PracticalDermatology

When it comes to sports dermatology, Brian Adams, MD, MPH, professor and chair of the department of dermatology at the University of Cincinnati and chief of dermatology at the Veteran’s Affairs Medical Center-Cincinnati, literally wrote the book. He published “Sports Dermatology” in 2006 and is currently working on the second edition. Dr. Adams spoke to Practical Dermatology® about his career trajectory, the top skin ailments of athletes, and the importance of sun protection during outdoor athletic activity.

How did you get involved in sports dermatology?

Brian Adams, MD, MPH: I grew up in a home that equally cherished academics and athletics. Having spent eight years not involved in organized competitive athletics after college, I very much missed this exposure and experience. I wanted to build a career based on two of my great loves: dermatology and sports. After finishing residency in 1999, I became an assistant varsity cross-country, indoor, and outdoor track coach at the all-boys Moeller High School in Cincinnati and have been coaching there ever since. I began to consult for national sports-related publications and started to give national and international sports dermatology lectures at the annual meetings of dermatology and sports medicine societies. I started a sports dermatology clinic once per week at the beginning of my career where I see elite high school, collegiate, and professional athletes. I became a member of the undergraduate athletic training program at the University of Cincinnati. Almost of all my research has revolved around sun safety in youth athletes and National Collegiate Athletic Association (NCAA) participants. I have consulted with the NCAA regarding dermatology and teach several seminars at the College of Medicine for sports medicine fellows and athletic training students. I also am the official dermatologist for the Women’s Tennis Association (WTA).

What are some of the more common sports-related skin conditions?

Dr. Adams: Probably the most common skin ailments in athletes are traumatic such as blisters caused by friction between your equipment and your skin. Recurrent blisters can be a problem, cause pain, and can get infected.

Another traumatic injury, jogger’s nipple is an extremely painful rash of the nipple although when you examine the nipple there are little changes noted. It usually occurs during races or runs of longer distances. The friction between your coarse-fibered shirt and your nipple causes jogger’s nipple. Sometimes these lesions will bleed, and if a runner has a white shirt (demonstrated well in marathons), you will see lines of blood from the nipple on the shirt. I call this the “red eleven.” Chafing, particularly of the underarms and inner thighs, usually occurs during races or runs of longer distances too. The friction, moisture, and heat between your clothing or even adjacent skin and your skin cause chafing. Sometimes these lesions will bleed. Jogger’s toe is caused by the constant slamming of the longest toe into the toe box. The second toe is often the longest and when only one toe bears the brunt of the body’s pressure, significant long-term changes occur on the skin of the toe and the nail. A callus may build on the end of the toe, and bleeding may occur under the nail. It is also not uncommon for athletes to damage their toe so extensively that they lose their toenail.

How do you treat or prevent these traumatic sports-related skin injuries?

Dr. Adams: Anything that decreases the moisture in your skin decreases blisters such as applying a drying agent to your feet and wearing moisture-wicking clothing etc. Athletes can also decrease the coefficient of friction by placing Vaseline on the “hot spot” where a blister will soon form. Never remove the blister roof. It is the best and certainly cheapest dressing you can buy for your blister. Anything that decreases the friction between the runner’s nipple and the shirt/bra will decrease the breakdown in skin that occurs in jogger’s nipple. Save those race give-a-way shirts for a time when you are not running. Synthetic moisture-wicking shirts/bras are the way to go. Commercially available pads can also be placed on the nipple for protection. Athletes can also decrease the coefficient of friction by placing a liberal amount of Vaseline on the nipple pre-run. Once a runner has jogger’s nipples, the application of antibacterial ointment or petroleum jelly can assuage symptoms and speed healing. Complications of jogger’s nipples are extremely rare.Chafing is treated in a very similar way to jogger’s nipples. When it comes to jogger’s toe, the best treatment is prevention. It is imperative that you have adequately fitted shoes so that your longest toe does not slam into the toe box. Specialty running stores in your area should be able to help you with this.

Any other causes of sports-related skin issues?

Dr. Adams: Most outdoor athletes experience an inordinate amount of ultraviolet (UV) radiation. The first and most important aspect for preparing one’s skin for outdoor athletic activity is sun protection. First, athletes should try to avoid the hours between 10am and 4pm when the intensity of the sun is maximum. Second, athletes should wear a hat, try to exercise where there is shade (if at all possible), and lastly wear sweatproof sunscreen SPF 30 or higher. No sunscreen withstands intense workouts for prolonged periods, especially if you are in the water. Research has shown that sweating can make the athlete more likely to burn than when the athlete is not sweating. Bring extra sunscreen to your venue or stash it with your Gatorade along your running route for reapplication. Darker-colored clothing blocks more UV rays than white so go for the darker colors. Built-in sunblock can be found in some clothing. You can also wash your clothing with an Ultraviolet Protection Factor (UPF) enhancer.

What about skin infections in athletes?

Dr. Adams: Many sports involve intense close skin-to-skin contact that results in transmission of the microorganisms and sweating and abrasions inherent to athletic activity make the skin more susceptible to infection. Frequent sharing of equipment such as towels also allows the transmission of the organism from one athlete to another. The most common gram-positive bacteria to infect athletes is S. aureus, followed by Streptococcus. Most athletes can be treated with topical antibiotics but occasionally oral antibiotics are necessary. Many team sports have seen MRSA epidemics for many of the myriad reasons above. Some athletes are “carriers” of the bacteria in their noses. While some MRSA isolates are still sensitive to topical mupirocin, others have developed resistance and required oral antibiotics.

Any sports-specific skin infections?

Dr. Adams: Tinea corporis (aka ringworm) is so common among wrestlers that it is termed tinea corporis gladiatorum (TCG). Most commonly the lesions appear on the head, neck, and upper extremities and develop after contact with infected wrestlers. Early in the disease process the lesions do not acquire the ring shape (clear in the middle) and appear as relatively non-specific, red, round lesions. Any athlete with intense skin-to-skin contact could acquire TCG but the intensity of skin-to-skin contact makes wrestling the highest-risk sport. Topical or oral antifungal agents clear the disease. Evidence-based recommendations for the duration of disqualification after TCG are lacking. Herpes simplex is so common among wrestlers, the condition is termed herpes gladiatorum. Early in the course of the disease the lesions appear as non-specific, red lesions, but then acquire the characteristic grouped blisters on a red base. Treatment includes oral antiviral agents which allows the wrestler to compete (without being infectious) in four to five days. Wrestlers who spar with an infected partner have a one in three chance of contracting the skin infection.

Are most dermatologists skilled at diagnosing these conditions?

Dr. Adams: Dermatologists, not surprisingly, are very adept at diagnosing skin conditions in athletes. The one caveat is that very competitive/elite athletes with infections present very early in the course of their disease. These athletes are surrounded by clinicians in the training room and skin issues are often identified early as some can be disqualifying. I mostly diagnose tinea corporis in wrestlers long before the lesions have developed the typical ring shape. A dermatologist may not realize that their patient is an athlete or practices a specific sport. Without the identification of that exposure, the dermatologist may miss the sports-related issue. Aside from sport-specific involvement, it is very important to identify exposures on the field, sidelines, training room, and living quarters. I always have athletes coming into my sports dermatology clinic bring their footwear and uniforms. The key is to understand the athlete’s sport and their practice and competition schedule. Close collaboration with the athletic training staff and coaches will ensure the best treatment and prevention for athletes.”