Marathon Dermatology

Current growing fitness trends including long distance running, biking, and Iron Man competitions often lead patients to present with a variety of skin ailments not typically covered in a dermatology residency. Blisters, chafing, or jogger’s nipples may not seem challenging, but dermatologists need rapid ready responses to not only address the acute presenting problem but also counseling measures to help prevent them from recurring. From the head down, this article attempts to address frequently asked questions.

Skin Cancer Danger

Marathon runners are at increased risk of skin cancer. One study found that only 56.2 percent of runners report regular use of sunscreen, so there is room for improvement. While it may seem helpful to bring up that around 10,000 people a year die in this country from melanoma and other skin cancers, don’t be surprised if a patient mentions that a million more die from cardiac disease, which the runner might be trying to address.

Figure 1

Sunscreens. The typical lament is that sunscreens can cause stinging and burning, particularly around the eyes. As guidelines call for reapplication after two to three hours of exposure, it helps to remember that at least half of the 50,000 people who finished the New York City Marathon this past year took more than four hours and some more than six hours. In general, many cyclists and runners may also be out all day, typically in just shorts and a T-shirt or tank top. It may not be a culture a typical dermatologist can easily relate to, but it is incumbent upon us to adapt our answers to the patient’s lifestyle.

Self-labeled “sport” sunscreens are widely believed to sting less. Coppertone and Banana Boat both make SPF 30 brands that are anecdotally well tolerated. Thick cream sunscreens give a sensation of retaining heat as well as running into the eyes once an athlete works up a sweat. Spray-on sunscreens spread easily and are easier to apply after a few hours outside. Some runners prefer rubbing a stick sunscreen, which may be easier to apply when on the go. On exceptionally cold winter days, Dermatone SPF 23 (the frostbite fighter, Figure 1) can protect the skin from the elements. Overall, water-resistant sunscreens are preferred. Exercising when the sun is not directly overhead is recommended. Lightweight caps with visors are readily available at running stores.

Jogger’s Nipples

Figure 2

Jogger’s nipples are a frequent source of pain and discomfort for an otherwise young, healthy population. Friction against a shirt can lead to painful erosions, which often lead to scratching, use of topical pain relievers, and antibiotics. Patients can present with unilateral or bilateral lichenified plaques with focal erosion. Staphylococcal infection can also be documented. Treatment with topical or oral antibiotics after culture and mild topical steroids can lead to rapid improvement. Going forward, the patient should be instructed to avoid irritating the area. Since the patient will want to keep running, that may not be as simple as it sounds. Applying Vasoline or Aquaphor prior to running is helpful. Wearing a simple bandaid across the areola will suffice and can surprisingly last 26.2 miles.

Chafing

Chafing starts acutely as erythematous slightly eroded skin in the groin folds from the repetitive movement of body parts and clothes in the groin folds. It can quickly take on the appearance of lichen simplex chronicus. Itching and pain can be severe. It helps to recommend OTC calming products. The author gets good results with Vitamin A and D ointment. Acute fissuring of the skin may resolve with prescription compounds with 1% hydrocortisone with iodoquinol. Since patients will want to remain active, prophylactic application of Aquaphor or Vasoline can be helpful. More elegant, popular products include BodyGlide, which comes in a stick roll-on and Chamois Butt’r (Figure 2). Changing immediately out of sweat soaked clothes is also helpful.

Blisters

Figure 3

Blisters on the feet are a common complaint of marathon runners. Wearing two pairs of socks can be particularly helpful for those runners just starting out. Sweating of the feet can be uncomfortable, smelly, and lead to painful blistering. Most powders absorb moisture and decrease friction.2

Tom’s Blister Shield, available in powder and roll-on, is popular for long distance runners with blister-prone feet. Marathon blisters can be significantly large, as shown in Figure 3 (an actual NYC marathon runner). The best approach is to drain the bulla with a sterile 11 blade or needle through a small opening, preferably on a non-weight bearing side, carefully leaving the roof of the bulla intact to serve as a dressing. No antibiotics are typically needed, and speedy resolution is the rule. Pitted keratolysis may occur in runners who sweat a lot. Topical aluminum chloride can help.

Damaged Toenails

The article ends, as does the body, with the toes. Most athletes have either significantly bruised or even lost a nail. The key is prevention, meaning keeping the nails short at all times. Most subungual hemorrhages will resolve and grow out without medical intervention. However, we have observed the same damaged nail ultimately developing onycholysis and subsequent culture confirmed onychomycosis. There is insufficient evidence to recommend antifungal prophylaxis at this time, but is important to mention the need for patients to follow-up with any nail changes that fail to resolve.

Barry Goldman, MD is Clinical Instructor, Cornell Medical College.

1. Ambros CM, Hofman-Wellenhof R, Richtig E. et al. Malignant melanoma in marathon runners. Arch Dermatol. 2006;142:1471-1474.

2. Heymann WR. Dermatologic problems of the endurance athlete. J Am Acad Dermatol. 2005:52;345-6

3. Mailler EA, Adams BB, The wear and tear of 26.2;dermatological injuries reported on marathon day. Br J Sports Med 2004:38;498-501