presentation ( format)

ACHA 2014 Annual Meeting
San Antonio, Texas
Thursday, May 29, 2014 @ 10:00 am
Session TH2-304
Common Dermatologic Problems
in Physically Active Young Adults
Michael J. Huey, MD, DABFM,
CAQ Sports Medicine
Assistant Vice President and Executive Director
Emory University Student Health and Counseling Services
Head Team Physician, Emory Eagle Varsity Athletics
Associate Professor (MEST), Family and Preventive Medicine
Emory University School of Medicine
Faculty Disclosure
Neither I nor my spouse
have a financial interest,
arrangement or affiliation with any
organization or business entity (including
self-employment or sole proprietorship)
that could be perceived as a conflict of
interest or source of bias in the context of
this presentation.
My wife is the President and CEO of
The Center for the Visually
Impaired of Georgia
Diversity-Focused Presentation
2014 ACHA Annual Conference
At the conclusion of this presentation, attendees should be able to:
Identify and treat many common traumatic
dermatologic problems in young adults
Identify and treat many common infectious
dermatologic problems in young adults, including
viral, bacterial and fungal etiologies
Identify and treat a common inflammatory
dermatologic problems in young adults
Identify important pre-malignant and malignant
dermatologic problems in young adults (if time)
Hey, this looks familiar
somehow . . .
This is the exact talk I gave at
SCHA in Atlanta, March 2014
It is OK to leave now if you want
to . . . I won’t be offended . . .
There are lots of good talks at
ACHA this year:
Cancer SurvivorLink: How to
Prevent “Lost in Transition”: Lillian
Meacham (Emory/Children’s
Healthcare of Atlanta) and Ron
Forehand (UGA)
What’s up
with that?
Every college student is an
athlete. . .
And they are pretty much
covered in skin. . .
Additional Risk Factors of
the Physically Active Young Adult
Prolonged exposure to
Chemicals and water
Protective athletic
Secondary infection
We all know this to be true. . .
Atypical presentation of
common diseases
are more often seen than
Typical presentations of
uncommon diseases
Case #1
Joseph Morelli, MD, UpToDate 2014
21 year old female student who has had
“dry skin” all of her life, occasionally flares
up with sweat from exercise or during the
spring, especially on her fingers and
antecubital fossae.
She has red patch on her right hand that
4-5 days ago started to get painful and
now has “pimples” on it. She is
frightened. There are the other usual dry
scaling patches on her body. She is
Your nurse has given her a canned sports
beverage and she is feeling better. . .
ACHA 2014 Annual Meeting
San Antonio, Texas
Thursday, May 29, 2014 @ 10:00 am
Session TH2-304
Common Dermatologic Problems
in Physically Active Young Adults
Michael J. Huey, MD, DABFM,
CAQ Sports Medicine
Assistant Vice President and Executive Director
Emory University Student Health and Counseling Services
Head Team Physician, Emory Eagle Varsity Athletics
Associate Professor (MEST), Family and Preventive Medicine
Emory University School of Medicine
Atopic Dermatitis = COMMON
(with secondary infection)
Atopic dermatitis might be the
most common significant
dermatologic diagnosis you
will see in your athletes.
Made worse by exposure,
sweat, 2-3 showers a day
(“water is the enemy”) and
Made worse by stress, topical
irritants, secondary infection.
Classic distribution in adults
Allergic diathesis
Yusoff Saifuzzaman, MD, Dermatlas;
2/3 of adults
with atopic
have a family
history of
allergic rhinitis
Likely IgE
Clues to diagnosis
History of
Severely pruritic, typical
Excoriated, lichenified,
secondarily infected or
Post-inflammatory hyperor hypopigmentation
Dyshydrotic vessicles in
older children and adults
Prevention and Treatment
Remove exacerbating
situations: Water,
allergens, sweat,
chemicals, equipment,
Moisturize ointments >
Rx = Topical
corticosteroids (avoid
fluorinated on face,
Allergy desensitization
Dyshydrotic papules, common location
Goodheart HP. Goodheart's photoguide to common
skin disorders, 2nd ed, Lippincott Williams & Wilkins,
Philadelphia 2003.
Good Soap. . .
Bad Soaps and Body Washes
(also things that students like)…
Not Too Bad Soap. . .
Case #2
(don’t worry, they get tougher . . . sort of)
20 y/o male undergraduate training for
his first half-marathon in April
Has recently increased his mileage to 7
miles/day 4 times a week
Wearing new running shoes
recommended by a friend with a high
heel counter
c/o pain over his Achilles tendon area
He is upset that he may miss his halfmarathon, but your nurse has given him
a canned sports beverage and he is
feeling better. . .
Friction Blisters = COMMON
Blisters on the feet occur from a
combination of skin friction and
Friction from rubbing the skin over and
over in one spot (such as the back of
the heel or ball of the foot) causes the
layers of the skin to begin to separate.
Fluid then seeps into this newly
created space between the layers
forming the blister.
Blisters on the feet are by far the most
common running injury reported
among marathon finishers.
Blister basics:
To drain or not to drain
Small non-painful blisters heal quickly
Large painful blisters hurt less if drained and not
irritated, but hurt more and have a slightly higher risk of
getting infected if they are drained and the activity (such
as running) is continued
Blisters with the overlying blister roof removed will heal
faster, but hurt more initially
All blisters should be drained, completely de-roofed and
treated by a podiatrist if patient is a diabetic due to risk
of infection. A blister anywhere on the foot in a diabetic
runner is a medical emergency.
Case #3
23 y/o female graduate nursing
student is a cycling enthusiast
and rides to campus daily
Fell trying to avoid a distracted
pedestrian on campus (is there
any other kind?) landing on her
right shoulder
Large, weeping, painful
She was initially tearful but the
canned sports beverage has
helped. . .
“Road Rash”
Deep, weeping abrasions from
falls onto concrete, blacktop, dirt
(“base stealer’s strawberry),
grass, artificial turf
Very painful
Often contaminated with rocks,
soil, grass, glass and other
foreign bodies
Significant risk of tattooing if not
aggressively cleaned
Risk of secondary infection
Cleaning deep abrasions
You won’t be able to appropriately and deeply clean
without topical anesthesia
Smaller areas can be field blocked with injectable
2% viscous lidocaine gel applied with a tongue blade (for a
large abrasion, 4% liquid may be lead to much lidocaine
absorption). Let it sit 5-10 minutes minimum.
Remove large debris (glass, rocks, wood) with forceps.
Tap water lavage
Scrub area with surgical sponge or gauze pad
Abrasion dressings
Hydrocolloid dressings (Tegaderm, Duoderm, others) can be
very effective in controlling pain & reducing healing time
Gelatin, pectin and/or carboxymethylcellulose, serve as occlusive or
semi-occulsive dressings
Absorb wound exudates to form a hydrophillic gel
Waterproof, allow water vapor and gases to cross
Long wear time (up to 7 days) can reduce visits and costs
Transparent film dressings (OpSite, Comfeel, others)
Intl J Sports Med 12(6),1991: Hydrocolloid v. Gauze
38 racing cyclist abrasions in 24 athletes
Hydrocolloid occlusive dressings had faster healing times (5.6 v. 8.9
days), smaller risk of infection (0% v. 10%), less pain at race time (91%
no pain at race time v. 30%)
Case #4
18 y/o undergraduate was lifting
weights at Rec Center and
dropped 25# dumbbell onto big
Pain kept him awake all night
Roommate (with MD parent) went
after him with a heated paper clip
but patient respectfully declined
and came to SHS
He is holding an icy canned sports
beverage against his throbbing
toe when you enter the room. . .
Subungual hematoma
The blow causes bleeding of the nail
matrix (nail bed) with resultant
subungual hematoma formation.
Patients complain of throbbing pain
and blue-black discoloration under the
nail as the hematoma progresses.
Pain is relieved immediately for most
patients with simple nail trephination.
Drain hematomas that are acute (<24
to 48 hours old) and painful. Beyond
48 hours, most have clotted and
trephination is not effective.
You need to have trauma
(sometimes can be repetitive)
Subungual melanoma
Junctional nevi
Splinter hemorrhages –
often associated with
infectious endocarditis
Kaposi sarcoma
Subungual melanoma arises from
the nail matrix
Nail trephination
• A heated device is
pressed against the
nail in the center of the
• Care should be taken
to avoid the lunula and
to create a hole large
enough for continued
Fastle, RK, UpToDate 2014
I like to spin an 18G needle
When to refer and
suboptimal outcomes
Refer to podiatry or
• Displaced fractures
• Intraarticular fractures
• Infected wounds
• Unsure diagnosis
Bad nail outcomes
with crushed matrix
Case #5
26 y/o male medical student has
a non-painful fluid filled bump on
the inside of his lower lip
He bit the inside of his lip playing
soccer last year and now tends
to chew on the area when he
When he bites it, a salty mucus
comes out.
He declined the nurses offer of a
canned sports beverage but
expressed his appreciation at
the offer. . .
Pseudocysts of minor salivary
gland origin
Formed when salivary gland
secretions dissect into the soft
tissues surrounding the gland,
usually as a result of trauma
that causes pooling of mucous
Treatment: Observe, unroof
or marsupialized, or “Bite me.”
Case #6
42 y/o female Master’s of
Divinity student has thickened,
itchy area on the outside of her
right ankle
She says that she leaves it
alone and it still won’t go away,
but then guiltily admits to
“rubbing at it sometimes during
bible study and long sermons”
She is scratching the area with
an empty sports beverage can
when you enter the room. . .
Lichen simplex chronicus
Pruritus is a common symptom that
occurs in a wide variety of clinical
settings, such as dermatologic and
neuropathic disorders, and
systemic or psychiatric disease.
If you can reach it, you can scratch
it. . . If you scratch it often enough,
it lichenifies
LSC: Lichenified plaques and
excoriations are typically present
Treatment of
Lichen simplex chronicus
Treatment = taking measures to break the itch/scratch cycle
Unna boots or other occlusive dressings (e.g. hydrocolloid)
Topical and oral anithistamines
Topical or intralesional corticosteroids
Topical Capsaicin (8-methyl-N-vanillyl-6 nonenamide)
Topical calcineurin inhibitors
tacrolimus and pimecrolimus
Oral gabapentin
Topical anesthetics
Fazio SB et al, UptoDate 2014
Case #7
21 y/o male club wrestler presents
with a painful area on the right side of
his face and neck
It started out as groups of bumps that
changed into vesicles and then broke
down into an open ulcerated area
This is the third time he has had the
rash in this same area; His coach
says there is medication to prevent it
He is wearing a “Powerade Wrestling”
t-shirt but is drinking a Gatorade. . .
Herpes gladiatorum
(scrum pox, mat herpes, wrestler’s herpes)
Classic Herpes simplex Type 1 (or perhaps
type 2) lesions in atypical locations
Spread by skin to skin contact; Contact sports
with “grinding” contact face to body (e.g.
wrestling, rugby)
Can occur in outbreaks on teams, at sports
camps (Outbreak of herpes gladiatorum in 60 of 175
high school wrestlers attending a summer training
camp in Minneapolis: Belongia et al, NEJM, 1991)
Herpes Viruses and Sports
NCAA regulations
prohibit participation
with active viral lesions;
can be occulsively
Can suppress with an
anti-viral during season,
NCAA tournament,
wedding day, etc..
Herpes Zoster
UpToDate 2014
Case #8
19 y/o female intercollegiate basketball player
with painful spots on the
sole of her right foot.
2 weeks into the season
and she can barely run
“Do something before
Friday’s game, please!”
She is drinking a sports
beverage from a sports
bottle when you enter the
UpToDate 2014
Plantar warts
HPV type 1
Extremely uncomfortable
to painful, tender to
Weight bearing areas of
heels, toes, metatarsal
Pare with scapel if dense
callous, looking for
thrombosed capillaries
(“wart pegs”)
Thrombosed capillaries
Treatment of plantar warts
Pare down the callous carefully
Liquid nitrogen (careful, can be painful, cause blood
Salicylic acid
40% Plasters (Mediplast, Duofilm patch, others), applied to the wart
and a few millimeters of surrounding skin, taped into place with duct or
athletic tape and kept dry for 48 to 72 hours. Patch is then removed,
wart pared down, and process repeated.
Duct tape alone; 5 flourouracil (Efudex, others) cream;
Imiquimod (Aldara, others), intralesional immunotherapy; Other
Would refer surgical approaches unless very confident
(painful scarring on sole of foot)
Case #9
21 y/o female intramural
soccer player with a itchy
eruption on the sides of her
feet and between her toes
She has had athlete’s foot in
the past and it quickly
responded to OTC antifungals, but this has not
It is dry, it cracks and bleeds,
and it hurts.
All the sports beverages in the
world are not going to make
her happy. . .
WebMD 2014: Phanie / Photo
Researchers, Inc.
Tinea pedis is the most
common cutaneous fungal
infection in athletes
Common things are
common and things don’t
always get better the first
Can take 4+ weeks
Soccer players, swimmers,
runners and basketball
players are most
commonly infected
Kamihami, T et al, Public Health 111
Topical anti-fungals
How supplied
Terbinafine (Lamisil)*
Cream, gel
Clotrimazole (Lotrimin)*
Cream, lotion, solution
Econazole (Spectazole)
Sulconazole (Exelderm)
Cream, solution
Oxiconazole (Oxistat)
Cream, lotion
Naftifine (Naftin)
Cream, gel
Ciclopirox (Loprox)
Cream, lotion, liquid
Ketoconazole (Nizoral)
Sertaconazole (Ertaczo)
Miconazole (Monistat)*
Tolnaftate (Tinactin)*
Cream, gel, powder, spray, liquid
Prevention of Tinea Pedis
Keep feet clean and dry
Synthetic, moisture wicking socks (not cotton)
Wear sandals in locker room, showers, and on
pool deck
Consider anti-fungal foot powders on feet and in
When indoors, wear socks without shoes
Allow shoes to dry out between use . . . Or get
new shoes
Treat past the time your feet appear to be all better
Case #10
19 y/o male intramural
basketball player presents
with a painful, intensely red
rash in his groin area
Has used an OTC anti-fungal
cream for “jock itch” but it
has not gotten better
He says that cool
compresses and packs help
and you see the top of a
sports beverage can sticking
out of his gym shorts. . .
Goodheart, HP, Goodheart's Photoguide of Common Skin Disorders,
2nd ed, Lippincott Williams & Wilkins, Philadelphia 2003.
Candida Intertrigo
Risk of infection is increased by
specific factors that increase skin
friction, increase moisture within
folds, or interfere with the immune
response and/or promote fungal
Promoting factors include diabetes,
obesity, tight fitting clothing that
chafes skin, moisture, antibiotics
and corticosteroids
Janniger, CK et al, Am Fam Physician. 2005 Sep 1;72(5):833-838.
UpToDate 2014
Location, location,
Satellite lesions
KOH prep of skin
Differential includes
bacterial intertrigo,
tineal infections,
contact dermatitis
Candida Intertrigo: Treatment
Remove moisture, friction and
darkness (“Wear no pants”)
Topical and/or oral antifungals
(Nystatin, Fluconizole 50-100 mg)
Topical and/or oral antibiotics
(Cephalosporins, Quinolones)
Topical corticosteroid (low potency,
non-fluorinated: 1-2% HC)
Little or no evidence for topical
corn starch, talc, etc.; may promote
secondary infections
UpToDate 2014
Case #11
18 y/o male recreational
athlete/exerciser (regular
First noted slightly dark,
smooth, non-itchy areas on his
back and chest 4 months ago.
Now it is late spring and the
areas are refusing to take a
tan. He is otherwise well.
You have a discussion with
him about sports drinks and
proper hydration in the sun. . .
UpToDate 2014
“Tinea” versicolor
Brown or white round/coalescing
macules, minimally scaly, on back and
upper chest
Lipid-dependent yeast; “Spaghetti and
Meatballs” on KOH prep
Highest incidence in tropical climates,
most commonly adolescents and
young adults
Treatment (depigmentation can
Topicals: Ketoconizole 2% cream (10-14 days)
or shampoo (once x 5 minutes); Selenium
sulfide 2% (Selsun) for 2 weeks
Fluconizole (Diflucan) 150-300 mg once
weekly x 2 weeks (exercise to sweat)
Malassezia furfur. Cluster of yeast cells in
skin scraping. PAS, 630X.
Case #12
19 y/o male ultimate frisbee
player had a single, slightly itchy
lesion on his back 10 days ago
Now his back is covered with
smaller, slightly red, scaly, oval
lesions, with lesser numbers on
his chest and extremities
He had STI testing on Monday
and his RPR is negative
He is wearing an Emory hat . . .
Your nurse recommends that
you search for a sports
beverage by Coca Cola. . .
UpToDate 2014
Pityriasis rosea
Adolescents and young adults, acute,
self-limited, slightly inflammatory, oval,
papulosquamous lesions on the trunk
and proximal areas of the extremities
Hypothesized viral etiology: sometimes
mild URI prodrome
“Herald patch” – 2-3 cm, oval, raise,
scaly; followed 5-10 days later by
generalized, “Christmas tree” pattern of
oval macules with “collarette” scales.
Spontaneous remission 4-6 weeks
Sunshine; check RPR
Herald patch
UpToDate 2014
Case #13
19 y/o female intercollegiate
volleyball player has a painful
lesion on her thigh
3 players on the team have
been bitten by spiders recently
and had similar lesions
The area burst open and
drained last night
She declined a sports beverage
because she is feeling a little
nauseated looking from at the
lesion. . .
Community Acquired
Methicillin Resistant Staph Aureus
• If you don’t think MRSA, you
will miss MRSA
• Spiders are not taking over
your residence halls or
locker rooms
Presentation of a MRSA infection
Patients infected with CA-MRSA
most commonly present with skin
or soft tissue infections (SSTI)
Often mistaken for bug or spider
bite, because bump enlarges,
becomes firm, tender and often
forms a pimple/pustule very
The 5 C’sof SSTI: Crowding,
frequent skin Contact,
Compromised skin, sharing
Contaminated personal care
items, lack of Cleanliness =
COLLEGE is the 6th “C”
MRSA abscess in the
thumb/index web space
“Spider bite-like” MRSA
MRSA progresses quickly from a “bite” to a painful abscess, often with
multiple draining sites
MRSA cellulitis/abscesses
Multiply pointing MRSA abscess with
cellulitis (carbuncle)
IDSA evidence-based guidelines
February 2011
Clinical Infectious Diseases: February 1, 2011
American Family Physician 84(4): 455-463,
August 15, 2011
IDSA (Infectious Disease Society of America)
Guidelines on the Treatment of MRSA
Infections in Adults and Children
CDC and IDSA say: Incision
and Drainage is routine care
If you can drain something, do it. It may be all
that is needed
If unsure, try to aspirate pus/fluid with an
adequate sized needle (16 to 19G needle on a 10
cc syringe)
If indicated, apply local heat and see patient back
soon (but don’t be surprised if it drains
CDC MRSA Treatment Algorithm 9/2007
Infectious Disease Society of America (2/2011) Evidence-based Guidelines for Treatment of MRSA
Oral Antibiotics effective
against MRSA
Clindamycin 300-450 po mg QID alone (Emory ER)
Trimethoprim-sulfamethoxazole (TMP-SMX DS) 1-2
tabs po q 8-12h – but not effective against Group A
Strept, need to combine with Beta-lactam antibiotic for
cellulitis and/or pending culture
Tetracyclines (doxycycline100 mg po BID) in
combination with Beta-lactam antibiotic
Linezolid (Zyvox) alone – not gonna tell you the dose
At Emory SHCS, we use TMP-Sulfa DS 2 BID or Doxy
100 mg BID + Cephalexin pending culture results, then
drop one or the other
CDC MRSA Treatment Algorithm 9/2007
Infectious Disease Society of America (2/2011) Guidelines for Treatment of MRSA
Someday, we’re gonna write a paper :
Everyone is allergic to sulfa
if you use it long enough in
a high enough dose. . .
Antibiotics that are not
recommended for MRSA infections
Beta-lactams and cephalosporins (of course!)
Flouroquinolones (ciprofloxicillin, levofloxicillin,
etc.): rapid development of resistance while on
Rifampin alone (or as adjunctive Rx per IDSA)
Macrolides (erythomycin, azithromycin,
clarithromycin): resistance is common among
MRSA isolates
CDC Convened Experts Panel 2006
Infectious Disease Society of America (2/2011) Guidelines for Treatment of MRSA
MRSA on your team – Our
Meet with team: “See the trainer or team
physician immediately for skin lesions/ infections.
Do not try to drain an infection yourself!”
Shower with an alcohol-based soap (e.g.
Hibiclens, others) entire team – NOT EVIDENCE
Cover wounds
Clean hands (alcohol-based cleaners in the
locker rooms)
Do not share razors, towels, personal items
Aggressive approach to infection: I&D
abscesses, treat with antibiotics
No return to play/practice until fully resolved (no
purulence, drainage, significant erythema) =
NCAA guideline
Case #14
19 y/o male rugby player had
several facial abrasions as a
result of last week’s match
Over the past 3 days the areas
got red and angry and started
to weep serum
Now the lesions are drying with
a honey-colored crust
He declines a sports beverage,
saying his coach does not allow
pre-game hydration for fear of
cramping during a match . . .
Predisposing factors:
Poor hygiene
Neglected minor trauma
Eczema, herpes, scabies
Clues to diagnosis:
Round to oval lesions, can coalesce
Minimally pruritic
Adherent goldenrod crusts
Regional adenopathy
Oral antibiotics for Group A strep and
Staph aureus
Mupirocin (Bactroban®) 2% cream or ointment
Stedman's Medical Dictionary.
Copyright © 2008 Lippincott
Williams & Wilkins.
Case #15
24 y/o male physically active
medical student presents with a
very itchy scattered papular rash
around his waist, in the genital
region and between his fingers and
His partner also has a similar rash
He has bathed repeatedly and used
OTC diphenhydramine without any
When offered a sports beverage, he
asks “Will it make itching go away?”
More views
Infestation by the mite Sarcoptes scabiei
Results in an intensely pruritic eruption
with a characteristic distribution pattern
Transmission is usually from person to
person by direct contact
Mites can survive off a host for 24 to 36
hours; survive much longer in colder
conditions with high relative humidity
Female mites (which burrow into the
skin and cause disease) survive longer
than their male counterparts
Mite + eggs + feces = delayed Type IV
hypersensitivity reaction = itching
UpToDate 2014
Sarcoptes scabiei and eggs:
UpToDate 2014
5% permethrin cream (Nix,
others) is less neurotoxic than
1% lindane lotion (Kwell, others)
Massage cream thoroughly into
skin from neck to soles of the
feet, including areas under the
fingernails and toenails.
Remove by shower or bath at 814 hours
Thirty grams usually sufficient for
an average adult
Data on repeat treatment 1-2
weeks unclear
Treatment, reinfection and
CDC recommends ivermectin 200 mcg/kg po as
single dose with repeat dose two weeks later as
equal of topical permethrin
Oral med = ease of use, lack of treatment associated
dermatitis, and increased compliance.
Itching can persist after treatment 1-2 weeks
To prevent spread and reinfestation, close contacts
should be treated simultaneously
Clothing and linens should be washed and dried or
bagged for several days
Case #16
35 y/o female PhD student
presents to have you look
at a changing mole
She has had this mole in a
freckled area or her back
for years.
Her partner noticed that it
has been changing and it
bled yesterday
(No sports beverage joke)
UptoDate 2014
Superficial spreading melanoma
Malignant Melanoma ABCDE
New York University 1985
Asymmetry (if a lesion is bisected, one half
is not identical to the other half)
Border irregularities
Color variegation (brown, red, black or
blue/gray, and white)
Diameter ≥6 mm
Evolving: a lesion that is changing in size,
shape, or color, or a new lesion
Malignant melanomas
Lentigo maligna in area of
sun damaged skin
UptoDate 2014
A rapid change in size, color, and
shape in a preexisting nevus over
months should raise the suspicion of
Basal cell carcinoma
Nodular BCC: Pearly papule with
telangiectasias and ulceration
UptoDate 2014
Superficial BCC: Erythematous,
slightly scaly patch
Basal cell carcinoma
Pigmented BCC: Pink/brownish
macule with slightly atrophic
center and irregular, elevated,
hyperpigmented borders
Nodular BCC in a more classic
UptoDate 2014
Final (silly) Case
35 y/o female MPH student has an
unusual circular “target-like” lesion
on her back
Lesion is not really painful; she has
not been ill; cannot recall any
She has not been practicing selftattooing nor has she been
abducted by aliens
Interestingly, the lesion is about the
diameter of the top of a can of
sports beverage . . .
Don’t lean back on the suction port of your
hot tub or you will get a:
Not unlike Cupping
Adams, BB, Skin Infections in Athletes, Expert Rev
Dermatol 2010, 5(5): 567-577.
Sarabahi, S, Recent Advances in Topical Wound Care,
Indian J Plast Surg 2012 May-Aug, 45(2): 379-387.
Janniger, CK et al, Intertrigo and Common Secondary
Skin Infections, Am Fam Physician 2005 Sep 1,
Lambert, M, IDSA Guidelines on the Treatment of
MRSA Infections in Adults and Children, Am Fam
Physician 2011; 84: 455.
Bibliography (2)
2014 UpToDate, Inc., Release: 22.2 - C22.44
Belongnia, EA, et al, An Outbreak of Herpes
Gladiatorum at a High School Wrestling Camp,
NEJM 325 (13): 906-910, September 1991.
IDSA (Infectious Disease Society of America)
Guidelines on the Treatment of MRSA Infections in
Adults and Children:
Bibliography (3)
Goodheart, HP, Goodheart's Photoguide of
Common Skin Disorders, 2nd ed, Lippincott
Williams & Wilkins, Philadelphia 2003.
Kamihama, T et. al., Tinea pedis outbreak in
swimming pools in Japan, Public Health 1997,
111(4): 249-253.
Thank you!
Emory University
Student Health and
Counseling Services