Dermatological problems in the football player

Football athletes are susceptible to many dermatological conditions which are more exaggerated and have a greater occurrence, proportionally, than in other athletes. Perspiration, heat, body contact, trauma, equipment, and climatic conditions all play significant roles in the development of these disease processes.1 Moreover, football players have been shown to have depressed immune systems and retarded neutrophil function during the football season which could also explain their increased susceptibility to a number of cutaneous infections discussed in this paper.2 The major skin problems in football players are acne, contact/irritant dermatitis, bacterial and viral infections, athletes nodules, ganglion cysts, frostbite, intertrigo, striae distensae, calcaneal petechiae, and calluses. Therefore, it is important to recognize and treat each of these conditions in order to facilitate athletic participation and prevent diseases spreading to other athletes. Acne mechanica is seen regularly in football players and has been referred to as "football acne".3 The term acne mechanica designates papulopustular eruptions caused by pressure, tension, friction, stretching, rubbing, pinching, pulling, and almost any type of mechanical stress or strain on the skin.4 It is this type of acne that may be noticed in many types of athletes. Most of the protective padding in football is in direct contact with the face, shoulder, and back, which manifest the densest concentration of sebaceous units.3 Football acne begins to appear once padding is worn during the season and has been shown to recede immediately after padding is discontinued at the end of the season. Football acne appears most commonly on the chin in the precise area occluded by the chin strap,3,5 and certain hydrocarbon products and occlusive plastic materials used in these protective straps and pads are known to induce these acneiform eruptions.5 These chemical and physical factors, in addition to increased androgen levels caused by physical exertion, exert influences on the pilosebaceous follicle.5 It has been suggested that acne mechanica is a complication of acne vulgaris and that without this underlying disease acne mechinca would not occur,4 but this is not necessarily the case. Pre-existent acne vulgaris in football players is not necessarily a precursor of acne mechanica, but causative factors of acne mechanica such as stress and strain may exacerbate acne vulgaris.3 Prevention of acne mechanica begins with wearing synthetic wicking clothing underneath football uniforms. Treatments for acne mechanica consist of topical retinoids including tazarotene and tretinoin. Systemic antibiotics such as tetracycline and erythromycin may be of limited assistance. Acne keloidalis nuchae (AKN) is another type of acne that is also found in football players and is a chronic folliculitis and perifolliculitis, usually limited to the occipital scalp and posterior neck. It consists of multiple inflammatory papules and nodules occurring mainly in African-American football players. A study comparing the prevalence of AKN in African-American players to that in white players demonstrated that they are more likely to develop AKN lesions than white players. This study also revealed that AKN is more frequently found in football athletes playing at a college or professional level.7 Several causes of AKN have been proposed e.g., mechanical factors, curved or ingrown hairs following a short haircut, infection, and chronic inflammation. Football helmets, although protective, cause an occlusive and macerating effect on the scalp and have been linked to a direct cause of AKN in football athletes.6,7 Prophylaxis for AKN involves avoiding short haircuts. Effective short-term treatments for AKN include intralesional steroid injections, oral or topical antibiotics, and surgical excision.7 Whilst many of these treatments are effective the discontinuation of protective pads and helmets shows the greatest resolution of these conditions.3 The term irritant dermatitis is used to describe nonimmunologic changes that result from direct tissue damage after contact with a stimulus.8,9 Conversely, allergic contact dermatitis reactions are mediated through immunologic mechanisms, and more specifically, delayed-type hypersensitivity reactions.9 Both reactions appear as erythematous areas with edema, vesicles and sometimes bullae that may become crusted or eroded.8 Thinner and damaged areas of skin predispose an athlete to developing dermatitis. In football players, materials that usually cause allergic dermatitis include rubber back adhesive tape, adherents that make the tape stick, and rubber materials that are found in shoes and equipment. Mercaptobenzothiazole, thiurams, and carbamates are all chemicals found in these rubber products that may cause allergic contact dermatitis; patch testing is necessary to determine the chemical responsible for the reaction.10 Irritant dermatitis reactions occur more commonly when exposed to calcium oxide, which is used in field markings. Players may also develop irritant dermatitis though exposure to the contents of cold ice packs.11 Diagnosis of each of these conditions is generally based on clinical appearance, history, and patch testing. Once a reaction has been established, exclusion of the offending agent is important.8 Therapy may include cold compress, potent topical steroids, oral steroids, and PUVA therapy.9 Impetigo is a superficial cutaneous bacterial infection common to football athletes,1 and is usually observed in athletes who experience direct physical contact. Impetigo is commonly caused by streptococcal and staphylococcal micro-organisms.12 Lesions appear as red papules or plaques, flaccid blisters or erosions with golden yellow crusting which are well-defined and usually distributed over the head and neck. Bacterial cultures, although not always necessary, confirm this diagnosis.11,13 This infection is usually acquired by direct contact with an infected individual or with mats, equipment or towels carrying the micro-organism.11,13 Acute glomerulonephritis can be a complication of impetigo.13 Treatment of impetigo consists of a 7–10-day course of systemic antibiotics such as erythromycin or a penicillinase-resistant penicillin,13 and topical cleansing with a mild soap is recommended. The athlete should not share towels and equipment in addition to avoiding contact with other athletes until the infection has resolved.13 Furunculosis epidemics have been reported in football teams, and an epidemiological study found that up to 25% of football players developed furunculosis at some point in their high school football career.14 The abscesses begin when staphylococcus is introduced through a hair follicle, a sebaceous gland, or across skin compromised by an abrasion or wound.15 Direct person-to-person contact compounded with cuts, abrasions and blunt injury provide transmission and increased susceptibility to staphylococcus aureus infections. Two studies evaluating the outbreak of furunculosis in independent football teams in Kentucky and Illinois showed a wide spectrum of factors associated with the development of furuncles among team members. In the case of the Kentucky football team, the overall prevalence of furuncles was 25%, and 90% of these cases were found in varsity players. Also the majority of furuncles were located on the players' extremities, and 96% of the infected athletes reported sustaining an abrasion prior to the development of a furuncle. The risk of developing furuncles was increased in those athletes who wore wrist and/or elbow pads compared with those who did not wear this protection. Finally, exposure to school showers were not related to the development of furuncles, as those athletes who showered at home had near rates of infection.14 A similar outbreak of furunculosis in a high school football team was reported in central Illinois, where of the 26 players who developed furuncles, 43% were varsity players. Additionally, 60% were linemen and 40% were cornerbacks and defensive backs. As observed in the Kentucky epidemic, the majority of furuncles were reported on the players' extremities. This study also suggested that the use of skin lubricants (often shared between players in the same team), elbow and forearm pads, athletic tape and whirlpool baths were clearly linked with the development of furuncles.15 These studies also illustrated that the evolution of furuncles is intimately associated with prior bruises and open wounds.14,15 The prevention and control of furunclosis could begin with wearing uniforms that cover all body parts which will reduce the potential of direct personal contact as well as the frequency of bruises or breaks to the skin. Additionally, open wounds should be cleaned and topical ointment applied with a dressing. Hot water and soap have been reported to be helpful.14,15 Keeping facilities, equipment, and clothing clean is essential. Systemic antibiotic treatment is mainly reserved for severe or recurrent furuncles. In such instances, a 10-day course of oral penicillin-resistant penicillin is the treatment of choice.13 It is important to note that systemic therapy, however, does not reduce transmission rates. Methicillin-resistant Staphylococcus aureus (MRSA) outbreaks have recently been reported in high school, college and professional level football. The MRSA infections are microbiologically unique as a result of genetic mutation,16 and clinically MRSA may cause furunculosis or cellulitis. Local infection occurs as a result of direct physical contact during practice or competitive play with other infected individuals, or indirectly by touching contaminated objects such as towels or sports equipment. Diagnosis requires wound culture.16,17 A case has been reported involving a 23-year-old college wide receiver who developed MRSA furunculosis following trauma to his dorsal hand during football practice. Even after proper washing and antibiotic ointment application, the player developed two abscesses within 10 days of his injury. Subsequently, the player was given ceftriaxone intramuscular injections and treated empirically with trimethoprim/sulfamethoxazole and the abscesses were incised and drained, and the infected player was held from practice for 10 days. Latterly, a further six players were diagnosed with MRSA that season.16 Close physical contact and sharing of towels and equipment were believed to be contributive factors and consequently towel sharing on the football field was prohibited. Whirlpool bath usage was also stopped for 3 months following the outbreak, and additional antibacterial hand wash was placed in the training washrooms.16 A similar incident occurred in September 2003, and a retrospective cohort study of another team was conducted in order to investigate this outbreak. Ten players were identified with MRSA wounds, and, of these, there were 13 reported infections (nine cases of furunculosis and four cases of cellulitis), and two players were eventually hospitalized. Cornerbacks, defensive backs and wide receivers all had the highest infection risk accounting for eight of the reported 10 cases. Players with turf burns had a seven times higher risk of developing the infection, and the use of protection pads was associated with an even higher risk of infection. Moreover, players who reported body shaving were 6.1 times more likely to develop MRSA infections. Sharing a whirlpool bath also appeared to show an increase in MRSA infection susceptibility.17 Wound cleaning and coverage was not predictive of infection risk. Prevention of MRSA begins with covering all wounds, and it is also important to encourage good hygiene among players. Using hot water and soap to cleanse, avoiding equipment and towel sharing, and reporting all skin lesions to a trainer are all essential.16,17 Once MRSA is suspected, it is appropriate to begin oral trimethoprim/sulfamethoxazole, oral clindamycin, an oral floroquinolone, or topical mupirocin until sensitivities are determined. These antibiotics are usually recommended for 10–14 days. If systemic symptoms are present, the player should be admitted and parental vancomycin administered.16 Parental qunupristin and dalfopristin are also effective; linezolid has also been shown to treat MRSA in both parental and oral forms.16 In response to an increasing number of MRSA outbreaks in college and professional football, the National Collegiate Athletic Association (NCAA) Committee on Competitive Safeguards and Medical Aspects of Sports advised vigilance at member institutions.16,18 Case reports of folliculitis found in football players are associated with rehabilitation whirlpools, and thus the term "whirlpool folliculitis" is often applied.19,20 This type of folliculitis is characterized by a diffuse pattern of erythematous papules and pustules located on water-immersed body surfaces.19 Factors such as skin trauma, occlusive properties of bathing suits, dilated follicles, and superhydrated skin allow for bacteria to penetrate and cause infection. Pseudomonas aeruginosa (particularly serotypes O:4 and O:11) has been identified as the most common cause of whirlpool folliculitis.19 Systemic complications may often be present and include symptoms such as painful eyes, earache, sore throat, headache, fever, malaise, rhinorrhea, nausea, vomiting, and abdominal cramps.19 Follicular eruptions tend to resolve in 7–14 days and occasionally display post inflammatory hyperpigmentation. Prevention of whirlpool folliculitis consists of maintaining adequate chlorine levels in the whirlpool bath, and any rehabilitation whirlpool baths should be thoroughly cleaned after every use. Open wounds should be properly managed and occlusive dressings applied before each whirlpool treatment. Some authors have suggested that the player should also refrain from antibacterial soap after exposure.19,20 These measures should be carefully followed, especially with respect to football players, many of whom have extensive epithelial damage and open wound injuries. There are a several cutaneous viral infections that afflict football players including warts, molluscum contagiosum, and the herpes simplex virus.1 These diseases are important to recognize and treat in order to prevent further transmission. Acquisition of warts (caused by the human papilloma virus) results from direct contact with another symptomatic individual or with fomites harboring the virus.21 The wart is diagnosed clinically as an irregularly surfaced, dome-shaped, and verrucous lesion and must be distinguished from callosities, which tend to be thickened lesions that with paring reveal no capillaries.22 A wart also resembles corns, which are often times more painful and contain a central plug.22 There are a variety of combination treatments that are effective in treating warts.23 Current treatments include salicylic acid, cryotherapy, CO2 laser, pulse dye laser, photodynamic treatment, podophyllin, bleomycin, imiquimod, and retinoids.22,23 Less painful methods of treatment may be considered during the season so as not to hinder the athletes performance. Molluscum contagiosum, caused by the pox virus, is spread via skin to skin contact or through contact with fomites such as clothing and towels which harbor the virus.24 Abrasions in the epidermis are believed to facilitate transmission.22 Molluscum contagiosum are asymptomatic, firm, smooth, round papules with a central umbilicus. These lesions tend to be approximately 2–6 mm in diameter.24 They may be confused with and must be differentiated from herpes simplex virus infection, small epidermal inclusion cysts, and warts.24 Molluscum often spontaneously disappear with no residual scarring. Treatment options include curettage, laser and cryotherapy. Imiquimod has been shown to be effective, especially in cases where numerous lesions are present22. Herpes simplex virus infections may occur in athletes owing to direct body contact.25 Herpetic infections present as a tender erythematous macule associated with malaise and neuralgia that eventually develops small grouped vesicles.26 The optimum standard for diagnosis is culture. A tzank smear or direct florescence is also helpful to make the diagnosis.27 Treatments must include antiviral therapy.26 Antiviral medications helpful in treating herpes include acyclovir, famcyclovir, and valacyclovir, and these medications also inhibit DNA replication in infected cells. Dosing regiments vary for primary and recurrent infections: typically, for primary infections valacyclovir 1 g-twice-daily for 7–10 days has shown to be effective, and for recurrent infections valacyclovir 500 mg twice-daily for 3–5 days has also been shown to reduce the duration of infection.28 Recent evidence reveals that 2 g valacyclovir twice for 1 day only is also effective for recurrent infections. This dosing regimen may increase compliance. A rare case of disseminated curvularia lunata was reported in a 25-year-old immune-competent football player believed to have become inoculated while playing football. Curvularia lunata is a brown/black pigmented saprophytic soil fungus that is considered to be rarely pathogenic in human beings. In this case, the individual experienced deep, soft tissue abscesses that were believed to have originated around abrasions and wound sites.29 The patient was hospitalized with abscesses in both legs and neck which were accompanied by pleurisy, hemoptysis, and lumbosacral pain. These abscesses gradually progressed to include pulmonary suppuration, paravertebral abscesses and even cerebral abscesses. Cultures provided accurate diagnosis in this case. As illustrated by this case, exposure to this fungus does have the potential for systemic dissemination. Prompt and aggressive treatment with surgical drainage of affected sites, and administration of miconazole and amphotericin B is necessary.29 Athlete's nodules are benign dermal nodules that are frequently found in football athletes as a result of chronic trauma or pressure to a specific area.30 These sport-related nodules can be found on the knuckles, knees, and dorsal aspect of the athlete's foot.31 Morphologically, they are firm, asymptomatic, frequently symmetrical, skin colored, indurated nodules that range in size from 5–40 mm.32 The differential is quite broad for this benign neoplasm and varies with respect to the location of the nodule.32 Protective padding at trauma sites may prevent growth of athlete's nodules. Additionally, avoiding tight-fitting athletic footwear may also prevent these nodules from forming on the dorsum of the feet. Treatments include keratolytic agents, topical and/or intralesional steroids, and surgical excision.30–32 A case of a ganglion cyst in a professional football athlete was also reported where the ganglion cyst occurred around the third metatarsal and resulted from an underlying stress fracture.33 Ganglion cysts are benign masses that result from myxoid degeneration of connective tissue, and although more commonly found in the upper extremities, they may be found in the lower extremities, especially in athletes participating in repetitive weight-bearing sports such as football. Since excessive training seems to be a factor,33 treatment involves rest and anatomic support. Aspiration of the cyst is associated with a 75% recurrence rate, but combining aspiration with steroid injections has a lower recurrence rate. Surgical excision has also been reported.33 Frostbite may occur during the latter half of the football season during the winter months as a result of over-exposure to temperatures less than minus 2 °C where anoxia and vasoconstriction can cause cellular metabolism to halt.1,13,34 Frostbite typically affects the smaller and more exposed body areas such as the fingers, feet, nose, face, and ears.34 Skin may appear hard, pale, mottled, and cyanotic.1,34 Extensive damage owing to vasoconstriction produces necrosis and gangrene. Prevention consists of wearing proper clothing that covers vulnerable exposed areas. Treatment includes moving to an indoor heated area and rapidly warming the affected area in a warm water bath regulated to 38 °C. It is also important to avoid rubbing the frost-bitten skin. Analgesics, whirlpool baths, and antibiotics are sometimes beneficial.13 Intertrigenous eruptions tend to occur in football linemen, especially those obese,13 and eruptions manifest through the effects of heat, moisture, friction, and maceration ultimately caused by friction between two adjacent epidermal surfaces.35 Frequent areas of involvement include the groin, axilla, umbilicus and interdigital webs. Intertrigenous eruptions in this setting may have microbial, allergic, or physical etiologies.35 The eruptions are intensely pruitic, diffusely erythematous and sharply marginated.35 Treatment consists of losing weight, wearing lose-fitting synthetic undergarments, gentle cleansing of affected areas with warm water and soap, and using Burrows solution three times a day followed by application of diiodohydoxyquin with 1% hydrocortisone cream. In cases caused by organisms such as Candida albicans, which is quite common, topical application of antifungals such as ketoconazole or clotrimazole is appropriate treatment.13,35 Commonly referred to as stretch marks, football players are prone to developing striae on their chest, shoulders, upper-outer arms, thighs and legs as a result of weight training.13,36 The etiology of striae is unclear, however, it is hypothesized that the loss and fragmentation of elastic fibers owing to rapid growth and physical stress is a major cause. Clinically, striae presents as linear flesh-colored atrophic patches.13 Avoiding less strenuous weight training may prevent the development of striae distensae and steroid use is strongly discouraged. Pulse dye laser has shown to be potentially effective in reducing striae.36 Calcaneal petechiae, otherwise known as black heel, is a condition that is traumatic in origin. More specifically, the etiology of this condition appears to be owing to the contact of the athlete's with the which usually occurs with and This contact causes the of small in the Lesions may be or and appear as linear areas of the of the the of the This condition requires no treatment are areas that in response to They usually appear on the feet, and over sometimes in football and may not consists of paring the with a or keratolytic such as and salicylic There is a of dermatological conditions to which football players are Close contact with other players, cutaneous damage during the use of equipment specific to the and conditions all appear to play roles in the development of these dermatological treatment, and prevention of these conditions among athletes.