Sports and Skin

Michelle Wanna, MD

Avera Medical Group Dermatology

3rd Annual Avera Sports Medicine Symposium

June 10, 2016

Objectives

• Review skin infections that can impact sports participation

• Review common skin diseases seen in athletes

• Discuss patterns suspicious for contact dermatitis and

potential triggers

• Review acne mechanica, Isotretinoin-related sports issues,

and the impact of supplements on acne

• Recognize cholinergic urticaria

• Understand the Koebner phenomenon

Skin Infections

• Folliculitis

• Furuncles

• Impetigo

• Bullous Impetigo

• Tinea

• Herpes simplex

• Molluscum Contagiosum

Folliculitis

• Infection of the hair follicle

• S. aureus most common infectious cause

• Risk factors include maceration, occlusion, hair removal,

environmental factors

• Superficial forms can be treated with antibacterial washes while

more extensive involvement may require oral antibiotics

• Mupirocin oint BID nares/genital area x 5 days, antibacterial

washes, dilute sodium hypochlorite baths, and cleaning of fomites

may be needed for recurrent cases

Folliculitis

Folliculitis

Folliculitis

Furuncles

• Follicle based abscesses, typically caused by S.

aureus

• Frictional areas and hair-bearing regions of face,

neck, axillae, buttocks, thighs, and perineum

most common

• Painful, erythematous nodule that eventually

becomes fluctuant

Furuncles

• Treatments include:

– Warm compresses

– Incision and drainage

– Oral antibiotic therapy for high risk areas (face,

hands, genitalia), multiple lesions, associated

cellulitis, immunosuppressed, concern for MRSA

Furuncle

Impetigo

• Erythematous macule that develops fragile pustule with

associated “honey-colored” crust

• Occurs in an area of skin disruption

• S. aureus and group A beta-hemolytic Strep (Streptococcus

pyogenes)

• Contact sports is a risk factor

• 5% rate of post-streptococcal glomerulonephritis in S.

pyogenes cases

Impetigo

Bullous Impetigo

• Caused by exfoliative toxins (ETA, ETB) by S. aureus phage

group II

– Same toxins seen systemically in staphylococcal scalded skin

syndrome (SSSS)

• Small vesicles develop into large bullae which rupture

easily and leave characteristic collarette of scale

• Can occur on intact skin

• S. aureus can be cultured from vesicle/bulla fluid

Bullous Impetigo

Bullous Impetigo

Staphylococcal Scalded Skin Syndrome

Tinea • Typically caused by Trichophyton, Microsporum, and

Epidermophyton species

• Clinical findings:

– Annular, erythematous scaly plaques trunk and extremities (tinea

corporis)

– Erythema of inguinal fold with scaling, advancing border (tinea cruris)

– Maceration and scaling in webspaces and surrounding areas (tinea

pedis)

– Erythema, scaling, and alopecia (tinea capitis)

Tinea Corporis/Capitis

Tinea Capitis

Tinea Capitis

Tinea Corporis

Tinea Corporis

Tinea Corporis

Tinea

Tinea Cruris

Tinea Pedis

Tinea pedis

Tinea Pedis

KOH

Majocchi’s Granulomas

Majocchi’s Granulomas

Herpes Simplex

• Herpes gladiatorum is typically HSV-1

• Grouped vesicles on erythematous base

• Spread by contact with saliva or vesicle fluid

• Occurs within 3-7 days of exposure

• Initial outbreaks can also have lymphadenopathy, malaise, fever as

prodrome prior to onset

• Lesions are painful, pruritic, or burning

• Subsequent recurrences are not typically as severe as initial

Herpes Simplex

Herpes Simplex

Herpes Simplex

Herpes Gladiatorum

Eczema Herpeticum

Eczema Herpeticum

Molluscum Contagiosum

• Flesh-colored umbilicated papules 2-8 mm in size

• Koebner phenomenon can be seen

• May resolve spontaneously

• Can be associated with molluscum dermatitis

• Treatments include topical cantharidin (compounded),

imiquimod (off-label use), topical retinoids (off-label

use), curettage, cryotherapy

Molluscum

Molluscum

Molluscum

Skin Diseases and Clinical Findings in Athletes

• Tinea Versicolor

• Pitted Keratolysis

• Contact Dermatitis

• Cholinergic Urticaria

• Striae

• Miliaria

Tinea Versicolor

• Presents in adolescence

• Scaly, oval macules, thin plaques, and patches either

hyper or hypopigmented

• Yeast forms of Malassezia furfur

• Characteristic KOH findings

• Exacerbated by sweating and hot, humid

environmental conditions

Tinea Versicolor

Tinea Versicolor

Tinea Versicolor

Tinea Versicolor

KOH

Pitted Keratolysis

• 1-7 mm pits or depressions within the stratum corneum

• Associated with hyperhidrosis and malodor

• Causes include Micrococcus sedentarius and

Corynebacterium

• Treated with topical antibiotics including erythromycin,

clindamycin and aluminum chloride for hyperhidrosis

Pitted Keratolysis www.dermquest.com/image/028993H

Allergic Contact Dermatitis

• Delayed-type hypersensitivity reaction

• Occurs after exposure to a previously sensitized chemical

• Acute cases can be vesicular

• Chronic exposures tend to be lichenified, scaly

erythematous plaques

• Correspond to the area of contact with the inciting

chemical

• Patch testing is the gold standard for diagnosis

Shoe Allergic Contact Dermatitis

Shoe Allergic Contact Dermatitis

Cholinergic Urticaria

• Small 1-3 mm urticarial papules or wheals with

erythematous flare

• Occur predominantly trunk

• Persist for 30 minutes to hours, with 24 hour refractory

period

• Can be associated with systemic symptoms

• Triggered by acetylcholine action on the mast cell

• Seen in exercise, increased temperatures, stress

Cholinergic Urticaria

Striae

• Linear atrophic lesions from dermal damage

related to excessive stretching of the skin

– Seen in significant weight fluctuations,

pregnancy, puberty (30%), strength training

– Iatrogenic: topical steroid use

– Cushing’s

Striae

Miliaria

• Obstruction of the eccrine sweat duct by keratin plugs

• Results in sweat retention within the skin

• Clinical findings are based on level of obstruction

– Miliaria crystallina

• Stratum corneum – clear vesicles, easily ruptured

– Miliaria rubra (most common)

• Mid epidermis – erythematous papules, macules, vesicles, pustules

– Miliaria profunda

• Dermal-epidermal junction – 1-3mm white papules

• Occurs in settings of significant sweating and occlusion

Miliaria Rubra

Acne and Sports Participation

• Acne Mechanica

• Isotretinoin Use and Sports

• Acne and Supplements

Acne Mechanica

• Triggered by:

– Occlusion

– Friction

– Moisture

– Heat

– Pressure

• Treatments include:

– Avoidance

– Removal of offending garments, helmets, pads, etc. and skin cleansing as

soon as possible after physical activity

– Traditional acne treatments

Acne Mechanica

Acne

Acne

Acne

Acne

Acne

Isotretinoin and Athletes

• Increased fragility of the skin with erosions

– Increased risk of secondary infections with non-intact skin

• Tendonitis

• Myalgias in 15%

• Diffuse interstitial skeletal hyperostosis, premature epiphyseal

closure, osteophyte formation, decreased bone density

– Dose and duration dependent

– Not found in typical isotretinoin course of acne treatment

• Photosensitivity

Supplements, Diet, and Acne

• Anabolic steroid-induced acne

• Review of studies implicating whey protein, milk

consumption, and glycemic index with acne

– American Academy of Dermatology (AAD) Guidelines

of Care in the Management of Acne 2/2016

Koebner Phenomenon

• Occurrence of particular skin diseases in areas

of trauma

• Common skin diseases include psoriasis,

vitiligo, molluscum contagiosum

Psoriasis

Psoriasis

Psoriasis

Psoriasis

Psoriasis

Vitiligo

Vitiligo

References

• National Library of Dermatologic Teaching Slides (NLDTS) 4.0, American Academy of Dermatology

• Paller, A., Mancini, A. (2011). Hurwitz Clinical Pediatric Dermatology. (4th ed.). Elsevier Saunders.

• Bolognia, J., Jorizzo, J. Schaffer, J. (2012). Dermatology. (3rd ed.). Elsevier Saunders.

• James, W., Berger, T., Elston, D. (2011). Andrews’ Diseases of the Skin Clinical Dermatology. (11th ed.).

Elsevier Saunders.

• Calonje, E., Brenn, T., Lazar, A. McKee, P. (2012). McKee’s Pathology of the Skin with Clinical Correlations.

(4th ed.). Elsevier Saunders.

• Wolverton, S. (2012 ). Comprehensive Dermatologic Drug Therapy. ( 3rd ed.). Elsevier Saunders.

• Goldsmith, L., Katz, S., Gilchrest, B., Paller, A., Leffell, D., Wolff, K. (Eds.). (2012). Fitzpatrick’s

Dermatology in General Medicine. (8th ed.). McGraw-Hill.

References

• Zaenglein AL, Pathy AL, Schlosser BJ, Alikhan A, Baldwin HE, Berson DS, et al. Guidelines of care for the

management of acne vulgaris. J Am Acad Dermatol. 2016 Feb 15.

• LaRosa CL, Quach KA, Koons K, Kunselman AR, Zhu J, Thiboutot DM, Zaenglein AL. Consumption of dairy

in teenagers with and without acne. J Am Acad Dermatol. 2016 May 27. [Epub ahead of print]

• Adebamowo CA, Spiegelman D, Berkey CS, Danby FW, Rockett HH, Colditz GA, Willett WC, Holmes MD.

Milk consumption and acne in teenaged boys. J Am Acad Dermatol. 2008 May;58(5):787-93.

• Adebamowo CA, Spiegelman D, Danby FW, Frazier AL, Willett WC, Holmes MD. High school dietary dairy

intake and teenaged acne. J Am Acad Dermatol. 2005 Feb;52(2):207-14.

• Silverberg NB. Whey protein precipitating moderate to severe acne flares in 5 teenaged athletes. Cutis.

2012 Aug;90(2):70-2.

• Simonart T. Acne and whey protein supplementation among bodybuilders. Dermatology.

2012;225(3):256-8.