How To Identify And Treat Pruritic Conditions In Athletes

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Impetigo contagiosa, a common pruritic skin infection, occurs frequently among groups of individuals, such as athletes, who have an increased risk of bruising injuries and who are in close contact with each other.
Chronic interdigital tinea pedis usually starts in the toe web spaces and is characterized by scaling, maceration and itching. (Photo courtesy of Gary Dockery, DPM)
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By Mark Caselli, DPM

   Pruritis, a common complaint in athletes, has many causes. In addition to the eczematous dermatoses previously discussed (see “A Closer Look At Eczematous Dermatitis In Athletes,” pg. 112, February issue), one should be aware of other equally important conditions that may cause itching in athletes. These conditions include infections, parasite infestations, insect stings or bites, allergic reactions and systemic conditions.

   When a patient presents with a pruritic skin rash, there is often a great temptation to jump to a diagnostic conclusion of one of the eczematous dermatoses and immediately prescribe a topical corticosteroid preparation. However, it is important to obtain a thorough history of the pruritic condition and carefully observe the type and distribution of the presenting lesions.

   Impetigo contagiosa is a common pruritic skin infection. Although it is most common in children, it also occurs frequently among groups of individuals, such as athletes, who have an increased risk of bruising injuries and who are in close contact with each other. The infection is spread by skin to skin contact or contact with a fomite piece of athletic equipment, particularly wrestling mats. Infection is more likely to occur in skin folds and areas subject to friction such as the arms and legs.

   When these athletes have atopic or contact dermatitis, they have a greater risk for secondary impetiginization. This contagious superficial skin infection usually begins as a vesicular or pustular lesion that develops into exudative and crusting stages. Unless there is trauma or excoriation to the lesions, they usually heal without scarring. Staphylococcus aureus is the predominant organism isolated from impetiginous lesions. The combination of S. aureus and group A streptococcus is the next most common isolate. Staphylococcus pyogenes is less common as a causative agent with this condition.

   Impetigo can present in one of two classic forms, the more common superficial type and the bullous type. Superficial vesiculopurulent pyoderma or common impetigo is most prevalent during the summer months and in areas with high humidity. Lack of hygiene and crowding, which occur in athletes’ locker rooms, are also predisposing factors. The typical lesion of superficial impetigo usually starts as an erythematous vesicle or papule in a traumatized area (scratch or insect bite). Then small vesicles may form and the lesion rapidly evolves to a thick, crusted lesion with a honey-color crust. When one removes the crust, the base of the lesion excretes a serous amber exudate and rapidly becomes encrusted again. These lesions are rarely painful and are often neglected for extended periods of time. Although regional lymphadenopathy is common, other systemic signs such as malaise, fever and toxic appearance are usually absent.

   Bullous impetigo is much less common than superficial impetigo. The characteristic lesions are thin-walled bullae that are usually less than 3 cm in diameter. These lesions are prone to easy rupture. The fluid in the blisters may be a thin, amber liquid or an opaque pus that is white or yellow. Once the blister ruptures, the erythematous base dries quickly, forming a thin and shiny surface classically referred to as a varnish-like crust. The causative bacteria is usually S. aureus.

Treating And Preventing Impetigo

   Treating impetigo involves the use of both topical and systemic antibiotics. Mupirocin 2% ointment is the most effective topical agent. One should clean the lesions with soap and water or peroxide before applying the ointment and a dry dressing. Multiple lesions often require oral antibiotics such as cefadroxil, cephalexin, dicloxacillin, amoxicillin/clavulanate or erythromycin. However, keep in mind that streptococcal species are showing increased resistance to erythromycin.

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