Sports related skin infections position statement and guidelines

Sports Related Skin Infections
Position Statement and Guidelines
National Federation of State High School Association (NFHS)
Sports Medicine Advisory Committee (SMAC)

Skin-related infections in both the community setting and the sports environment
have increased considerably over the past several years. While the majority of
these infections are transmitted through skin-to-skin contact, a significant number
are due to shared equipment, towels, or poor hygiene in general. The NFHS
Sports Medicine Advisory Committee (SMAC) has put forth general guidelines for
the prevention of the spread of theses diseases (See NFHS General Guidelines
for Sports Hygiene, Skin Infections and Communicable Diseases).
The NFHS SMAC recognizes that even if these guidelines are strictly adhered to,
skin infections will continue to occur given the nature of certain sports. For
example, the risk of transmission is much higher in sports with a great deal of
direct skin-to-skin contact such as football and wrestling. Therefore, the NFHS
SMAC has developed specific guidelines for the skin infections most commonly
encountered in sports. The guidelines set forth follow the principles of Universal
Precautions and err in favor of protecting participants in situations where skin-to-
skin contact may occur. Consideration may be given to the particular sport
regarding risk of transmission, but these rules must be strictly adhered to in
sports such as wrestling, football, and basketball where skin to skin contact is
frequent and unavoidable.
Ringworm, Tinea Corporis
These fungal lesions are due to dermatophytes. As they are easily transmissible
the athlete should be treated with an oral or topical antifungal medication for a
minimum of 72 hours prior to participation. Once the lesion is considered to be no
longer contagious it may be covered with a bio occlusive dressing.
Impetigo, Folliculitis, Carbuncle and Furuncle
While these infections may be secondary to a variety of bacteria, they should all
be treated as Methicillin-Resistant Staphylcoccus aureus (MRSA) infections. The
athlete should be removed from practices and competition and treated with oral
antibiotics. Return to contact practices and competition may occur after 72 hours
of treatment providing the infection is resolving.
All lesions are considered infectious until each one has a well-adherent scab
without any drainage or weeping fluids. Once a lesion is no longer considered
infectious, it should be covered with a bio occlusive dressing until complete
resolution. Since nasal colonization of these bacteria is common, treatment with
intranasal topical mupirocin should be considered for recurrent episodes.
All team members should be carefully screened for similar infections. If multiple
athletes are infected, consideration should be given to obtaining nasal cultures of
all teammates. This can identify carriers and allow for targeted treatment with
intranasal mupirocin and daily body washes with a chlorhexidine 4% solution for
at least five days.
Shingles, Cold Sores
These are viral infections which are transmitted by skin-to-skin contact. Lesions
on exposed areas of skin that are not covered by clothing, uniform, or equipment
require the player to be withdrawn from any activity that may result in direct skin-
to-skin contact with another participant. Covering infectious lesions with an
occlussive dressing is not acceptable. Primary outbreaks of shingles and cold
sores require 10-14 days of oral antiviral medications while recurrent outbreaks
require five days of treatment as a minimum treatment time prior to returning to
participation. To be considered “non-contagious,” all lesions must be scabbed
over with no oozing or discharge and no new lesions should have occurred in the
preceding 48 hours.
Herpes Gladiatorum
This skin infection, primarily seen among wrestlers, is caused by Herpes Simplex
Virus Type 1 (HSV-1). The spreading of this virus is strictly skin-to-skin with the
preponderance of the outbreaks developing on the head, face and neck,
reflecting the typical lock-up position. The initial outbreak is characterized by a
raised rash with groupings of 6-10 vesicles (blisters). The skin findings are
accompanied by sore throat, fever, malaise and swollen cervical lymph nodes.
The infected individual should be removed from contact and treated with antiviral
medications. They may return to contact only after all lesions are healed with
well adherent scabs, no new vesicle formation and no swollen lymph nodes near
the affected area. Consideration should be given to prophylactic oral antivirals
for the remainder of the season and each subsequent season.
Recurrent outbreaks usually involve a smaller area of skin, milder systemic
illness and a shorter duration of symptoms. Treatment should include oral
antivirals. If antiviral therapy is initiated, the participant must be held from
wrestling for five days and there should be no swollen lymph nodes near the
affected area. If antivirals are not used, the infected participant may return to
contact only after all lesions are well healed with well adhered scabs, no new
vesicle formation, and no swollen lymph nodes near the affected area. Even
greater consideration should be given to prophylactic antivirals for the remainder
of the current season and each subsequent season when a wrestler has suffered
a recurrent outbreak.
As the HSV-1 may spread prior to vesicle formation, anyone in contact with the
infected individual during the three days prior to the outbreak must be isolated
from any contact activity for eight days and be examined daily for suspicious skin
lesions. To be considered “non-contagious,” all lesions must be scabbed over
with no oozing or discharge and no new lesions should have occurred in the
preceding 48 hours.

Miscellaneous Viral Infections
Molluscum contagiosum and verruca are types of warts that are caused by
viruses, but are not considered highly contagious. Therefore these lesions
require no treatment or restrictions, but should be covered if prone to bleeding
when abraded.
Revised and Approved April 2010


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