Clinical Quiz Answer

Red Plaque on a High School Wrestler

Brian B. Adams, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO. 2 - FEBRUARY 2001

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To confirm the clinical diagnosis of tinea corporis (ringworm), a potassium hydroxide (KOH) examination of skin scrapings was performed that revealed many branched hyphae. A diagnosis of tinea corporis gladiatorum was made (figure 2). The patient was treated with a topical fungicidal cream (terbinafine hydrochloride 1%), and the lesion resolved in approximately 2 weeks.

Discussion

Herpes simplex infection in wrestlers, called herpes gladiatorum, is a well-known, frequently reported condition (1,2). Infection with tinea corporis is not as well studied but is probably at least as common. The importance of both, in addition to essential morbidity, is that the presence of either infection will disqualify an athlete from competition. Rapid identification and treatment of this condition is essential in preventing epidemics on wrestling teams and in averting missed practices and competitions.

There has been some controversy regarding the naming of tinea corporis on wrestlers' skin. It has been given various names, including tinea gladiatorum (3) and trichophytosis gladiatorum (4), but tinea corporis gladiatorum (5,6) seems to be the most descriptive term. Epidemiologic studies (5,7) attempting to identify the prevalence of this condition have found that 24% to 75% of high school wrestlers are afflicted with tinea corporis gladiatorum. Variability in study methodology probably explains the vast range of prevalence. For example, the highest prevalence was reported by investigators who had been alerted to an epidemic in a high school wrestling team (5), while the lowest was reported in a high school team without a known epidemic (7). Both studies confirmed the diagnosis of tinea corporis by using KOH examination.

The transmission of tinea corporis gladiatorum appears to be by skin-to-skin contact and not through contact with colonized wrestling mats (5,8,9). Several host factors of wrestlers may make these athletes particularly susceptible. Abrasions and cuts allow easier transmission of fungal organisms, and moisture and occlusive clothing provide an optimal environment for the organism to grow (10). Therapy for tinea corporis gladiatorum has included both topical and oral antifungal agents (1,8,10-13).

After consulting with the Centers for Disease Control and Prevention in Atlanta, investigators examining an epidemic in a high school wrestling team in Alaska recommended that wrestlers with tinea corporis be excluded from matches (5). Furthermore, the investigators suggested that griseofulvin be used for 1 month by wrestlers with more than two lesions or any facial lesions and that topical ketoconazole or econazole nitrate be used for 1 month by all others.

One study (13) compared the efficacy of oral weekly fluconazole versus twice-daily topical clotrimazole in the treatment of tinea corporis gladiatorum and suggested that oral fluconazole should be the first-line treatment. Interestingly, even in the fluconazole-treated group, 50% of the cultures were still positive after 11.1 days. Yet another study (12) suggested that using 200 mg of itraconazole twice a day, for 1 day every 2 weeks, was effective prophylaxis. Overall data are insufficient to recommend a specific duration of either topical or oral antifungal therapy.

In addition to treatment with antifungal agents, measures should be taken to ensure that the infection is not transmitted to other wrestlers. Beller and Gessner (5) have suggested that wrestlers be excluded from participation until they complete 10 days of topical therapy or 15 days of oral treatment. Dienst et al (10) have suggested that wrestlers be excluded for 5 days if the tinea corporis lesion cannot be covered. Unfortunately, it is not known how long a patient requires treatment before he or she is considered noninfectious. Furthermore, no published study of tinea corporis gladiatorum has investigated the recently marketed topical fungicidal allylamines (such as terbinafine hydrochloride, naftifine hydrochloride, and butenafine hydrochloride), which may be of great benefit to high school wrestling teams.

Recommendations

Untreated dermatophyte infections should disqualify wrestlers from practicing and participating in competitions. Close observation by coaches and athletic trainers is important in keeping all high school wrestlers eligible to compete. Any suspicious skin lesion should be evaluated by a physician as soon as possible. Upon diagnosis of tinea corporis gladiatorum, appropriate therapy should be instituted without delay.

References

1. Porter PS, Baughman RD: Epidemiology of herpes simplex among wrestlers. JAMA 1965;194(9):150-152
2. Belongia EA, Goodman JL, Holland EJ, et al: An outbreak of herpes gladiatorum at a high-school wrestling camp. N Engl J Med 1991;325(13):906-910
3. Cohen BA, Schmidt C: Tinea gladiatorum, letter. N Engl J Med 1992;327(11):820
4. Cohen DE, Foa H, Sangueza OP: Trichophytosis gladiatorum, letter. J Am Acad Dermatol 1993;28(6):1022
5. Beller M, Gessner BD: An outbreak of tinea corporis gladiatorum on a high school wrestling team. J Am Acad Dermatol 1994;31(2 pt 1):197-201
6. Stiller MJ: Trichophytosis gladiatorum, letter reply. J Am Acad Dermatol 1993;28(6):1022
7. Adams BB: Tinea corporis gladiatorum: a cross-sectional study. J Am Acad Dermatol 2000;43(6):1039-1041
8. Stiller MJ, Klein WP, Dorman RI, et al: Tinea corporis gladiatorum: an epidemic of Trichophyton tonsurans in student wrestlers. J Am Acad Dermatol 1992;27(4):632-633
9. Frisk A, Heilborn H, Melen B: Epidemic occurrence of trichophytosis among wrestlers. Acta Derm Venereol 1966;46(5):453-456
10. Dienst WL Jr, Dightman L, Dworkin MS, et al: Pinning down skin infections: diagnosis, treatment, and prevention in wrestlers. Phys Sportsmed 1997;25(12):45-56
11. Weringhaus K: Tinea corporis in wrestlers, letter. J Am Acad Dermatol 1993;28(6):1022-1023
12. Hazen PG, Weil ML: Itraconazole in the prevention and management of dermatophytosis in competitive wrestlers. J Am Acad Dermatol 1997;36(3 pt 1):481-482
13. Kohl TD, Martin DC, Berger MS: Comparison of topical and oral treatments for tinea gladiatorum. Clin J Sport Med 1999;9(3):161-166

Dr Adams is an assistant professor in the department of dermatology at the University of Cincinnati College of Medicine and chief of dermatology at the Veterans Administration Medical Center in Cincinnati. Address correspondence to Brian B. Adams, MD, Dept of Dermatology, University of Cincinnati, College of Medicine, Box 670592, Cincinnati, OH 45267-0592; e-mail to adamsbb@email.uc.edu.