Dermatoses in Competitive Athletes
Auftreten von Dermatosen bei (Hochleistungs-)Sportlern
Problem: The skin is exposed to numerous stresses during sport. In addition to infection-related or allergic triggers, the development of sport-associated skin diseases depends on the discipline practiced and can be caused by mechanical stressors, thermal damage, and UV radiation. Methods: This review intends to give an overview of study results on the incidence and prevalence of skin diseases in competitive athletes. Publications describing case reports of the outbreak of a specific skin disease within a small cohort of athletes of a defined discipline were included as well as publications comparing the incidence of dermatoses between different disciplines based on large study cohorts.
Results: Most studies focus on the analysis of the ocurrence of certain skin diseases in athletes of only one defined discipline, in most cases athletes performing sports with close body contact. Hardly any studies deal with dermatoses in competitive athletes among multiple disciplines. This review displays the occurrence of infectious, allergic, traumatic, UV-induced, and sebaceous dermatoses in competitive athletes by taking different disciplines into account.
Discussion: Depending on the training environment, flow of movement, climatic influences and other factors, certain skin diseases occur frequently in athletes of specific disciplines.
Key Words: High-Performance Athlete, Skin Disease, Training, Specific Disciplines
Problem: Die Haut ist beim Sport zahlreichen Belastungen ausgesetzt. Neben infektionsbedingten oder allergischen Auslösern werden sportbedingte Dermatosen je nach Sportart durch die Beanspruchung der Haut im Zuge von mechanischer Belastung, thermischer Schädigung und UV-Strahlung ausgelöst.
Methoden: Dieser Überblick soll Studienergebnisse zum Auftreten von Hauterkrankungen bei Leistungssportlern aufzeigen. Fallberichte zum Ausbruch spezifischer Krankheiten innerhalb einer kleinen Kohorte an Sportlern einer Disziplin wurden dabei ebenso berücksichtigt wie disziplinenübergreifende Vergleichsstudien.
Ergebnisse: Viele Studien fokussieren sich auf die Analyse und Beschreibung des Vorkommens von Dermatosen oder gar einer einzigen, spezifischen Hauterkrankung bei Sportlern einer bestimmten Sportart. Es gibt nur wenige Studien, die sich disziplinenübergreifend mit der Verbreitung von Dermatosen unter Leistungssportlern beschäftigen und vergleichend ein repräsentatives Bild von Anfälligkeit, bestehenden Prädispositionsfaktoren und der tatsächlicher Erkrankungshäufigkeit zwischen Athleten verschiedener Disziplinen aufzeichnen. In diesem Review wird das Vorkommen infektiöser, allergischer, traumatischer, UV-induzierter und Talgdrüsenassoziierter Dermatosen bei Leistungssportlern dargestellt. Dabei soll das Erkrankungsgeschehen unter Einbezug unterschiedlichster Sportarten präsentiert werden.
Diskussion: In Abhängigkeit von Trainingsumfeld, Bewegungsablauf, Witterungseinflüssen und anderen Faktoren treten bestimmte Hauterkrankungen gehäuft in einzelnen Sportdisziplinen auf.
Schlüsselwörter: Leistungssportler, Hauterkrankungen, Training, Sportdisziplin
Practicing sport has many benefits on our general wellbeing, including physical and psychological aspects. People who practice sports regularly are at lower risk for the development of conditions such as obesity or type 2 diabetes. Although the benefits are plentiful, participation in athletic activity, especially in high-performance sports, can also have negative effects on the body. Hereafter, the impact of sport on skin health is explained and an overview of various sport-related skin diseases in competitive athletes of different disciplines is provided.
A top athlete’s skin is exposed to a wide range of environmental, physical, and infectious agents threatening the integrity of the skin barrier (Figure 1). Furthermore, increased sweating, increased heat, friction caused by sports clothing, and close body contact support the onset and wide distribution of dermatoses in top athletes (20). Traumatic injuries, like blisters or grazes, are commonly found and surely the most obvious dermatological abnormalities. Infectious lesions caused by bacterial, viral, or mycotic agents, are often diagnosed in athletes, too (2, 21, 57). Other potentially harmful factors that can cause aberrations of the physiological appearance of the skin are allergies and increased exposure to UV radiation. Intense sun exposure must not be underestimated as it remains one of the major risk factors for the development of skin cancer (1, 2, 15). Allergic reactions can be triggered by multiple allergens found in the air, in water, or sportswear, depending on the environment associated with the sports discipline. Considering the huge variety of stressors as well as the multitude of disciplines, it is not surprising that some lesions are more prevalent in athletes of specific disciplines compared to others.
Material and Methods
Using the PubMed database, a literature search was conducted to identify clinical studies, articles from medical specialist books, and review articles that assessed the prevalence of various sport-related skin diseases in competitive athletes of different disciplines. The research was limited to English or German language articles published between 1971 and 2019. The following keywords were used to perform the literature search: [athletes OR competitive athletes OR top athletes] AND [Skin disease (names of the various skin diseases, e.g. furunculosis OR impetigo OR folliculitis)] AND [sports discipline (names of the various sports, e.g. American football OR rugby OR judo, wrestling OR basketball)]. Search terms were entered in several combinations. Articles were selected when they covered at least one of the topics of interest in the above mentioned diseases.
Infectious diseases in athletes are, in contrast to non-infectious diseases, comparatively well described (Table 1-3). It should be emphasized, however, that the majority of studies addressing this topic include athletes practicing sports with close physical contact. Sosin et al. report, that the incidence of boils found in American football and basketball players was four times higher than in athletes who did not participate in team sports (55). Turbeville et al. conducted a literature search related to infectious diseases in athletes including publications from 1966 to 2005. They report that more than half of all infectious diseases in athletes (56%) were of cutaneous origin (57). A more recent literature review by Collins et al. from 2005-2010 revealed, that the percentage of skin as well as soft tissue infectious diseases in athletes was 71% (12). Direct skin to skin contact, which is inevitable in some sports (e.g., American football, rugby, judo, or wrestling), contributes to the spread of infectious diseases.
Bacteria Induced Dermatoses
Among the most frequently diagnosed infectious diseases of bacterial origin in athletes are furunculosis, impetigo and folliculitis (Figure 2), or abscesses (29, 36, 55). Staphylococcus and streptococcus species are widespread and often the causative agent for non-purulent or purulent skin infections (Table 1). While many infections are easily treated with antibiotics, infections with methicillin-resistant Staphylococcus aureus (MRSA) pose a growing problem for modern medicine. In a literature research from 2005 to 2010, Collins et al. report that, out of all infectious diseases diagnosed in athletes, 33% were caused by MRSA (12). A more recent study of Champion et al. concluded that 76% of college wrestlers are carriers of CA-MRSA (11). While these athletes are prone to develop infections themselves, they also put competitors at risk of infection. Mascaro et al. investigated the prevalence of S. aureus infections among contact sport athletes in Italy and confirmed S. aureus in 42% of 238 enrolled athletes. Of all athletes, 1.3% carried MRSA (39).
Mycotic Infectious Diseases
Mycotic infections on finger-/ toenails are a common disorder that is difficult to cure. The likelihood of developing onychomycosis is 2.5 times higher in athletes (Figure 2). A common location are the toenails which are affected seven times more often than the fingernails (14). Mycotic skin infections are caused by dermatophytes, yeasts, or molds (Table 2). The most common dermatophytosis in athletes is Tinea. Tinea is mostly caused by Trichophyton spp., primarily by T. tonsurans and T. rubrum. Another frequently diagnosed mycosis is Pityriasis versicolor. It is evoked by different species of Malassezia, especially Malassezia furfur (Table 2) (4, 16). Athletes who engage in close physical contact are at particular risk of infections with dermatophytes (2). In a literature analysis of the outbreak of infectious diseases in competitive sports between 2005 and 2010, Collins et al. summarize that 29% of relevant articles report an outbreak of Tinea – all of them among wrestlers and judo fighters (12). In a survey including 454 wrestlers Ahmadinejad et al. detected mycotic agents in 8.2% of these athletes. Malassezia furfur (50%) and Trichophyton tonsurans (30%) were the most prevalent germs (3). Hedayati et al. diagnosed a clinically manifest Tinea corporis gladiatorum in 62 out of 324 wrestlers (20.1%) (26).
One of the reasons for Tinea pedis and unguium being widespread among athletes may be the shared use of showers and changing rooms (2). Swimmers in particular seem to be exposed to fungal spores and mycotic infections.
Several studiesinvestigated the incidence of mycotic spores in swimmers. Attye et al. found that 15% of swimmers tested positive for mycotic spores (7). Kamihama et al. showed, that 63.6% of athletes included in their study tested positive for dermatophytes – almost four times as many as in the reference group (28).
Viral infections are not uncommon among athletes, whereby the most frequently encountered viral infections are Herpes simplex, Verrucae, or Mollusca contagiosa (Table 3) (2). In the case of herpes, the majority of affected patients develop lesions in the orofacial area (Figure 2). The virus survives in the ganglia and establishes a latent residency. Therefore, the chance of recurrent infections after reactivation of the dormant virus is high. Winter sports athletes, especially high-altitude skiers, tend to suffer from recurring outbreaks of Herpes simplex labialis. Mills et al. reported, that 6 out of 51 (12%) skiers with a history of skiing-triggered recurring Herpes labialis developed a manifest infection within one week (41). Presumably, the reason is exposure to intense UV-Radiation.
Since herpes simplex infections are very common among wrestlers and rugby players, the disease received its own name for these sports: herpes gladiatorum or herpes rugbeiorum (Table 3). 94-97% of infections are caused by the Herpes simplex virus type 1 (HSV-1) (6, 10, 23). Clearly, direct skin to skin contact is responsible for the transmission (9). Anderson examined participants of a high school wrestling camp for herpes gladiatorum and found that 96% of manifest infections occurred on the front of the body. Of these, 71.9% were located on the head, face (especially periorbital), and neck (6). In contrast, non Wrestlers rather showed manifest herpes simplex infections in the orofacial area.
Traumatic Skin Defects
Almost every type of physical activity is connected to traumatic skin lesions. Above all, traumatic skin defects can be found on the feet in form of bullae, callosities, corns, and onychodystrophies. Mailler and Adams reviewed studies investigating skin defects in marathon runners. On the day of the race, bullae were detected in 0.2-39% of runners. 2-16.3% of all participants suffered from jogger’s nipple – skin lesions of the mamillae caused by increased friction with sportswear (38).
Another widespread traumatic skin defect found in athletes of diverse disciplines are subungual hematoma on the toes (so-called jogger’s toe, tennis toe, skier’s toe) caused by repetitive collision of the toenail with the shoe tip. Furthermore, intracorneal hemorrhage may occur in the heal area (talon noir or black heel) or the palms (tache noir, black palm) (18, 22, 27, 60). Talon noir is associated with quick starts and abrupt stops as performed in tennis, squash, basketball etc. Black palm or tache noir describe similar hemorrhages on the palms occurring in sports exerting a lot of pressure on the hands such as weight lifting or gymnastics. Both conditions are harmless and resolve spontaneously (21).
Striae cutis distensae are streaky athrophies of the skin, running in parallel, due to stretch-related (tears) changes in the connective tissue. Such changes are observed not only during pregnancy (stretch marks), in obesity, or in rapid growth in adolescence. The same applies to those who build muscles very quickly in weight training / bodybuilding (34, 35, 52). Especially the prolonged use of systemic or local glucocorticoids (steroid striae) leads to the formation of stretch marks (27, 30, 59).
The sources of irritative contact eczema as well as contact allergies are manifold in athletes of different sport disciplines. In the case of water sports (e.g., swimming, scuba diving, surfing, sailing), allergic contact eczema caused by ingredients of sports wear, especially rubber, neoprene suits, fins, googles, and snorkels, are frequent (Figure 3).
Substances like benzoylperoxid, various thiourea, and many others, can act as contact allergens (37, 48, 56). Furthermore, chemicals like chlorine or bromide, which are used as disinfectants in pool water, can lead to irritative contact eczema (49, 56). In the case of athletes who exercise outdoors (e.g. marathon runners or sailors), type IV allergies to sunscreen components, especially different UVA and/or UVB filters, need to be considered. In general, contact and photocontact sensitivity to sunscreen was reported and reviewed previously, independent of sporting activity (47, 50). The frequent use of sunscreen in outdoor athletes increases the risk of developing an allergic reaction to these chemical components.
In runners and in athletes of other disciplines not related to water, delayed allergic reactions can often be found on the feet. Causative agents are components of shoes, such as rubber, leather, glue, or dyes (33). Sportswear and diverse externa (e.g., anti-inflammatory or anesthetic cremes, gels, or sprays) can cause allergic reactions, too.
Sun-Related Skin Diseases
UV induced skin cancer may indirectly be caused by physical activity dependent on the time spent outdoors. Intense and prolonged sun exposure is one of the most important factors leading to the development of melanomas and other types of skin cancer (Figure 4). A series of dosimetric studies revealed that triathletes, cyclists, mountain climbers, skiers, and snowboarders are often exposed to enormous doses of UV radiation due to prolonged sun exposure, reflection of UV radiation by snow and water, and reduction of the minimal erythema dose (MED = smallest dose of UV radiation to produce erythema within 1-6 hours) (43, 46). Moehrle revealed that the UV exposure rate of participants of the Ironman in Hawaii was increased to 8.3 MED (44). Similar results were found when the UV exposure of cyclists racing the Tour de Suisse was measured (45). Ambros-Rudolph et al. conducted a case-control study with 210 marathon runners comparing the athletes to non-athletes of the same age and gender. The runners showed more dysplastic nevi, lentigines, and suspicious skin lesions related to white skin cancer. The results correlated positively with exercise intensity (5). The most common, immune-mediated photodermatosis induced by UV rays is the so called "Polymorphic light eruption". Clinical symptoms, such as papules, vesicles, plaques, cocardial lesions, etc., occur after a latency period of hours or a few days on sun-exposed body parts (24, 25). It is a phenomenon that has already been observed in athletes who engage in outdoor sports activities (13, 17).
Sebaceous Gland Related Diseases
Acne mechanica, cutaneous lesions caused by mechanical stress, manifests itself in the form of papulopustular eruptions and nodules. It is caused by a combination of sweating, occlusion, friction, and pressure, especially beneath protective sports gear like helmets or shoulder pads (8, 19, 42). Predilective sites of clinical manifestation are the chin, forehead, jawline, neck, and the shoulders (1) (Figure 5). Sports commonly associated with heavy forms of acne mechanica are for example American football and ice hockey, where protective head and body gear is part of the equipment. In addition, boxers, equestrians (beneath the helmet straps and on the forehead), and athletes of other disciplines are frequently affected by acne mechanica.
Another severe form or acne, located in the neck and occipital scalp area, is acne keloidalis nuchae. It constitutes a chronic fibrotic folliculitis and perifolliculitis leading to the development of hypertrophic scars or celoids. Knabe et al. investigated the manifestation of acne mechanica and acne keloidalis in 453 high school, college, and professional football players and found that acne keloidalis nuchae occured primarily in college athletes and professional players. Interestingly, acne keloidalis nuchae affected almost exclusively Afro-American players (32).
Various cases in professional sports have brought the matter of doping - the use of performance-enhancing drugs – to the attention of dermatologists. Acne induced by abuse of anabolic-androgenic steroids (AAS) and whey proteins, so-called "steroid acne", is developed by up to 50% of all AAS users (40, 53). These products are used in the bodybuilding and fitness scene. With continuous abuse of AAS, in addition to strongly pronounced seborrhea as a clinical appearance, the development of acne vulgaris, acne papulopustulosa, acne conglobata, or acne fulminans is possible (31, 51, 54, 58).
When practicing sports, an athlete's skin is exposed to various stress factors and certain sports predispose the athlete to specific skin diseases. Numerous studies examine the occurrence of specific dermatoses in defined sport disciplines. The onset / outbreak of skin diseases is highly correlated with the discipline practiced. Infectious skin diseases are most commonly diagnosed in athletes participating in contact sports. Traumatic lesions are found in athletes of various disciplines with feet and hands being predisposed locations. Allergic reactions arise from a multitude of allergens, for example substances used for the production of sports gear or ingredients of sunscreen. UV rays per se can trigger photo dermatoses. Furthermore, intense UV radiation can be the trigger for the development of skin cancer. Athletes often suffer from severe forms of acne. This is connected to skin irritation due to contact with protective sports wear or caused by the abuse of anabolic drugs.
Up to now, there are only a few studies, that compare the prevalence of dermatoses in athletes of various sports disciplines within one demographic-epidemiological setup. Hardly any studies examine the variants of dermatoses across disciplines and the overarching effect of high-performance sports on skin diseases. Further studies should be carried out to examine the general effects of sport on skin health. To this end, a stronger interdisciplinary cooperation between sports physicians and dermatologists is required.
Conflict of Interest
The authors have no conflict of interest.
- Dermatologic disorders of the athlete. Sports Med.2002; 32: 309-321.
- Sports Dermatology. NY: Springer, New York, 2006.
- Prevalence of fungal skin infections in Iranian wrestlers. Asian JSports Med. 2012; 4: 29-33.
- Enzyklopädie Dermatologie, Allergologie,Umweltmedizin. Springer-Verlag Berlin Heidelberg, Heidelberg,2013.
- Malignant melanoma in marathonrunners. Arch Dermatol. 2006; 142: 1471-1474.
- The epidemiology and clinical analysis of severaloutbreaks of herpes gladiatorum. Med Sci Sports Exerc. 2003; 35:1809-1814.
- Incidence of occult athletes foot in swimmers. EurJ Epidemiol. 1990; 6: 244-247.
- Acne mechanica in athletes. Cutis. 1992; 50: 125-128.
- Herpes gladiatorum: a growing problem in sportsmedicine. Cutis. 1992; 50: 150-152.
- An outbreak ofherpes gladiatorum at a high-school wrestling camp. N Engl JMed. 1991; 325: 906-910.
- Prevalence and characterization of methicillinresistantStaphylococcus aureus isolates from healthy universitystudent athletes. Ann Clin Microbiol Antimicrob. 2014; 13: 33.
- Infectious disease outbreaks incompetitive sports, 2005-2010. J Athl Train. 2012; 47: 516-518.
- Common cutaneous disorders in athletes. SportsMed. 1990; 9: 100-119.
- Onychomycosis inAthletes. Am J Clin Dermatol. 2019; 20: 691-698.
- Skin manifestations ofathletes competing in the summer olympics: what a sportsmedicine physician should know. Sports Med. 2012; 42: 399-413.
- KlinikleitfadenDermatologie. Urban & Fischer, 2011.
- A clinicoepidemiologicalstudy of polymorphic light eruption ina tertiary care centre in Salem: a region of South India.International Journal of Research in Dermatology. 2017; 3: 113-119.
- Sports Dermatology: Part 1 of 2Traumatic or Mechanical Injuries, Inflammatory Conditions,and Exacerbations of Pre-existing Conditions. J Clin AesthetDermatol. 2015; 8: 31-43.
- Football acne - anacneiform eruption. Cutis. 1977; 20: 356-360.
- Skin diseases of football and wrestlingparticipants. Cutis. 1977; 20: 333-341.
- Sports dermatology part 1:common dermatoses. CMAJ. 2004; 171: 851-853.
- Tennis toe. Arch Dermatol. 1973; 107: 918.
- A cross-sectional study of herpes simplex virus types 1 and 2 incollege students: occurrence and determinants of infection. JInfect Dis. 1990; 162: 306-312.
- Polymorphous lighteruption: clinic aspects and pathogenesis. Dermatol Clin. 2014;32: 315-334, viii.
- Polymorphous Light Eruption. Adv Exp Med Biol.2017; 996: 61-70.
- A study ontinea gladiatorum in young wrestlers and dermatophytecontamination of wrestling mats from Sari, Iran. Br J SportsMed. 2007; 41: 332-334.
- Sports dermatology. Clin Dermatol. 1998;16: 159-165.
- Tinea pedis outbreak in swimming pools in Japan. PublicHealth. 1997; 111: 249-253.
- Common and uncommon dermatologicdiseases related to sports activities. Exerc Sport Sci Rev. 1988;16: 215-253.
- Sport als Risikofaktor undtherapeutisches Prinzip in der Dermatologie [Sports as a riskfactor and therapeutic principle in dermatology]. Hautarzt.2002; 53: 98-103.
- Drug-induced acne. Clin Dermatol.2017; 35: 156-162.
- Prevalence of acne keloidalisnuchae in football players. J Am Acad Dermatol. 1997; 37: 570-574.
- Contact dermatitis in athletes.J Am Acad Dermatol. 2007; 56: 1048-1055.
- Physiological Striae Atrophicaeof Adolescence with Involvement of the Axillae andProximal Arms. Case Rep Pediatr. 2017; 2017: 7678086.
- Dermatologic aspects of sports medicine. DermatolNurs. 1994; 6: 179-186, quiz 187-188.
- MethicillinresistantStaphylococcus aureus in a high school wrestlingteam and the surrounding community. Arch Intern Med. 1998;158: 895-899.
- Scuba diver facial dermatitis: allergic contactdermatitis to N-isopropyl-N-phenylpara-phenylenediamine.Contact Dermat. 1975; 1: 330.
- The wear and tear of 26.2: dermatologicalinjuries reported on marathon day. Br J Sports Med. 2004; 38:498-501.
- Prevalence of Staphylococcus aureus carriage and pattern ofantibiotic resistance, including methicillin resistance, amongcontact sport athletes in Italy. Infect Drug Resist. 2019; 12: 1161-1170.
- Abuse of anabolic-androgenicsteroids and bodybuilding acne: an underestimated healthproblem. J Dtsch Dermatol Ges. 2007; 5: 110-117.
- Recurrent herpes labialis in skiers. Clinical observationsand effect of sunscreen. Am J Sports Med. 1987; 15: 76-78.
- Acne mechanica. Arch Dermatol. 1975; 111:481-483.
- Outdoor sports and skin cancer. Clin Dermatol.2008; 26: 12-15.
- Ultraviolet exposure in the Ironman triathlon. MedSci Sports Exerc. 2001; 33: 1385-1386.
- Extreme UV exposureof professional cyclists. Dermatology. 2000; 201: 44-45.
- Reduction ofminimal erythema dose by sweating. PhotodermatolPhotoimmunol Photomed. 2000; 16: 260-262.
- Contact Dermatitis to Medicationsand Skin Products. Clin Rev Allergy Immunol. 2019; 56: 41-59.
- Allergic contact dermatitisfrom ethylbutylthiourea in neoprene. Contact Dermat. 1993; 28:193.
- Allergic contact dermatitisfrom chlorinated swimming pool water. Contact Dermat. 1999;41: 347-348.
- Contact and photocontact sensitivity tosunscreens. Review of a 15-year experience and of the literature.Contact Dermat. 1997; 37: 221-232.
- Effects of anabolic-androgenic steroids onthe pilosebaceous unit. Cutis. 1992; 50: 113-116.
- Stria Migrans. Arch Dermatol. 1964; 90:193-194.
- Acne and whey protein supplementationamong bodybuilders. Dermatology. 2012; 225: 256-258.
- Outpatient clinic for users of anabolicandrogenic steroids: an overview. Neth J Med. 2018; 76: 167.
- An outbreak offurunculosis among high school athletes. Am J Sports Med.1989; 17: 828-832.
- Aquatic sports dermatoses:part 1. In the water: freshwater dermatoses. Int J Dermatol.2010; 49: 874-885.
- Infectious diseaseoutbreaks in competitive sports: a review of the literature. Am JSports Med. 2006; 34: 1860-1865.
- Acne induced by ‘Sus’ and ‘Deca’.Clin Exp Dermatol. 2006; 31: 297-298.
- Side-effects oftopical androgenic and anabolic substances and steroids. Ashort rewreviewreview. Acta Dermatovenerol Alp PanonicaAdriat. 2007; 16: 117-122.
- Talon noir. Arch Dermatol. 1971; 104: 452.
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