HEALTH WATCH Making wrestling safer Guide to recognition of skin infectionsThe sport of wrestling faces many challenges. With each one, its community has responded in a positive way. One example came in the late 1990's, three fatalities prompted necessary changes in weight cutting. In many ways. this improved the sport and the training programs of our wrestlers.
Identification and management of infectious skin diseases have always been an issue, but we are now facing a more insidious outbreak of infections that could mean the loss of life and limb. The Center of Disease Control has issued a warning about a "cluster" of Staphylococcus aureus bacteria that is resistant to many of the more common oral antibiotics. We have clinical identification of this bacteria in wrestlers in IN, football players in FL, CA, CO and WI. Most have resulted in significant loss of competition, hospitalization and surgical skin grafting.
Additional information about the warning at www.cdc.gov or at thematdoc.com ("Am I Disqualified" DVD)
As result of this new challenge, it is critical that every parent, coach and physician that works with the sport of wrestling must be aware of what to look for and the appropriate action to take. There are basically three types of skin infections that plague this sport:
- Bacterial-Small organisms that are found everywhere in the air, water, ground, mats and on skin. These organisms only become a problem if they get into and under the skin and "colonize". The two major strains (types) are Staphylococcal and Streptococcal that produce infectious lesions within the sport. Early identification and management of bacterial infection is critical in minimizing the impact on the athlete.
- Viral-Microscopic "parasitic" structures that require a host cell to survive. Viruses are constantly changing and mutating but cannot survive without a "host". Within the Sport of Wrestling the primary agent being Herpes Simplex Type-I. The major concern with Herpes is once an athlete has contracted the virus, they are infected for life and can have a breakout at any time. They become carriers and can develop a breakout lesion at any time. If a breakout infection occurs the athlete can "share" the virus with any wrestler they have direct contact with.
- Fungal-Small Parasitic Plant Organisms that are found throughout daily living. They spread through the dispersal of spores and can be very contagious. These organisms love moist conditions and in some cases prefer to be anaerobic. Common types seen in athletics are "Athlete's Foot", "Jock Itch" and Ringworm.
There are specific guidelines that should be followed in recognition of a skin lesion that should be seen by physician for identification and management:
1. Lesions with a red, flaky border.
2. Weepy lesions, especially with "pus" or yellowish fluid.
3. Facial lesions associated with fever, redness and swollen lymph nodes.
4. Any skin lesion that is around the mouth, crosses the face into the scalp or redevelops in the same area.
5. Lesions that produce '"Pins and Needles" sensation.
"The best cure for skin infections is prevention"
The best way to treat contagious skin infections is prevention. The following rules are critical to the success of preventing wrestlers from becoming infected:
1. GOOD Hygiene: Shower immediately and no longer than 30 minutes after practice, change workout clothes and socks daily, consistently washing your hands during the day, DO NOT share equipment.
2. If you notice an open lesion, keep it clean, cover it with a dressing and show it to the Athletic Trainer or coach immediately.
3. Do not reuse razors, towels, or lotions that have had contact with an infected lesion.
4. Self "skin checks" and workout partner "skin checks" daily.
5. Report any redness of a lesion to coach or Athletic Trainer.
6. If you have a sudden area that "itches", show it to the Athletic Trainer or coach.
7. If you come in contact with an opponent or workout partner with an open lesion clean the area with appropriate cleanser that contains Triclosan 1%; Nonoxynol 9;
8. Clean all practice mats and equipment daily with a 10% bleach or appropriate cleaner.
9. If it appears to be infected get to the physician quickly and have the lesion tested to determine the specific organism. Certain lesions may be covered with a bioocclusive agent (i.e. Tegaderm), but not herpes to protect teammates, opponents or family members.
Additional information is available at the following websites:
Bacteria is always present on human skin and on mucous membranes (coating of mouth, nose, throat) but only when the bacteria enters into the skin or membrane and "colonizes" does it become infectious. Regardless of the specific strain of bacteria (Streptococcal of Staphylococcus) the "colonization" is classified as:
a. localized (mild superficial)
b. to a specific area (such as a boil)
c. regional (such as impetigo)
d. systemic (severe/invasive) such as MRSA-CA (Methacillin-Resistant Staph aureus) or Necrotizing fascitis ('flesh eating bacteria").
Bacterial infections that cause skin infections are spread from one person to another person by direct contact (skin to skin) or indirect contact with inanimate objects such as towels, clothes, mat surfaces, headgear and workout areas. If several individuals become infected in a small group such as a team or individuals in the same tournament this is classified as a "cluster".
Treatment: A Bacterial infection needs to be treated by appropriate medical professional. Any infected wound needs to be "cultured" to identify the specific strain of Bacteria before appropriate action is taken, Simply placing the infected wrestler on an antibiotic is not enough. Using the wrong antibiotic can actually worsen the infection especially with MRSA-CA.
The types of Bacterial Infections that have been identified within the sport are:
- Folliculitis: Mild superficial bacterial infection of the hair follicles. Presents with "pus" filled lesions around the base of the hair. In normal healthy individuals, the immune system will neutralize the bacteria. If no "pus" filled blisters present not considered infectious.
- Boil (Furuncle): Bacterial Infection that is the result of a Staphylococcus Strain that "colonizes" in a specific location within the skin. Lesion will be hard to the touch, raised red or purplish border; "pus" contained blister and is warm to the touch (feverish). Infectious lesion that should be seen by a physician and a specific diagnosis of bacterial strain determined prior to treatment. In some cases the lesion must be opened by physician and allowed to drain.
- Impetigo: Bacterial Infection that is the result of an open lesion (scratch or abrasion) that becomes infected by either a Streptococcal or Staphylococcus Strain. The lesions will have a raised red or purple outside border, yellowish blisters develop with either "pus" or honey colored drainage. Very infectious by both direct and indirect contact. If infection remains localized can be treated with topical antibiotic but if infection "colonizes" and spreads the lesion needs to be treated by a physician and an accurate diagnosis of the Bacterial Strain obtained and treatment based on appropriate antibiotic.
- Secondary Bacterial Infections: Athletes can develop a "secondary" bacterial infection of a lesion such as a bug bite, fungal infection such as athlete's foot, acne or poison ivy. These bacterial infections must be treated as any bacterial infection if they present with "pus" or honey colored drainage. A definitive diagnosis of the Bacterial Strain is critical and appropriate medical care plan initiated.
- Subcutaneous Infectious cyst: Bacterial infection that colonizes within the tissue below the skin often forming into a cyst. Generally, the infected athlete will not feel well, present with "red streaks" spreading toward the heart from the lesion. A fever will be present at the regional site. Any athlete with any such presentation is highly infectious and needs to be treated aggressively to prevent the bacterial infection from becoming systemic.
- Septic Shock: Very severe illness that can result in loss of limb or life. Signs and symptoms include high fever, malaise, radiating redness along lymphatic tissue. Generally requires hospitalization. Bacteria can spread from skin to bone, blood, muscle and lymphatic tissue. May require surgery, Intravenous antibiotic treatment, and skin grafts.
- Methicillian-Resistant Staphylococcus aureus: A strain of Staphylococcus bacteria that is resistant to the majority of antibiotics that are used to treat any bacterial skin infection. Almost always spread by direct physical contact or indirectly by contact with towels, dressings, shared clothing or workout surfaces contaminated by an infected individual. Infection usually occurs through an open wound or abrasion. Early detection is the key, but usually missed due to culturing not performed on a routine basis.
- Usually the physician prescribes an antibiotic course of treatment for the most common organisms causing this type of infection. Since culturing will take several days to get a result, it isn't common to perform on everyone who seeks treatment for a staph infection.
- Necrotizing fascitis: "Skin eating disease" is an infection of skin, fascia, and bone caused by a Group A Streptococcal Strain. Symptoms and signs are the same for any bacterial infection. Redness around the lesion, fever, oozing of pus and "honey colored" fluid in the initial phase but rapidly moves into the tissue beneath the skin.
A parasitic structure comprised of a sheath of protein and nucleic acids. Requires a host cell to survive, with the most infamous viruses of our time being HIV and hepatitis (bloodborne viruses). For all practical purposes viruses require a living human cell to infect to survive and reproduce. Therefore they must be transmitted via direct contact with skin or bodily fluids. Rarely can transmission be from indirect contact.
Besides the Blood borne viral conditions, the two significant viral conditions found in athletics are:
- Herpes Gladiatorum (Herpes Simplex Type-1): Viral condition that is generally found on the face, scalp, arms, neck and upper chest. The infection presents as small clusters of "purplish" round blisters that when broken can secrete a clear or yellowish fluid. The outbreak is generally preceded by a "pins and needles" sensation and extreme itching sensation. Generally the lymph nodes near the infected tissue will be swollen and sore. Initial outbreaks also present with a low-grade fever, sore throat and malaise (general fatigue/"does not fell well"). This virus is extremely contagious the 24 hours prior to outbreak and during the formation of the blisters. Once an individual has contracted the virus, the virus remains dormant in the tissue and can reoccur when the individual experiences any type of stress such as physical stress, emotional stress or "making weight for a big tournament". Once the tissue is infected cleaning with any topical cleaner including Bleach will not kill the virus. Cleansers are designed to kill organisms and may kill some of he infected cells and cause tissue damage but the virus will survive. The acceptable medical course is to place the infected individual on oral famicilovir or valcyclovir. A physician can test presence of the virus by testing for the antibody to the virus, or by culturing an open vesicle, to determine if the individual should be placed on suppressive therapy.
- Molluscum contagiosum: A viral condition that is characterized by small perfectly round, waxy lesions generally appearing on body and shoulders. Minor infection but is contagious and should be screened for and referred to physician for management.
A plant organism that is probably from the class of Fungi Imperfecti that infests human tissue. The fungi organism actually lives in the tissue. It is spread by minute plant spores and can be transmitted by both direct and indirect contact. Many fungi are actually anaerobic but all require a moist environment to survive. There are numerous manifestations of fungi infections in human tissue but the most contagious and greatest challenge to athletics is "ringworm". Please remember "Athletes Foot" and "Jock Itch" are fungi.
- Ringworm: A rash presentation with a raised exterior border. The lesion grows in a circular pattern, but may present in ovals or rounded square pattern. Sometimes you may have more than one culture growing at the same time and will present in intersecting circles. The tissue in the middle area will be a lighter color and will develop a "scaly" appearance. Topical or oral antifungal agents must be used. Using Bleach to "kill" the fungus will only kill the skin tissue and leave a chemical burn of the skin. A major concern with any fungal infection is the possibility of a secondary bacterial infection. It is most difficult to deal with in the axillary area and in areas that contain hair follicles.
Additional information can be obtained by contacting:
Jim Porter at firstname.lastname@example.org
Thanks to Dr. BJ Anderson of MN for providing the pictures and his leadership is the field of Management of Skin Infections in the Sport of Wrestling.
About the author: Jim Porter is a NATA Certified Athletic Trainer who works as a Regional Outreach Coordinator for HEALTHSOUTH. He has worked in the sport for over thirty years as an Athletic Trainer and Medical Coordinator for numerous events from local wrestling tournaments to the FILA World Championships.