Skin Infections in Athletes

Viral infections centre on herpes gladiatorum, a skin infection with the herpes simplex virus (HSV), usually type 1, classically seen in wrestlers and sometimes called scrumpox in rugby. It spreads by direct skin-to-skin contact and produces clusters of small, painful blisters on a red base, often on the head, neck and arms, occasionally with fever and swollen glands in a first episode, and it tends to recur at the same site. Molluscum contagiosum, with its pearly dimpled papules, and viral warts also occur.

Fungal infections are the dermatophyte, or tinea, infections. Tinea corporis, ringworm on the body, which in contact sport is sometimes called tinea gladiatorum, gives an itchy, scaly, ring-shaped plaque with a raised advancing edge and central clearing. Tinea pedis, athlete's foot, affects the toe webs and soles, and tinea capitis affects the scalp. All spread by contact and via mats, floors and shared items. Bacterial infections are led by impetigo, usually caused by Staphylococcus aureus or Streptococcus pyogenes, which produces superficial golden or honey-coloured crusted lesions and is highly contagious, along with folliculitis and boils. Meticillin-resistant Staphylococcus aureus (MRSA) can also cause skin and soft tissue infection in athletes and spreads by the same routes.

Herpes gladiatorum shows as grouped blisters on red skin, often with pain or tingling first, and may bring fever and swollen glands in a first attack before recurring at the same place. Tinea corporis is the itchy, scaly, ring-shaped plaque with central clearing, while tinea pedis gives itchy, macerated, scaly toe webs. Impetigo produces golden-crusted erosions that spread, often on exposed skin or around the nose and mouth.

The clinical skill is to separate the three groups confidently, because treatment and the rules for returning to sport differ between them. A vesicular, painful, grouped eruption points to herpes, an annular scaly plaque to tinea, and a honey-crusted spreading lesion to impetigo, though atypical or severe presentations warrant a lower threshold for confirming the diagnosis and for escalation.

Most of these infections are diagnosed clinically, with confirmation reserved for when the diagnosis is uncertain, when a lesion is not responding, or to document an outbreak or a return-to-play decision. Herpes is confirmed by swabbing a fresh blister or ulcer base for polymerase chain reaction (PCR) testing for the herpes simplex virus. Tinea is a clinical diagnosis in most cases, with skin scrapings for microscopy and fungal culture arranged when it is uncertain, atypical, extensive, recurrent or resistant to treatment, or before starting systemic antifungal treatment, while a Wood's lamp is of limited value for most of the dermatophytes that affect athletes. Impetigo and other bacterial infection can be swabbed for culture and sensitivities, which is particularly worthwhile when the lesion is not settling or when meticillin-resistant Staphylococcus aureus is suspected, so that treatment can be guided accordingly.

Herpes gladiatorum is treated with an oral antiviral such as aciclovir for episodes, and athletes with recurrent disease may take preventive antiviral treatment through the season, recognising that the infection is not cured and can recur. For tinea corporis, a topical antifungal is used for localised disease, with an oral antifungal such as terbinafine reserved for extensive or stubborn infection, and tinea pedis is treated with a topical antifungal alongside foot hygiene. Tinea capitis is different and always needs a systemic antifungal with appropriate sampling, as topical treatment alone is inadequate.

For impetigo, current United Kingdom practice for localised non-bullous disease is hydrogen peroxide 1% cream where suitable, with a topical antibiotic if it is not, while widespread non-bullous disease is treated with a topical or an oral antibiotic, and bullous impetigo or systemic illness needs oral antibiotics; routine combined topical and oral antibiotics are avoided. Boils and abscesses may need incision and drainage, with antibiotics added where there is surrounding cellulitis or systemic upset, and meticillin-resistant Staphylococcus aureus is swabbed and treated on microbiology advice, with urgent escalation only where infection is rapidly progressive, deep, severely painful or systemically unwell. In every case the lesion is kept clean, the exclusion and return rules below are followed, and the rest of the squad is considered, since a single case may be the first of several.

The core principle is that an athlete with an active, contagious skin infection is generally excluded from skin-to-skin contact and shared-mat sport until it is adequately treated and no longer infectious, and covering an untreated or actively infectious lesion does not by itself make contact safe. This differs from many other conditions and is a frequent exam point. The specific criteria are set by the sport's governing body and should be followed, and the timings below are sport-specific or NHS examples rather than universal rules. For herpes gladiatorum, wrestling criteria typically require a course of oral antiviral treatment, no new lesions for 72 hours and all lesions crusted and dried, with no systemic symptoms, and active herpes precludes contact. For tinea, return is usually allowed after at least 72 hours of treatment, with localised lesions covered where the rules permit, and scalp disease treated systemically for longer. For impetigo, return follows adequate antibiotic or antiseptic treatment with no new or draining lesions, and NHS guidance generally considers it no longer contagious around 48 hours after starting hydrogen peroxide or antibiotics, or once untreated lesions have dried and crusted, while governing-body rules may be stricter.

Prevention is the other half of the topic. It rests on good hygiene, showering after training and washing kit, not sharing towels, razors, water bottles or equipment, regular cleaning and disinfection of mats and shared surfaces, covering existing wounds, skin checks before competition as used in wrestling, and early recognition and treatment with affected athletes kept out until cleared. When a case appears, it is managed as a potential outbreak across the squad rather than in isolation.

• •United Kingdom primary care guidance on impetigo, fungal skin infections and herpes simplex underpins the diagnosis and treatment set out here.
• •Governing-body rules, particularly in wrestling and combat sports, set the specific exclusion and return-to-play criteria and the skin-check requirements.
• •Guidance on meticillin-resistant Staphylococcus aureus and on skin and soft tissue infection informs management of bacterial disease.
• •Sport and exercise medicine reviews address skin infections in athletes and the prevention of outbreaks.

• •Skin infections in athletes are mainly viral (herpes gladiatorum), fungal (tinea) and bacterial (impetigo), spread by contact and shared equipment.
• •Herpes gladiatorum is the herpes simplex virus, classically in wrestlers, giving grouped painful blisters that recur.
• •Tinea gives an itchy, scaly, ring-shaped plaque with central clearing, and impetigo gives golden, honey-coloured crusts.
• •An athlete with an active contagious skin infection is generally excluded from contact until treated, and covering an untreated or infectious lesion does not make contact safe.
• •Suspected herpes eye involvement, with eye pain, a red eye or visual change, needs same-day ophthalmology.
• •Prevention relies on hygiene, not sharing equipment, cleaning mats, covering wounds and skin checks.