- Email: [email protected]
Skin infections among US high school athletes: A national survey
ORIGINAL
ARTICLE
Skin infections among US high school athletes: A national survey Kurt A. Ashack, BA,a Kyle A. Burton, BS,c Teresa R. Johnson, BA, MS, PhD,b Dustin W. Currie, MPH,d R. Dawn Comstock, PhD,d,e and Robert P. Dellavalle, MD, PhD, MSPHd,f,g Grand Rapids, Michigan; Orlando, Florida; and Aurora and Denver, Colorado Background: Skin infections have long been a reported problem among high school athletes, particularly wrestlers. There has yet to be a national study describing the epidemiology of skin infections across multiple high school sports. Objective: We sought to report the epidemiology of skin infections among US high school athletes. Methods: High school sports-related skin infections resulting in time loss were reported by a convenience sample of US high schools from 2009/2010 through 2013/2014 via High School Reporting Information Online. Results: During the study, 474 skin infections were reported among 20,858,781 athlete exposures, a rate of 2.27 per 100,000 athlete exposures. The largest number of skin infections occurred in wrestling (73.6%) followed by football (17.9%). The most common infections were bacterial (60.6%) and tinea (28.4%) infections. Body parts most often affected were the head/face (25.3%) followed by the forearm (12.7%). Limitations: The study included only high schools with National Athletic Trainers’ Associationeaffiliated athletic trainers, which may limit generalizability. However, using athletic trainers as data reporters improved data quality. Conclusions: Skin infections are an important subset of high school sports-related adverse events. An understanding of the epidemiology of sports-related skin infections should promote awareness and drive evidence-based prevention efforts. ( J Am Acad Dermatol http://dx.doi.org/10.1016/j.jaad.2015.10.042.) Key words: athletes; competition; high school; injury; prevention; skin infections; sports.
S
ports-related injury is a risk each of the 7 million plus high school student athletes in the United States face.1 Dating back to 1979, an
outbreak of furunculosis was reported among 26 high school football players.2 Since then, there have been multiple reports of skin infection outbreaks
From Michigan State University College of Human Medicine, Grand Rapidsa; Department of Medical Education,b University of Central Florida College of Medicine,c Orlando; Department of Epidemiology, Colorado School of Public Health,d Department of Pediatrics (Emergency Medicine),e and Department of Dermatology,f University of Colorado Anschutz Medical Campus, Aurora; and Dermatology Service, US Department of Veterans Affairs, Eastern Colorado Health Care System, Denver.g Mr Ashack and Mr Burton are co-first authors. The content of this report representing data collection by the National High School Sports-Related Injury Surveillance Study (High School Reporting Information Online) was funded in part by the Centers for Disease Control and Prevention grants R49/CE000674-01 and R49/CE001172-01. We also acknowledge the generous research funding contributions of the National Federation of State High School Associations, the National Operating Committee on Standards for Athletic Equipment, DonJoy Orthotics, and EyeBlack. The content of this report is solely the responsibility of the authors and does not necessarily
represent the official views of the Centers for Disease Control and Prevention or any of the other institutions that provided financial support for this research. Disclosure: Dr Dellavalle is an employee of the US Department of Veterans Affairs. The US Department of Veterans Affairs had no role in the writing of this manuscript. Any opinions expressed herein do not necessarily reflect the opinions of the US Department of Veterans Affairs. Mr Ashack, Mr Burton, Mr Currie, and Drs Johnson and Comstock have no conflicts of interest to declare. Accepted for publication October 17, 2015. Reprint requests: Robert P. Dellavalle, MD, PhD, MSPH, Dermatology Service, US Department of Veterans Affairs, 1055 Clermont St, Box 165, Denver, CO 80220. E-mail: robert.dellavalle@ucdenver. edu. Published online January 28, 2016. 0190-9622 Published by Elsevier on behalf of the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2015.10.042
1
2 Ashack et al
J AM ACAD DERMATOL
n 2015
associated with high school athletics, particularly sample of 100 US high schools with certified wrestling.3-6 athletic trainers, stratified by school population Contact sports have the highest risk of cutaneous and US Censusedefined geographic region. The infectious disease.7-9 However, it is important to original sample included 9 sports (boys’ wrestling, understand the epidemiology of skin infections boys’ football, boys’ soccer, girls’ soccer, girls’ across all sports, as serious bacterial skin infections, volleyball, boys’ basketball, girls’ basketball, boys’ specifically methicillin-resistant Staphylococcus baseball, and girls’ softball). aureus, have also been reBeginning in 2008/2009, ported in noncontact sports High School RIO expanded CAPSULE SUMMARY such as volleyball and cross the list of sports for which 10-12 country. In addition, skin data were collected to Sports-related skin infections occurring infection rates and patterns eventually add 13 sports. in high school athletes have been in high school athletics Nationally representative commonly reported in literature and are appear to have changed samples of high schools known to cause significant morbidity throughout time. Many could not be recruited for and time loss from competition. skin infections previously each additional sport This report highlights the epidemiology stemmed from herpes simbecause of geographic variof high school athletic skin infections on plex virus, Staphylococcus ability in popularity of some a national level. (methicillin susceptible and sports, so a convenience methicillin resistant), or This information should promote sample of schools has been tinea.6,13 awareness and help drive targeted, recruited annually to The multiple skin infecevidence-based prevention efforts. augment the 100 randomly tions that may present in selected nationally represenhigh school athletics have tative sample of schools. The varying degrees of morbidity. Although most skin study began collecting data on specific types of skin infections require a week of recovery on average, infection (ie, bacterial, herpetic, tinea) in the 2009/ others may have more serious sequelae such as 2010 academic year. This study analyzed High ocular and neurologic involvement from a primary School RIO skin infection data from 2009/2010 herpes simplex virus infection.6,10 Methicillinthrough 2013/2014. Because of the relatively rare resistant Staphylococcus aureus and soft tissue skin nature of skin infections, data from the larger infections can lead to systemic infections such as convenience sample of 22 sports were used, with septic shock and osteomyelitis.14 the exception of national estimates, which are To our knowledge, no study to date specifically reported for only the 9 sports included in the original evaluates skin infections in high school athletes nationally representative sample. using data from a large national sample and including multiple sports. The objective of this Data collection study was to describe the epidemiology of skin Athletic trainers at participating schools received infection in US high school athletes. Specific aims weekly e-mails reminding them to enter their were to report rates of skin infection by sport, school’s weekly exposure reports for their assigned evaluate body sites most commonly affected, and sports. Weekly exposure reports collected number of evaluate severity of skin infections in terms of time to athlete competitions and athlete practices for sports return to play. The ultimate goal of this report is to in session and the number of reportable injuries that increase understanding of the epidemiology of occurred in each sport. For each injury, athletic sports-related skin infections, which will promote trainers completed an injury report, providing awareness and drive effective evidence-based detailed information about the injured player (eg, prevention efforts. age, year in school), injury (eg, site, type, severity), and injury event (eg, time in season, mechanism, phase of play). Athletic trainers could view all METHODS submitted data throughout the study and update Study sample reports as needed (eg, need for surgery, days until This study used data collected by High School resuming play). Reporting Information Online (RIO), an Internetbased high school sports injury surveillance system Study definitions that has been described previously.15,16 Briefly, the An athlete exposure is defined as 1 athlete study began during the 2005/2006 academic year, participating in 1 practice or competition. A team using a randomly selected nationally representative d
d
d
Ashack et al 3
J AM ACAD DERMATOL
VOLUME jj, NUMBER j
season is defined as all injuries in a single school, sport, and academic year. In High School RIO, reportable injuries/adverse events: 1. Occurred during an organized high school practice, competition, or performance (for cheerleading only), and; 2. Required medical attention by an athletic trainer or physician, and; 3. Resulted in restriction of the athlete’s participation for at least 1 day beyond the injury/adverse event date. Therefore, this study includes only skin infections that resulted in time loss from sport participation. Statistical analysis Categorical data are presented as frequencies and percentages. Descriptive statistics were derived using SPSS software, Version 22.0 (IBM Corp, Armonk, NY), and SAS software, Version 9.3 (SAS Institute, Cary, NC). Sport-specific rates are calculated by dividing the number of skin infections by the number of athletic exposures within each sport. Exposures were not stratified by practice and competition as skin infections have differing incubation periods resulting in difficulty determining when initial exposure occurred. Weighting factors used in calculating national estimates of skin infection reflect the inverse probability of a school’s selection into the study (based on the 8 strata representing school size and geographic location). Weighting factors are only available to calculate national estimates for the 9 original sports reported by the 100 randomly selected nationally representative schools.
RESULTS Skin infection incidence During the study period, 474 skin infections were reported during 20,858,781 athlete exposures for a rate of 2.27 per 100,000 athlete exposures. Skin infections accounted for 1.2% of all sports-related injuries/adverse events captured by High School RIO. The overall burden ranged from no skin infections reported in several sports to skin infections representing 12.4% of all injuries/adverse events in wrestling. In the 9 sports, encompassing the original sample (described in ‘‘Methods’’ above), an estimated 76,813 skin infections occurred nationally during the 5-year study period. Skin infection rates varied by sport, with the wrestling rate (28.56/100,000 athlete exposures) more than 10 times that of the next highest, football (2.32/100,000 athlete exposures). All other sports
Table I. Incidence rate of skin infection by high school sport, National High School Sports-Related Injury Surveillance Study, 2009/2010 through 2013/ 2014
Sport*
Boys’ wrestling Boys’ football Boys’ ice hockey Boys’ lacrosse Boys’ basketball Girls’ volleyball Girls’ field hockey Girls’ swimming and diving Girls’ cross country Boys’ baseball Boys’ swimming and diving Girls’ basketball Girls’ softball Total
No. of infections
Athlete exposures
Incidence rate/100,000 athlete exposures*y
349 85 2 3 9 7 2 2
1,222,097 3,656,371 292,120 551,168 1,693,645 1,311,473 463,098 495,535
28.56 2.32 0.68 0.54 0.53 0.53 0.43 0.40
1 3 1
250,420 1,272,308 424,721
0.40 0.24 0.24
1,348,035 937,659 20,858,781y
0.22 0.11 2.27
3 1 474
*No skin infections were reported in boys’ volleyball, girls’ gymnastics, girls’ lacrosse, boys’ or girls’ track and field, girls’ soccer, cheerleading (a co-ed sport), or boys’ cross country. y Total number of athlete exposures includes exposures from sports listed above in the table and sports in which no skin infections occurred.
had rates of less than 1.00 per 100,000 athlete exposures. Eight sports reported no skin infections (Table I). Wrestling also had the highest frequency of skin infections (n = 349, 73.6% of all skin infections) followed by football (n = 85, 17.9%). Despite small differences, there was no significant annual trend over time in skin infection rates. However, skin infections tended to be reported in clusters within team seasons. For example, 3.6% of all skin infections reported occurred within a single school’s wrestling season one school year, and 9.9% occurred during 4 schools’ wrestling seasons another school year. There were also 3 separate football team seasons in which at least 5 skin infections were reported. Organism type Skin infections were most commonly of bacterial origin (n = 288, 60.6%), followed by tinea (n = 131, 28.4%), herpetic lesions (ie, simplex, fever blisters/ cold sores, zoster, gladiatorum) (n = 24, 5.2%), and other (n = 15, 3.2%) (Fig 1). Source of infection was not documented in 12 cases (2.5%). Tinea had the highest proportion of skin infections that were
4 Ashack et al
J AM ACAD DERMATOL
n 2015
missing data regarding time loss. When stratifying by skin infection type, herpetic lesions resulted in the longest time loss (59.1% resulting in loss of at least 10 days or the season ending before the athlete could return to play). Most tinea lesions resulted in less than 1 week time loss (78.0%). Similarly, 62.1% of bacterial infections resulted in less than 1 week of time loss (Table II; available at http://www.jaad.org). Athletic trainers reported 92 (19.4%) skin infections were assessed using blood work or laboratory testing. Of the 11 skin infections requiring surgery (2.3% of all skin infections), 10 were bacterial (the other was missing information on skin infection type).
Fig 1. Distribution of skin infection by specific infectious organism, National High School Sports-Related Injury Surveillance Study, 2009/2010 through 2013/2014. *Specific infectious organism data were missing for 12 skin infections. yIncludes unspecified organisms, combined fungal and bacterial infections, chickenpox and shingles, pityriasis rosea, and noninfectious rashes (poison ivy, dermatitis).
reported to be recurrent infections (n = 26, 20.0%), whereas only 1 herpetic infection was recurrent (4.4%). It is also important to note that the type of skin infection varied by sport (Fig 2). Body part Skin infections most commonly occurred on the head/face (n = 120, 25.3%), followed by forearm (n = 60, 12.7%), upper aspect of arm (n = 38, 8.0%), lower aspect of leg (n = 33, 7.0%), knee (n = 32, 6.8%), and thigh/upper aspect of leg (n = 27, 5.7%) (Fig 3). Affected body part varied by responsible organism. A large majority of herpetic lesions were on the head/face (60.9%). Bacterial infections were more spread out, with 27.4% affecting the head/face, 31.6% affecting the upper extremities, and 24.0% affecting the lower extremities. Tinea lesions were most commonly located on upper extremities (39.6%), with smaller percentages on the head/face (17.9%) and lower extremities (14.0%) (Table II; available at http://www.jaad.org). Impact on participation in sport Return to play time after skin infection varied. The most common return to play time was within 3 to 6 days of an identified skin infection (45.5%), followed by 7 to 9 days (18.8%), 1 to 2 days (18.6%), 10 to 21 days (10.6%), and 22 days or more (5.8%). There were 12 skin infections that had
Patterns by sport Wrestling. Wrestlers made up the majority of skin infections (n = 349, 73.6%), resulting in an estimated 53,518 skin infections occurring nationally over the 5-year study period. The most common body part infected was the head/face (n = 107, 30.7%), followed by forearm (n = 42, 12.0%), upper aspect of arm (n = 29, 8.3%), chest/t-spine/ribs (n = 21, 6.0%), thigh/upper aspect of leg (n = 19, 5.4%), knee and neck/cervical spine (n = 17, 4.9% for each category), lower aspect of leg (n = 16, 4.6%), shoulder (n = 14, 4.0%) and elbow (n = 13, 3.7%). The most common infectious organisms were bacterial (n = 184, 53.8%), followed by tinea (35.7%) and herpetic lesions (6.7%). Football. Football players had the second highest frequency of skin infection (n = 85, 17.9%), resulting in an estimated 14,631 skin infections occurring nationally during the study period. The most common body parts infected were the forearm (n = 17, 20%), followed by elbow (n = 12, 14.1%), and knee (n = 11, 12.9%). The most common infectious organisms were bacterial (n = 72, 87.8%), followed by tinea lesions (n = 5, 6.1%) and scabies or head lice (n = 3, 3.7%).
DISCUSSION This study describes skin infections in high school athletes using data captured from a large national sample of athletes participating in multiple sports over a multiyear study period. Skin infection are common in high school sports and in some sports can result in significant time loss from participation. Prevention and education has been shown somewhat effective but some reports indicate that many high school athletic programs have no policies on hand hygiene or restricting athletes from play with skin infections.17 Thus it is of utmost importance to understand rates and patterns of skin
J AM ACAD DERMATOL
VOLUME jj, NUMBER j
Ashack et al 5
Fig 2. Percentages of types of skin infection by sport, National High School Sports-Related Injury Surveillance Study, 2009/2010 through 2013/2014. *Includes unspecified organisms, combined fungal and bacterial infections, chickenpox and shingles, pityriasis rosea, and noninfectious rashes (poison ivy, dermatitis). ySports reported #3 cases of skin infections per sport.
Fig 3. Skin infection by affected body part, National High School Sports-Related Injury Surveillance Study, 2009/2010 through 2013/2014. *Not shown is ‘‘other’’ category that was affected 9.9% of the time and included nonspecific locations reported such as ‘‘skin,’’ impetigo, carbuncle, and staph in the survey. Staph, staphylococcus aureus.
infections in high school athletes to drive effective evidence-based prevention efforts. The study, evaluating all skin infections reported from 2009/2010 through 2013/2014 by high school athletes participating in 22 sports, found the skin infection rate was 2.27 per 100,000 athlete exposures. This differs from a 2013 Iowa study reporting a skin and soft-tissue infection rate of 12.2 per 1000 student athletes.17 This difference is likely an artifact of the different denominators used to calculate rates in the 2 studies: athlete exposures in this study and number of athletes in the Iowa study. The Iowa study was also
limited to wrestling, football, and basketball, contact sports with higher incidence of skin infections.17 Our data indicating skin infection rates varied widely by sport with the highest rates in the full contact sports of wrestling and football. We found the annual number of skin infections were relatively stable over time with peaks in 2010/2011 and 2013/2014 linked to localized outbreaks within a small number of high schools. It is also important to note that most infections were relatively minor, resulting in return to play within 3 to 6 days. These data suggest that preventative measures should focus more on contact sports, such as wrestling, compared with noncontact sports. In our study wrestling had the highest skin infection rate, followed by football. This supports the prevalent theory that contact sports are associated with a higher risk for skin infections. This is consistent with literature reporting wrestlers have the highest frequency of skin infections,17 suggesting that high school wrestling may benefit the most from prevention efforts.18 In high school wrestling the most common infection was of bacterial origin, consistent with a recent survey of high school wrestlers after a tournament, which reported 46% of skin infections were caused by impetigo.19 Thus, preventative measures should focus on potential sources of bacterial infections, such as wrestling headgear and mats. A number of recommended best practices are available to prevent sports-related skin infections. For example, the Centers for Disease Control and Prevention currently recommend athletes take showers directly after each competition.20 This effective prevention practice was demonstrated in a
6 Ashack et al
2012 study that reported only 7.9% of athletes chose not to shower after competition and skin infections declined when athletes used soap-and-water skin wipes.18 Another preventative measure currently recommended by the National Federation of State High School Associations is the implementation of a more standardized prematch procedure regarding having either referees performing skin checks or verifying skin checks have been performed.21 These measures could reduce infection rates in high school athletics if applied broadly. Although our study presents a large amount of data describing high school sports-related skin infections on a national level, it has limitations. Only schools with National Athletic Trainers’ Associationeaffiliated athletic trainers were eligible and data were collected from a convenience sample of schools, representing only a fraction of the total number of high schools nationwide, which may affect generalizability of our findings. For example, schools without athletic trainers may have higher skin infection rates. Skin infections in which the athlete did not receive care from the athletic trainers are also not included in this study, thus the data presented here are likely an underestimate of the true rate of skin infection. Another limitation is that skin infections that did not result in at least 1 day of time loss from sport participation were excluded from this study. There may be important differences between skin infections that do and do not result in time loss, particularly if future research indicates variability between clinicians in how long athletes are kept out of play and under what conditions they are allowed to return after contraction of a skin infection. In addition, the tendency of skin infections to cluster may affect the stability of national estimates, as single schools with outbreaks can dramatically influence these estimates. Nevertheless, this study’s use of a large national surveillance database of high school sports-related injuries/adverse events provides the most robust discussion of the epidemiology of sports-related skin infections to date. Sports continue to play an immense role in the lives of US high school students. High school athletics have the potential to lead to better performance in school and a decreased number of school absences.3 With this report we highlight a relatively common yet understudied adverse event of high school sports, skin infection, hoping to both promote awareness and drive effective evidencebased prevention efforts. We thank the certified athletic trainers who report data to High School RIO; without their dedication this research would not be possible.
J AM ACAD DERMATOL
n 2015
REFERENCES 1. Darrow CJ, Collins CL, Yard EE, Comstock RD. Epidemiology of severe injuries among United States high school athletes: 2005-2007. Am J Sports Med. 2009;37:1798-1805. 2. Bartlett PC, Martin RJ, Cahill BR. Furunculosis in a high school football team. Am J Sports Med. 1982;10:371-374. 3. Yard EE, Collins CL, Dick RW, Comstock RD. An epidemiologic comparison of high school and college wrestling injuries. Am J Sports Med. 2008;36:57-64. 4. Becker TM, Kodsi R, Bailey P, Lee F, Levandowski R, Nahmias AJ. Grappling with herpes: herpes gladiatorum. Am J Sports Med. 1988;16:665-669. 5. Adams BB. Tinea corporis gladiatorum: a cross-sectional study. J Am Acad Dermatol. 2000;43:1039-1041. 6. Turbeville SD, Cowan LD, Greenfield RA. Infectious disease outbreaks in competitive sports: a review of the literature. Am J Sports Med. 2006;34:1860-1865. 7. Adams BB. Skin infections in athletes. Dermatol Nurs. 2008;20: 39-44. 8. Anderson BJ. The epidemiology and clinical analysis of several outbreaks of herpes gladiatorum. Med Sci Sports Exerc. 2003; 35:1809-1814. 9. Likness LP. Common dermatologic infections in athletes and return-to-play guidelines. J Am Osteopath Assoc. 2011;111: 373-379. 10. White WB, Grant-Kels JM. Transmission of herpes simplex virus type 1 infection in rugby players. JAMA. 1984;252:533-535. 11. Shinoda H, Nishimoto K, Mochizuki T. Screening examination of Trichophyton tonsurans among Judo practitioners at the All Japan Inter High School Championships, Saga 2007 [in Japanese]. Nihon Ishinkin Gakkai Zasshi. 2008;49:305-309. 12. Barr B, Felkner M, Diamond PM. High school athletic departments as sentinel surveillance sites for community-associated methicillinresistant staphylococcal infections. Tex Med. 2006;102:56-61. 13. Collins CJ, O’Connell B. Infectious disease outbreaks in competitive sports, 2005-2010. J Athl Train. 2012;47:516-518. 14. O’Laughlin DM, Cook J. Financial analysis of methicillinresistant Staphylococcus aureus in a high school wrestler. J Pediatr Nurs. 2009;35:130-136. 15. Rechel JA, Yard EE, Comstock RD. An epidemiologic comparison of high school sports injuries sustained in practice and competition. J Athl Train. 2008;43:197-204. 16. Centers for Disease Control and Prevention (CDC). Sports-related injuries among high school athleteseUnited States, 2005-06 school year. MMWR Morb Mortal Wkly Rep. 2006;55(38): 1037-1040. 17. Pedersen M, Doyle MR, Beste A, Diekema DJ, Zimmerman MB, Herwaldt LA. Survey of high school athletic programs in Iowa regarding infections and infection prevention policies and practices. Iowa Orthop J. 2013;33:107-113. 18. Anderson BJ. Effectiveness of body wipes as an adjunct to reducing skin infections in high school wrestlers. Clin J Sport Med. 2012;22:424-429. 19. Williams C, Wells J, Klein R, Sylvester T, Sunenshine R. Notes from the field: outbreak of skin lesions among high school wrestlerseArizona, 2014. MMWR Morb Mortal Wkly Rep. 2015; 64:559-560. 20. Centers for Disease Control and Prevention (CDC). Prevention information and advice for athletes. 2014. Available at: http:// www.cdc.gov/mrsa/community/team-hc-providers/advice-forathletes.html. Accessed July 14, 2015. 21. Sieck B. Pre-match requirements for referees clarified in high school wrestling. Available from: URL: https://www.nfhs.org/ articles/pre-match-requirements-for-referees-clarified-in-highschool-wrestling/. Accessed July 21, 2015.
Ashack et al 6.e1
J AM ACAD DERMATOL
VOLUME jj, NUMBER j
Table II. Type of skin infection by sport, athlete, and school characteristics Type of skin infection
Characteristic
Type of sport Boys’ wrestling Boys’ football Boys’ basketball Girls’ volleyball Boys’ soccer All othersy Time to return to sportz 1-2 d 3-6 d 7-9 d 10-21 d $22 d Medical disqualification for season Athlete chose not to return Season ended before return Other Principal body part injuredx Head/face Ear(s) Neck/cervical spine Shoulder Upper aspect of arm Elbow Forearm Wrist Hand Chest/t-spine/ribs Abdomen Lower aspect of back/l-spine/pelvis Thigh/upper aspect of leg Knee Lower aspect of leg Ankle Foot Mouth/teeth Clavicle/collarbone Axilla Other// School size{ [1000 Students #1000 Students School region{ Midwest Northeast South West
Bacterial infection, n = 288
Tinea lesion, n = 129
Herpetic lesion, n = 23
Other,* n = 15
Scabies/ head lice, n=4
Molluscum contagiosum, n=3
Total, N = 462
184 72 5 6 5 16
(63.9) (25.0) (1.7) (2.1) (1.7) (5.6)
122 5 2 0 0 0
(94.6) (3.9) (1.6) (0.0) (0.0) (0.0)
23 0 0 0 0 0
(100.0) (0.0) (0.0) (0.0) (0.0) (0.0)
9 2 2 0 0 2
(60.0) (13.3) (13.3) (0.0) (0.0) (13.3)
1 3 0 0 0 0
(25.0) (75.0) (0.0) (0.0) (0.0) (0.0)
3 0 0 0 0 0
(100.0) (0.0) (0.0) (0.0) (0.0) (0.0)
342 82 9 6 5 18
(74.0) (17.7) (1.9) (1.3) (1.1) (3.9)
49 126 59 28 3 2 5 8 2
(17.4) (44.7) (20.9) (9.9) (1.1) (0.7) (1.8) (2.8) (0.7)
26 73 19 5 2 0 1 1 0
(20.5) (57.5) (15.0) (3.9) (1.6) (0.0) (0.8) (0.8) (0.0)
2 4 3 10 0 0 0 3 0
(9.1) (18.2) (13.6) (45.5) (0.0) (0.0) (0.0) (13.6) (0.0)
2 5 3 2 1 0 1 0 1
(13.3) (33.3) (20.0) (13.3) (6.7) (0.0) (6.7) (0.0) (6.7)
2 0 1 1 0 0 0 0 0
(50.0) (0.0) (25.0) (25.0) (0.0) (0.0) (0.0) (0.0) (0.0)
0 0 1 2 0 0 0 0 0
(0.0) (0.0) (33.3) (66.7) (0.0) (0.0) (0.0) (0.0) (0.0)
81 208 86 48 6 2 7 12 3
(17.9) (45.9) (19.0) (10.6) (1.3) (0.4) (1.5) (2.6) (0.7)
74 5 7 11 18 17 36 3 6 7 6 3 16 30 23 3 11 0 0 2 19
(25.7) (1.7) (2.4) (3.8) (6.3) (5.9) (12.5) (1.0) (2.1) (2.4) (2.1) (1.0) (5.6) (10.4) (8.0) (1.0) (3.8) (0.0) (0.0) (0.7) (6.6)
21 2 12 8 18 7 15 2 1 16 0 1 9 2 7 0 0 0 0 0 8
(16.3) (1.6) (9.3) (6.2) (14.0) (5.4) (11.6) (1.6) (0.8) (12.4) (0.0) (0.8) (7.0) (1.6) (5.4) (0.0) (0.0) (0.0) (0.0) (0.0) (6.2)
14 0 0 0 1 1 2 0 1 0 0 0 0 1 0 0 0 1 0 0 2
(60.9) (0.0) (0.0) (0.0) (4.3) (4.3) (8.7) (0.0) (4.3) (0.0) (0.0) (0.0) (0.0) (4.3) (0.0) (0.0) (0.0) (4.3) (0.0) (0.0) (8.7)
3 0 0 0 0 0 4 1 0 1 1 0 0 1 1 0 1 0 0 0 1
(20.0) (0.0) (0.0) (0.0) (0.0) (0.0) (26.7) (6.7) (0.0) (6.7) (6.7) (0.0) (0.0) (6.7) (6.7) (0.0) (6.7) (0.0) (0.0) (0.0) (6.7)
0 0 0 0 0 0 0 0 0 1 2 1 0 0 0 0 0 0 0 0 1
(0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (25.0) (50.0) (25.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (25.0)
0 0 0 0 0 1 2 0 1 0 0 0 0 0 0 0 0 0 1 0 0
(0.0) (0.0) (0.0) (0.0) (0.0) (33.3) (66.7) (0.0) (33.3) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (33.3) (0.0) (0.0)
112 7 19 19 37 26 59 6 9 25 9 5 25 34 31 3 12 1 1 2 31
(24.2) (1.5) (4.1) (4.1) (8.0) (5.6) (12.8) (1.3) (1.9) (5.4) (1.9) (1.1) (5.4) (7.4) (6.7) (0.6) (2.6) (0.2) (0.2) (0.4) (6.7)
217 (75.6) 70 (24.4) 94 61 81 51
(32.8) (21.3) (28.2) (17.8)
91 (70.5) 38 (29.5)
20 (87.0) 3 (13.0)
9 (60.0) 6 (40.0)
4 (100.0) 0 (0.0)
3 (100.0) (0.0)
344 (74.6) 117 (25.4)
41 27 32 29
13 0 6 4
3 3 4 5
1 0 0 3
0 1 1 1
152 92 124 93
(31.8) (20.9) (22.5) (22.5)
(56.5) (0.0) (26.1) (17.4)
(20.0) (20.0) (26.7) (33.3)
(25.0) (0.0) (0.0) (75.0)
(0.0) (33.3) (33.3) (33.3)
(33.0) (20.0) (26.9) (20.2)
Values are presented as frequency (percentage). *Includes unspecified organisms, combined fungal and bacterial infections, chickenpox and shingles, pityriasis rosea, and noninfectious rashes (poison ivy, dermatitis). y Sports reported #3 cases of skin infections per sport. z Missing values for 9 cases. x Sums of frequencies (percentages) will exceed n (100.0) for bacterial infection, scabies/head lice, molluscum contagiosum, and total categories, as multiple sites of infection were documented for 6 cases. // Includes nonspecific location reported as ‘‘skin,’’ impetigo, carbuncle, and staph. { Missing value for 1 case.
ARTICLE
Skin infections among US high school athletes: A national survey Kurt A. Ashack, BA,a Kyle A. Burton, BS,c Teresa R. Johnson, BA, MS, PhD,b Dustin W. Currie, MPH,d R. Dawn Comstock, PhD,d,e and Robert P. Dellavalle, MD, PhD, MSPHd,f,g Grand Rapids, Michigan; Orlando, Florida; and Aurora and Denver, Colorado Background: Skin infections have long been a reported problem among high school athletes, particularly wrestlers. There has yet to be a national study describing the epidemiology of skin infections across multiple high school sports. Objective: We sought to report the epidemiology of skin infections among US high school athletes. Methods: High school sports-related skin infections resulting in time loss were reported by a convenience sample of US high schools from 2009/2010 through 2013/2014 via High School Reporting Information Online. Results: During the study, 474 skin infections were reported among 20,858,781 athlete exposures, a rate of 2.27 per 100,000 athlete exposures. The largest number of skin infections occurred in wrestling (73.6%) followed by football (17.9%). The most common infections were bacterial (60.6%) and tinea (28.4%) infections. Body parts most often affected were the head/face (25.3%) followed by the forearm (12.7%). Limitations: The study included only high schools with National Athletic Trainers’ Associationeaffiliated athletic trainers, which may limit generalizability. However, using athletic trainers as data reporters improved data quality. Conclusions: Skin infections are an important subset of high school sports-related adverse events. An understanding of the epidemiology of sports-related skin infections should promote awareness and drive evidence-based prevention efforts. ( J Am Acad Dermatol http://dx.doi.org/10.1016/j.jaad.2015.10.042.) Key words: athletes; competition; high school; injury; prevention; skin infections; sports.
S
ports-related injury is a risk each of the 7 million plus high school student athletes in the United States face.1 Dating back to 1979, an
outbreak of furunculosis was reported among 26 high school football players.2 Since then, there have been multiple reports of skin infection outbreaks
From Michigan State University College of Human Medicine, Grand Rapidsa; Department of Medical Education,b University of Central Florida College of Medicine,c Orlando; Department of Epidemiology, Colorado School of Public Health,d Department of Pediatrics (Emergency Medicine),e and Department of Dermatology,f University of Colorado Anschutz Medical Campus, Aurora; and Dermatology Service, US Department of Veterans Affairs, Eastern Colorado Health Care System, Denver.g Mr Ashack and Mr Burton are co-first authors. The content of this report representing data collection by the National High School Sports-Related Injury Surveillance Study (High School Reporting Information Online) was funded in part by the Centers for Disease Control and Prevention grants R49/CE000674-01 and R49/CE001172-01. We also acknowledge the generous research funding contributions of the National Federation of State High School Associations, the National Operating Committee on Standards for Athletic Equipment, DonJoy Orthotics, and EyeBlack. The content of this report is solely the responsibility of the authors and does not necessarily
represent the official views of the Centers for Disease Control and Prevention or any of the other institutions that provided financial support for this research. Disclosure: Dr Dellavalle is an employee of the US Department of Veterans Affairs. The US Department of Veterans Affairs had no role in the writing of this manuscript. Any opinions expressed herein do not necessarily reflect the opinions of the US Department of Veterans Affairs. Mr Ashack, Mr Burton, Mr Currie, and Drs Johnson and Comstock have no conflicts of interest to declare. Accepted for publication October 17, 2015. Reprint requests: Robert P. Dellavalle, MD, PhD, MSPH, Dermatology Service, US Department of Veterans Affairs, 1055 Clermont St, Box 165, Denver, CO 80220. E-mail: robert.dellavalle@ucdenver. edu. Published online January 28, 2016. 0190-9622 Published by Elsevier on behalf of the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2015.10.042
1
2 Ashack et al
J AM ACAD DERMATOL
n 2015
associated with high school athletics, particularly sample of 100 US high schools with certified wrestling.3-6 athletic trainers, stratified by school population Contact sports have the highest risk of cutaneous and US Censusedefined geographic region. The infectious disease.7-9 However, it is important to original sample included 9 sports (boys’ wrestling, understand the epidemiology of skin infections boys’ football, boys’ soccer, girls’ soccer, girls’ across all sports, as serious bacterial skin infections, volleyball, boys’ basketball, girls’ basketball, boys’ specifically methicillin-resistant Staphylococcus baseball, and girls’ softball). aureus, have also been reBeginning in 2008/2009, ported in noncontact sports High School RIO expanded CAPSULE SUMMARY such as volleyball and cross the list of sports for which 10-12 country. In addition, skin data were collected to Sports-related skin infections occurring infection rates and patterns eventually add 13 sports. in high school athletes have been in high school athletics Nationally representative commonly reported in literature and are appear to have changed samples of high schools known to cause significant morbidity throughout time. Many could not be recruited for and time loss from competition. skin infections previously each additional sport This report highlights the epidemiology stemmed from herpes simbecause of geographic variof high school athletic skin infections on plex virus, Staphylococcus ability in popularity of some a national level. (methicillin susceptible and sports, so a convenience methicillin resistant), or This information should promote sample of schools has been tinea.6,13 awareness and help drive targeted, recruited annually to The multiple skin infecevidence-based prevention efforts. augment the 100 randomly tions that may present in selected nationally represenhigh school athletics have tative sample of schools. The varying degrees of morbidity. Although most skin study began collecting data on specific types of skin infections require a week of recovery on average, infection (ie, bacterial, herpetic, tinea) in the 2009/ others may have more serious sequelae such as 2010 academic year. This study analyzed High ocular and neurologic involvement from a primary School RIO skin infection data from 2009/2010 herpes simplex virus infection.6,10 Methicillinthrough 2013/2014. Because of the relatively rare resistant Staphylococcus aureus and soft tissue skin nature of skin infections, data from the larger infections can lead to systemic infections such as convenience sample of 22 sports were used, with septic shock and osteomyelitis.14 the exception of national estimates, which are To our knowledge, no study to date specifically reported for only the 9 sports included in the original evaluates skin infections in high school athletes nationally representative sample. using data from a large national sample and including multiple sports. The objective of this Data collection study was to describe the epidemiology of skin Athletic trainers at participating schools received infection in US high school athletes. Specific aims weekly e-mails reminding them to enter their were to report rates of skin infection by sport, school’s weekly exposure reports for their assigned evaluate body sites most commonly affected, and sports. Weekly exposure reports collected number of evaluate severity of skin infections in terms of time to athlete competitions and athlete practices for sports return to play. The ultimate goal of this report is to in session and the number of reportable injuries that increase understanding of the epidemiology of occurred in each sport. For each injury, athletic sports-related skin infections, which will promote trainers completed an injury report, providing awareness and drive effective evidence-based detailed information about the injured player (eg, prevention efforts. age, year in school), injury (eg, site, type, severity), and injury event (eg, time in season, mechanism, phase of play). Athletic trainers could view all METHODS submitted data throughout the study and update Study sample reports as needed (eg, need for surgery, days until This study used data collected by High School resuming play). Reporting Information Online (RIO), an Internetbased high school sports injury surveillance system Study definitions that has been described previously.15,16 Briefly, the An athlete exposure is defined as 1 athlete study began during the 2005/2006 academic year, participating in 1 practice or competition. A team using a randomly selected nationally representative d
d
d
Ashack et al 3
J AM ACAD DERMATOL
VOLUME jj, NUMBER j
season is defined as all injuries in a single school, sport, and academic year. In High School RIO, reportable injuries/adverse events: 1. Occurred during an organized high school practice, competition, or performance (for cheerleading only), and; 2. Required medical attention by an athletic trainer or physician, and; 3. Resulted in restriction of the athlete’s participation for at least 1 day beyond the injury/adverse event date. Therefore, this study includes only skin infections that resulted in time loss from sport participation. Statistical analysis Categorical data are presented as frequencies and percentages. Descriptive statistics were derived using SPSS software, Version 22.0 (IBM Corp, Armonk, NY), and SAS software, Version 9.3 (SAS Institute, Cary, NC). Sport-specific rates are calculated by dividing the number of skin infections by the number of athletic exposures within each sport. Exposures were not stratified by practice and competition as skin infections have differing incubation periods resulting in difficulty determining when initial exposure occurred. Weighting factors used in calculating national estimates of skin infection reflect the inverse probability of a school’s selection into the study (based on the 8 strata representing school size and geographic location). Weighting factors are only available to calculate national estimates for the 9 original sports reported by the 100 randomly selected nationally representative schools.
RESULTS Skin infection incidence During the study period, 474 skin infections were reported during 20,858,781 athlete exposures for a rate of 2.27 per 100,000 athlete exposures. Skin infections accounted for 1.2% of all sports-related injuries/adverse events captured by High School RIO. The overall burden ranged from no skin infections reported in several sports to skin infections representing 12.4% of all injuries/adverse events in wrestling. In the 9 sports, encompassing the original sample (described in ‘‘Methods’’ above), an estimated 76,813 skin infections occurred nationally during the 5-year study period. Skin infection rates varied by sport, with the wrestling rate (28.56/100,000 athlete exposures) more than 10 times that of the next highest, football (2.32/100,000 athlete exposures). All other sports
Table I. Incidence rate of skin infection by high school sport, National High School Sports-Related Injury Surveillance Study, 2009/2010 through 2013/ 2014
Sport*
Boys’ wrestling Boys’ football Boys’ ice hockey Boys’ lacrosse Boys’ basketball Girls’ volleyball Girls’ field hockey Girls’ swimming and diving Girls’ cross country Boys’ baseball Boys’ swimming and diving Girls’ basketball Girls’ softball Total
No. of infections
Athlete exposures
Incidence rate/100,000 athlete exposures*y
349 85 2 3 9 7 2 2
1,222,097 3,656,371 292,120 551,168 1,693,645 1,311,473 463,098 495,535
28.56 2.32 0.68 0.54 0.53 0.53 0.43 0.40
1 3 1
250,420 1,272,308 424,721
0.40 0.24 0.24
1,348,035 937,659 20,858,781y
0.22 0.11 2.27
3 1 474
*No skin infections were reported in boys’ volleyball, girls’ gymnastics, girls’ lacrosse, boys’ or girls’ track and field, girls’ soccer, cheerleading (a co-ed sport), or boys’ cross country. y Total number of athlete exposures includes exposures from sports listed above in the table and sports in which no skin infections occurred.
had rates of less than 1.00 per 100,000 athlete exposures. Eight sports reported no skin infections (Table I). Wrestling also had the highest frequency of skin infections (n = 349, 73.6% of all skin infections) followed by football (n = 85, 17.9%). Despite small differences, there was no significant annual trend over time in skin infection rates. However, skin infections tended to be reported in clusters within team seasons. For example, 3.6% of all skin infections reported occurred within a single school’s wrestling season one school year, and 9.9% occurred during 4 schools’ wrestling seasons another school year. There were also 3 separate football team seasons in which at least 5 skin infections were reported. Organism type Skin infections were most commonly of bacterial origin (n = 288, 60.6%), followed by tinea (n = 131, 28.4%), herpetic lesions (ie, simplex, fever blisters/ cold sores, zoster, gladiatorum) (n = 24, 5.2%), and other (n = 15, 3.2%) (Fig 1). Source of infection was not documented in 12 cases (2.5%). Tinea had the highest proportion of skin infections that were
4 Ashack et al
J AM ACAD DERMATOL
n 2015
missing data regarding time loss. When stratifying by skin infection type, herpetic lesions resulted in the longest time loss (59.1% resulting in loss of at least 10 days or the season ending before the athlete could return to play). Most tinea lesions resulted in less than 1 week time loss (78.0%). Similarly, 62.1% of bacterial infections resulted in less than 1 week of time loss (Table II; available at http://www.jaad.org). Athletic trainers reported 92 (19.4%) skin infections were assessed using blood work or laboratory testing. Of the 11 skin infections requiring surgery (2.3% of all skin infections), 10 were bacterial (the other was missing information on skin infection type).
Fig 1. Distribution of skin infection by specific infectious organism, National High School Sports-Related Injury Surveillance Study, 2009/2010 through 2013/2014. *Specific infectious organism data were missing for 12 skin infections. yIncludes unspecified organisms, combined fungal and bacterial infections, chickenpox and shingles, pityriasis rosea, and noninfectious rashes (poison ivy, dermatitis).
reported to be recurrent infections (n = 26, 20.0%), whereas only 1 herpetic infection was recurrent (4.4%). It is also important to note that the type of skin infection varied by sport (Fig 2). Body part Skin infections most commonly occurred on the head/face (n = 120, 25.3%), followed by forearm (n = 60, 12.7%), upper aspect of arm (n = 38, 8.0%), lower aspect of leg (n = 33, 7.0%), knee (n = 32, 6.8%), and thigh/upper aspect of leg (n = 27, 5.7%) (Fig 3). Affected body part varied by responsible organism. A large majority of herpetic lesions were on the head/face (60.9%). Bacterial infections were more spread out, with 27.4% affecting the head/face, 31.6% affecting the upper extremities, and 24.0% affecting the lower extremities. Tinea lesions were most commonly located on upper extremities (39.6%), with smaller percentages on the head/face (17.9%) and lower extremities (14.0%) (Table II; available at http://www.jaad.org). Impact on participation in sport Return to play time after skin infection varied. The most common return to play time was within 3 to 6 days of an identified skin infection (45.5%), followed by 7 to 9 days (18.8%), 1 to 2 days (18.6%), 10 to 21 days (10.6%), and 22 days or more (5.8%). There were 12 skin infections that had
Patterns by sport Wrestling. Wrestlers made up the majority of skin infections (n = 349, 73.6%), resulting in an estimated 53,518 skin infections occurring nationally over the 5-year study period. The most common body part infected was the head/face (n = 107, 30.7%), followed by forearm (n = 42, 12.0%), upper aspect of arm (n = 29, 8.3%), chest/t-spine/ribs (n = 21, 6.0%), thigh/upper aspect of leg (n = 19, 5.4%), knee and neck/cervical spine (n = 17, 4.9% for each category), lower aspect of leg (n = 16, 4.6%), shoulder (n = 14, 4.0%) and elbow (n = 13, 3.7%). The most common infectious organisms were bacterial (n = 184, 53.8%), followed by tinea (35.7%) and herpetic lesions (6.7%). Football. Football players had the second highest frequency of skin infection (n = 85, 17.9%), resulting in an estimated 14,631 skin infections occurring nationally during the study period. The most common body parts infected were the forearm (n = 17, 20%), followed by elbow (n = 12, 14.1%), and knee (n = 11, 12.9%). The most common infectious organisms were bacterial (n = 72, 87.8%), followed by tinea lesions (n = 5, 6.1%) and scabies or head lice (n = 3, 3.7%).
DISCUSSION This study describes skin infections in high school athletes using data captured from a large national sample of athletes participating in multiple sports over a multiyear study period. Skin infection are common in high school sports and in some sports can result in significant time loss from participation. Prevention and education has been shown somewhat effective but some reports indicate that many high school athletic programs have no policies on hand hygiene or restricting athletes from play with skin infections.17 Thus it is of utmost importance to understand rates and patterns of skin
J AM ACAD DERMATOL
VOLUME jj, NUMBER j
Ashack et al 5
Fig 2. Percentages of types of skin infection by sport, National High School Sports-Related Injury Surveillance Study, 2009/2010 through 2013/2014. *Includes unspecified organisms, combined fungal and bacterial infections, chickenpox and shingles, pityriasis rosea, and noninfectious rashes (poison ivy, dermatitis). ySports reported #3 cases of skin infections per sport.
Fig 3. Skin infection by affected body part, National High School Sports-Related Injury Surveillance Study, 2009/2010 through 2013/2014. *Not shown is ‘‘other’’ category that was affected 9.9% of the time and included nonspecific locations reported such as ‘‘skin,’’ impetigo, carbuncle, and staph in the survey. Staph, staphylococcus aureus.
infections in high school athletes to drive effective evidence-based prevention efforts. The study, evaluating all skin infections reported from 2009/2010 through 2013/2014 by high school athletes participating in 22 sports, found the skin infection rate was 2.27 per 100,000 athlete exposures. This differs from a 2013 Iowa study reporting a skin and soft-tissue infection rate of 12.2 per 1000 student athletes.17 This difference is likely an artifact of the different denominators used to calculate rates in the 2 studies: athlete exposures in this study and number of athletes in the Iowa study. The Iowa study was also
limited to wrestling, football, and basketball, contact sports with higher incidence of skin infections.17 Our data indicating skin infection rates varied widely by sport with the highest rates in the full contact sports of wrestling and football. We found the annual number of skin infections were relatively stable over time with peaks in 2010/2011 and 2013/2014 linked to localized outbreaks within a small number of high schools. It is also important to note that most infections were relatively minor, resulting in return to play within 3 to 6 days. These data suggest that preventative measures should focus more on contact sports, such as wrestling, compared with noncontact sports. In our study wrestling had the highest skin infection rate, followed by football. This supports the prevalent theory that contact sports are associated with a higher risk for skin infections. This is consistent with literature reporting wrestlers have the highest frequency of skin infections,17 suggesting that high school wrestling may benefit the most from prevention efforts.18 In high school wrestling the most common infection was of bacterial origin, consistent with a recent survey of high school wrestlers after a tournament, which reported 46% of skin infections were caused by impetigo.19 Thus, preventative measures should focus on potential sources of bacterial infections, such as wrestling headgear and mats. A number of recommended best practices are available to prevent sports-related skin infections. For example, the Centers for Disease Control and Prevention currently recommend athletes take showers directly after each competition.20 This effective prevention practice was demonstrated in a
6 Ashack et al
2012 study that reported only 7.9% of athletes chose not to shower after competition and skin infections declined when athletes used soap-and-water skin wipes.18 Another preventative measure currently recommended by the National Federation of State High School Associations is the implementation of a more standardized prematch procedure regarding having either referees performing skin checks or verifying skin checks have been performed.21 These measures could reduce infection rates in high school athletics if applied broadly. Although our study presents a large amount of data describing high school sports-related skin infections on a national level, it has limitations. Only schools with National Athletic Trainers’ Associationeaffiliated athletic trainers were eligible and data were collected from a convenience sample of schools, representing only a fraction of the total number of high schools nationwide, which may affect generalizability of our findings. For example, schools without athletic trainers may have higher skin infection rates. Skin infections in which the athlete did not receive care from the athletic trainers are also not included in this study, thus the data presented here are likely an underestimate of the true rate of skin infection. Another limitation is that skin infections that did not result in at least 1 day of time loss from sport participation were excluded from this study. There may be important differences between skin infections that do and do not result in time loss, particularly if future research indicates variability between clinicians in how long athletes are kept out of play and under what conditions they are allowed to return after contraction of a skin infection. In addition, the tendency of skin infections to cluster may affect the stability of national estimates, as single schools with outbreaks can dramatically influence these estimates. Nevertheless, this study’s use of a large national surveillance database of high school sports-related injuries/adverse events provides the most robust discussion of the epidemiology of sports-related skin infections to date. Sports continue to play an immense role in the lives of US high school students. High school athletics have the potential to lead to better performance in school and a decreased number of school absences.3 With this report we highlight a relatively common yet understudied adverse event of high school sports, skin infection, hoping to both promote awareness and drive effective evidencebased prevention efforts. We thank the certified athletic trainers who report data to High School RIO; without their dedication this research would not be possible.
J AM ACAD DERMATOL
n 2015
REFERENCES 1. Darrow CJ, Collins CL, Yard EE, Comstock RD. Epidemiology of severe injuries among United States high school athletes: 2005-2007. Am J Sports Med. 2009;37:1798-1805. 2. Bartlett PC, Martin RJ, Cahill BR. Furunculosis in a high school football team. Am J Sports Med. 1982;10:371-374. 3. Yard EE, Collins CL, Dick RW, Comstock RD. An epidemiologic comparison of high school and college wrestling injuries. Am J Sports Med. 2008;36:57-64. 4. Becker TM, Kodsi R, Bailey P, Lee F, Levandowski R, Nahmias AJ. Grappling with herpes: herpes gladiatorum. Am J Sports Med. 1988;16:665-669. 5. Adams BB. Tinea corporis gladiatorum: a cross-sectional study. J Am Acad Dermatol. 2000;43:1039-1041. 6. Turbeville SD, Cowan LD, Greenfield RA. Infectious disease outbreaks in competitive sports: a review of the literature. Am J Sports Med. 2006;34:1860-1865. 7. Adams BB. Skin infections in athletes. Dermatol Nurs. 2008;20: 39-44. 8. Anderson BJ. The epidemiology and clinical analysis of several outbreaks of herpes gladiatorum. Med Sci Sports Exerc. 2003; 35:1809-1814. 9. Likness LP. Common dermatologic infections in athletes and return-to-play guidelines. J Am Osteopath Assoc. 2011;111: 373-379. 10. White WB, Grant-Kels JM. Transmission of herpes simplex virus type 1 infection in rugby players. JAMA. 1984;252:533-535. 11. Shinoda H, Nishimoto K, Mochizuki T. Screening examination of Trichophyton tonsurans among Judo practitioners at the All Japan Inter High School Championships, Saga 2007 [in Japanese]. Nihon Ishinkin Gakkai Zasshi. 2008;49:305-309. 12. Barr B, Felkner M, Diamond PM. High school athletic departments as sentinel surveillance sites for community-associated methicillinresistant staphylococcal infections. Tex Med. 2006;102:56-61. 13. Collins CJ, O’Connell B. Infectious disease outbreaks in competitive sports, 2005-2010. J Athl Train. 2012;47:516-518. 14. O’Laughlin DM, Cook J. Financial analysis of methicillinresistant Staphylococcus aureus in a high school wrestler. J Pediatr Nurs. 2009;35:130-136. 15. Rechel JA, Yard EE, Comstock RD. An epidemiologic comparison of high school sports injuries sustained in practice and competition. J Athl Train. 2008;43:197-204. 16. Centers for Disease Control and Prevention (CDC). Sports-related injuries among high school athleteseUnited States, 2005-06 school year. MMWR Morb Mortal Wkly Rep. 2006;55(38): 1037-1040. 17. Pedersen M, Doyle MR, Beste A, Diekema DJ, Zimmerman MB, Herwaldt LA. Survey of high school athletic programs in Iowa regarding infections and infection prevention policies and practices. Iowa Orthop J. 2013;33:107-113. 18. Anderson BJ. Effectiveness of body wipes as an adjunct to reducing skin infections in high school wrestlers. Clin J Sport Med. 2012;22:424-429. 19. Williams C, Wells J, Klein R, Sylvester T, Sunenshine R. Notes from the field: outbreak of skin lesions among high school wrestlerseArizona, 2014. MMWR Morb Mortal Wkly Rep. 2015; 64:559-560. 20. Centers for Disease Control and Prevention (CDC). Prevention information and advice for athletes. 2014. Available at: http:// www.cdc.gov/mrsa/community/team-hc-providers/advice-forathletes.html. Accessed July 14, 2015. 21. Sieck B. Pre-match requirements for referees clarified in high school wrestling. Available from: URL: https://www.nfhs.org/ articles/pre-match-requirements-for-referees-clarified-in-highschool-wrestling/. Accessed July 21, 2015.
Ashack et al 6.e1
J AM ACAD DERMATOL
VOLUME jj, NUMBER j
Table II. Type of skin infection by sport, athlete, and school characteristics Type of skin infection
Characteristic
Type of sport Boys’ wrestling Boys’ football Boys’ basketball Girls’ volleyball Boys’ soccer All othersy Time to return to sportz 1-2 d 3-6 d 7-9 d 10-21 d $22 d Medical disqualification for season Athlete chose not to return Season ended before return Other Principal body part injuredx Head/face Ear(s) Neck/cervical spine Shoulder Upper aspect of arm Elbow Forearm Wrist Hand Chest/t-spine/ribs Abdomen Lower aspect of back/l-spine/pelvis Thigh/upper aspect of leg Knee Lower aspect of leg Ankle Foot Mouth/teeth Clavicle/collarbone Axilla Other// School size{ [1000 Students #1000 Students School region{ Midwest Northeast South West
Bacterial infection, n = 288
Tinea lesion, n = 129
Herpetic lesion, n = 23
Other,* n = 15
Scabies/ head lice, n=4
Molluscum contagiosum, n=3
Total, N = 462
184 72 5 6 5 16
(63.9) (25.0) (1.7) (2.1) (1.7) (5.6)
122 5 2 0 0 0
(94.6) (3.9) (1.6) (0.0) (0.0) (0.0)
23 0 0 0 0 0
(100.0) (0.0) (0.0) (0.0) (0.0) (0.0)
9 2 2 0 0 2
(60.0) (13.3) (13.3) (0.0) (0.0) (13.3)
1 3 0 0 0 0
(25.0) (75.0) (0.0) (0.0) (0.0) (0.0)
3 0 0 0 0 0
(100.0) (0.0) (0.0) (0.0) (0.0) (0.0)
342 82 9 6 5 18
(74.0) (17.7) (1.9) (1.3) (1.1) (3.9)
49 126 59 28 3 2 5 8 2
(17.4) (44.7) (20.9) (9.9) (1.1) (0.7) (1.8) (2.8) (0.7)
26 73 19 5 2 0 1 1 0
(20.5) (57.5) (15.0) (3.9) (1.6) (0.0) (0.8) (0.8) (0.0)
2 4 3 10 0 0 0 3 0
(9.1) (18.2) (13.6) (45.5) (0.0) (0.0) (0.0) (13.6) (0.0)
2 5 3 2 1 0 1 0 1
(13.3) (33.3) (20.0) (13.3) (6.7) (0.0) (6.7) (0.0) (6.7)
2 0 1 1 0 0 0 0 0
(50.0) (0.0) (25.0) (25.0) (0.0) (0.0) (0.0) (0.0) (0.0)
0 0 1 2 0 0 0 0 0
(0.0) (0.0) (33.3) (66.7) (0.0) (0.0) (0.0) (0.0) (0.0)
81 208 86 48 6 2 7 12 3
(17.9) (45.9) (19.0) (10.6) (1.3) (0.4) (1.5) (2.6) (0.7)
74 5 7 11 18 17 36 3 6 7 6 3 16 30 23 3 11 0 0 2 19
(25.7) (1.7) (2.4) (3.8) (6.3) (5.9) (12.5) (1.0) (2.1) (2.4) (2.1) (1.0) (5.6) (10.4) (8.0) (1.0) (3.8) (0.0) (0.0) (0.7) (6.6)
21 2 12 8 18 7 15 2 1 16 0 1 9 2 7 0 0 0 0 0 8
(16.3) (1.6) (9.3) (6.2) (14.0) (5.4) (11.6) (1.6) (0.8) (12.4) (0.0) (0.8) (7.0) (1.6) (5.4) (0.0) (0.0) (0.0) (0.0) (0.0) (6.2)
14 0 0 0 1 1 2 0 1 0 0 0 0 1 0 0 0 1 0 0 2
(60.9) (0.0) (0.0) (0.0) (4.3) (4.3) (8.7) (0.0) (4.3) (0.0) (0.0) (0.0) (0.0) (4.3) (0.0) (0.0) (0.0) (4.3) (0.0) (0.0) (8.7)
3 0 0 0 0 0 4 1 0 1 1 0 0 1 1 0 1 0 0 0 1
(20.0) (0.0) (0.0) (0.0) (0.0) (0.0) (26.7) (6.7) (0.0) (6.7) (6.7) (0.0) (0.0) (6.7) (6.7) (0.0) (6.7) (0.0) (0.0) (0.0) (6.7)
0 0 0 0 0 0 0 0 0 1 2 1 0 0 0 0 0 0 0 0 1
(0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (25.0) (50.0) (25.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (25.0)
0 0 0 0 0 1 2 0 1 0 0 0 0 0 0 0 0 0 1 0 0
(0.0) (0.0) (0.0) (0.0) (0.0) (33.3) (66.7) (0.0) (33.3) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (33.3) (0.0) (0.0)
112 7 19 19 37 26 59 6 9 25 9 5 25 34 31 3 12 1 1 2 31
(24.2) (1.5) (4.1) (4.1) (8.0) (5.6) (12.8) (1.3) (1.9) (5.4) (1.9) (1.1) (5.4) (7.4) (6.7) (0.6) (2.6) (0.2) (0.2) (0.4) (6.7)
217 (75.6) 70 (24.4) 94 61 81 51
(32.8) (21.3) (28.2) (17.8)
91 (70.5) 38 (29.5)
20 (87.0) 3 (13.0)
9 (60.0) 6 (40.0)
4 (100.0) 0 (0.0)
3 (100.0) (0.0)
344 (74.6) 117 (25.4)
41 27 32 29
13 0 6 4
3 3 4 5
1 0 0 3
0 1 1 1
152 92 124 93
(31.8) (20.9) (22.5) (22.5)
(56.5) (0.0) (26.1) (17.4)
(20.0) (20.0) (26.7) (33.3)
(25.0) (0.0) (0.0) (75.0)
(0.0) (33.3) (33.3) (33.3)
(33.0) (20.0) (26.9) (20.2)
Values are presented as frequency (percentage). *Includes unspecified organisms, combined fungal and bacterial infections, chickenpox and shingles, pityriasis rosea, and noninfectious rashes (poison ivy, dermatitis). y Sports reported #3 cases of skin infections per sport. z Missing values for 9 cases. x Sums of frequencies (percentages) will exceed n (100.0) for bacterial infection, scabies/head lice, molluscum contagiosum, and total categories, as multiple sites of infection were documented for 6 cases. // Includes nonspecific location reported as ‘‘skin,’’ impetigo, carbuncle, and staph. { Missing value for 1 case.