Skin infections in athletes: Treating the patient, protecting the team
When your patient is an athlete with a cutaneous infection, you have dual concerns: eradicating the infection and eliminating the risk to his teammates.
Alternatively, fungal infection can be confirmed retrospectively, by culture on selective media. Dermatophyte test medium (DTM) is convenient and easy to use, and usually reveals fungal growth within 7 days. A newer selective media, DBM (bromothymol blue is the pH indicator) is a modification of the DTM formulation that may offer earlier and more accurate identification of fungi.11
Keep in mind, however, that a negative KOH preparation or culture does not necessarily rule out a fungal infection.12 Polymerase chain reaction (PCR), an emerging technology performed on a specimen swab, has a greater sensitivity than either KOH or culture in identifying fungal pathogens. PCR can identify the presence of fungi even if the dermatophyte growth on culture is hidden by the overgrowth of Candida albicans.13
In patients with onychomycosis, dermatophytes may be exceedingly difficult to isolate on either KOH or culture medium, and the results of these tests often conflict. Onychomycosis is best diagnosed histopathologically by examination of periodic acid-Schiff-stained nail clippings.14
Topical or systemic treatment?
Treatment of dermatophyte infections is site-dependent. For simple epidermal infection, other than scalp or nail, topical therapy is first-line treatment. In a recent Cochrane review, topical allylamines, azoles, butenafine, ciclopirox olamine, tolciclate, and tolnaftate were all found to be effective. However, the allylamines had the greatest efficacy, which increased with duration of use.15
Topical terbinafine was found to be effective in as little as one to 3 days of treat-ment for tinea pedis. Mycological cure with near total symptom elimination at 28 days was reported in 61% and 78% of those receiving topical treatment for one day and 3 days, respectively; the difference was not statistically significant.16
Use this topical when bacterial infection complicates care. Although 1% naftifine gel requires a prescription and costs more than many other topicals, its advantages may offset the higher costs. Once-daily naftifine gel is as effective as other allylamines that require twice-daily application, and has both antihistamine and corticosteroid effects to offset inflammation. What’s more, naftifine is active against both gram-positive and gram-negative bacteria; therefore, it should be considered in instances in which bacterial superinfection is a possibility, as suggested by a high degree of inflammation with bright red and yellow crusts.17,18
Scalp, nail, and complicated foot infections typically require systemic therapy. Griseofulvin is the most widely used systemic treatment for tinea capitis.10 While terbinafine requires a shorter duration of treatment (4-6 weeks) and is similar in efficacy—except in cases of microsporum infection of the scalp, for which griseofulvin has been found to have higher cure rates19—it is often not used because it has a higher cost.
Tinea pedis and onychomycosis often occur concurrently, making eradication difficult and increasing the potential for reinfection. For recalcitrant cases of onychomycosis, a combination of topical and systemic therapy may be required, along with trimming, debridement, nail abrasion, and partial nail avulsion.20 A recent study found laser therapy to be a promising treatment for onychomycosis, but randomized controlled trials have yet to be done.21
NCAA and NFHS rules. Both the NCAA and the National Federation of State
High School Associations (NFHS) mandate that a wrestler with tinea corporis receive a minimum of 72 hours of topical therapy prior to participation; 14 days of systemic antifungal therapy are required for athletes with tinea capitis.22,23 The NCAA allows wrestlers to be cleared to participate on an individual basis, at the discretion of the examining physician or certified trainer.
The degree of disease involvement, the activity of disease as judged by KOH preparation, or the review of therapeutic regimen and the ability to properly cover lesions securely are taken into account.22 Proper coverage could consist of a semiocclusive or occlusive dressing such as film, foam, hydrogel, or hydrocolloid covered with stretch tape.24 Similarly, the NFHS permits a wrestler to participate once the lesion is deemed to be no longer contagious and can be covered with a bio-occlusive dressing.23
Prophylactic oral fluconazole, given in a 3-day regimen twice during the season to all team members, has been shown to be successful in reducing a high burden of tinea gladiatorum in a high school wrestling setting.25
CASE You presumptively diagnose tinea gladiatorum based on both the presentation and the patient’s history as a wrestler and prescribe topical terbinafine therapy twice daily. You schedule a follow-up appointment in 3 days, and tell Shane he must refrain from wrestling practice at least until then.
Staph and strep infections
Bacterial skin infections are also common among athletes, with S aureus reported to be responsible for 22% of infectious disease outbreaks.26 Here, too, infections occur primarily in contact sports such as football, rugby, and soccer, as well as wrestling.
