Which skin infections are transmitted between athletes?

Myriad dermatoses can affect athletes. One of the most common cutaneous manifestations of athletic activity are skin infections caused by bacteria,^1,2,3,4 viruses,^{1,2,4,5,6,7,8} and fungi.^{1,2,4,9,10,11} Many infections are contagious and may have serious ramifications for team practices and competitions. Knowledge of these infections facilitates implementation of rapid treatment and preventive measures to ensure the least disruption in daily team activities.

BACTERIAL INFECTIONS

Several specific sports-related dermatologic conditions are caused by bacterial infection. Staphylococcal infection is the most common, but streptococcal infection is also common.^1,2,3,4 Both organisms may present as various clinical disorders, such as impetigo, erysipelas, folliculitis,^1,2,4 and furunculosis.³ These infections are probably contagious. Impetigo, characterized by well-defined, erythematous, yellow-crusted, scaling plaques, and erysipelas, characterized by well-defined, advancing, erythematous plaques, can be treated with topical warm soaks and oral antibiotics.^1,4 Folliculitis (figure 1) manifests as small follicular pustules that can be treated with topical or oral antibiotics.¹ These bacterial infections occur in athletes participating in sports in which close personal contact occurs, including rugby, judo, and wrestling.^2,4 Furunculosis outbreaks, however, have been noted also in football and basketball athletes. One study showed that 25% of high school athletes in these sports developed furunculosis.³ Direct contact with furuncles was significantly associated with transmission; exposure to equipment seemed to be less important in its transmission. Some authors, however, have suggested that athletic bags and wrestling mats may also facilitate transmission of organisms.⁴ Rapid treatment and isolation of the affected athlete from other competitors is important to decrease the rapid spread of the bacteria.^1,2,4 Other authors have suggested that if the incidence of infection is low, bandaging may be a reasonable means to prevent transmission.³ If outbreaks continue within a team, the bacterial carrier status of the members can be evaluated by culturing crural areas and nasal passages,⁴ and appropriate treatment can be instituted.

Figure 1.

Sports involving close personal contact allow easy transmission of bacterial infections, such as folliculitis shown here

St Bartholomews/SPL

VIRAL INFECTIONS

Three main viral infections that affect athletes are verruca (warts), molluscum contagiosum, and herpes simplex. Verruca (figure 2) can occur on any skin surface and can be transmitted by direct contact, but shared showers and locker room floors may also act as reservoirs.⁴ Swimmers may be particularly susceptible to plantar verruca.⁴ Destroying verruca will help to prevent it from growing and possibly causing pain. Furthermore, destruction of verruca may decrease transmission of the virus to other members of the team. Athletes with plantar verruca should wear sandals while showering in shared facilities.⁴

Figure 2.

Verruca (warts) can occur on any skin surface

Parker/SPL

Molluscum contagiosum is characterized by discrete white to skin-colored papules and can be found particularly in wrestlers. Molluscum contagiosum can be quite contagious through direct contact and should be treated promptly with destructive methods to decrease the transmission to other athletes.^1,4

Herpes simplex infection, known as herpes gladiatorum when identified in wrestlers, has been reviewed extensively.^1,2,4,6,7,8 Herpes simplex infection may also be endemic in rugby players.⁵ The clinical presentation is that of vesicles on an erythematous plaque. Rupture of these vesicles may result in erosions. In a study of 1 wrestling camp, 34% of participants were infected with herpes simplex.⁷ Transmission is primarily through skin-to-skin contact; transmission through formites is felt to be less important.^7,8 Identifying infected athletes promptly and excluding them from direct contact with other wrestlers help to halt epidemic occurrences.^7,8 Rapid administration of antiviral treatment may accelerate an athlete's return to wrestling.

FUNGAL INFECTIONS

Fungal organisms can significantly affect athletes. Tinea pedis can be characterized by scaling plaques in a moccasin-like distribution on the plantar surfaces of the feet, by interdigital maceration, or by discrete vesicles on the foot. Tinea pedis can affect many athletes because the causative organism thrives in warm and moist environments. Runners, skaters, and long-distance walkers may be particularly at risk.⁴ Affected athletes should be treated with antifungal agents and also wear protective footwear while using shared facilities to decrease transmission to other athletes.

Tinea corporis is characterized by well-defined, scaling, erythematous, occasionally annular plaques. This infection has been extensively reported in wrestlers and has been termed tinea gladiatorum, trichophytosis gladiatorum, and tinea corporis gladiatorum.^9,10,11 Tinea corporis gladiatorum seems to be the most descriptive term, but it is not comprehensive because it excludes tinea capitis, which is transmitted between wrestlers. Several studies have examined the epidemiology of tinea corporis gladiatorum^6,9,10,11 in wrestlers. The frequency with which tinea corporis affects wrestling teams was found to range from 24% to 77% and varied with the methodology of each study. In 2 of these studies, investigators attempted to determine the incidence of tinea corporis in specific wrestling teams, both at the high school level.^10,11 Results of 1 study, prompted by an alert from a local health department, noted an epidemic affecting 75% of wrestlers on a high school team.¹⁰ The other study, which involved investigating a team without a known epidemic, found 24% of the wrestlers infected with tinea corporis.¹¹

Wrestling teams, often aware of the potential difficulties associated with tinea corporis infection, fastidiously clean equipment and mats. Transmission of the fungal organism, however, is most likely primarily through skin-to-skin contact and not through fomites.^10,11 This suggestion is supported by 2 findings. First, most lesions of tinea corporis gladiatorum are located on the head, neck, and arms, which are the areas of most contact between 2 competing wrestlers.^10,11 If wrestling mats played a larger role in transmission, one would expect more lesions on the lower extremities. Furthermore, attempts to culture organisms from mats have been unsuccessful.⁹

Athletes, particularly wrestlers and others subjected to extensive skin-to-skin contact, should be examined carefully before each practice and competition.^10,11 Athletes with signs of tinea infection should be treated promptly with antifungal agents and should be removed from direct contact with other wrestlers if the infected area cannot be appropriately covered using bandaging techniques.

Skin infections, to varying degrees, are transmitted among athletes. Data support the fact that most cutaneous infections are caused by close skin-to-skin contact. Prevention of epidemics of skin infection in sports teams is key to avoiding unnecessary morbidity and minimizing any disruption in team practices and competitions.