Dermatology

 
and Sport

   

• Introduction

• Skin infections

○ Fungal infections

 Tinea curis

 Tinea versicolour

 Tinea incognita

○ Bacterial infections

 Impetigo

 Pitted keratolysis

○ Viral infections

 Herpes simplex virus

 Herpes gladiatorum

 Molluscum contagiosum

 Common warts

• Sports-related allergic and irritant dermatitis

○ Urticaria

○ Contact dermatitis

• Dermatological manifestations of physical, cold, and electromagnetic injury

○ Acne mechanica

○ Trauma - induced skin disease

○ Athlete’s nodules

• Heat and cold related skin disease

○ Intertrigo

○ Miliaria, (‘prickly heat’)

○ Erythema ab igne

• Ultraviolet-related skin disease

○ Sunburn
 • Exacerbation of pre-existing skin disease

• Dermatological effects of anabolic-androgenic steroids

Introduction
The skin plays an important role in protecting the body from noxious external stimuli such as
mechanical forces, temperature changes, and harmful chemicals. It is no surprise, therefore,
that cutaneous disorders are an important factor in every athletic specialty. Sports
dermatology is concerned with skin disorders related to athletic activity, manifesting either as
a primary disorder or as an exacerbation of a pre existing dermatological dermatosis. Sports
dermatology is an enlarging field and this chapter summarizes some of the more commonly
encountered problems.

Skin infections

Fungal infections
Dermatophytic fungi live in the stratum corneum (most superficial epidermal layer) and can
cause superficial infections. Tinea pedis or ‘athlete’s foot’ affects the interdigital and lateral
areas of the feet and is characterized by pruritis, scaling, and occasional soreness. The
classic ‘wet form’ presents with white macerated scale, fissures, and occasionally with
vesicles and bullae. Less commonly a ‘dry form’ or ‘moccasin foot’ is seen as a dry, rough,
diffuse white scale affecting the sole. The problem is often bilateral and the toenails may also
be involved (manifest by discolouration, thickening, crumbling and Subungual scale of one or
more toenails). Tinea pedis is a chronic disorder and patients may be afflicted for decades.
Infection occurs by person-to-person or by contact with infected fomites such as a towel or
floormat. It is undoubtedly influenced by the microenvironment of the clad foot, and factors
which exacerbate the condition include a moist, warm environment; a sweaty foot enclosed in
a non-absorbent sock and occlusive shoe such as a ‘trainer’ is a likely target for tinea pedis.
Secondary bacterial infection is sometimes seen and may present as cellulitis, lymphangitis,
or inguinal lymphadenopathy. The diagnosis of tinea pedis is confirmed by examining
scrapings of keratinous debris in a 10% potassium hydroxide (KOH) preparation and
observing the characteristic hyphae. Culture permits identification of the causative fungus
(usually Trichophyton rubrum, T. mentagrophytes, or Epidermophyton floccosum). The
differential diagnosis includes pompholyx, pustular psoriasis, pitted keratolysis and allergic
contact dermatitis to shoes; a positive skin scraping however does not necessarily exclude
these dermatoses, as a superficial dermatophyte infection may be superimposed upon an
area of already broken skin.

Treatment Acutely inflamed ‘wet’ forms of superficial fungal infections should be treated with
a combination of shooting antiseptic soaks or paints (e.g. Castellan’s) and topical antifungals.
Soaks should be lukewarm and contain potassium permanganate 1 in 10 000 and the feet
immersed in the solution for 15 minutes three times daily. Effective topical antifungals include
the newer imidaoles such as miconazole, econazole or clotrimoxazole in a cream or tincture
base; these should be applied twice daily for approximately two weeks. Careful attention
should be given to avoidance of exacerbating factors such as sweat, heat, and occlusion.
Socks should be cotton or wool, and preferably changed once or twice during the day.
Footwear such as thongs or clogs should be worn while using communal showers or change
rooms. Athletes should alternate pairs of sneakers or shoes if possible to allow airing in
between periods of wear. Infection of the nails is an indication for oral antifungal therapy as
dermatophyte in the nail are relatively resistant to topical agents. A new allylamine drug,
terbinafine, can achieve a mycological cure of toenail onychomycosis in 70-80% of patients
following twelve weeks of therapy1. Other oral agents used include griseofulvin,
ketoconazole and intermittent itraconazole. Although generally safe agents, ketoconazole is
contraindicated in patients with hepatic disorders and can interact with other medications, for
example, warfarin. Itraconazole has fewer hepatic side effects but is considerably more
expensive than other oral antifungals. Amorolfine 5% nail lacquer can be applied to affected
nails once or twice per week and has shown to cure approximately 40-55% of patients with
toenail onychomycosis 2.

1. Tosti A, Piraccini BM, Stinchi C, Venturo N, Bardazzi F, Colombo MD. 1996 Treatment of
dermatophyte nail infections: An open randomized study comparing intermittent terbinafine
therapy with continuous terbinafine treatment and intermittent itraconazole therapy. Journal of
the American Academy of Dermatology, 34, 595-600.

2. Haria M and Bryson HM. Amorolfine. 1995 A review of its pharmacological properties and
therapeutic potential in the treatment of onychomycosis and other superficial fungal
infections. Drugs, 49 (1): 103-20.

Other fungal infections include tinea cruris, tinea versicolour and tinea incognita.

Tinea curis (‘jock itch’)

Commences in the groin folds and extends out in an annular or circular fashion with a scaly,
inflamed border. Hyphae can also be identified on KOH preparation of scale taken from the
active advancing border. Treatment of tinea cruris is with oral griseofulvin and concomitant
topical treatment with one of the newer imidazole creams.

Tinea versicolour

Not actually a dermatophyte infection but is due to the saprophytic yeast Pityrosporum
orbicular which develops into is parasitic fungal form Malasezia furfur. This transformation
may be provoked by humidity, ambient heat, as a result of exercise, secondary to diabetes
mellitus or iatrogenic immunosuppression e.g. systemic corticosteroid treatment or
immunosuppressives for solid organ transplants.

Tinea versicolour infection produces hyper-or hypopigmented macules on the torso and
proximal limbs with fine bran like scale. Infection can be chronic and recurrent with
exacerbations following climatic changes in humidity. Organisms can be detected in a KOH
preparation of skin scrapings. Treatment of pityriasis versicolour has traditionally been with
selenium sulphide (Selsun® shampoo) applied as a cream to the affected areas twice daily or
more recently with imidazole creams or foaming washes.

Treatment needs to be applied to skin beyond the disappearance of the eruption, however,
relapses are common with topical therapies. A course of oral ketoconazole or itraconazole for
seven days is effective in eliminating the reservoir of Pityriasis organisms and helps prevent
further relapses.

Tinea incognita

Refers to the specific clinical picture seen when a potent topical corticosteroid preparation is
mistakenly applied to a tinea infection. Inflammatory features such as erythema may be
absent; typically a mild, pink, scaly annular macule with central clearing is seen. Skin
scrapings stained with KOH show abundant hyphae and permit the correct diagnosis.

Bacterial infections

Impetigo
A superficial bacterial infection characterized by honey-coloured crusts or vesicles on a moist
erythematous base. Impetigo is highly infectious and is spread by direct contact or fomites
and can infect intact skin. The organism(s) responsible are usually streptococcus or
staphylococcus aureus. High ambient temperatures, humidity, low altitude and poor hygiene
may favour development and transmission of impetigo. Streptococcal impetigo has spread
amongst footballers and those playing North American football1.

Treatment consists of topical or systemic antibiotics directed against both streptococcus and
staphylococcus. Removal of crusts by gentle soaking with warm compresses of potassium
permanganate (1 in 10 000) dilution followed by a topical antibiotic such as mupirocin or
fusidic acid, for approximately seven to ten days is effective. The entire skin, scalp included,
should be washed with an antiseptic soap daily for ten days. Alternatively, a ten day course of
broad spectrum oral antibiotics active against ß-lactamase producing staphylococci is also
efficacious.

The patient should be isolated until clearance of crusts and not allowed to compete in contact
sports. In particular, sportsmen such as wrestlers should be free of new lesions for at least 48
hours prior to competition and should have no moist, exudative or draining lesions prior to
tournament participation.
. Bartlett P, Martin R, Cahill B. 1982 Furunculosis in a high school football team (1982).
American Journal of Sports Medicine, 10: 371-4.

Pitted keratolysis

A bacterial infection of the palmar surface of the feet due to superficial infection with
corynebacterium species. It characteristically appears as shallow white pits or dents in the
stratum corneum. Increased sweating (hyperhidrosis) is thought to play an aetiological role in
the condition and thus may be seen with increased frequency in athletes. Maceration and
malodour may be associated findings. Treatment consists of general preventative measures
to control hyperhidrosis (absorbent socks, leather shoes, ‘shoe-free’ intervals), topical
application of antiperspirants containing 20% aluminium chloride, an topical antibiotics such
as 1-2% erythromycin or clindamycin solution.

Viral infections

Herpes simplex virus (HSV)

HSV is a double stranded DNA virus which typically causes recurrent infections of the
mucous an periorifical membranes. However, it can infect any skin surface and remain latent
in the ganglia of peripheral nerves.

Herpes gladiatorum

Herpes gladiatorum has been described in participants in close contact sports such as
wrestling and rugby (also known in the latter as ‘scrumpox’) and in a recent study of
American college wrestlers 7.6% were reported to have had a herpes skin infection in the
preceding 12 months1. Herpes gladiatorum is transmitted primarily by direct skin to skin
contact, and abrasions in the skin may allow a pathway of infection. The majority of lesions
occur on the head or face, followed by the trunk and/or extremities. A prodromal itching or
burning sensation is followed by clustered vesicular lesions on an erythematous base which
heal with crusts over about one to three weeks. Less commonly headache, malaise, sore
throat and fever may accompany the primary infection. Recurrent episodes may occur
following the initial infection and may precipitated by sunburn, illness, and emotional stress.
HSV antibodies, acquired from previous cold sores, may be protective from acquiring herpes
gladiatoraum eruptions. Because of its unexpected location on the cutaneous surface, herpes
gladiatorum any be confused with impetigo, varicella, staphylococcal furunculosis, or allergic
or irritant contact dermatitis. Adequate treatment, counseling and public health strategies
depend on making an accurate diagnosis, hence viral immuno fluorescence and cultures
should be obtained by gently breaking an intact vesicle and firmly rubbing the swab tip across
the base of the erosion.

Treatment of herpes gladiatorum is ideally with oral acyclovir (200mg five times a day for the
five days) and is most effective if commenced at the first symptoms of an outbreak. Topical
acyclovir is available but is probably less effective. Concomitant secondary impetiginisation
should also be treated. HSV can survive for hours to days outside the host if environmental
conditions are appropriate2 hence all contaminated surfaces should be cleaned with
antiseptic solution. In the vesicular phase and until the crusts have separated, patients
should avoid sports which could involve physical contact.

1. Becker TM. Herpes Gladiatorum: 1992 A Growing Problem in Sports Medicine (1992).
Cutis 50: 150-2

2. Nerurkar LS, West F, May M et al. Survival of herpes simplex virus in water specimens
collected from hot tubs in spa facilities and on plastic surfaces (1983). Journal of the
American Medical Association 250: 3081-3.

Molluscum contagiosum

A highly infectious pox virus which can also be spread by human contact. The organism
appears to be easily spread in an aqueous medium, for example, in communal baths, spas
and pools. Amongst athletes, swimmers and cross country runners have the highest
incidence of mollusca. Their incidence may be increased in patients with underlying active
atopic dermatitis. They typically appear as solitary or multiple flesh-coloured dome shaped
papules with a central umbilication. The differential diagnosis includes multiple basal cell
carcinomata, cryptococcosis and appendageal tumours such as trichoepitheliomas. They can
be treated by gently breaking the surface of the lesion and extracting the central keratinous
plug. Other treatments employed are cryosurgery with liquid nitrogen, electrodessication and
topical trichloroacetic acid or tretinoin. Athletes may resume contact sports 48 to 72 hours
after the lesions have cleared.

Common warts

Are epidermal growths caused by infection by the human papillomavirus group (HPV).
Infection can occur if infected debris from warts comes in contact with abraded skin and can
result in either autoinoculation or transmission to susceptible individuals. However, it is not
generally thought to be highly infective and thus not limit participation in contact sports.
Plantar warts can cause pain with ambulation, thereby limiting performance in sporting
activities. Warts may also be more common in callouses which develop in sport1. Paring of
plantar warts with a #15 blade reveals small black spots corresponding to thrombosed
capillaries within papillae, thus distinguishing the lesions from callouses or corns, which lack
these dots and have a central hyaline core.

Treatment of plantar warts is challenging and may cause as much inconvenience to the
athlete as the presence of the wart itself. Daily application of salicylic and lactic acid
preparations under occlusion with concomitant paring with an emery board may be effective,
as may repeated cryosurgery and paring at two or three week intervals. For resistant warts,
intralesional bleomycin injections or carbon dioxide ablation can be used. Oral high dose
Cimetidine therapy (30-40mg/kg/day) has reportedly been successful in childhood warts;
however other studies have shown no advantage in Cimetidine over placebo in adults2.
1 Kantor G and Bergfeld W. 1988 Common and uncommon Dermatologic diseases related to
sports activities. Exercise and Sports Science Reviews 16: 215-53

2 Yilmaz E, Alpsoy E, Basaran E. 1996 Cimetidine therapy for warts: A placebo-controlled,

double-blind study. Journal of the American Academy of Dermatology 34: 1005-7.

Sports-related allergic and irritant dermatitis

Urticaria
Urticaria or hives, is relatively common disorder and its incidence is highest in young adults.
It can be defined as a transient red and/or oedematous swelling of the dermis or
subcutaneous tissues. Some factors which can provoke urticaria include medications such as
analgesics and non-steroidal anti inflammatory agents, which may be ingested by athletes
from time to time. Of particular interest are the physical urticarias. These are triggered by a
variety of physical causes such pressure, cold, heat, water (aquagenic), and solar irradiation.
Most patients suffer from idiopathic urticaria as well; that is, physical factors may not always
contribute to urticarial lesions. Athletes may develop pressure urticaria from tight fitting belts,
clothing, or on the soles of feet following running. Cold induced urticaria can be precipitated
by food, drinks, and changes in the ambient temperature. If the whole body is cooled
suddenly, as when diving into a swimming pool, an episode of urticaria could lead to
circulatory collapse. It is thus very important to recognize this uncommon condition and
instruct patients to avoid such triggers. Exposure to the sun or artificial light sources may
rarely be followed by itching, erythema and wheals. Cholinergic urticaria is a type of eruption
associated with sweating. The weals are characteristically small and surrounded by large red
halos, and last less than an hour following the trigger. Flushing, faintness, asthma, nausea,
vomiting, and diarrhoea may occasionally occur as a result of systemic histamine released by
mast cells. Water-induced urticaria presents in a similar fashion. The treatment of the
physical urticarias is firstly to eliminate the triggers as far as is possible. An episode of
Cholinergic urticaria may be followed by a refractory period of up to 24 hours; athletes may
therefore wish to ‘warm up’ a few hours prior to a specific event where the unpleasant effects
of weals may be undesirable. Non-sedating antihistamine agents such as loratadine or
cetirizine are usually effective treatment.

Contact dermatitis
Many natural and synthetic substances can induce dermatitis or inflammation of the skin
upon physical contact. Sports enthusiasts may be particularly vulnerable to irritant dermatitis
from equipment and medicaments. In addition, sweat and local heat and humidity may
enhance a substance’s allergenic or irritating potential by interfering with the normal barrier
function of the skin. An irritant reaction will result in dermatitis independently of a specific
immunological reaction and will tend to produce a similar reaction in all persons exposed to
the irritant. For example, chronic exposure to water and detergents may result in irritant
contact hand dermatitis.

An allergic contact dermatitis, however, is a delayed (type IV) immunological reaction

involving specifically sensitized T lymphocytes in a susceptible individual. Some of detective
work may be required to identify the offending allergen; for example, a linear abdominal
eruption in a surfer may be attributable to allergic contact dermatitis to nickel contained in the
zip fastener of a wet suit. A spectrum of clinical presentations may be seen in both irritant and
allergic contact dermatitis. Classically, contact with an allergenic plant (e.g. Rhus iv, grevillea,
primula obconica) in a sensitized individual results in a bullous, intensely itchy, linear eruption
of the forearms. These reactions may be seen in outdoor athletes. Rubber is a known
sensitizer and may produce either a delayed type contact dermatitis (usually due to
accelerants or antioxidants used in rubber manufacture) or an urticarial type immediate
reaction (due to latex allergy). Bathing caps, nose clips, ear plugs, fins and finstraps,
swimming goggles, diving suits, and underwater masks and mouthpieces are all capable of
producing potentially serious cutaneous reactions in swimmers or divers. Of particular
concern would be a patient with type 1 allergy to rubber latex who dived with a rubber
mouthpiece and experienced an urticarial reaction while diving. Allergic contact dermatitis to
shoes (tanning agents used in leather, rubber, glues, inner soles) may result in a symmetrical
bilateral dermatitis affecting the feet, in a distribution reminiscent of actual contact with the
allergen (for example, a rash on the lateral aspect of the soles may correlate with allergy to
inner soles). Sports participants may develop allergic contact dermatitis to topically applied
medicaments (salicylates, linaments, tea tree ail, antibiotics, antiseptics, and any fragrances
or preservatives contained therein) or tapes and plasters (colophony, para-tertiary-
butylphenol-resin).

PABA - containing sunscreens used by athletes may also result in allergic contact dermatitis,
often involving sun exposed skin only. Identification of the offending allergen may be difficult
and patients should be referred to specialist dermatology centres for detailed patch testing
should allergic contact dermatitis be suspected. Topical corticosteroids with wet dressings,
and occasionally oral corticosteroids, along with withdrawal of the offending substance, are
used to treat allergic contact dermatitis.

Dermatological manifestations of physical, cold, and electromagnetic injury

Acne mechanica
Acne mechanica is a papulopustular eruption caused by the physical factors of pressure,
occlusion, friction, and heat acting upon the skin1 . It is believed that these mechanical
stresses, rather than follicular infection by normal skin commensals (as in common acne)
play a primary causative role in sports-related acne. Pre-existent acne vulgaris is therefore
not necessarily a precursor of acne mechanica, although the mechanical stresses mentioned
above certainly aggravate common acne. Acne mechanica is one of the more prevalent
dermatoses among athletes. Heavy protective padding, headgear, occlusive synthetic
garments such as leotards, and golfers carrying heavy bags can precipitate acne mechanica.
It has thus been observed in American football players, hockey players, aerobics participants
and golfers. An unusual example of acne mechanica has been described on the neck of a
shot putter at the position where the shot is rested against the neck before being thrown.
Acne keloidalis is a specific chronic pilosebaceous disorder affecting the posterior occipital
scalp of predominantly black skinned individuals; it has reportedly developed in helmet-
wearing football players with no prior history of the disorder2. Prevention of the condition is
important in management and wearing a clean, absorbent cotton T shirt under uniforms and
equipment may be useful. Early removal of clothing and showering after sport will also
alleviate aggravating factors. Thorough cleansing followed by keratolytics such as salicylic
acid in ethanol, or tretinoin cream. Topical antibiotics such as clindamycin or erythromycin in
an astringent base are helpful in visibly infected cases. Systemic antibiotics, used with
success in common acne, seem to be of less benefit in acne mechanica. The eruption
invariably settles down during seasonal breaks from participation in sports activities.
1 Basler RSW. 1992 Acne Mechanica in Athletes (1992). Cutis 50: 125-128
2 Harris H. Acne Keloidalis Aggravated by Football Helmets (1992). Cutis 50: 154-156.

Trauma - induced skin disease

Foot blisters may result from heat and humidity combined with unaccustomed localized
friction. Improperly fitting shoes and sporadic training may contribute to their development.
They are best treated by sterile aspiration, leaving the overlying skin intact to form a natural
dressing. The area can then be treated with an antibiotic ointment or antiseptic and covered
with a simple dressing. Newer hydrophilic dressings are comfortable and absorbent and may
allow the athlete to resume participation. Prevention is the key to successful treatment; shoes
should be properly fitting and worn with two pairs of cotton socks. Foot powders may help to
absorb moisture and thus reduce skin shearing forces. Anecdotal evidence suggests that
application of Friar’s Balsam Amy ‘toughen’ skin and reduce the incidence of blisters.

Black heel or talon noir are petechiae occurring over the posterior aspect of the heel. They
are common in sports such as basketball, squash, or football, where frequent changes in
direction occur, resulting in a shearing effect on the skin. The colour of the eruption may
alarm the athlete and cause them to present. No treatment is required apart from
reassurance.

Jogger’s nipple is a painful and often fissured dermatitis eruption over the nipples produced
by friction from unyielding vests or T shirts and may also occur in women who do not wear
undergarments while jogging. Treatment is with anemollient such as emulsifying ointment or
white soft paraffin, or a mild topical corticosteroid, and elimination of the underlying trigger.
‘
Tennis toe’, actually observed in a variety of activities including cricket, jogging and skiing , is
due to haemorrhage under the nail plate of the great toe caused by impact between the distal
end of the nail plate and the shoe. This may result in an acutely painful subungual
haematoma which may require drainage. The injury may be prevented in some cases by
excising away a small portion of the toe of the shoe, thus reducing the impact effect on the
toe.

Repeated low grade trauma or pressure to the skin surface will result in a protective
hyperkeratotic response to prevent injury to underlying structures; eventually a callus will
form. The type of sport will determine the location and shape of the callus; for example, the
hands of a rower or weightlifter, or the soles of a jogger. Corns (clavi) are callosities over
bony prominences. Athletes with long second or third toes (Morton’s toe) may develop
buckling of the second toe which forces the second metatarsal head into the ground and
results in clavus formation in this position. Clavi are exquisitely tender to lateral pressure or
squeezing. Treatment of callosities and clavi begins with correction of the abnormal
mechanical stresses and consultation with a podiatrist may help to identify these. The lesions
can be pared with a scalpel blade and keratolytics applied to help remove excess keratin.
Cryotherapy of clavi requires relatively long freezing times (approximately 90 seconds); the
resultant crust is shaved in three or four weeks, and often one treatment can abolish the
clavus1

Athlete’s nodules
Athlete’s nodules are connective tissue naevi (collagenomas) at sites of recurrent trauma and
friction. They may appear in knuckles, pretibial areas or dorsal aspects of the feet, in an area
directly related to the particular sport.

‘Nike nodules’ appear on the dorsal foot from repetitive trauma associated with jogging2

Surfer’s nodules develop on the dorsal foot from trauma associated with surfboards.
Piezogenic papules are small, painful herniations of fat through areas of damaged dermis,
often appearing on the mediolateral aspects of the feet. They may only be apparent when the
foot is in a weightbearing position. Support stockings may afford some symptomatic relief.

1 Sheard C. Simple Management of Plantar Clavi (1992). Cutis 50: 138.

2 Basler RSW and Jacobs Senior Lecturer Orthopaedic Surgery. Athlete’s nodule. Reply
(letter) (1991). Journal of the American Academy of Dermatology 20: 318.

Heat and cold related skin disease

Intertrigo
An inflammatory dermatosis affecting the body folds, in particular the submammary and
genitocrural areas. Obesity, sweat and friction predispose to its development, and the clinical
appearances can range from mild erythema to frank dermatitis with secondary bacterial or
candidal infection. In refractory cases, diabetes mellitus should be excluded. Avoidance of
tight clothing, carefully applied wet dressings in the acute phase, and the application of one
of the imidazole preparations alone, or with a topical corticosteroid, may help control the
condition. It is important to remember that fleural psoriasis occasionally presents a similar
clinical picture and may lack the characteristic silvery scale in the moist flexural region.
Flexural psoriasis is generally more erythematous with a well defined border, and there is
often evidence of psoriasis elsewhere on the body such as the scalp, elbows or knees.

Miliaria, (‘prickly heat’)

Occurs in a hot and humid environment when sweat becomes trapped within ducts before it
reaches the epidermal surface. It mainly affects the torso. Three types of miliaria are seen
depending on the level of obstruction with the skin. Miliaria crystalline occurs when
obstruction is very superficial in the epidermis, resulting in fragile vesicles. Miliaria rubra is
the most common type and is due to obstruction in the intraepidermal sweat duct, and
presents as erythematous papules associated with pruritus and stinging. Miliaria profunda is
rarely seen outside of the tropics and is due to obstruction of deeper dermal sweat ducts.
Treatment of miliaria consists of reducing environmental heat and humidity, use of mildly
astringent lotions to help relieve ductal obstruction, and mild topical corticosteroids to reduce
inflammation. Miliaria may be followed by a period of hypohidrosis or defective sweating, and
may put athletes at risk for overheating injury for several weeks.

Erythema ab igne
Is a characteristic cutaneous eruption consisting of a well demarcated area of livedoid
erythema and pigmentation, most commonly seen on the lower legs of older women who sit
too close to a heater in winter. Vascular injury secondary to heat damage is thought to play a
role. Similar eruptions may be seen in athletes who apply heat packs to the skin for
musculoskeletal injuries. Cold compressions are also used for such injuries and cryogenic
damage to skin following their correct usage has been reported 1. The eruption consisted of
bullae and erythema 24 hours following a 25 minute exposure time to the cold compress. The
degree of hypothermia delivered by such cold compresses may be potentiated by applying
an elastic bandage and/or actually sitting on the cold compress thus firmly immobilizing it
against the skin. This method of application should therefore be avoided.
1 Cipollaro V. Cryogenic Injury Due to Local Application of a Reusable Cold Compress
(1992). Cutis 50: 111-112.

Ultraviolet-related skin disease

Sunburn
Sunburn is a preventable skin injury which has acute and chronic effects on the skin. Acute
effects include erythema, oedema and desquamation. Chronic effects comprise increased
incidence of cutaneous tumours (including malignant melanoma, squamous and basal cell
carcinomata, keratoacanthoma), photoaging and atrophy. Malignant melanoma is of
particular concern because of its aggressive behaviour and strong correlations between
frequency of sunburns in youth and the development of melanoma. Prevention of sunburn
and excessive photoexposure in sports participants is an area of preventative medicine which
should be endorsed by all sports enthusiasts - spectator, athlete, and official alike. Sporting
activities should ideally be timed for early morning or mid to late afternoon in order to avoid
the harsher midday ultraviolet rays. Broad spectrum sunscreen agents (which block out UVB,
UVA and infrared rays) with a sun protection factor (SPF) of at least 15 times normal should
be applied and reapplied frequently during outdoor exposure. Use of hats and protective
clothing, preferably also with good UV blocking abilities, should also be endorsed.

Ultraviolet light exposure may also result in phototoxic reactions to substances either orally
ingested, for example, non-steroidal antiinflammatory agents , or applied topically, for
instance perfumes and essential oils. Even brief exposure to ultraviolet light may cause
intense reactions in persons who have used photosensitizing agents, and this can persist
long after cessation of the offending agent.

Exacerbation of pre-existing skin disease

A variety of dermatological conditions may become exacerbated by sport activity. Although
acne may arise de novo following trauma from sport, it is also a common condition of young
people and may worsen with activity. It is important to remember that treatments for acne
such as isotretinoin (oral synthetic vitamin A derivative) may give rise to side effects such as
photosensitivity, skin fragility, and myalgias, which can interfere with sporting performance.
Minomycin, a commonly used oral antibiotic for acne, can also result in photosensitivity.

Psoriasis is a common skin disorder with quite varied clinical manifestations. Psoriasis is
often exacerbated by trauma (the Koebner or isomorphic response) and palmoplantar
psoriasis may also be influenced by chronic mechanical pressure. Retinoids and tar
preparations may result in photosensitivity.

Many patients with atopic dermatitis find that sweating aggravates their condition. Seasonal
exacerbations in spring and autumn are also frequent. Chlorinated, as opposed to saltwater,
pools can be very drying for atopic individuals, and frequent showering may also exacerbate
eczema. Exposure of the skin to irritant chemicals or physical trauma should thus be avoided
as far as possible.

Dermatological effects of anabolic-androgenic steroids

The use of self-administered anabolic-androgenic steroids by athletes and body builders may
be widespread and under recognized. Anabolic steroids are synthetic derivatives of
testosterone. High doses may stimulate the production of sebum by sebaceous glands and
increase the numbers of normal follicular bacteria. Acne, oily hair and skin, sebaceous cysts,
hirsutism, and rogenetic alopecia, striae (stretch marks), seborrheic dermatitis, and
secondary bacterial infections occur with increased frequency in this group of athletes.
Cutaneous side effects are often the initial clinical manifestations of anabolic steroid usage1 .

1 Scott MJ and Scott AM. Effects of Anabolic-Androgenic Steroids on the Pilosebaceous Unit (1992). Cutis 50:

113-117.