Chapter 17
SKIN CONDITIONS IN SPORTS
The skin is the largest organ of the human body. Two major layers of tissues, the dermis and the
epidermis, form the skin. A layer of subcutaneous fat is directly beneath the dermis (refer to Figure
17.1 on page 256). Skin serves a variety of functions, including protection from the environment,
control of fluid balance within the body, protection from disease organisms, temperature regulation,
and housing for sensory nerves. Skin can be damaged a variety of ways including external trauma
(wounds), exposure to ultraviolet light, temperature (either burning or freezing), infections, and
allergies.
I. Wounds. Sports injuries may cause various types of wounds, ranging from abrasions to
lacerations. Primary goals of initial care are control of bleeding and prevention of infection. A
primary concern when rendering first aid for any wound is to avoid contact with whole blood that
may transmit infectious disease agents such as HIV or HBV. The majority of sports-related wounds
are abrasions caused by rubbing, scraping, and burning; lacerations produced by a blunt object
tearing the skin; and incisions caused by sharp objects. A turf burn, a specialized form of abrasion,
is associated with playing on artificial turf.
A. Treatment. The treatment of wounds can be considered as a two-phase process. Initial first aid
care is designed to control bleeding and prevent further injury. This phase is followed by
continued protection of the area following return to participation.
1. An important aspect of wound care is protection of fellow athletes, coaches, and other
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personnel from exposure to whole blood from the wound, as well as blood-soaked
clothing and blood on playing surfaces.
2. According to NSC guidelines (1993):
a. Before rendering first aid, take precautions to avoid transmission of HIV/HBV.
Wear latex gloves and dispose of all waste in a biohazard storage container.
b. Remove clothing and/or equipment over the wound.
c. Control bleeding with direct pressure over the wound site by applying a sterile
dressing.
d. If dressing becomes soaked with blood, add more dressing on top of previous
dressing.
e. If direct pressure fails to control bleeding, combine direct pressure with
elevation.
f. If both measures fail, apply a pressure bandage to a point over either the brachial
or femoral arteries.
g. Tourniquets are only applied as a last resort.
h. All materials used to treat the wound must be stored in an appropriately marked
biohazard container.
3. At the time of initial injury, a decision must be made as to allow the athlete to return to
participation. The health and safety of the athlete must be considered, as well as, the risk
of exposing other participants, coaches, and related personnel to the athlete’s blood.
a. Lacerations and incisions to the scalp or face deserve special attention because of
their cosmetic impact. Such wounds should be referred to a physician for
evaluation and, possibly, stitches.
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b. As a general rule, any wound that is deeper than the dermal layer and more than a
centimeter in length, especially on the face, needs to be seen by a physician.
4. The NCS (1993) provides the following guidelines for cleaning wounds:
a. Wear latex gloves to avoid direct exposure to blood.
b. Wash the wound with sterile gauze pad saturated with soap and water. A 3%
solution of hydrogen peroxide may be used to clear away blood clots and related
debris.
c. Flush the wound with large amounts of water, then dry with a sterile gauze pad.
d. Use isopropyl alcohol to clean skin adjacent to the wound, but avoid applying the
alcohol to the wound.
e. Do not apply chemicals such as Mercurochrome, Merthiolate, or iodine.
f. Apply a sterile, dry dressing and hold in place with a bandage. A Band-Aid type
of bandage will be effective on smaller wounds; for larger wounds, the dressing
can be held in place by elastic adhesive tape.
g. Severe wounds should be treated for bleeding control and referred for medical
evaluation.
5. HIV/HBV and the Athlete. Although national attention has been focused on HIV
infection, the incidence of HBV infection is increasing as well in the United States. An
estimated 300,000 new HBV infections occur each year. In 1981, the first case of AIDS
was reported in the United States. Since that time, the Centers for Disease Control and
Prevention estimate that over 885,000 diagnosed cases of AIDS had been diagnosed by
2002 in this country.
a. Anyone who is sexually active is at risk of contracting HIV. Athletes using
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injection methods to take anabolic steroids may also be at risk if they share
needles.
b. The HBV virus is a bloodborne pathogen as well.
c. Although the possibility of transmitting HIV/HBV is remote in sports, some
precautions are necessary, especially in sports where bleeding is common.
d. OSHA has developed a comprehensive set of guidelines regarding preventing
exposure to HIV/HBV for health care workers. Coaching personnel and
athletes may be exposed to whole blood on a regular basis from contact with
bloody towels, water bottles, playing surfaces, and blood-soaked bandaging
materials.
1) All personnel should wash their hands and skin as soon as possible after
being exposed to the blood of an injured athlete. Coaches and health care
providers with open wounds should also protect athletes from exposure to
their blood by wearing latex gloves, bandages, and practicing good
personal hygiene.
2) Education of athletes, coaches, and parents about the transmission and
prevention of HIV/HBV is essential.
II. Other Skin Conditions
A. Ultraviolet Light-Related Skin Problems. Participating in outdoor sports often exposes large
areas of skin to the harmful rays of the sun. Summer sportswear typically does not cover arms or
legs, and in some sports, major portions of skin are unprotected from the sun. Even minor
sunburn
can be harmful to the skin.
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1. Two wavelengths of UV light are harmful: UVA and UVB. UVB light appears to be more
related to the development of skin-related problems than UVA light.
2. Some individuals have a higher risk of skin damage from sunlight exposure, including those
with lighter skin, red hair, and freckles.
3. Although sun exposure at any time of the day can result in sunburn, the hours of peak
exposure to sunlight are from 10:00 A.M. to 2:00 P.M.
4. Sunburn has two clinical phases. The first is the immediate erythema phase that involves
reddening of the skin and occurs during sunlight exposure. The second phase is the delayed
erythema phase that normally develops within a few hours of exposure and peaks at 24
hours.
1) Most sunburn cases result in mild discomfort, but more severe forms involve
blister formation, chills, and gastrointestinal distress.
5. The primary concern should be protection of exposed skin when outdoors. Athletes should
use a commercially prepared sunscreen with an SPF rating of 15 or greater to protect their
skin. Emphasis should be placed on protecting the skin of the ears, nose, lips, back of the
neck, forehead, forearms, and hands.
1) Sunblocks contain zinc oxide or titanium dioxide. These products prevent
light from reaching the skin.
2) Sunscreens contain chemicals that either absorb or reflect UVA or UVB,
such as PABA, cinnamates, salicylates, benzophenone-3, 3% avobenzone,
and dibenzoylmethane.
3) For best results, apply sunscreen products in advance of exposure and reapply
every 60 minutes. Athletes who use sunscreens advertised as water-resistant
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should also reapply them every 60 minutes.
6. Treatment of sunburn involves application of commercially made topical anesthetic as well
as a skin lotion. In severe cases, medical referral may be warranted.
B. Skin Infections. A variety of organisms, including fungi, bacteria, and viruses, can infect the
skin. Many apparent skin infections may be symptoms of more serious infections, such as
allergies, Lyme disease, or herpes.
1. Tinea (Ringworm). Tinea is a skin infection that is caused by a group of fungi. Common
locations for the infection include the groin (tinea cruris or jock itch), the feet and toes (tinea
pedis), and the scalp (tinea capitus).
a. Signs or symptoms include small, brownish-red elevated lesions that tend to be circular
in shape. When infections involve the toes, the lesions may include cracks between the
toes that ooze fluid and form crusts.
b. Itching and pain are associated with tinea pedis and tinea cruris; scaling of the skin over
the lesions may also occur.
c. Treatment includes cleaning the involved areas, then drying them; applying an over-thecounter topical treatment as well as moisture absorbing powder to the area; and wearing
clothing made of natural fibers such as cotton.
2. Tinea Versicolor (TV). This fungal infection is considered to be the most common warm
weather-related skin problem among teenagers and young adults.
a. The signs and symptoms include circular skin lesions that appear either lighter or darker
than the adjacent normal skin. The lesions usually appear on the upper trunk, neck, and
upper abdomen.
b. Treatment involves use of prescription drugs and may require weeks or months to be
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effective.
3. Bacterial Infections. Bacterial infections of the skin are relatively common in sports that
involve close physical contact between participants. These infections are known as
pyoderma (pus producing infection of the skin). Two common types of bacteria,
Staphylococcus aureus and Streptococcus, generally cause pyoderma.
a. Staphylococcus causes furuncles, carbuncles, and folliculitis; Streptococcus causes
impetigo and cellulitis. These conditions are characterized by infected, purulent skin
lesions.
b. Signs and symptoms of furuncles, carbuncles, and folliculitis include a pus-filled lesion;
folliculitis involves lesions at the base of a hair follicle; furuncles are lesions that form
large nodules around the base of a hair follicle and may burst; boils can appear
anywhere; and carbuncles are a collection of boils that are typically found at the
posterior neck and upper trunk regions.
c. Signs and symptoms of impetigo and cellulitis are pus-filled lesions; impetigo often
occurs on the face as groups of honey-colored, crusty, raised lesions. Cellulitis affects
the dermis. The infected skin will be red in color, warmer than adjacent skin, and painful
to the touch.
d. If the athlete has any form of pyoderma, he or she should be removed from participation
and referred for medical evaluation. If pyoderma is diagnosed, the athlete will probably
be treated with antibiotics.
4. Viral Infections. In sports, two of the more common viral infections are plantar warts and
herpes gladiatorum. Warts are common and caused by a group of viruses collectively known
as human papillomavirus (HPV). The majority of plantar warts are caused by HPV-1 and
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HPV-4. Although the infection is contagious, some individuals seem more susceptible, with
an incubation period ranging from 1 to 20 months. Warts are an abnormal buildup of
epidermis around the region of infection.
a. Plantar warts are simply warts that appear on the plantar surfaces of the feet.
1) The signs and symptoms include painful walking or running, small thickened areas
with tiny black or red dots within the area, and sometimes a group of warts will
develop (“mosaic wart”).
2) The treatment of plantar warts includes the application of chemicals to dissolve the
wart, freezing them with liquid nitrogen, and removing them with laser treatment or
by surgery. In some cases, plantar warts resolve spontaneously.
b. Herpes gladiatorum is the name given to an infection that affects wrestlers, which is
caused by the herpes simplex virus type 1 (HSV-1). This virus also causes the common
cold sore or fever blister than affects the outer lip area. Lesions are often associated with
physical trauma, sunburn, emotional disturbances, fatigue, or infection. Herpes
infections can remain dormant for long periods (months or years) between active
episodes when the lesions recur. The infection is most contagious
when the lesions
are present.
1) The signs and symptoms include the development of a lesion, often on the face,
which is characterized by blistering with a red, infected area of skin. Open draining
lesions may persist for a few days, after which they become crusted and begin to
heal. Additionally, the infected person has fatigue, body aches, and inflamed tender
lymph glands.
2) Outbreaks of the infection must be controlled, especially in sports such as wrestling.
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Athletes with active infections must be removed from participation until the lesions
are healed. Drugs to control the infection are available; however, a physician must
prescribe them.
5. Wrestling and Skin Infections. Wrestlers with active skin infections present special hazards
when they participate in the sport. Any open sore or skin lesion that cannot be covered
adequately should be grounds for removal from participation.
6. Allergic Reactions. Allergic skin reactions can result from exposure to a large number of
chemical agents from a variety of sources. An allergy that results from contact with the
offending agent is known as contact dermatitis.
a. Plants such as poison ivy, poison oak, and poison sumac contain chemicals that cause
allergic reactions in susceptible people. These plants result in allergic skin reactions in
90% of adults. The sap carries the offending chemical, and any contact with the sap can
cause it to be deposited onto the skin. The average time between exposure and symptoms
is 24 to 48 hours.
1) The earliest symptoms include itching and redness of the skin in the affected area.
2) Later symptoms include blisters that often break open and crust over. Healing takes
place within one to two weeks after the initial reaction.
3) Athletes who are allergic to plants should learn to recognize them and avoid areas
where they grow. Outdoor events, such as cross-country running, should be staged in
locations where such plants are not found.
b. Recently, allergies related to chemicals contained in clothing or sports equipment have
received more attention in sports medicine literature. Products which contain rubber,
topical analgesics, resins found in athletic tape, or epoxy used in face gear have been
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associated with allergic responses among athletes.
1) Such products contain sensitizing chemicals that produce contact dermatitis, swelling
and redness of the skin (erythema) followed by the development of pimple- or
blister-like lesions. Synthetic rubber additives that are often found in tennis shoes,
swim caps, goggles, and earplugs may be involved in allergic reactions.
2) An athlete suspected of having allergic contact dermatitis should be referred to a
dermatologist for diagnosis, identification of the sensitizer, and treatment.
REVIEW QUESTIONS
1. Review the primary goals of initial wound care.
Answer: The primary goals of initial wound care are control of bleeding followed by prevention of
infection through cleaning and bandaging.
Page: 256
2. List the precautions that should be taken when treating an athlete with an open wound to avoid
possible transmission of HIV and HBV.
Answer:
1.) Remove players from participation when excessive bleeding is evident.
2.) Those persons providing first aid care for such injuries should wear latex gloves and perhaps
even eye protection.
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3.) Athletes should be cautioned about sharing water bottles or blood-stained towels.
4.) Athletes, coaches and health care providers should wash hands and skin as soon as possible after
being exposed to the blood of an injured athlete.
Page: 257
3. Describe and differentiate between a wound dressing and a bandage.
Answer: A dressing is a sterile material, usually gauze, used to cover a wound to control bleeding
and prevent contamination. A bandage is used to hold the dressing in place.
Page: 258
4. True or False: With respect to the types of sunlight causing sunburn, evidence suggests that UVB
is more connected with the development of skin-related problems.
Answer: True. UVB is a shorter wavelength than UVA and seems more related to the development
of skin problems.
Page: 258
5. Discuss the two clinical phases of a sunburn as described in the chapter.
Answer: The first, known as the immediate erythema phase, involves reddening of the skin, which
occurs during exposure to sunlight. The second phase, called the delayed erythema phase, normally
develops within a few hours of exposure and peaks at 24 hours.
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Page: 259
6. Explain the acronym PABA.
Answer: Para-aminobenzoic acid
Page: 259
7. True or False: The term pyoderma implies a pus-producing infection of the skin.
Answer: True. Pyoderma is a pus-producing infection of the skin.
Page: 260
8. Describe the recommended treatment(s) for plantar warts.
Answer: Treatment of plantar warts ranges from the application of chemicals designed to dissolve
the wart to actual surgical removal, although the latter is not recommended by the medical
community. Even a form of laser surgery has been developed for use on plantar warts.
Page: 262–263
9. True or False: There is no evidence that synthetic materials such as tennis shoes, swim caps, and
swim goggles can cause allergic skin reactions.
Answer: False. Major sensitizers include rubber additives commonly found in certain brands of
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tennis shoes, swim caps, swim goggles, nose clips, and ear plugs.
Page: 264
10. True or False: The first case of AIDS was reported in the United States in 1981.
Answer: True. In 1981, the first diagnosed case of acquired immune deficiency syndrome was
reported.
Page: 258
11. True or False: The skin represents the smallest organ of the human body.
Answer: False. It is the largest organ of the human body.
Page: 256
12. List the roles of the skin.
Answer: It protects the body from the environment, is essential for controlling fluid balance within
the body, protects the body from disease organisms, regulates body temperature, houses nerves
receptors that register touch, temperature, and pressure, and can produce vitamin D.
Page: 256
13. What is the initial first aid provided during the treatment of wounds?
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Answer: Controlling the bleeding and protecting the area from further injury.
Page: 256
14. What is the standard guideline for referring an athlete with a laceration or incision to a physician
for evaluation?
Answer: Any wound going below the dermal layer that is more than a centimeter in length,
especially on the face.
Page: 257
15. What organization developed the comprehensive set of guidelines for health care workers
regarding prevention of exposure to HIV and HBV?
Answer: The Occupational Safety and Health Administration (OSHA)
Page: 258
16. True or False: Only moderate to severe sunburns may cause serious complications.
Answer: False. Research has shown that even minor sunburns can be harmful to the skin and can
lead to skin-related carcinomas and melanomas.
Page: 258
17. What individuals are at a higher risk for damage from sunlight exposure?
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Answer: Individuals with lighter skin, red hair, and freckles are at a higher risk for skin damage
from sunlight exposure.
Page: 258
18. Why are the groin region and the feet/toes more susceptible to tinea infections?
Answer: These body areas are common sites for infection because moisture and warmth make them
ideal for fungal growth.
Page: 259
19. What are the common conditions associated with bacterial infections?
Answer: Staphylococcus aureus-furuncles, carbuncles, and folliculitis; streptococcus-impetigo and
cellulitis.
Page: 260
20. Define contact dermatitis. What is the most common cause of contact dermatitis?
Answer: Contact dermatitis is an allergic skin reaction caused by exposure to any number of
chemical agents from a variety of sources. The most common sources are poison ivy, poison oak,
and poison sumac.
Page: 264
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