Athletics are a great way to stay healthy, build self-confidence and teach teamwork. Unfortunately, depending on the sport, they can also increase the risk for contracting certain skin infections.
Sports associated with close physical contact, perspiration and minor cuts and scrapes allow opportunistic viral, bacterial and fungal infections to be easily transmitted from one athlete to another. In a sport such as wrestling, the risk is increased because the mat used in competition is shared by many athletes. Exposure to infectious organisms is increased because the particular opponent's infection status is not the only relevant one; everyone who has been on that mat presents potential risk.
A 17-year-old boy presented to the office on Monday in a suggested follow-up from an emergency department visit over the weekend. He had received a diagnosis of cellulitis and a prescription for doxycycline 100 mg to be taken twice daily. The notes from the emergency department provider said the patient had redness and swelling that was tender and warm to the touch. The staff had informed the patient and his mother that his symptoms were likely a result of methicillin-resistant Staphylococcus aureus (MRSA) acquired during a wrestling match the prior Thursday. Twelve other wrestlers who had been in the same tournament had already been to the emergency department that weekend with similar symptoms.
The patient presented to the office with a 3-day history of a worsening rash on his face and forehead. The patient said the eruption had begun on Friday with slight redness and tenderness. On Saturday, he and his mother went to the emergency department because the redness had intensified and some "sores" and "bumps" had developed. The patient said he had been taking doxycycline for 2 days and that the eruptions had only worsened.
The patient described the rash as extremely painful and associated with a constant burning sensation. He also reported that multiple new sores and bumps appeared daily. The mother stated that several other wrestlers from the tournament were experiencing rashes that were progressing.
Figures 1 and 2: Initial presentation of the patient. photos courtesy the author
The patient's forehead and right temple and cheek were edematous, erythematous and had multiple vesicles ranging in size from 0.2 cm to 1.1 cm. These vesicles extended into the frontal and temporal scalp (Figures 1 and 2). Many of the vesicles had ruptured and begun scabbing. The patient admitted to popping and picking at several of them. His face was warm and extremely tender to touch.
Three potential diagnoses were suggested by the history and presentation: MRSA, molluscum contagiosum and herpes simplex infection.
MRSA. These bacterial infections are easily transmitted through close contact with an infected person or improperly sanitized surface.¹ The symptoms of MRSA vary depending on the location of the infection. In the case of our patient, the symptoms would be consistent with a deep bacterial folliculitis, in which lesions appear as large, tender erythematous papules and nodules.²
Molluscum contagiosum. This viral disease is common in children and is caused by a pox virus. The lesions present as small, firm, dome-shaped umbilicated papules. Transmission is through close physical contact.³
Herpes simplex virus. Herpes type 1 (HSV-1) affects the oral-labial regions and other skin surfaces and is highly contagious. Herpes type 2 affects the genitalia and is transmitted sexually.4 The typical presentation of both types of herpes is that of an evolving eruption that begins as an erythematous patch. Often, affected patients report precursory tingling or burning sensation. This patch progresses and forms multiple vesicles and pustules. After the vesicles rupture, they form crusted scabs before finally healing. Post-inflammatory pigmentation is common after a herpes outbreak.5
Assessment and Plan
Based on the clinical picture and history, the likely diagnosis for this wrestler is HSV-1. The patient had been started on doxycycline in the emergency department because the treating provider's initial impression was that the presentation was an MRSA infection. I obtained a culture to rule out a bacterial infection, MRSA or otherwise. I instructed the patient to continue taking the antibiotics until the culture could confirm or rule out infection. After receiving the results, I informed the mother and patient that the cause was likely HSV-1, contracted through contact with an infected person or surface, such as the wrestling mat. I explained the progression and likely outcomes, as well as the fact that outbreaks were likely to recur throughout his life.
Figures 3 and 4: Post-inflammatory pigmentation after acute signs and symptoms had resolved.
I prescribed valacyclovir and ordered blood work to confirm the diagnosis. I also informed the emergency department where he was seen so that the staff could contact the other wrestlers who had presented that weekend.
Antibody testing confirmed the diagnosis of HSV-1, and cultures were negative for bacterial infection. I saw the patient in follow-up 1 week after the initial visit. All lesions had resolved, but some post-inflammatory pigmentation remained (Figures 3 and 4). I informed the patient about strategies to prevent further outbreaks, such as suppressive therapy and avoiding sun exposure and stress.
I notified the high school where the tournament had occurred, so that the staff could take steps to reduce the risk of further infection transmission.
When parents register their children for sports, an inherent risk of injury is assumed - and sometimes spelled out in release forms. In this case and the case of the other wrestlers who contracted HSV-1 infection during a tournament, this was not an expected risk. Infections such as MRSA, warts and tinea are often dismissed as trivial by athletes, coaches, parents and administrators. This case illustrates that not all skin infections contracted in contact sports are inconsequential. The affected teenage boys have this infection for life, and they can transmit this virus to others. Steps must be taken not only to protect athletes by reducing their risk of injury, but also to reduce their risk for contagious diseases.
1. Moellering RC. MRSA: The first half century. J Antimicrob Chemother. 2012;67(1):4-11.
2. Blume JE, et al. Bacterial Diseases. In: Bolognia JL. Dermatology. 1st ed. New York, NY: Mosby; 2003: 1117-1144.
3. Mathes EF, Frieden IJ. Treatment of molluscum contagiosum with cantharidin: a practical approach. Pediatric Ann. 2010;39(3):124-128, 130.
4. Bernstein D, et al. Epidemiology, clinical presentation, and antibody response to primary infection with herpes simplex virus type 1 and type 2 in young women. Clin Infect Dis. 2013;56(3):344-351.
5. Du Viver A. Viral Infections. In: Dermatology Pocket Picture Book. 1st ed. Malden, MA: Blackwell; 2002: 129-148.
Raymond Shultstad is a dermatology nurse practitioner who is vice president of the National Academy of Dermatology Nurse Practitioners. He practices at the Center for Dermatology and Skin Surgery in Spring Hill, Fla. He has completed a disclosure statement and reports no relationships related to this article.
The National Academy of Dermatology Nurse Practitioners (NADNP) is a professional advanced practice nursing organization dedicated to setting the standards in dermatology practice, education, research and professional development. The NADNP's mission is to serve as a resource and to support all NPs with an interest in dermatology. Visit www.NADNP.net for more information.