Microsoft powerpoint - skin infections in wrestlers-new mshsl slide show.ppt

Skin Infections in Wrestlers B.J. Anderson, M.D.
-Boynton Health Service University of Minnesota -Team Physician for Augsburg College Wrestling Team All materials included in this slide presentation are the property of B.J. Anderson, M.D. and the Minnesota State High School League.
Reproduction is allowed but not to include any photos without the permission of B.J. Anderson, M.D. B.J. Anderson, 2007. All rights reserved.
„ Present understanding of these infections and conditions „ Clinical diagnosis of skin lesions „ Recommendations for treatment and

As the sport expands, skin infections won't be limited to males Dermatology Topics „ Skin Infections „ Abscesses/CA-MRSA „ Tinea Corporis Gladiatorum „ Molluscum Contagiosum „ Herpes Gladiatorum Bacterial Infections-Cellulitis, Impetigo, Folliculitis, Carbuncle, „ Bacterial infections due to Staphylococcus aureus or Group A Streptococcus „ Primarily associated with neglected minor skin trauma or secondarily infected viral infections „ Face and extremities are common sites „ Can be spread via skin-to-skin or fomites (inanimate objects like mats, knee pads or

Cellulitis: Note the spreading redness. The skin texture is firm. No vesicles or flakiness.

Impetigo: Large weeping lesions containing pus. No vesicles or flakiness.
Treatment Guidelines for Bacterial Infections (Except CA-MRSA) „ Oral antibiotics for at least 72 hours before return to competition „ No draining, oozing or moist lesions „ If no improvement in 72 hours, consider MRSA or viral etiology Oral Treatment for Bacterial Infections (Excluding CA-MRSA) „ Keflex (Cephalexin) 500 mg 2-4 times a „ Duricef (Cefadroxil) 1 gm once a day „ If penicillin allergic: „ Clindamycin 300 mg 4 times a day for 7-10 CA-MRSA: Community Associated Methicillin Resistant Staph aureus Community-associated Looks identical to other Methicillin-resistant forms of staph infections, staphylococcal aureus but usually doesn't respond to first line Different strain of staph that doesn't respond to Very invasive and normal antibiotics (i.e., group of antibiotics called surrounding skin and soft Can spread to the lungs and cause a serious form Now seen in community and believed is due to Can only be diagnosed over usage of antibiotics by culturing an infection for ear infections and When it occurs, usually seen as an abscess or boil (59%) vs cellulitis (42%) or folliculitis (7%) CA-MRSA: Community-Associated Methicillin-Resistant Staph aureus Primarily seen in contact sports: Football, Locations are primarily on the extremities Sites organisms found: Whirlpools, equipment (Pads), Saunas, Lockers CA-MRSA in Wrestling „ Guidelines at this time from the CDC, NCAA and NFHS focus on hygiene „ Present treatment for bacterial infections requires 3 days of oral antibiotics „ Due to the destructive nature of this bacterium and the ease of its spread, treatment regimens may require a longer CA-MRSA in Wrestling When necessary treatment should be aggressive to promptly remove or eradicate the organism Treatment primarily focuses in lancing or Incision and Drainage Culture of the draining material is essential to guide treatment Antibiotics should be used, for 10 days, to expedite clearance: Clindamycin 300 mg 4 times a day Septra (Trimethoprim/Sulfamethoxazole) DS twice a day Doxycycline 100 mg twice a day The athlete should be withheld from competition/practice for a For multiple team members or recurrent outbreaks on the same individual, consult the Public Health Department for guidance Tinea Corporis Gladiatorum „ Called "Ringworm" „ Caused by the dermatophyte Trichophyton „ Not from fomites(Mats), only via direct contact with infected individuals* „ Documented outbreaks in wrestlers dating back to mid 1960's with Swedish teams- * May spread via spores on surfaces Ringworm: Reddened area on the perimeter. No warmth and central area is clearing. No pus or vesicle. No swollen lymph nodes.
Ringworm. Perimeter is reddened and flaky. Center is clearing. No pustular appearance.
T. tonsurans - Treatment „ Proper hygiene „ Wash clothing and shower-immediately after each „ Wash mats before practice to reduce grit to help prevent skin abrasions „ Appropriate medication „ Use antifungal creams for single body lesions „ Use antifungal oral medications for scalp, facial and multiple body lesions Treatment guidelines for „ Oral/topical treatment for 3 days for „ Oral treatment for 14 days for scalp „ For scalp lesions, use Nizoral 1% shampoo (over the counter) daily to help debride fungal spores. Use until completely cleared.
Ringworm Treatment Lamisil (Terbinafine) 1% Lamisil (Terbinafine) 250 Mentax (Butenafine) 1% Naftin (Naftifine) 1% Sporanox (Itraconazole) Spectazole (Econazole) 100mg once a day for 2 -For each apply twice a day Diflucan (Fluconazole) 200 mg once a week for Apply creams until rash is gone, then 1 Antifungal Treatment Regimen „ Sporanox (Itraconazole) 200mg twice a day for one day every other week „ Diflucan (Fluconazole) 100 mg once a „ Lamisil (Terbinafine) 250mg once a „ Anecdotal evidence of efficacy Molluscum Contagiosum „ Mostly seen in children under 10-12 yrs „ Treat to prevent transmission Treatment Guidelines for Molluscum Contagiosum „ Lesions must be curetted or removed 24 hours before meet „ After treatment, lesions can be covered by Bioclusive covering, followed by Treatment options for Molluscum Contagiosum „ Cryotherapy (freezing) „ Curettage and Hyfrecator (Express and „ Aldara 5% cream Herpes Gladiatorum-True or „ How can it be? We wash the mats 3 times a „ Skin checks look for vesicles. Only when they are present do we worry about transmission „ It's only a cold sore, not Herpes Gladiatorum „ That's that sexually transmitted stuff, isn't it? „ It's impetigo! I always get it there each All of these excuses have been mistakenly give for why a lesion is not Herpes! Herpes Gladiatorum (HG) „ Term coined by Selling and Kibrick (1964) „ Due to Herpes Simplex virus Type-1 „ Numerous outbreaks since first diagnosed in 1960's – Selling (1964), Wheeler (1965), Porter (1965), Dyke (1965) and Belongia „ Prevalence in wrestlers: „ 2.6-29% High School „ 7.6-12.8% Collegiate „ 20-40% Division I Herpes Gladiatorum- 73% on Head and Face 42% on Extremities Appear 3-8 days after Primarily at locations of ‘Lock-up' position Only from skin-to-skin No association with Herpes Gladiatorum-Primary „ With facial/head involvement „ Fever (101°-102°F) „ Regional adenopathy „ Vesiculopapular lesions „ Lasts 10-14 days Primary HG: Note grouped vesicles on forehead and along jawline Herpes Gladiatorum-Recurrent „ Latency and Reactivation are the rule „ Usual reoccurrences last 3-5 days „ Less signs and symptoms than primary „ Brought on by stress, i.e. weight cutting, abrading or rubbing facial skin, sun exposure, suppressed cell-mediated Recurrent HG: Note smaller area involved Herpes Gladiatorum- „ Lesions crossing the facial-hair line „ Recurrent ‘folliculitis' in the same area „ Other teammates in the same wrestling group with the same lesions „ Regional adenopathy out of proportion for small areas of folliculitis or cellulitis Treatment Guidelines for Herpes Gladiatorum-MSHSL No new lesions for 48 hours and all lesions are scabbed over Must be on oral antiviral medications for minimum of 10 days No swollen, tender lymph nodes or systemic signs of continued infection. If present, then extend time out of competition/practice For Recurrent HG: Must be on oral antiviral medication. May return to competition/practice on the 7th day of treatment. If already on antiviral medication for suppression, may return on the 7th day after vesicle formation If no medication used, no visible lesions or systemic signs may be present, including swollen lymph nodes May not be covered Oral Treatment for Herpes „ Primary outbreak „ Valtrex (Valacyclovir) 1000mg twice a day for 10- „ Acyclovir 200-400mg 5 times a day for 10-14 days „ Recurrent outbreak „ Valtrex (Valacyclovir) 500mg twice a day for 1 „ Acyclovir 200-400mg 5 times a day for 1 week Prevention (Prophylaxis) of Recurrent outbreaks of Herpes Gladiatorum „ Individuals who suffer from recurrent HG or ‘cold sores' should be on daily oral antiviral medication throughout the season to reduce the occurrence of outbreaks „ Studies prove that daily dosage of these medications can significantly reduce that risk „ Prophylactic dosing: „ Valtrex (Valacyclovir) 1000mg once a day 96% „ Acyclovir 400mg 2 times a day 50-78% effective *For coaches or those with greater than 2 yr history of recurrences, Valtrex 500mg once a day may be effective. With breakthrough, increase to 1000mg Herpes Management with Outbreaks during the Season Individual Outbreaks Once an outbreak occurs, isolation and oral antiviral medication are For Primary outbreaks, ensure cultures are done to verify HSV-1 is the cause. Follow treatment guidelines (previous slides) For Recurrent outbreaks, verify its HSV-1 and follow treatment guidelines (previous slides) All wrestlers in contact with these individuals, over the past 3 days, should be isolated and monitored for 8 days. By that time, if no lesions develop, he may return to competition Outbreaks in individuals already on prophylactic antiviral medications should be removed from practice/competition. If on Valtrex 1000mg a day, divide the tablet and take ½ twice a day for the next 7 days. On the 7th day, may return to competition and restart Valtrex 1000mg once a day Herpes Management with Outbreaks during the Season „ Multiple wrestlers „ If multiple members of a team become infected, strongly consider shutting down the whole team for 8-days. Other means of conditioning and exercise may be implemented, but no direct contact with other wrestlers during this time „ Anyone who develops suspicious lesions should be evaluated for HG with cultures taken for HSV-1 Herpes Prevalence and Risk of Present studies indicate that 2.6% of HS wrestlers have known HG, but blood studies indicate that over 10x this many have the virus Once an outbreak occurs on a team, uninfected wrestlers have 33% chance of contracting the virus Due to the high prevalence and risk of contracture during an outbreak: Those who have no history of HG should consider HSV antibody testing at the beginning of each wrestling season. Once positive, should consider being on oral antiviral medication prophylactically all season long Post-Exposure Protocol for Herpes Gladiatorum „ Previous outbreaks of HG indicate that over 90% of individuals will develop HG within 8 days from exposure „ Teams should consider an 8-day period of isolation after large multi-team tournaments. Since the virus is transmitted before rash formation, newly infected individuals may clear skin checks and still be spreading the virus to other wrestlers „ Skin infections are a significant problem in „ Seek evaluation and treatment from the same medical provider-don't ‘doctor shop' „ Isolate and treat. For HG, culture to verify and be sure to isolate until confirmation of „ Coaches and physicians need to work closely with Certified Athletic Trainers to properly treat and control these infections


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