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Prevention Key to Reducing Skin Infections in High School Wrestling

By B.J. Anderson, M.D., and Larry Cooper, MS, LAT, ATC on December 21, 2015 hst Print

In recent years, the issue of serious skin infections has come to the forefront in secondary school athletics – particularly in wrestling. It is increasingly more common that news media reference a professional athlete being afflicted with Methicillin-Resistant Staph Aureus (MRSA). This serious problem not only affects professional athletes but also collegiate and high school student-athletes.

Among high school athletes, wrestlers seem to be the most susceptible due to the constant skin-to-skin contact. In wrestling, three common infectious agents are present: Ringworm (Tinea Corporus Gladiatorum), Herpes Gladiatorum and bacterial infections, including MRSA.

Prevention is paramount and must be started at the beginning of the season. Any wrestler with a history of Herpes Gladiatorum, or cold sores, must consider being on preventative antiviral medication starting five days before the season starts and continuing through the season. Studies have shown it significantly reduces the risk of outbreaks and transmission to teammates and opponents. As the season progresses, proper protocol must be in place to prevent outbreaks and transmission to fellow student-athletes and opponents.

Hygienic Principles to Reduce Skin Infections in Wrestling
• Skin checks must be performed every day before practices and meets.
• Any skin infection must be examined and cleared by a health-care professional, in accordance with the wrestling skin form.
• Clean workout gear for each practice, including bags.
• All wrestlers must shower immediately after practice/meets.
• Mats must be cleaned before each practice with appropriate disinfectant.

Coaches and certified athletic trainers (ATCs) must be well-versed in these infectious agents and their appearance. Skin checks are meant to detect these skin lesions before a student-athlete gets on the mat and potentially exposes others. Any suspicious lesion must be evaluated by a health-care professional. If a lesion is present, the student-athlete should be treated in accordance with the NFHS Wrestling Skin Form.
Student-athletes must shower immediately after practice and meets. They should not wait until they get home. A recent study showed that about eight percent of high school wrestlers don’t shower until they get home. That can amount to up to 12 hours that these infectious agents may exist on an athlete’s skin before they attempt to wash them away. This allows plenty of time for these agents to invade the skin and for an infection to develop. At tournaments, showering is also recommended after each match. If this is not feasible, the use of baby wipes has proved beneficial and superior to alcohol-based wipes in reducing skin infections.

Cleaning and disinfecting other pieces of equipment is just as important. Weekly washing of knee pads and cleaning headgear with soap and water or wipes will also help to remove these agents and reduce the risk of infections developing.

Treating and preventing these infections focuses on the aforementioned basic Hygienic Principles. Additional means to treat and control these infectious agents focuses on medications.
Herpes Gladiatorum is one of the skin infections commonly seen in high school wrestlers. It is a viral infection caused by the Herpes Simplex Type-1 (HSV-1) that accounts for more than 40 percent of all skin infections in collegiate wrestling. HSV-1 is an extremely contagious virus with a 30-percent chance that other team members will contract the infection once an outbreak occurs. Unfortunately, only about 10 percent of those affected realize that they actually have the disease, which complicates eradication and increases the spread within the team.

With the potential for lifelong problems, the proper treatment and containment of this disease is paramount. Typically, 10-14 days are needed for the infection to clear, although it may shut down a team for two to three weeks. Since the head, face and neck are involved in more than 70 percent of the outbreaks, the potential for eye involvement is a great concern. Although rare, it can have serious consequences for the student-athlete.

As with cold sores, which are also caused by HSV-1, recurrence is the rule rather than the exception. Commonly brought on by stress of cutting weight, academics, personal issues or a compromised immune system, outbreaks can occur multiple times through the course of a season. Since outbreaks may take up to two weeks to clear, it is obvious that an athlete’s season can be seriously disrupted. Due to the constant close body contact of wrestling, it is easy to understand why this virus spreads so quickly and is difficult to control.

In dealing with HSV-1, treatment requires 10-14 days with a primary outbreak. Recurrent outbreaks require 120 hours of treatment before returning to practice and/or competition. Treating herpes within the athletic arena is different than the non-athletic population. Non-wrestlers use antiviral medication to treat symptoms, whereas in wrestling the treatment focuses on clearance of the virus to prevent transmission to teammates and opponents.

Ringworm, or Tinea Gladiatorum, is primarily due to a dermatophyte called Trichophyton tonsurans and is transmitted primarily by direct skin-to-skin contact. It is a nuisance-type infection that up to 70 percent of these student-athletes get each season. This can be easily treated with topical agents, unless there is scalp involvement. Once in the scalp, it may become a deeper form of infection that requires oral medication and longer treatment time. Complete clearance takes up to 21 days for superficial infections, but guidelines address practical versus adequate treatment. Three days of treatment is adequate, unless there is scalp involvement, which requires oral medications for at least 14 days before allowing the athlete back to practice/competition.

Bacterial infections are typically folliculitis, impetigo and cellulitis. Primarily seen on the extremities and face, they are caused by Staph and Strep organisms. Treatment requires a minimum of three days of oral antibiotics before return to practice/competition. Complications of these infections are usually abscess formation or misdiagnosis. Dynamic changes in an athlete’s progression require the health-care providers to monitor these infections on a daily basis. Abscess development should prompt concern for MRSA. Progression of ‘vesicles’ initially treated as folliculitis may also need re-evaluation for possible herpes. Treatment for MRSA usually requires draining the collection of pus and culturing to verify that proper antibiotics have been prescribed. Antibiotics used for MRSA are different for simple folliculitis, impetigo and cellulitis.
Finally, infections at the end of a season can be disastrous to a young wrestler’s season. For athletes with recurrent tinea infections, there is evidence-based research that shows preventative usage of oral antifungal medication can reduce the risk of developing ringworm. Herpes Gladiatorum is notorious for occurring late in the season, right before the individual tournament that leads to the state championships. A recent study published in the Clinical Journal of Sports Medicine showed that the use of antiviral medication can reduce the risk of contracting herpes and with limited usage has application for these young athletes at this crucial time of their season.

Hopefully, these guidelines will improve the safety of all student-athletes and allow everyone to compete. It is also hopeful that reduced exposure and incidence to these types of skin conditions will promote interest and increase participation levels in wrestling, as well as change the public’s perception of the sport and the often-associated skin conditions.