Skin Disorders: What Clinicians Need to Know - PowerPoint Presentation

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Skin Disorders: What Clinicians Need to Know

Nilesh Shah, MD, CAQSMSlide2

Disclosure

NoneSlide3

Objectives

Review dermatologic infections related to sports

Review the return to play guidelines for skin infections in sports

Review

other dermatologic problems in sportsSlide4

Epidemiology

8.5% HS & 20.9% College – of all injuries

50% head, neck, face

HS: 30% impetigo, 20% herpes, 20% tinea

College: 47% herpes, 37% impetigo, 7% tinea, 6% cellulitis, 3% MRSA

Miss < 7 days: 70%

Yard EE, et al. AJSM. 2008 Slide5
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Herpes Infection

HSV I or II

Direct contact

Incubation period 2-12 days

Initial lesion lasts about 10-14 daysReactivation commonStress (physical/ emotional)

Menses

IllnessesSlide7

Herpes Infection

Initial infection- lesion very painful

Vesicles on red base

Tingling/ itching

Burning

Flu-like symptoms

±

Lymph nodes

Clinical diagnosis

Tzanck Prep/ HSV DNASlide8

Herpes Infection

Herpes Gladiatorum

Wrestling – head lesions

Valacyclovir 1000mg BID (500mg BID)

Acyclovir – works well, very cumbersomeRTP after no new lesions for 48 hours and all lesions crusted and 5 days of tx

Consider suppressive tx

Herpes

Labials

Skiers – cold winds, sunburn, chappingSlide9
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Herpes TreatmentSlide12

Herpes Return to PlaySlide13
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Impetigo

Staph > Strep Non-bullous > bullous

Vesicles, Honey-crusted lesions

Incubation 1-3 days

Lasts 6-14 days

Spreads by close contact

Warm, moist environments

Clinical diagnosis

Bacterial culture can be performedSlide15

Impetigo

Common in wrestling

Post streptococcal Glomerulonephritis:

Impetigo > pharyngitis

Tx:

Mupirocin TID 7-10 days (not effective about scalp and should not be used around mouth) or fusidic acid

Diclox 250mg QID, Clox250 QID or 500mg BID

IM Benzathine – one time dose

Cephalexin 250mg QID/ 500mg BID

Erythromycin 250mg QID/ 500mg BID (increasing resistance)

Local cleansing with hydrogen

peroxideSlide16

Impetigo Return to PlaySlide17
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Folliculitis

Staph and strep

Infection of hair follicle

Incubation period about 48 hours (8 hours-5 days)

Itchy bumpy rash, may have pustulesTrunk, upper arms/ legs

Clinical diagnosisSlide19

Occlusive Folliculitis

Usually under protective padding

Carbuncle/ furuncles – I & D

Deep, inflamed pustular papules

Inferior gluteal folds in swimmersTx:

Clinda or erythromycin topical solution

Absorbant powder (Zeasorb)

Remove equipment ASAP after useSlide20

Folliculitis

Pseudomonas

Whirlpools and pools

Gentamicin cream

Ciprofloxacin (oral) – carefulSlide21
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Presentation of MRSA

“SPIDER-bite” lesion

Painful with swelling

Likely drainage

Multiple lesions sometimes present

Abscess/cellulitis (5-7cm of induration)

Indistinguishable from MSSA &

StrepSlide24

MRSA

Local infection can try to treat locally

Mupirocin

Retapamulin

Warm moist compresses

Deeper infection

I & D

ABx

Bactrim (TMP/ SMX) DS BID

Doxycycline

No fluoroquinolones

Newer Abx on the horizonSlide25

Reports of MRSA

MSSA infections first reported in 1964 at Dartmouth College. 24/74 players with extremity Staph skin

infections

CA-MRSA was first reported in the

1980’s

1993 – 7 high school wrestlers in Vermont were diagnosed with

CA-MRSA

2003 – CA-MRSA in 5 pro football

players

Pollard

JG College

Health. 1966; 234-238

Rihn

JA et al. Am

J

Sprt

Med. 2005; 33: 1924-1929

Kazakova

SV

N Engl J Med. 2005; 352; 5: 468-475Slide26

Sports with MRSA Outbreaks

American

Football

Rugby

Wrestlers

Soccer

Basketball

Volleyball

Weight

Lifting

Cross-country

Fencing

Kirkland

E et al. J

Am Acad Derm 2008;59:494-502Slide27

MRSA Return to Play

Oral antibiotics 72 hours

No new lesions 48 hours

All lesions dried and crustedSlide28
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Tinea

Incubation period 4-10 days

Direct contact, sharing equipment, pets

Red, scaly, itchy –

collarette of scale

Normal skin in middle with sharp borders

Hearty spores

Clinical diagnosis

KOH prepSlide30
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Tinea

Tinea pedis

Miconazole cream BID – inexpensive

Tx for 2-4 weeks

Consider prophylaxis 1-2x/ wkPrevention: Cool/ absorbent socks

Keep feet dry (after showers/ powders)

Tinea Corporis

1-2 week topical treatment

RTP 3 days topical treatment (consider coverage)

Oral tx for widespread disease Slide32
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Oral Antifungals

N/V/D

HA

Skin complaints

Liver dysfunctionSlide36

Tinea Return to PlaySlide37
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Tinea Versicolor

Hypopigmented, scaly macules to patches

Can be hyperpigmented

KOH Prep – spaghetti and meatballs

Wood’s Lamp: copper-orange

fluorescence

Treatment

2.5% selenium sulfide scrub for 15 min x3 d

Topical or oral antifungals

Ketoconazole 200mg daily for 3 days

Anti-dandruff shampoos, daily for 2 weeks

RTP

Contagiousness is low, no restrictionsSlide39
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Molluscum Contagiosum

Flesh-colored

or pink with central umbilication

Pox virus

Incubation 2-7 weeks

Cryotherapy

Curettage Slide41
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Molluscum Return to PlaySlide43
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Erythrasma

Corynebacterium

minutissium

Dull, red, round plaques – intertriginous areas

Pink/

red

florescence with Wood’s

lamp

Erythromycin 250 QID for 1 wk

Topical e-

mycin

/

clinda

beneficial

Good cleansing and keeping area drySlide45

ErythrasmaSlide46
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Pitted

Keratolysis

of Feet

Small dells on plantar aspect of foot

Hyperhydrosis

and malodorous

Erythromycin 250 QID for 1 wk

Topical e-

mycin

/

clinda

beneficial

Good cleansing and keeping area drySlide48

Risk Factors – Bacterial Skin Infections

Antibiotic use within previous year

Compromised skin integrity

Uncovered Abrasions

Shared fomites

Suboptimal cleanliness

Not showering prior to pool use

Poor hygiene

Inadequate hand washing

Insufficient laundry and environmental sterilizationSlide49
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Scabies

Sarcoptes scabiei

mite

Erythematous burrows in superficial skin

Permetherin 5%

Lindane

Malathion

Ivermectin

Fomite decontamination

RTP – 24 hours after treatmentSlide52
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Pediculosis

Lice

Permetherin 5%

Lindane

MalathionIvermectinFomite decontamination

RTP 24 hours after treatmentSlide54

Mechanical/ Physical Problems

Sunburn – may increase risk of heat illness

Blisters/ Corns

Most common dermatoses in athletes

Blisters:

May be drained, do not unroof

Corns:

Painful collection of hyperkeratosis

Pared w/ scalpel or debride with pumice stone

40%salicylic acid plaster

Wider toe box, metatarsal barsSlide55
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Talon noir

Black heel

Subcorneal petechiae from rapid starting/ stopping

Rupture of capillaries in papillary dermis resulting in hemorrhage in stratum corneum

No treatment neededSlide58
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Jogger’s Nipples

Nipples do not form calluses

Usually from repetitive friction

Tops of synthetic material – especially polyester

Treatment:

Band-Aids

Skin lubeSlide60

Tennis Toe (trail runners, hikers, skiiers

)

Painful subungual hemorrhage (usually to great/ 2nd toe)

Treatment

Rest

Warm soak

DrainageSlide61

Mogul Skier’s Palm

Hypothenar ecchymosis on volar aspect of the

plam

resulting from repetitive planting of ski polesSlide62

Hooking Thumb

Abrasions, hematomas, bullae, denudation, calluses, and subungual hematomas on distal thumb caused by hooking (gripping) barSlide63
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Swimmer’s Shoulder

Erythematous plaque on shoulder resulting from irritation from unshaven face during freestyle swimming

Chafing from wet-suitSlide65

Rower’s Rump

Frictional form of lichen simplex

chronicus

resulting from rowing while sitting on unpadded seatSlide66

Skin Cancer

Cancerous Lesions

Basal cell carcinoma

Squamous cell carcinoma

Malignant melanomaSlide67

Malignant Melanoma

Mnemonic for clinical features

A = asymmetry

B = border irregularity

C = color variation

D = diameter > 6mm

E = elevation above skin surface, EvolutionSlide68

Malignant Melanoma

Changes in following are danger signs

Color

Size

ShapeElevation

Surface

Surrounding skin

Sensation

ConsistencySlide69
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Thank You!