (MED), exceeding international exposure limits for personal exposure by more than 30-fold.[59] Six professional cyclists during the Tour de Suisse race, received a mean daily personal exposure of 8.1 MED.[60] In addition to the total time athletes are exposed to the sun, sweating and sea or pool water may also contribute to UVR-related skin damage. Skin hydration, in general, increases the photosensitivity of the skin, significantly decreasing the MED to UVB.[61] It is thought that this effect is Fig. 2. Athlete’s nodule over medial foot. Sports Med 2012; 42 (5) De Luca et al. 406 Fig. 3. Dermatographical ‘Olympic’ response in a runner, as evidenced by Olympic rings. the result of stratum corneum hydration, which shifts the absorption spectrum to shorter wavelengths and also decreases reflection and dispersion.[62] Water and sweat can wash away sunscreen and increase the risk for UVR in this way as well. All athletes in outdoor sports should be wearing water-resistant sunscreens and sun-protective clothing. They should also attempt to train during times of the day with low sun exposure and should regularly see a dermatologist. 2. Resistance The resistance sports include weightlifting and contact sports, such as freestyle and GrecoRoman wrestling, boxing, judo and taekwondo. Wrestling and judo are unique amongst the contact sports in the amount of time they spend in direct skin-to-skin contact with other athletes, making them particularly prone to the transmission of viral, fungal and bacterial infections. result in necrosis of the cartilage or may stimulate formation of fibroneocartilage resulting in the appearance of ‘cauliflower ear’.[63,64] ‘Cauliflower ears’ date back to ancient Greek Olympians and many coaches and athletes alike still regard this as a sign of hard work and as a ‘badge of courage’.[65,66] Numerous treatments exist to relieve the haematoma, but there is no consensus on which method produces the best cosmesis due to poor study designs. A recent Cochrane systematic review, however, suggests that treatment is superior to no treatment.[67] In most early cases, treatment should involve needle aspiration or possibly incision and drainage followed by one of the various modalities to prevent re-accumulation of blood.[67,68] If untreated, and ‘cauliflower ear’ has formed, then reconstructive plastic surgery can help restore the pinna to its natural shape.[69] Although head gear prevents auricular haematomas, it is not required for Olympic or international competition. Further, if headgear is used, it must be approved by the governing body for wrestling, the Fédération Internationale des Luttes Associées (FILA), prior to competition.[70] Overall, Olympic athletes in competition seldom use headgear. 2.2 Calluses Calluses occur among nearly all athletes, but are most notorious in Olympic weightlifters. The localized thickening of skin, from hyperproliferation and incomplete differentiation of epidermal 2.1 Auricular Haematoma Olympic contact sports, such as wrestling, boxing and judo are prone to development of auricular haematomas, which may later progress to ‘cauliflower ear’ if untreated.[14] Trauma to the athlete’s ears cause shearing forces, which can separate the perichondrium and cartilage leading to blood and serum accumulation, usually in the pinna (figure 4).[63] Over time, this trauma may Adis ª 2012 Springer International Publishing AG. All rights reserved. Fig. 4. Acute auricular haematoma in a wrestler. Sports Med 2012; 42 (5) Skin Manifestations of Athletes Competing in the Summer Olympics keratinocytes, serves as a protective mechanism from repetitive friction or pressure.[71] Calluses occur on the hands and feet and may prevent athletes from developing painful blisters, even giving a competitive advantage.[72] Weightlifters typically have callosities over the palmar metacarpophalangeal joints from gasping the bar. The bar also causes trauma to other body parts, such as during the ‘clean and jerk’, where the bar rests on the clavicular region, causing lichenified plaques.[73] Other sports that may develop calluses include gymnastics, tennis, rowing and running. Many other athletes also utilize weight lifting for strength training and can also develop calluses similar to Olympic weightlifters. In most cases the callus will be asymptomatic, but when they are painful they can be treated with topical keratolytics, gently pared down with a blade or debrided with a pumice stone after soaking in warm water. In addition, preventative management can include weight-lifting gloves and modification of footwear so that friction is minimized (extra room in the toe box, synthetic socks, shoe inserts and placement of padding to distribute weight more evenly). 2.3 Tinea Corporis Gladiatorum Skin infections can be epidemic among wrestlers. Although most infections are relatively benign, they can exclude wrestlers from practice and competition and can be destructive to the individual athlete and team. The wrestling environment is ideal for the transmission and survival of bacteria, fungi and viruses through direct skin-toskin contact, warmth, moisture and traumatized skin. Fungi cause frequent outbreaks of tinea capitis gladiatorum and tinea corporis gladiatorum in wrestlers. The reported prevalence rates of tinea corporis gladiatorum range from 20% to 77%.[74] Most reported cases of tinea corporis gladiatorum have been caused by Trichophyton tonsurans, which has recently been isolated in >90% of cases during a 2-year analysis in Iran.[75] This differs from the standard variety of isolates obtained from the groin and body, where T. rubrum accounts for 32–60%, and T. tonsurans 17.7–34.3%.[76] Adis ª 2012 Springer International Publishing AG. All rights reserved. 407 Fig. 5. Tinea corporis gladiatorum in a collegiate wrestler. Clinically, tinea corporis gladiatorum presents as well defined, erythematous, scaling papules and plaques located on the head, neck and upper extremities; areas that have direct skin-to-skin contact during wrestling (figure 5). The classic features of standard tinea corporis (annular shape, raised leading edge and central clearing) may not be present.[22] Treatment may consist of topical medication and/or oral treatment depending on disease severity. Many infected individuals may also remain contagious for weeks, and may need to keep lesions covered with bandages when practicing.[22] Preventative measures include showering, washing uniforms and disinfecting mats daily. Teams should also have strict surveillance by athletic trainers who should promptly refer affected athletes to physicians.[77] Oral prophylactic treatment with itraconazole and fluconazole significantly decreases the incidence of infection, but may not be clinically applicable due to the high cost and potential for adverse side effects.[35,78] 2.4 Herpes Gladiatorum Herpes gladiatorum (HG) can be devastating for wrestlers; not only do active lesions result in exclusion from competition, but primary infection in the eye can result in recurrent herpes keratitis and, rarely, blindness.[79,80] Many wrestlers are either infected or at risk for developing HG. The prevalence of HG in wrestlers ranges between 2.6% and 40.5%, and is transmitted via skin-to-skin Sports Med 2012; 42 (5) De Luca et al. 408 contact or autoinoculation with herpes simplex virus (HSV)-1.[81,82] Although clinically similar to orolabial herpes with grouped vesicles on an erythematous base, HG occurs on different locations on the face and also affects the head, neck, extremities and trunk (figure 6). The location affected corresponds with skinto-skin contact and often reflects the handedness of the wrestler. In one study, 86% of the wrestlers were right-handed and 74% had the herpetic lesion on the right side, since opponents typically lock-up with their dominant side.[83] When the lesions don’t display vesicles, as they do early and late in the course of an outbreak, the differential diagnosis includes tinea corporis gladiatorum, impetigo, acne and atopic dermatitis. Also, some wrestlers complicate accurate diagnosis when they attempt to conceal the infection, using sandpaper or bleach to alter the rash.[84] Diagnosis can be made with Tzanck smear, which is quick but less sensitive, or with more reliable tests such as viral culture, polymerase chain reaction (PCR) or direct fluorescent antibody testing. Treatment for active infections can be accomplished with oral antiviral agents: acyclovir, valacyclovir or famciclovir. Prevention is complicated by the fact that viral shedding occurs before the appearance of the skin lesions.[85,86] Valacyclovir may be given prophylactically during the wrestling season to both wrestlers with recurrent herpes gladiatorum and in HSV-1 naı̈ve athletes. Valacyclovir reduced outbreaks to 21% of those receiving valacyclovir 500 mg daily and 8% of those receiving valacyclovir 1000 mg daily. In wrestlers whose primary outbreak was more than 2 years prior taking valacyclovir 500 mg daily was 100% effective.[87] The potential for drug resistance is concerning, but at this time is not problematic; the reported acyclovir resistance in immunocompetent individuals is only 0.3%.[88] Again, as in tinea gladiatorum, prevention should also be directed at good hygienic practices. 3. Team Sport Teams currently competing in the summer Olympics include basketball, baseball, field hockey, handball, rowing, sailing, soccer, tennis, volleyball and water polo. Although many of the dermatological problems faced by these athletes have considerable overlap with endurance athletes, as mentioned in section 1, they are also at risk for some unique traumatic and infectious entities. 3.1 Talon Noir Basketball, soccer, tennis, gymnastics and running, all of which require frequent starts and stops, can lead to talon noir. Also known as black heel or calcaneal petechiae, repeated lateral shearing forces creating intraepidermal haemorrhages cause these lesions. Although completely benign, they can often clinically resemble verruca with thrombosis or acral melanomas, as they appear as blue-to-black linear, circular or oval shaped macules on the posterior or posterolateral aspect of the heel (figure 7).[8,89] Tennis players, gymnasts and weightlifters can also have similar lesions on the thenar eminence called tache noir, palmar petechiae or black palm. Dermatoscopic examination may help rule out melanoma.[90,91] If the diagnosis remains unclear, biopsy will reveal the diagnosis. 3.2 Piezogenic Pedal Papules Fig. 6. Herpes gladiatorum. Adis ª 2012 Springer International Publishing AG. All rights reserved. Piezogenic pedal papules, which result from the herniation of subcutaneous fat through the dermis, may occur more frequently in athletes, usually among long-distance runners, triathletes, volleyball players and basketball players.[7,16] One review of the literature suggests that athletes have a higher prevalence of the painful variety of Sports Med 2012; 42 (5) Skin Manifestations of Athletes Competing in the Summer Olympics 409 injections of botulinum toxin, reduces hyperhydrosis and make the sole a less hospitable environment for the microorganism.[24] Topical treatment includes clindamycin (with or without 5% benzoyl peroxide), mupirocin or erythromycin.[25-27,100] Another common bacterial skin manifestation in athletes who profusely sweat is occlusive folliculitus with Staphylococcus (see table I). 3.4 Cutaneous Larva Migrans Fig. 7. Talon noir in a professional tennis player. papules; however, no study has compared the prevalence of piezogenic papules or the associated pain in athletes versus non-athletes.[7] Piezogenic pedal papules appear as yellow or skin-coloured nodules, usually occurring bilaterally on the medial, posterior and lateral aspects of the heels (figure 8). Placing one’s weight on the affected foot would accentuate the lesions. Athletes with painful lesions may benefit from foot pads or heel cups, compression stockings, electroacupuncture, injections of betamethasone and bupivacaine (in equal parts), or surgery (deep punch biopsy or small excision).[23,92-94] 3.3 Pitted Keratolysis Pitted keratolysis, a gram-positive bacterial infection of the plantar surface of the feet, reportedly occurs in runners, and in tennis and basketball players.[9] A hyperhydrotic, occluded, and macerated foot hosts Corynebacterium, Micrococcus sedentarius (now renamed as Kytococcus sedentarius), and Dermatophilus congolensis, which produce proteinases that degrade the stratum corneum.[95-99] Athletes will have multifocal, discrete erosions ranging from 0.5 mm to 7.0 mm in diameter and from 1 mm to 2 mm in depth, and a foul odour (purportedly due to the production of sulphur-compound by-products).[96,97] Preventative measures include the use of synthetic socks and avoidance of prolonged use of occlusive shoes. Topical 20% aluminum chloride solution or Adis ª 2012 Springer International Publishing AG. All rights reserved. Beach volleyball players risk developing a chronic parasitic infection, cutaneous larva migrans, via animal hookworm larva, most commonly Ancylostoma braziliense.[101] The larvae of A. braziliense emerge from dog or cat faeces in the sand and can penetrate the skin of the player’s lower extremities.[101,102] The larvae then migrate within the skin and thereby produce erythematous, serpiginous, elevated tunnels, which gradually advance with time. The intensity of the pruritus with these lesions may disturb sleep.[103] Players will most likely develop cutaneous larva migrans from practice or competitions in subtropical or tropical endemic areas.[104] First-line treatments include ivermectin, albendazole or topical thiabendazole.[105,106] 4. Performing Arts Diving, synchronized swimming and rhythmic gymnastics are sports that are included in this category. Overall, they acquire many of the same Fig. 8. Piezogenic pedal papules in a runner. Sports Med 2012; 42 (5) De Luca et al. 410 dermatological problems as other sports, such as those exposed to trauma or sharing equipment. Divers and synchronized swimmers, like other aquatic athletes, can develop contact dermatitis: irritant from the chemicals (chlorine and bromine) in the pool, or allergic from the nose clips, ear plugs, swimming caps, fins, goggles or pool water.[107] They are also prone to swimmer’s xerosis; pools both dilute the skin’s sebum and draw water from the skin (via osmosis). This xerosis may paradoxically result in aquagenic acne, which is primarily thought to be a result of rebound hyperactivity of the sebaceous glands. Another contributing factor is pilosebaceous obstruction, which may be caused by overhydration of the stratum corneum or by chlorine irritating the follicular orifice.[12] 4.1 Green Hair Green hair occurs in water sport athletes: divers, synchronized swimmers, water polo players and swimmers. Athletes with blonde, grey or white hair are prone to pigmentation by copper ions in pools, which originate from the water’s source, the pipes or the algicides.[12,108] Physical and chemical damage to the hair, including sunlight and chlorinated water, also contributes to the development of green hair.[109] Green hair can be prevented by wearing a cap and using a chelating shampoo. Treatment with a penicillamine containing shampoo, hydrogen peroxide (2–3%) or chelating agents, also clears green hair.[12,29,109] 5. Conclusion There are numerous dermatological conditions that may occur in Olympic athletes due to the extreme nature of their training, and their constant environmental exposures to heat, sweat, trauma, sun and various other exogenous factors. Sports medicine physicians, as well as dermatologists, should be aware of these findings for prompt and appropriate management. Acknowledgements No funding was received to assist in the preparation of this review. The authors have no conflicts of interest that are directly relevant to the content of this review. Adis ª 2012 Springer International Publishing AG. All rights reserved. References 1. Ljungqvist A, Jenoure PJ, Engebretsen L, et al. The International Olympic Committee (IOC) consensus statement on periodic health evaluation of elite athletes. Clin J Sport Med 2009; 19: 347-65 2. Carlsen KH, Kowalski ML. Asthma, allergy, the athlete and the Olympics. Allergy 2008; 63: 383-6 3. Derman WE. 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Cutis 1995; 56: 37-40 Correspondence: Dr Gil Yosipovitch, Department of Dermatology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1071, USA. E-mail: [email protected] Sports Med 2012; 42 (5)