CLINICAL PRACTICE
Skin infections in high school wrestlers: A nurse practitioner’s guide to diagnosis, treatment, and return to participation Krista R. Estes, DNP, FNP-C (Assistant Professor) University of Colorado, Anschutz Medical Campus, Aurora, Colorado
Keywords Adolescents; sports medicine; clinical decision making; disease; prevention; nurse practitioners; dermatology. Correspondence Krista Estes, DNP, FNP-C, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045. Tel: 303-724-5845; Fax: 303-724-8560 E-mail: [email protected] Received: 12 October 2012; accepted: 25 February 2013 doi: 10.1002/2327-6924.12136
Abstract Purpose: To provide nurse practitioners (NPs) with a current guide for the diagnosis and treatment of high school wrestlers who present with common skin infections and to familiarize NPs with the National Federation of High School Associations Sports Medicine Advisory Committee return to participation guide and medical release form. Data sources: Literature review of evidence-based research, journal articles, and reference texts related to skin lesions and high school wrestlers. Conclusions: High school wrestlers with skin infections present in a variety of clinical settings. Improperly diagnosed and/or managed skin infections have the potential to get worse and continue to spread among teammates. Accurate diagnosis and treatment in combination with the use of a return to participation guide can improve outcomes and return the wrestler to participation sooner. Implications for practice: NPs have a responsibility to accurately diagnose and treat skin lesions in a timely, safe, and efficient manner. In wrestling, athletes are exposed to unique opportunities to develop skin infections. With a working knowledge of the clinical presentation, diagnostic testing, and return to participation recommendations for common skin diseases, spread of skin infections to other wrestlers can be prevented and the athlete can return to play safely.
Nurse practitioners (NPs) diagnose and treat high school wrestlers with skin lesions in a variety of settings. Oftentimes, these athletes have been affected by communicable skin infections, transmitted by either direct or indirect contact with other wrestlers or equipment (Zinder, Basler, Foley, Scarlata, & Vasily, 2010). While many of these skin infections are without complications, if misdiagnosed, infections can worsen and spread among teammates, leading to regional epidemics (Likness, 2011). In addition to potential health implications, the high school wrestler can experience a disruption in their participation in wrestling. With the nature of the sport being both physically and mentally demanding, these athletes are often eager to return to play and many times request a “quick fix” to release them. NPs have a responsibility to diagnose and treat in a timely, safe, and efficient manner in order to prevent the spread of the skin infection to other athletes and return the wrestler to play as soon as possible. The purpose of this article is to provide NPs
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with a current guide for the diagnosis and treatment of high school wrestlers who present with common skin infections and to familiarize the NP with the National Federation of State High School Associations (NFHS) Sports Medicine Advisory Committee (SMAC) return to participation guide and medical release form.
Epidemiology Infectious diseases among wrestlers have been reported for many years. In 1922, Patton reported an epidemic of Chlamydia trachomatis among wrestlers. A later study by Porter and Baughman (1965) analyzed an outbreak of extensive cutaneous herpes infection in seven of 19 wrestlers during a 2-week period at Dartmouth College during the 1964–1965 wrestling season. A national survey of athletic trainers indicated that 7.6% of college wrestlers and 2.6% of high school wrestlers had a herpes simplex virus skin infection
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during the 1984–1985 wrestling season (Becker et al., 2008). The incidence of skin-related infections in high school athletes has increased substantially over the past several years (NFHS SMAC, 2010a). Wrestling community awareness increased, when the national news reported a 17-year-old high school wrestler died from complications of methicillin-resistant Staphylococcus aureus (MRSA) after returning from a wrestling camp (Stallworth, 2008). According to the NFHS high school athletics participation survey, 281,083 boys and girls participated in the sport of wrestling in 2010–2011 (NFHS, n.d.). The 2009– 2010 National High School Sports-Related Injury Surveillance Study reported that 7% of wrestlers in competition and 8% in practice had skin infections (Comstock, Collins, & McIlvan, n.d.). The most common mode of infectious disease transmission in competitive sports is skinto-skin contact (Turbeville, Cowan, & Ronald, 2006). In a small surveillance study of skin infections among high school wrestlers, impetigo (30%), herpes simplex (20%), and tinea corporis (20%) were found to be the most prevalent (Yard, Collins, Dick, & Comstock, 2008), while a larger study in Minnesota found impetigo to represent 18% of skin infections and tinea corporis 71% (Anderson, 2008). The majority of these skin infections were noted to be on the head, face, neck, and arms, which reflects the lock-up position and skin-to-skin contact of wrestlers (Yard et al., 2008).
Skin infections in wrestlers Three of the most common skin infections in high school wrestlers are impetigo, herpes simplex, and tinea corporis. The incidence and awareness of MRSA is increasing among the sport of wrestling. The following outlines the background, clinical presentation, diagnostic testing, plan, and recommendations for return to wrestling for these four skin infections. Table 1 provides a summary of the NFHS SMAC minimum return to participation recommendations for skin lesions.
Impetigo Background. Impetigo is one of the most commonly reported skin infections found in athletes (Adams, 2010). It is a highly contagious superficial bacterial infection of the skin most commonly caused by either S. aureus or Streptococcus pyogenes, sometimes both. Predisposing factors include breaks in the skin, warm climates, and poor hygiene (Cash & Glass, 2011). In wrestling, it is not uncommon for minor skin trauma to develop into a secondary infection with impetigo. While impetigo usually
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does not have complications, in rare cases, poststreptococcal glomerulonephritis can occur (Pecci, Comeau, & Chawla, 2009). Clinical presentation. The two common types of impetigo are bullous and nonbullous. Nonbullous impetigo starts as a single, small red macule or papule that quickly becomes a vesicle. Erosions then form after the vesicles rupture and the fluid dries to form a honey-colored crust. Bullous impetigo typically begins with superficial vesicles that enlarge quickly to form flaccid bullae with sharp margins. Yellow crusts with oozing result after the bullae rupture (Cole & Gazewood, 2007). A common symptom of both bullous and nonbullous impetigo is pruritus (Dunphy, Winland-Brown, Porter, & Thomas, 2011). The athlete may or may not complain of pain (Pecci et al., 2009). Diagnostic testing. In most cases, impetigo is a clinical diagnosis. Usually, diagnostic testing is not necessary except in cases of questionable lesions, reoccurrence, or resistance to treatment. A culture and sensitivity from the moist crusts of the lesions can help confirm the diagnosis (Cash & Glass, 2011). Plan. The treatment of impetigo relies on both general interventions and pharmacologic therapy. Athletes should be instructed to expose the skin surfaces where bacteria are present by washing them with antibacterial soap three to four times daily to gently remove the crusted lesions. This makes topical pharmacologic interventions more efficacious by improving drug absorption (Cash & Glass, 2011; Dunphy et al., 2011). In many mild cases, nonbullous impetigo can be treated with a topical antibiotic such as mupirocin. For bullous impetigo (or when symptoms are more severe, resistant, and/or systemic), the use of an oral antistaphylococcal antibiotic such as cephalexin should be considered. In cases in which MRSA is suspected, retapamulin topical ointment (Dunphy et al., 2011) and/or an oral antibiotic such as doxycycline, minocycline, or trimethoprimsulfamethoxazole is a consideration (Adams, 2010). Although penicillin has been used in the past as the standard treatment for impetigo, this is no longer the primary treatment of choice because of increasing resistance (Dunphy et al., 2011).
Recommendations for returning to wrestling. According to NFHS SMAC (2012), impetigo is “noncontagious” when all lesions are scabbed over and dry. There should no longer be any oozing or discharge and for at least 48 h there should be no new lesions present. Antibiotic treatment for at least 72 h is considered minimum to achieve this. If after 72 h of treatment new lesions and drainage continue to appear, other diagnoses such as MRSA or herpes gladiatorum should be considered. 5
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Table 1 Summary of NFHS SMAC minimum return to participation recommendations for skin lesions in high school wrestlers Skin lesion
Minimum requirements for treatment prior to returning to wrestling
Impetigo (MRSA not suspected)
Considered noncontagious when Lesions scabbed over with no drainage No new lesions for at least 48 h (Note. Antibiotic treatment for ࣙ72 h minimum to achieve these criteria) Lesions scabbed over with no drainage No new lesions for ࣙ48 h (In addition to general requirements): Treatment and no participation for 10 days If systemic symptoms present, extend to 14 days (In addition to general requirements): Treatment for at least 5 full days Treatment for ࣙ72 h Lesions scabbed over with no drainage No new lesions for ࣙ48 h Treatment for ࣙ10 days or until all lesions scabbed over (whichever occurs last)
Herpes Gladiatorum: General Herpes Gladiatorum: First episode Herpes Gladiatorum: Recurrence Tinea corporis MRSA
Adapted from NFHS SMAC 2012 Medical Release form for Wrestler to Participate with Skin Lesions (http://www.cifccs.org/nfhs/20112012%20April%20WR%20Skin%20Form.pdf).
Herpes simplex Background. Herpes simplex type-1 (HSV-1) is a viral infection of the skin that typically presents with vesicular lesions most commonly on the lips or mouth (Cash & Glass, 2011). When HSV results from wrestling, the condition is referred to as herpes gladiatorum. In the past, it has been estimated that 2.6% of high school age wrestlers were affected by this virus, but more recent data suggest 29.8% may actually be affected (NFHS SMAC, 2007). Estimates are that only 2%–3% of wrestlers are aware they have herpes gladiatorum and they continue to participate in the sport, unknowingly exposing others (NFHS SMAC, 2007). The incubation time from initial skin-toskin exposure to vesicle eruption averages 3–5 days; however, the incubation period can range from 2 and 20 days (Fatahzadeh & Schwartz, 2007). Viral shedding occurs prior to vesicle formation, therefore the virulence of this condition can be very high. For example, the contraction of this virus was found to be as high as 32.7% from a wrestler with an active outbreak (Anderson, 2003). Herpes gladiatorum occurs mostly on the head, face, and neck through skin-to-skin contact (Jaworski, Donohue, & Kluetz, 2011). Recurrent herpes gladiatorum can develop around the eye, which has the potential for the serious consequence of the athlete’s visual acuity being affected. Unfortunately, wrestlers who contract this virus have the potential to suffer reoccurrences throughout his or her life and potentially can spread the virus to others (NHFS SMAC, 2007). Clinical presentation. Usually with a primary outbreak, symptoms such as tingling, burning, and stinging may occur prior to lesion eruption. Then, raised vesic6
ular lesions with clear fluid on an erythematous base merge into groupings. These vesicles may rupture forming crusted plaques or moist ulcers (Pecci et al., 2009). With a first time outbreak, other symptoms may include sore throat, fever, swollen cervical lymph nodes, and malaise. With reoccurrence, a smaller area is usually involved and the athlete usually experiences less systemic signs and for a shorter duration (NHFS SMAC, 2007). Diagnostic testing. In one study analyzing several outbreaks of herpes gladiatorum, the virus was often initially misdiagnosed as folliculitis (Anderson, 2003). With its highly contagious nature, it is important to accurately diagnose these wrestlers at their initial visit to avoid further spread to others. A Tzanck smear from a freshly deroofed vesicle is the most inexpensive and rapid diagnostic test (Pecci et al., 2009). However, a culture of lesion scrapings is the most conclusive test, but the results may take days (Zinder et al., 2010). Plan. If the athlete presents with new, active lesions, oral antivirals are the mainstay of treatment as they shorten the duration of illness and decrease the chance of transmission. However, if the lesions are fully formed, ruptured, and crusted over, these lesions are usually unaffected by antiviral medication (Zinder et al., 2010). Topical antiviral medications are not recommended for wrestlers, primarily because it requires frequent daily dosing and compliance is usually poor. Additionally, many studies do not support the ability of topical antivirals to consistently reduce transmission and viral shedding (Anderson, 2008). The NFHS SMAC (2007) recommends the consideration of prophylactic antiviral dosing to help reduce the reoccurrence of outbreaks. For healthcare providers
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treating these athletes, concerns regarding prophylactic antivirals exist because of inconsistent benefits, the potential risks, and possible development of resistance (NFHS SMAC, 2007).
Recommendations for returning to wrestling. Because the virus can spread before vesicles are present, a proactive approach is important for containment. According to the NFHS SMAC (2007), once an outbreak occurs on a wrestling team, it is important to remove the affected athlete from the team to avoid further spread. It is recommended that all wrestlers who were in contact with the affected individual within 3 days from the appearance of the vesicle, be thoroughly examined and continuously monitored for up to 8 days for suspicious lesions. When the occurrence of a primary outbreak involving multiple teams in Minnesota occurred, an 8-day isolation period contained the outbreak in more than 90% of exposed individuals (Anderson, 2008). Therefore, removal of wrestlers from contact during this period of virulence should be strongly considered (NFHS SMAC, 2007). The NFHS SMAC (2012) describes the “noncontagious” wrestler as one who has all of the existing lesions scabbed over with absolutely no discharge or oozing and no new lesions for at least 48 h. For first outbreaks of herpes gladiatorum, wrestlers should be treated with oral antivirals for at least 10 days prior to being able to participate. He or she must be free of any systemic symptoms (fever, lymphadenopathy, malaise, etc.). If these are still present, the minimum period of treatment should be extended to at least 14 days. With recurrent outbreaks, the athlete must have completed at least five full days of oral antiviral treatment and all lesions must be covered by a firm, adherent scab (NFHS SMAC, 2012).
Tinea corporis Background. Tinea corporis, otherwise known as “ringworm,” is a superficial fungal infection commonly seen on the face, extremities, and trunk of wrestlers (Cash & Glass, 2011). Tinea corporis gladiatorum describes the presence of this fungal infection in wrestlers (Dunphy et al., 2011). Factors that increase the chance of infection include moist, warm climates, participation in close contact sports, excessive sweating, and poor air circulation (Cash & Glass, 2011). Tinea corporis gladiatorum epidemics have been reported to affect up to 77% of a wrestling team (Adams, 2002). In most cases, Trichophyton tonsurans is the causative organism. Interestingly, this organism is usually responsible for tinea capitis infections (Adams, 2010). Clinical presentation. The athlete often presents with an annular, erythematous plaque, which is well de-
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marcated and scaly with hypopigmentation in the center. He or she may complain of pruritis, although sometimes they are asymptomatic. The size of the lesion can range from small to large and can vary in number from one to multiple (Dunphy et al., 2011). A particular challenge of tinea corporis gladiatorum is the varying appearance with the age of the lesion. Early lesions may present with a nonspecific erythematous papules like other skin infections seen with wrestlers, such as impetigo and herpes gladiatorum (Adams, 2010). Diagnostic testing. While tinea corporis gladiatorum is mostly diagnosed by clinical presentation, there are options to confirm the diagnosis, especially if an athlete presents early in the course of the disease and the diagnosis is questionable. A diagnosis can be confirmed by scraping the lesion border and performing potassium hydroxide (KOH) microscopy. Alternatively, a fungal culture can be obtained, which can require up to 2 weeks for results. While the results of a KOH preparation are more immediate, a culture is a more definitive test (Zinder et al., 2010). Fungal cultures are generally recommended when the provider is unsure of the diagnosis or in cases of treatment failure (Dunphy et al., 2011). Plan. Topical antifungal agents should be applied once or twice daily until no further infection is visible. It is recommended that the athlete continue antifungal topical application, extending application a few centimeters beyond the edges of the lesion, for 1 week after the visual appearance of the lesion has resolved. In more severe cases, systemic antifungals should be considered (Dunphy et al., 2011). Brickman, Einstein, Sinha, Ryno, and Guiness (2009) evaluated the use of prophylactic fluconazole in reducing the incidence of tinea gladiatorum in 373 high school wrestlers. Over the course of 10 years, the incidence of tinea gladiatorum dropped from 67.4% to 3.5%. While prophylactic pharmacologic treatment with fluconazole has shown a decreased prevalence of tinea gladiatorum in wrestlers, these drugs have significant medication interactions and the potential for hepatic side effects (Adams, 2010).
Recommendations for returning to wrestling. The NFHS SMAC (2012) recommends oral or topical treatment for 72 h for skin lesions prior to returning to wrestling participation. According to the National Athletic Trainers’ Association Position Statement, it is recommended that lesions be adequately covered with a gas permeable membrane during participation after use of the topical fungicide for at least 72 h (Zinder et al., 2010).
Methicillin-resistant S. aureus Background. Staphylococcus aureus is a bacteria commonly carried on the skin or in the nose of healthy 7
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people. While S. aureus can colonize in human hosts without causing disease, infections with both methicillinsensitive S. aureus (MSSA) and antimicrobial-resistant strains such as MRSA, are a growing health concern among wrestling athletes. The Centers for Disease Control and Prevention (CDC) estimated that 25% to 30% of the population is colonized with S. aureus, with approximately 1% colonized with MRSA (CDC, 2010). Yearly, it is estimated that S. aureus skin infections account for approximately 12 million office visits. More than half of these skin infections are likely caused by MRSA (CDC, 2011). A study evaluating populationbased estimates of MRSA infections among Nebraska high school athletes from 2006 to 2008 showed an increase in MRSA incidence from 19.6 to 60.1 per 10,000 wrestlers (Buss, Mueller, Theis, Keyser, & Safranek, 2009). Improperly treated MRSA skin and soft tissue infections can progress from a mild, superficial infection, to a deeper soft tissue abscess. Complications can require admission to the hospital for surgical incision and drainage (I&D) and the administration of intravenous antibiotics (Gorwitz, Jernigan, Powers, & Jernigan, 2006). Clinical presentation. The appearance of MRSA and MSSA is similar and will typically appear in the form of abscesses, furuncles, and carbuncles. They are often described by athletes as a “spider” or “insect” bite. Skin lesions are typically red, swollen, painful, warm, and fluctuant to the touch, contain pus or other fluid, and at times are accompanied by a fever or other systemic symptoms (CDC, 2011). Cellulitis can surround the abscess on some occasions (Pecci et al., 2009). It is important to recognize that at presentation, MSSA and MRSA can resemble other clinical conditions such as folliculitis, impetigo, and cellulitis (Adams, 2010). Diagnostic testing. It is recommended that a culture be obtained in all wrestlers with abscesses and other purulent skin and soft tissue infections when they meet one or more of the following criteria: antibiotics will be used, severe local infection or signs of systemic illness are present, failure to respond to initial treatment, and if there is concern for an outbreak (Liu et al., 2011). Culture and sensitivity results help to establish local prevalence of S. aureus and susceptibility to antimicrobials (Gorwitz et al., 2006). Plan. If an immunocompetent athlete presents with a simple cutaneous abscess without surrounding cellulitis, I&D alone is the treatment of choice (Liu et al., 2011; Pecci et al., 2009). Clinical judgment should be used to assess whether the lesion is purulent or not. The decision to complement I&D with an antimicrobial is controversial. Antibiotics should be considered when the abscess is associated with severe or widespread dis8
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ease; has quick progression with the association of cellulitis or septic phlebitis; when systemic symptoms are present; if the patient has comorbidities or immunosuppression; if the abscess is difficult to fully drain; and if the athlete fails to respond to I&D alone. Should the wrestler require oral antibiotics and MRSA is suspected or confirmed, options include clindamycin, trimethoprimsulfamethoxazole, doxycycline, minocycline, and linezolid (Liu et al., 2011). Antibiotic choice should be guided by local susceptibility data.
Recommendations for returning to wrestling. NFHS SMAC (2012) considers athletes “non-contagious” if the lesion is scabbed over with no oozing or discharge and there is no new development of a lesion for at least 48 h. If the wrestler is placed on antibiotics, he or she should be treated for 10 days before returning to wrestling or until all lesions are scabbed over (whichever occurs last). Because most abscesses are not complicated and do not require oral antibiotics, when the lesion is dry, most athletes can return to play (Pecci et al., 2009). The National Athletic Trainers’ Association Position Statement on Skin Diseases recommends that all athletes with suspected skin lesions be isolated from other team members (Zinder et al., 2010).
Return to participation guide and medical release form The NFHS SMAC addresses skin infections in wrestlers. Unlike many other sports, the nature of wrestling requires significant contact with an opponent and equipment (e.g., mats, benches, and weight lifting equipment), thus the risk of transmission is high and the sport requires its own guideline and protocol (NFHS SMAC, 2010a). With the increased outbreaks of MRSA and other skin lesions among wrestlers, the NFHS SMAC has developed a medical release form for healthcare providers to utilize when a wrestler presents with a skin lesion. This form is reproducible and can be edited to meet the needs of the individual or institution. The 2012–2013 NFHS Medical Release Form for Wrestler to Participate with Skin Lesion(s) (http://www.cifccs.org/nfhs/2011–2012%20April%20 WR%20Skin%20Form.pdf) was developed and modified after surveying specialty, academic, public health, and primary care physicians. The goals of this medical release form are to protect wrestlers from communicable skin infections, reduce missed sports participation, decrease practice variation among healthcare professionals, and provide support to the healthcare provider’s decision on his or her recommendation for return to play. This form outlines minimum criteria for clearance to participate in wrestling (NFHS SMAC, 2012). As with any
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medical release form, it is up to the NP to use clinical judgment in the application of the information. When a diagnosis is uncertain, use of conservative treatment (such as a recommendation for longer period for return to participation) is rational (Likness, 2011). When determining return to participation, NPs should take into consideration NFHS rules. According to rule 4-2-3, if the coach or referee suspects a wrestler to have a communicable skin disease at weigh-in, a current written document (as defined by the NFHS or the state associations) from a healthcare professional must be submitted stating that the condition is not communicable or harmful to others. NFHS rule 4-2-4 says that designated onsite meet healthcare professionals can overrule the diagnosis of the healthcare professional who had signed the medical release form. Lastly, NFHS rule 4-25 states that a wrestler may have documentation from a healthcare professional indicating a noncommunicable skin condition. This documentation is good for the duration of the current wrestling season with the caveat that if the skin condition becomes infected their status will require reevaluation. Noncommunicable skin lesions (i.e., birthmarks, eczema, and psoriasis) can be covered to allow participation. Covering a contagious skin lesion is not an option for participation (NFHS SMAC, 2012). Accurately completing the NFHS SMAC medical release form provides detailed documentation for treatment and follow-up. The date and recommended treatment needs to be clearly written, as well as noting the earliest date a wrestler can return to active participation. Identified lesions need to be clearly marked on the “bodygram” in nonblack ink. Writing the number of lesions and location helps to identify the development of new lesions. The NFHS SMAC gives permission for organizations or individuals to reproduce or edit the medical release form. Variability may exist between forms and as to which healthcare professional can sign the form (NFHS SMAC, 2012).
Prevention Education is an essential component to decreasing reoccurrence and further spread of skin infections to others. Wrestlers need to be aware of the signs of skin infections and educated to advise their coach at the first sign of a skin lesion, so they can receive timely treatment. The NFHS SMAC general guideline for sports hygiene, skin infections, and communicable diseases outlines a universal hygiene protocol. This protocol provides five components (listed below) for high school athletes to minimize the spread of communicable skin infections.
r r r r r
Showering immediately after every competition and practice. Washing all workout clothing after each practice or competition. Weekly washings of all personal gear. No sharing of towels or personal hygiene products. Avoiding full body shaving.
In addition to universal hygiene precautions, the NFHS SMAC outlines additional strategies to reduce exposure to infectious skin diseases including (a) notification of a parent or guardian, athletic trainer and coach of any skin lesion prior to competition or practice, (b) evaluation of any skin lesion by a qualified healthcare provider prior to return to practice or competition, (c) evaluation of all members of a team if an outbreak occurs of any skin infection, and (d) adherence to NFHS or state/local guidelines on return to participation recommendations by coaches, officials, and appropriate healthcare professionals (NFHS SMAC, 2010b).
Conclusion NPs frequently encounter high school wrestlers with skin infections. The diagnosis of these skin infections can be challenging. It is important to have a good working knowledge of the clinical presentation of common skin diseases seen in wrestlers and diagnostic testing available in order to accurately diagnose and treat their condition in a timely manner. Using a guide, such as the NFHS Medical Release Form for Wrestler to Participate with Skin Lesion(s), provides the NP with a guide to support his or her recommendation for return to participation. This guide provides minimum criteria for clearance and it is imperative to balance clinical judgment with treatment. By accurately diagnosing skin infections in wrestlers early, further spread to other athletes can be minimized, potential health complications can be reduced, and the wrestler can return to participation sooner.
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Brickman, K., Einstein, E., Sinha, S., Ryno, J., & Guiness, M. (2009). Fluconazole as a prophylactic measure for tinea gladiatorum in high school wrestlers. Clinical Journal of Sports Medicine, 19(5), 412–414. Buss, B., Mueller, S., Theis, M., Keyser, A., & Safranek, T. (2009). Population-based estimates of methicillin-resistant Staphylococcus aureus (MRSA) infections among high school athletes—Nebraska, 2006–2008. Journal of School Nursing, 25(4), 282–291. Cash, J. C., & Glass, C. A. (2011). Family practice guidelines (2nd ed.). New York, NY: Springer. Centers for Disease Control and Prevention (CDC). (2010). Definition of MRSA. Retrieved from http://www.cdc.gov/mrsa/definition/index.html Centers for Disease Control and Prevention (CDC). (2011). Recognize and prevent MRSA infections. Retrieved from http://www.cdc.gov/features/ mrsainfections Cole, C., & Gazewood, J. (2007). Diagnosis and treatment of impetigo. American Family Physician, 75(6), 859–864. Comstock, D., Collins, C., & McIlvan, N. (n.d.). National high school sports-related injury surveillance study: 2009–2010 school year. Retrieved from http://www.nationwidechildrens.org/Document/Get/103354 Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011). Primary care: The art and science of advanced practice nursing (3rd ed.). Philadelphia: F.A. Davis. Fatahzadeh, M., & Schwartz, R. (2007). Human herpes simplex virus infections: Epidemiology, pathogenesis, symptomatology, diagnosis, and management. Journal of the American Academy of Dermatology, 57, 737–763. Gorwitz, R., Jernigan, D., Powers, J., Jernigan, J., & Participants in the CDC Convened Experts’ Meeting on Management of MRSA in the Community. (2006). Strategies for clinical management of MRSA in the community: Summary of an experts’ meeting convened by the centers for disease control and prevention. Retrieved from http://www.cdc.gov/mrsa/pdf/MRSA-StrategiesExpMtgSummary-2006.pdf Jaworski, C., Donohue, B., & Kluetz, J. (2011). Infectious disease. Clinical Journal of Sports Medicine, 30, 575–590. Likness, L. (2011). Common dermatologic infections in athletes and return-to-play guidelines. Journal of the American Osteopathic Association, 111(6), 373–379. Liu, C., Bayer, A., Cosgrove, S., Daum, R., Fridkin, S., Gorwitz, R., . . . Chambers, H. (2011). Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus
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Skin infections in high school wrestlers: A nurse practitioner’s guide to diagnosis, treatment, and return to participation Krista R. Estes, DNP, FNP-C (Assistant Professor) University of Colorado, Anschutz Medical Campus, Aurora, Colorado
Keywords Adolescents; sports medicine; clinical decision making; disease; prevention; nurse practitioners; dermatology. Correspondence Krista Estes, DNP, FNP-C, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045. Tel: 303-724-5845; Fax: 303-724-8560 E-mail: [email protected] Received: 12 October 2012; accepted: 25 February 2013 doi: 10.1002/2327-6924.12136
Abstract Purpose: To provide nurse practitioners (NPs) with a current guide for the diagnosis and treatment of high school wrestlers who present with common skin infections and to familiarize NPs with the National Federation of High School Associations Sports Medicine Advisory Committee return to participation guide and medical release form. Data sources: Literature review of evidence-based research, journal articles, and reference texts related to skin lesions and high school wrestlers. Conclusions: High school wrestlers with skin infections present in a variety of clinical settings. Improperly diagnosed and/or managed skin infections have the potential to get worse and continue to spread among teammates. Accurate diagnosis and treatment in combination with the use of a return to participation guide can improve outcomes and return the wrestler to participation sooner. Implications for practice: NPs have a responsibility to accurately diagnose and treat skin lesions in a timely, safe, and efficient manner. In wrestling, athletes are exposed to unique opportunities to develop skin infections. With a working knowledge of the clinical presentation, diagnostic testing, and return to participation recommendations for common skin diseases, spread of skin infections to other wrestlers can be prevented and the athlete can return to play safely.
Nurse practitioners (NPs) diagnose and treat high school wrestlers with skin lesions in a variety of settings. Oftentimes, these athletes have been affected by communicable skin infections, transmitted by either direct or indirect contact with other wrestlers or equipment (Zinder, Basler, Foley, Scarlata, & Vasily, 2010). While many of these skin infections are without complications, if misdiagnosed, infections can worsen and spread among teammates, leading to regional epidemics (Likness, 2011). In addition to potential health implications, the high school wrestler can experience a disruption in their participation in wrestling. With the nature of the sport being both physically and mentally demanding, these athletes are often eager to return to play and many times request a “quick fix” to release them. NPs have a responsibility to diagnose and treat in a timely, safe, and efficient manner in order to prevent the spread of the skin infection to other athletes and return the wrestler to play as soon as possible. The purpose of this article is to provide NPs
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with a current guide for the diagnosis and treatment of high school wrestlers who present with common skin infections and to familiarize the NP with the National Federation of State High School Associations (NFHS) Sports Medicine Advisory Committee (SMAC) return to participation guide and medical release form.
Epidemiology Infectious diseases among wrestlers have been reported for many years. In 1922, Patton reported an epidemic of Chlamydia trachomatis among wrestlers. A later study by Porter and Baughman (1965) analyzed an outbreak of extensive cutaneous herpes infection in seven of 19 wrestlers during a 2-week period at Dartmouth College during the 1964–1965 wrestling season. A national survey of athletic trainers indicated that 7.6% of college wrestlers and 2.6% of high school wrestlers had a herpes simplex virus skin infection
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during the 1984–1985 wrestling season (Becker et al., 2008). The incidence of skin-related infections in high school athletes has increased substantially over the past several years (NFHS SMAC, 2010a). Wrestling community awareness increased, when the national news reported a 17-year-old high school wrestler died from complications of methicillin-resistant Staphylococcus aureus (MRSA) after returning from a wrestling camp (Stallworth, 2008). According to the NFHS high school athletics participation survey, 281,083 boys and girls participated in the sport of wrestling in 2010–2011 (NFHS, n.d.). The 2009– 2010 National High School Sports-Related Injury Surveillance Study reported that 7% of wrestlers in competition and 8% in practice had skin infections (Comstock, Collins, & McIlvan, n.d.). The most common mode of infectious disease transmission in competitive sports is skinto-skin contact (Turbeville, Cowan, & Ronald, 2006). In a small surveillance study of skin infections among high school wrestlers, impetigo (30%), herpes simplex (20%), and tinea corporis (20%) were found to be the most prevalent (Yard, Collins, Dick, & Comstock, 2008), while a larger study in Minnesota found impetigo to represent 18% of skin infections and tinea corporis 71% (Anderson, 2008). The majority of these skin infections were noted to be on the head, face, neck, and arms, which reflects the lock-up position and skin-to-skin contact of wrestlers (Yard et al., 2008).
Skin infections in wrestlers Three of the most common skin infections in high school wrestlers are impetigo, herpes simplex, and tinea corporis. The incidence and awareness of MRSA is increasing among the sport of wrestling. The following outlines the background, clinical presentation, diagnostic testing, plan, and recommendations for return to wrestling for these four skin infections. Table 1 provides a summary of the NFHS SMAC minimum return to participation recommendations for skin lesions.
Impetigo Background. Impetigo is one of the most commonly reported skin infections found in athletes (Adams, 2010). It is a highly contagious superficial bacterial infection of the skin most commonly caused by either S. aureus or Streptococcus pyogenes, sometimes both. Predisposing factors include breaks in the skin, warm climates, and poor hygiene (Cash & Glass, 2011). In wrestling, it is not uncommon for minor skin trauma to develop into a secondary infection with impetigo. While impetigo usually
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does not have complications, in rare cases, poststreptococcal glomerulonephritis can occur (Pecci, Comeau, & Chawla, 2009). Clinical presentation. The two common types of impetigo are bullous and nonbullous. Nonbullous impetigo starts as a single, small red macule or papule that quickly becomes a vesicle. Erosions then form after the vesicles rupture and the fluid dries to form a honey-colored crust. Bullous impetigo typically begins with superficial vesicles that enlarge quickly to form flaccid bullae with sharp margins. Yellow crusts with oozing result after the bullae rupture (Cole & Gazewood, 2007). A common symptom of both bullous and nonbullous impetigo is pruritus (Dunphy, Winland-Brown, Porter, & Thomas, 2011). The athlete may or may not complain of pain (Pecci et al., 2009). Diagnostic testing. In most cases, impetigo is a clinical diagnosis. Usually, diagnostic testing is not necessary except in cases of questionable lesions, reoccurrence, or resistance to treatment. A culture and sensitivity from the moist crusts of the lesions can help confirm the diagnosis (Cash & Glass, 2011). Plan. The treatment of impetigo relies on both general interventions and pharmacologic therapy. Athletes should be instructed to expose the skin surfaces where bacteria are present by washing them with antibacterial soap three to four times daily to gently remove the crusted lesions. This makes topical pharmacologic interventions more efficacious by improving drug absorption (Cash & Glass, 2011; Dunphy et al., 2011). In many mild cases, nonbullous impetigo can be treated with a topical antibiotic such as mupirocin. For bullous impetigo (or when symptoms are more severe, resistant, and/or systemic), the use of an oral antistaphylococcal antibiotic such as cephalexin should be considered. In cases in which MRSA is suspected, retapamulin topical ointment (Dunphy et al., 2011) and/or an oral antibiotic such as doxycycline, minocycline, or trimethoprimsulfamethoxazole is a consideration (Adams, 2010). Although penicillin has been used in the past as the standard treatment for impetigo, this is no longer the primary treatment of choice because of increasing resistance (Dunphy et al., 2011).
Recommendations for returning to wrestling. According to NFHS SMAC (2012), impetigo is “noncontagious” when all lesions are scabbed over and dry. There should no longer be any oozing or discharge and for at least 48 h there should be no new lesions present. Antibiotic treatment for at least 72 h is considered minimum to achieve this. If after 72 h of treatment new lesions and drainage continue to appear, other diagnoses such as MRSA or herpes gladiatorum should be considered. 5
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Table 1 Summary of NFHS SMAC minimum return to participation recommendations for skin lesions in high school wrestlers Skin lesion
Minimum requirements for treatment prior to returning to wrestling
Impetigo (MRSA not suspected)
Considered noncontagious when Lesions scabbed over with no drainage No new lesions for at least 48 h (Note. Antibiotic treatment for ࣙ72 h minimum to achieve these criteria) Lesions scabbed over with no drainage No new lesions for ࣙ48 h (In addition to general requirements): Treatment and no participation for 10 days If systemic symptoms present, extend to 14 days (In addition to general requirements): Treatment for at least 5 full days Treatment for ࣙ72 h Lesions scabbed over with no drainage No new lesions for ࣙ48 h Treatment for ࣙ10 days or until all lesions scabbed over (whichever occurs last)
Herpes Gladiatorum: General Herpes Gladiatorum: First episode Herpes Gladiatorum: Recurrence Tinea corporis MRSA
Adapted from NFHS SMAC 2012 Medical Release form for Wrestler to Participate with Skin Lesions (http://www.cifccs.org/nfhs/20112012%20April%20WR%20Skin%20Form.pdf).
Herpes simplex Background. Herpes simplex type-1 (HSV-1) is a viral infection of the skin that typically presents with vesicular lesions most commonly on the lips or mouth (Cash & Glass, 2011). When HSV results from wrestling, the condition is referred to as herpes gladiatorum. In the past, it has been estimated that 2.6% of high school age wrestlers were affected by this virus, but more recent data suggest 29.8% may actually be affected (NFHS SMAC, 2007). Estimates are that only 2%–3% of wrestlers are aware they have herpes gladiatorum and they continue to participate in the sport, unknowingly exposing others (NFHS SMAC, 2007). The incubation time from initial skin-toskin exposure to vesicle eruption averages 3–5 days; however, the incubation period can range from 2 and 20 days (Fatahzadeh & Schwartz, 2007). Viral shedding occurs prior to vesicle formation, therefore the virulence of this condition can be very high. For example, the contraction of this virus was found to be as high as 32.7% from a wrestler with an active outbreak (Anderson, 2003). Herpes gladiatorum occurs mostly on the head, face, and neck through skin-to-skin contact (Jaworski, Donohue, & Kluetz, 2011). Recurrent herpes gladiatorum can develop around the eye, which has the potential for the serious consequence of the athlete’s visual acuity being affected. Unfortunately, wrestlers who contract this virus have the potential to suffer reoccurrences throughout his or her life and potentially can spread the virus to others (NHFS SMAC, 2007). Clinical presentation. Usually with a primary outbreak, symptoms such as tingling, burning, and stinging may occur prior to lesion eruption. Then, raised vesic6
ular lesions with clear fluid on an erythematous base merge into groupings. These vesicles may rupture forming crusted plaques or moist ulcers (Pecci et al., 2009). With a first time outbreak, other symptoms may include sore throat, fever, swollen cervical lymph nodes, and malaise. With reoccurrence, a smaller area is usually involved and the athlete usually experiences less systemic signs and for a shorter duration (NHFS SMAC, 2007). Diagnostic testing. In one study analyzing several outbreaks of herpes gladiatorum, the virus was often initially misdiagnosed as folliculitis (Anderson, 2003). With its highly contagious nature, it is important to accurately diagnose these wrestlers at their initial visit to avoid further spread to others. A Tzanck smear from a freshly deroofed vesicle is the most inexpensive and rapid diagnostic test (Pecci et al., 2009). However, a culture of lesion scrapings is the most conclusive test, but the results may take days (Zinder et al., 2010). Plan. If the athlete presents with new, active lesions, oral antivirals are the mainstay of treatment as they shorten the duration of illness and decrease the chance of transmission. However, if the lesions are fully formed, ruptured, and crusted over, these lesions are usually unaffected by antiviral medication (Zinder et al., 2010). Topical antiviral medications are not recommended for wrestlers, primarily because it requires frequent daily dosing and compliance is usually poor. Additionally, many studies do not support the ability of topical antivirals to consistently reduce transmission and viral shedding (Anderson, 2008). The NFHS SMAC (2007) recommends the consideration of prophylactic antiviral dosing to help reduce the reoccurrence of outbreaks. For healthcare providers
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treating these athletes, concerns regarding prophylactic antivirals exist because of inconsistent benefits, the potential risks, and possible development of resistance (NFHS SMAC, 2007).
Recommendations for returning to wrestling. Because the virus can spread before vesicles are present, a proactive approach is important for containment. According to the NFHS SMAC (2007), once an outbreak occurs on a wrestling team, it is important to remove the affected athlete from the team to avoid further spread. It is recommended that all wrestlers who were in contact with the affected individual within 3 days from the appearance of the vesicle, be thoroughly examined and continuously monitored for up to 8 days for suspicious lesions. When the occurrence of a primary outbreak involving multiple teams in Minnesota occurred, an 8-day isolation period contained the outbreak in more than 90% of exposed individuals (Anderson, 2008). Therefore, removal of wrestlers from contact during this period of virulence should be strongly considered (NFHS SMAC, 2007). The NFHS SMAC (2012) describes the “noncontagious” wrestler as one who has all of the existing lesions scabbed over with absolutely no discharge or oozing and no new lesions for at least 48 h. For first outbreaks of herpes gladiatorum, wrestlers should be treated with oral antivirals for at least 10 days prior to being able to participate. He or she must be free of any systemic symptoms (fever, lymphadenopathy, malaise, etc.). If these are still present, the minimum period of treatment should be extended to at least 14 days. With recurrent outbreaks, the athlete must have completed at least five full days of oral antiviral treatment and all lesions must be covered by a firm, adherent scab (NFHS SMAC, 2012).
Tinea corporis Background. Tinea corporis, otherwise known as “ringworm,” is a superficial fungal infection commonly seen on the face, extremities, and trunk of wrestlers (Cash & Glass, 2011). Tinea corporis gladiatorum describes the presence of this fungal infection in wrestlers (Dunphy et al., 2011). Factors that increase the chance of infection include moist, warm climates, participation in close contact sports, excessive sweating, and poor air circulation (Cash & Glass, 2011). Tinea corporis gladiatorum epidemics have been reported to affect up to 77% of a wrestling team (Adams, 2002). In most cases, Trichophyton tonsurans is the causative organism. Interestingly, this organism is usually responsible for tinea capitis infections (Adams, 2010). Clinical presentation. The athlete often presents with an annular, erythematous plaque, which is well de-
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marcated and scaly with hypopigmentation in the center. He or she may complain of pruritis, although sometimes they are asymptomatic. The size of the lesion can range from small to large and can vary in number from one to multiple (Dunphy et al., 2011). A particular challenge of tinea corporis gladiatorum is the varying appearance with the age of the lesion. Early lesions may present with a nonspecific erythematous papules like other skin infections seen with wrestlers, such as impetigo and herpes gladiatorum (Adams, 2010). Diagnostic testing. While tinea corporis gladiatorum is mostly diagnosed by clinical presentation, there are options to confirm the diagnosis, especially if an athlete presents early in the course of the disease and the diagnosis is questionable. A diagnosis can be confirmed by scraping the lesion border and performing potassium hydroxide (KOH) microscopy. Alternatively, a fungal culture can be obtained, which can require up to 2 weeks for results. While the results of a KOH preparation are more immediate, a culture is a more definitive test (Zinder et al., 2010). Fungal cultures are generally recommended when the provider is unsure of the diagnosis or in cases of treatment failure (Dunphy et al., 2011). Plan. Topical antifungal agents should be applied once or twice daily until no further infection is visible. It is recommended that the athlete continue antifungal topical application, extending application a few centimeters beyond the edges of the lesion, for 1 week after the visual appearance of the lesion has resolved. In more severe cases, systemic antifungals should be considered (Dunphy et al., 2011). Brickman, Einstein, Sinha, Ryno, and Guiness (2009) evaluated the use of prophylactic fluconazole in reducing the incidence of tinea gladiatorum in 373 high school wrestlers. Over the course of 10 years, the incidence of tinea gladiatorum dropped from 67.4% to 3.5%. While prophylactic pharmacologic treatment with fluconazole has shown a decreased prevalence of tinea gladiatorum in wrestlers, these drugs have significant medication interactions and the potential for hepatic side effects (Adams, 2010).
Recommendations for returning to wrestling. The NFHS SMAC (2012) recommends oral or topical treatment for 72 h for skin lesions prior to returning to wrestling participation. According to the National Athletic Trainers’ Association Position Statement, it is recommended that lesions be adequately covered with a gas permeable membrane during participation after use of the topical fungicide for at least 72 h (Zinder et al., 2010).
Methicillin-resistant S. aureus Background. Staphylococcus aureus is a bacteria commonly carried on the skin or in the nose of healthy 7
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people. While S. aureus can colonize in human hosts without causing disease, infections with both methicillinsensitive S. aureus (MSSA) and antimicrobial-resistant strains such as MRSA, are a growing health concern among wrestling athletes. The Centers for Disease Control and Prevention (CDC) estimated that 25% to 30% of the population is colonized with S. aureus, with approximately 1% colonized with MRSA (CDC, 2010). Yearly, it is estimated that S. aureus skin infections account for approximately 12 million office visits. More than half of these skin infections are likely caused by MRSA (CDC, 2011). A study evaluating populationbased estimates of MRSA infections among Nebraska high school athletes from 2006 to 2008 showed an increase in MRSA incidence from 19.6 to 60.1 per 10,000 wrestlers (Buss, Mueller, Theis, Keyser, & Safranek, 2009). Improperly treated MRSA skin and soft tissue infections can progress from a mild, superficial infection, to a deeper soft tissue abscess. Complications can require admission to the hospital for surgical incision and drainage (I&D) and the administration of intravenous antibiotics (Gorwitz, Jernigan, Powers, & Jernigan, 2006). Clinical presentation. The appearance of MRSA and MSSA is similar and will typically appear in the form of abscesses, furuncles, and carbuncles. They are often described by athletes as a “spider” or “insect” bite. Skin lesions are typically red, swollen, painful, warm, and fluctuant to the touch, contain pus or other fluid, and at times are accompanied by a fever or other systemic symptoms (CDC, 2011). Cellulitis can surround the abscess on some occasions (Pecci et al., 2009). It is important to recognize that at presentation, MSSA and MRSA can resemble other clinical conditions such as folliculitis, impetigo, and cellulitis (Adams, 2010). Diagnostic testing. It is recommended that a culture be obtained in all wrestlers with abscesses and other purulent skin and soft tissue infections when they meet one or more of the following criteria: antibiotics will be used, severe local infection or signs of systemic illness are present, failure to respond to initial treatment, and if there is concern for an outbreak (Liu et al., 2011). Culture and sensitivity results help to establish local prevalence of S. aureus and susceptibility to antimicrobials (Gorwitz et al., 2006). Plan. If an immunocompetent athlete presents with a simple cutaneous abscess without surrounding cellulitis, I&D alone is the treatment of choice (Liu et al., 2011; Pecci et al., 2009). Clinical judgment should be used to assess whether the lesion is purulent or not. The decision to complement I&D with an antimicrobial is controversial. Antibiotics should be considered when the abscess is associated with severe or widespread dis8
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ease; has quick progression with the association of cellulitis or septic phlebitis; when systemic symptoms are present; if the patient has comorbidities or immunosuppression; if the abscess is difficult to fully drain; and if the athlete fails to respond to I&D alone. Should the wrestler require oral antibiotics and MRSA is suspected or confirmed, options include clindamycin, trimethoprimsulfamethoxazole, doxycycline, minocycline, and linezolid (Liu et al., 2011). Antibiotic choice should be guided by local susceptibility data.
Recommendations for returning to wrestling. NFHS SMAC (2012) considers athletes “non-contagious” if the lesion is scabbed over with no oozing or discharge and there is no new development of a lesion for at least 48 h. If the wrestler is placed on antibiotics, he or she should be treated for 10 days before returning to wrestling or until all lesions are scabbed over (whichever occurs last). Because most abscesses are not complicated and do not require oral antibiotics, when the lesion is dry, most athletes can return to play (Pecci et al., 2009). The National Athletic Trainers’ Association Position Statement on Skin Diseases recommends that all athletes with suspected skin lesions be isolated from other team members (Zinder et al., 2010).
Return to participation guide and medical release form The NFHS SMAC addresses skin infections in wrestlers. Unlike many other sports, the nature of wrestling requires significant contact with an opponent and equipment (e.g., mats, benches, and weight lifting equipment), thus the risk of transmission is high and the sport requires its own guideline and protocol (NFHS SMAC, 2010a). With the increased outbreaks of MRSA and other skin lesions among wrestlers, the NFHS SMAC has developed a medical release form for healthcare providers to utilize when a wrestler presents with a skin lesion. This form is reproducible and can be edited to meet the needs of the individual or institution. The 2012–2013 NFHS Medical Release Form for Wrestler to Participate with Skin Lesion(s) (http://www.cifccs.org/nfhs/2011–2012%20April%20 WR%20Skin%20Form.pdf) was developed and modified after surveying specialty, academic, public health, and primary care physicians. The goals of this medical release form are to protect wrestlers from communicable skin infections, reduce missed sports participation, decrease practice variation among healthcare professionals, and provide support to the healthcare provider’s decision on his or her recommendation for return to play. This form outlines minimum criteria for clearance to participate in wrestling (NFHS SMAC, 2012). As with any
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medical release form, it is up to the NP to use clinical judgment in the application of the information. When a diagnosis is uncertain, use of conservative treatment (such as a recommendation for longer period for return to participation) is rational (Likness, 2011). When determining return to participation, NPs should take into consideration NFHS rules. According to rule 4-2-3, if the coach or referee suspects a wrestler to have a communicable skin disease at weigh-in, a current written document (as defined by the NFHS or the state associations) from a healthcare professional must be submitted stating that the condition is not communicable or harmful to others. NFHS rule 4-2-4 says that designated onsite meet healthcare professionals can overrule the diagnosis of the healthcare professional who had signed the medical release form. Lastly, NFHS rule 4-25 states that a wrestler may have documentation from a healthcare professional indicating a noncommunicable skin condition. This documentation is good for the duration of the current wrestling season with the caveat that if the skin condition becomes infected their status will require reevaluation. Noncommunicable skin lesions (i.e., birthmarks, eczema, and psoriasis) can be covered to allow participation. Covering a contagious skin lesion is not an option for participation (NFHS SMAC, 2012). Accurately completing the NFHS SMAC medical release form provides detailed documentation for treatment and follow-up. The date and recommended treatment needs to be clearly written, as well as noting the earliest date a wrestler can return to active participation. Identified lesions need to be clearly marked on the “bodygram” in nonblack ink. Writing the number of lesions and location helps to identify the development of new lesions. The NFHS SMAC gives permission for organizations or individuals to reproduce or edit the medical release form. Variability may exist between forms and as to which healthcare professional can sign the form (NFHS SMAC, 2012).
Prevention Education is an essential component to decreasing reoccurrence and further spread of skin infections to others. Wrestlers need to be aware of the signs of skin infections and educated to advise their coach at the first sign of a skin lesion, so they can receive timely treatment. The NFHS SMAC general guideline for sports hygiene, skin infections, and communicable diseases outlines a universal hygiene protocol. This protocol provides five components (listed below) for high school athletes to minimize the spread of communicable skin infections.
r r r r r
Showering immediately after every competition and practice. Washing all workout clothing after each practice or competition. Weekly washings of all personal gear. No sharing of towels or personal hygiene products. Avoiding full body shaving.
In addition to universal hygiene precautions, the NFHS SMAC outlines additional strategies to reduce exposure to infectious skin diseases including (a) notification of a parent or guardian, athletic trainer and coach of any skin lesion prior to competition or practice, (b) evaluation of any skin lesion by a qualified healthcare provider prior to return to practice or competition, (c) evaluation of all members of a team if an outbreak occurs of any skin infection, and (d) adherence to NFHS or state/local guidelines on return to participation recommendations by coaches, officials, and appropriate healthcare professionals (NFHS SMAC, 2010b).
Conclusion NPs frequently encounter high school wrestlers with skin infections. The diagnosis of these skin infections can be challenging. It is important to have a good working knowledge of the clinical presentation of common skin diseases seen in wrestlers and diagnostic testing available in order to accurately diagnose and treat their condition in a timely manner. Using a guide, such as the NFHS Medical Release Form for Wrestler to Participate with Skin Lesion(s), provides the NP with a guide to support his or her recommendation for return to participation. This guide provides minimum criteria for clearance and it is imperative to balance clinical judgment with treatment. By accurately diagnosing skin infections in wrestlers early, further spread to other athletes can be minimized, potential health complications can be reduced, and the wrestler can return to participation sooner.
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Brickman, K., Einstein, E., Sinha, S., Ryno, J., & Guiness, M. (2009). Fluconazole as a prophylactic measure for tinea gladiatorum in high school wrestlers. Clinical Journal of Sports Medicine, 19(5), 412–414. Buss, B., Mueller, S., Theis, M., Keyser, A., & Safranek, T. (2009). Population-based estimates of methicillin-resistant Staphylococcus aureus (MRSA) infections among high school athletes—Nebraska, 2006–2008. Journal of School Nursing, 25(4), 282–291. Cash, J. C., & Glass, C. A. (2011). Family practice guidelines (2nd ed.). New York, NY: Springer. Centers for Disease Control and Prevention (CDC). (2010). Definition of MRSA. Retrieved from http://www.cdc.gov/mrsa/definition/index.html Centers for Disease Control and Prevention (CDC). (2011). Recognize and prevent MRSA infections. Retrieved from http://www.cdc.gov/features/ mrsainfections Cole, C., & Gazewood, J. (2007). Diagnosis and treatment of impetigo. American Family Physician, 75(6), 859–864. Comstock, D., Collins, C., & McIlvan, N. (n.d.). National high school sports-related injury surveillance study: 2009–2010 school year. Retrieved from http://www.nationwidechildrens.org/Document/Get/103354 Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011). Primary care: The art and science of advanced practice nursing (3rd ed.). Philadelphia: F.A. Davis. Fatahzadeh, M., & Schwartz, R. (2007). Human herpes simplex virus infections: Epidemiology, pathogenesis, symptomatology, diagnosis, and management. Journal of the American Academy of Dermatology, 57, 737–763. Gorwitz, R., Jernigan, D., Powers, J., Jernigan, J., & Participants in the CDC Convened Experts’ Meeting on Management of MRSA in the Community. (2006). Strategies for clinical management of MRSA in the community: Summary of an experts’ meeting convened by the centers for disease control and prevention. Retrieved from http://www.cdc.gov/mrsa/pdf/MRSA-StrategiesExpMtgSummary-2006.pdf Jaworski, C., Donohue, B., & Kluetz, J. (2011). Infectious disease. Clinical Journal of Sports Medicine, 30, 575–590. Likness, L. (2011). Common dermatologic infections in athletes and return-to-play guidelines. Journal of the American Osteopathic Association, 111(6), 373–379. Liu, C., Bayer, A., Cosgrove, S., Daum, R., Fridkin, S., Gorwitz, R., . . . Chambers, H. (2011). Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus
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